Posts Tagged ‘Erickson’
by Marilia Baker
A long, meaningful, well-lived life ended on December 26, 2008, blessed with a peaceful death. Concepts such as beauty, truth, love, simplicity and complexity they all were encompassed in the lifetime of Elizabeth Euphemia Moore Erickson.
The last Holiday Greeting card I received from her contained the following:
I am still living in my Hayward Avenue home here in Phoenix and enjoying Life on a quiet scale. I have had the pleasure of visits from many family members and friends throughout the year, and have found that time goes by swiftly. I am now 92 years old and still up and about, though I limit my outings and have given up travel. I am glad to say that with the help of my good neighbor and friend, I get out every day for a spin through my neighborhood (in the foothills of Squaw Peak) in a wheelchair, which I use for extended walks. I really enjoy the beautiful flowers, the cacti, and the trees that are seen year round in Phoenix. I wish you and yours every happiness this season and in all the coming years.
These words resume the existential philosophy of an exceptional woman, who found true pleasure in the smallest of moments, and in the smallest of things around her. In weaving together the pieces on Elizabeth Erickson’s life, some concepts and meanings come to mind: well-born, well-bred, and much loved by family and friends; simplicity and complexity, as well as intellectual and emotional intelligence. The passionflower vine in her garden and the anniversary orchid from her husband of 44 years.
Elizabeth as the family bedrock: her years of motherhood, of caregiving, and of graceful widowhood come to mind. With a scientific mind and prodigious memory, she was her husband’s lifelong hypnotic subject and colleague extraordinaire. I am also reminded of the many seasons of Elizabeth’s life, who experienced each phase of her life-cycle to their full extent and splendor, despite grave, serious challenges at each turn. She lived well into her 93rd year, self-reliant and independent minded, always cultivating the art of le petit bonheur (little happiness). She knew quite well how to enjoy even the smallest moments of happiness, as she described in her Christmas card, above.
The foundation of Elizabeth’s early family life: born in Detroit in 1915, she was firmly set on her family’s triple vision: the pursuit of truth and excellence through higher education and lifelong learning; the pursuit of beauty through appreciation of nature and the arts. She was kind to humans and animals as well gentle in manners, completed by refined, sophisticated taste in self-care.
This foundation was also set on the pursuit of Love in its broadest sense: healthy self-love; love for Others, and love for Humanity. Throughout her lifetime Elizabeth lived to the letter the meaning of her middle name: Euphemia, from the Greek concept, euphemios – he/she-who-speaks-well. She not only pursued the right word, the good word, and the just, well-measured word (le bon mot), but she was also an indomitable, resolute pursuer of the well-written word. She was proud of her polished, demon proofreader skills!
A unique, remarkable woman, of an exceptional beauty and intelligence: these are all synonyms for uncommon. Elizabeth embodied these qualifiers throughout the many seasons of her life. Initially, as the undergraduate experimental psychologist in 1935, chosen by the respected Dr. Milton Erickson to be his research assistant at the Wayne County Hospital in Eloise, Michigan. Then as the adult professional who wrote, co-wrote, and edited countless scientific articles presenting the hypotheses and findings of their joint research and experiments. Always as the colleague extraordinaire who worked shoulder-to-shoulder with her husband in many capacities, for approximately 16, 000 days – while raising a lively family of eight children, four boys and four girls. While nurturing their passion for each other, Elizabeth and her husband found creative solutions to everyday family and professional challenges. As a team they faced the vicissitudes brought upon Elizabeth’s shoulders by times of severe physical illnesses suffered by Dr. Erickson.
Intellectual and emotional intelligence: Elizabeth’s intellectual pursuits were many and worthy. She authored and co-authored thirteen professional articles on hypnosis (see pp.5-6). She was an editor and co-editor of the American Journal of Clinical Hypnosis for many years. There are countless stories and vignettes about her sophisticated emotional intelligence, specifically in the process of welcoming her new husband’s three young children, and in fostering the power of imagination in all her children. Bert, Dr. Erickson’s eldest son, recalls with delight how Elizabeth prepared their peanut butter and jam sandwich, by smoothing and blending the two ingredients together… An appropriate ‘action metaphor’ by the young mother-to-be. Particularly meaningful to me was her habit of educating and nurturing their children’s imagination through storytelling.
Daughter Roxanna recalls the magical mornings in her childhood when her mother would read from L. Frank Baum’s The Wonderful Wizard of Oz series while braiding her long tresses and those of her younger sister’s Kristina. A major implication of this apparently simple tradition makes significant reference, in my view, to the indirect education of children for the lifelong habits of freedom of thought, autonomy, love for Others and respect for boundaries.
Storytelling with a purpose fosters habits of physical and mental health, self-reliance and resilience through the imagination. Evidence from neuroscience research corroborates the intricate relationship between imagination and health. What is therapeutic hypnosis if not the utilization of influential words and powerful imagery to mitigate human suffering so individuals may attain freedom from stress, dis-ease? Storytelling, by definition, through its hypnotic characteristics and post-hypnotic suggestions can build autonomy, self-reliance, altruism, and a healthy self-concept in children.
Of love for Others, here is a striking example of an indirect yet powerful suggestion: Elizabeth would systematically and thoughtfully pack a dress shirt with matching necktie for each ex-convict graduating from the Seventh Step halfway house program for former criminals, which Dr. Erickson was counsel to.
Leaving a trail of happiness: Elizabeth Erickson died peacefully at home the day after Christmas 2008, in the arms of her youngest daughter Kristina, a medical doctor. Elizabeth was surrounded by her granddaughter Joya, Kristina’s daughter and by Kathy Renée, a great-granddaughter by Bert, the Ericksons’ eldest son, named after his paternal grandfather, Albert. Four generations present together at the final moment. The life-cycle completes itself, and renews itself through the new generations.
Beauty, Symmetry, Simplicity and Complexity. The current concepts of beauty, symmetry, simplicity and complexity, whether expressed through the arts, prose, poetry, philosophy, science, physics, psychology are delicately intertwined within my reflection of what Elizabeth Moore Erickson’s life and work means to me. A simple dictionary definition of beauty, for instance, says that beauty contains all the qualities that give pleasure to the mind or senses.
There was everything in Elizabeth to encompass the depth of this concept: from her physical beauty to the harmony of her being and actions; from her lifelong pursuit of truth and excellence, to the truthfulness of her character and the meaningful, positive connotation she gave to all her actions and behaviors into the last days of her life. Upon emerging into consciousness from surgical anesthesia of several hours duration, Elizabeth was heard singing a favorite Irish tune, “Danny Boy”, a melancholic and somewhat premonitory song of an impending farewell, famous during the first decades of 20th Century America.
One of Elizabeth’s favorite poems contains all beauty and complexity of her life, and of her luminous passage through this Earth:
Flower in the crannied wall, I pluck you out of the crannies. I hold you here, root and all, in my hand. Little flower – but if I could understand what you are, Root and all, and all in all, I should know what God and Man is.
Alfred Lord Tennyson
Articles by Elizabeth M. Erickson
Erickson, E. M. and Erickson, M. H. (1938). Hypnotic Induction of Hallucinatory Color Vision Followed by Pseudo-Negative After Images. Journal of Experimental Psychology, 39, 6, 581-588.
Reprinted in: Rossi, E. L. (Ed.). (1980b). The Collected Papers of Milton H. Erickson on Hypnosis. Vol. II: Hypnotic Alteration of Sensory, Perceptual and Psycho-physiological Processes. New York: Irvington.
Erickson, E. M. and Erickson, M. H. (1941, Jan.). Concerning the Nature and Character of Post-Hypnotic Behavior. Journal of Genetic Psychology, 2 1, 95-133.
Reprinted in: Rossi, E. L. (Ed.). (1980d). The Collected Papers of Milton H. Erickson on Hypnosis. Vol. IV: Innovative Hypnotherapy. New York: Irvington.
Erickson, E. M. and Erickson, M. H. (1941, Aug.). Critical Comments on Hibler’s Presentation of His Work on Negative After Images of Hypnotically Induced Hallucinated Colors. Journal of Experimental Psychology, 29, 164-170.
Reprinted in: Rossi, E. L. (Ed.). (1980). The Collected Papers of Milton H. Erickson on Hypnosis. Vol. II: Hypnotic Alteration of Sensory, Perceptual and Psycho-physiological Processes,. New York: Irvington.
Erickson, E. M. and Erickson, M. H. (1958, Oct.). Further Considerations on Time Distortion: Subjective Time Condensation as Distinct from Time Expansion. American Journal of Clinical Hypnosis, 1, 2, 83-87.
Reprinted in: Rossi, E. L. (1980b). The Collected Papers of Milton H. Erickson on Hypnosis. Vol. II: Hypnotic Alteration of Sensory, Perceptual and Psycho-physiological Processes. New York: Irvington.
Erickson, E. M. (1962, Oct.). Observations Concerning Alterations in Hypnosis of Visual Perceptions. American Journal of Clinical Hypnosis, 5, 2, 131-134.
Reprinted in: Rossi, E. L. (Ed.). (1980b). The Collected Papers. Vol. II. New York: Irvington.
Erickson, E. M. (1966). Further Observations in Hypnotic Alteration of Visual Perception. American Journal of Clinical Hypnosis, 8, 3, 187-188.
Reprinted in: Rossi, E. L. (Ed.). (1980b). The Collected Papers. New York: Irvington.
Erickson, E. M. (Ed.). (1985) Certain Principles of Medical Hypnosis, by Milton H. Erickson, MD. In S. Lankton (Ed.). Ericksonian Monographs Number I: Elements and Dimensions of an Ericksonian Approach (pp. 22-25). New York: Brunner/Mazel.
Erickson, E. M., Erickson B.A. and Klein, R.E. Erickson (1999). “Erickson: A Framework of Therapy and Living”. In: Matthews, W.J. and Edgette, J.H. (Eds.) Current Thinking and Research In Brief Therapy. Vol. III (pp. 7-17). New York: Brunner/Mazel.
Baker, Marilia (2004). A Tribute to Elizabeth Moore Erickson. Colleague Extraordinaire, Wife, Mother, and Companion. Alom Editores: Mexico.
Battino, Rubin (2008). That’s Right, Is It Not? A Play About Milton H. Erickson, MD. The Milton H. Erickson Foundation Press: Phoenix, Arizona.
Erickson, Betty Alice and Keeney, Bradford (eds.) (2006). Milton H. Erickson, MD. An American Healer. Ringing Rocks Press: Sedona, Arizona.
Erickson-Klein, Roxanna (2006). Family Traditions: The Oz Books – Why They Are Treasured by the Erickson Family. Unpublished essay, distributed by the author to young family members, to preserve and nurture family memories and traditions.
Rossi, Ernest L. (2004). Discorso tra geni. Neuroscienza dell’Ipnosi terapeutica e della Psicoterapia. Editris s.a.s.: Benevento, Italy.
Rossi, E., Erickson-Klein, R. and Rossi, K. (Eds). Advanced Approaches to Therapeutic Hypnosis. In: The Collected Works of Milton H. Erickson, Vol. IV. The M. H. Erickson Foundation Press: Phoenix, Arizona.
Stewart, Ian (2007). Why Beauty is Truth. A History of Symmetry. Basic Books/Perseus Books Group: New York.
Milton Erickson was unencumbered by the prevailing orthodoxy of his time. His creativity continues to reverberate profoundly in often unacknowledged ways. Perhaps the most important of Erickson’s principles is utilization. Consider the following vignettes.
Erickson saw Kim, a teacher troubled by nude young men hovering just above her head. She told Erickson not to take her young men away, but rather stop their interference with her everyday life. He suggested that Kim leave the nude young men in a closet in his office where they would be secure and not interfere with her teaching. She checked on the young men at first, but gradually stopped. Much later, Kim moved to another city and worried about her “psychotic episodes.” Erickson suggested that she put her psychotic episodes in a manila envelope and mail it to him. Occasionally, she would send Erickson a psychotic episode and meanwhile continued a productive life (Erickson, 1980).
Erickson saw Bob, who requested that his irresponsible, reckless, driving be corrected. Erickson asked what he could do to be helpful and Bob’s answer was that Erickson could do nothing that Bob would have to do it his own way. Erickson asked how soon he wished to make the changes and Bob said that by the next month he should be driving properly. Bob’s statement that he would have to quit in his own way was repeated in various ways over two sessions. Two weeks later, Bob reported jubilantly that he had handled things in his own way. He had driven so recklessly that at one point he had to abandon his car just before it hurtled down a mountainside. Since that incident, he stated, he had been driving safely and within legal speed limits.
Consider these cases in the context of the following descriptions of utilization. “Exploring a patient’s individuality to ascertain what life learnings, experiences, and mental skills are available to deal with the problem … (and) then utilizing these uniquely personal internal responses to achieve therapeutic goals” (Erickson & Rossi, 1979, p. 1).
“These methods are based on the utilization of the subject’s own attitudes, thinking, feeling, and behavior, and aspects of the reality situation, variously employed, as the essential components of the trance induction procedure” (Erickson, 1980, p. 205).
“Utilization theory emphasizes that every individual’s particular range of abilities and personality characteristics must be surveyed in order to determine which preferred modes of functioning can be evoked and utilized for therapeutic purposes” (Rossi, 1980, p. 147).
“The therapist’s task should not be a proselytizing on the patient with his own beliefs and understandings. What is needed is the development of a therapeutic situation permitting the patient to use his own thinking, his own understandings, his own emotions in the way that best fits him in his scheme of life” (Erickson, 1980, p. 223).
Erickson’s brilliance transcended clever tasks or magical inductions and is best reflected in the principle of utilization. The utilization method encompasses an unwavering belief in the client’s self-healing, his or her regenerative capabilities. Erickson counted on Kim’s and Bob’s inherent abilities to provide direction in attaining their desired goals. Such a belief fits 40 years of outcome data demonstrating the client to be the most important component of the change process, accounting for 40% of outcome variance (Assay & Lambert, 1999; Tallman & Bohart, 1999). Research makes it abundantly clear that the client is the star of the therapeutic drama.
Utilization requires an intense focus on clients’ views of their concerns, their goals for therapy, and their ideas about change. Erickson understood the importance of not attempting to eliminate Kim’s nude men or confronting Bob’s desire to “do it his own way.” This focus includes an uninhibited determination (considered reckless abandon by some) to work within and respect the client’s world view. Erickson did not become mired in his own fears (e.g., that he might be “reinforcing Kim’s delusions”) or a priori treatment preferences (e.g., that he needed to do “something” with Bob). Erickson kept Kim’s envelopes in case she showed up to look at them- and she did. This stance of putting the client’s view first is also supported by outcome research. In total, client perceptions of the relationship account for 30% of positive outcome. Indeed, client ratings of the alliance are the best predictor of success (Bachelor & Horvath, 1999). This chapter connects Erickson’s principle of utilization to a community of both theoretical and empirical ideas, and suggests yet another application. Much has been written about the utilization of client resources and competencies by the therapist (e.g., Berg & Miller, 1992). Less often discussed is the utilization of the client’s perceptions of the presenting complaint, and how therapy and the therapist may best address the client’s goals and expectations of therapy – what we call the client’s theory of change.UTILIZING THE CLIENT’S THEORY OF CHANGE: A COMMUNITY OF IDEAS
The notion that client perceptions of problem formation and resolution have important implications for therapy has a rich, although somewhat ignored, theoretical heritage. Many have noted the clinical wisdom in attending to the client’s own formulations about change in therapy. As early as 1955, Hoch stated:
There are some patients who would like to submit to a psychotherapeutic procedure whose theoretical foundations are in agreement with their own ideas about psychic functioning. We feel that it would be fruitful to explain patients’ own ideas about psychotherapy and what they expect from it. (p. 322)
Later, Torrey (1972) asserted that sharing similar beliefs with clients about both the causes and treatment of mental disorders is a prerequisite to successful psychotherapy. Wile (1977), too, believed that clients enter therapy with their own theories about their problems, how they developed, and how they are to be solved. Wile stated that “many of the classic disputes which arise between clients and therapists can be attributed to differences in their theories of [etiology and] cure” (p. 437). Similarly, Brickman, Rabinowitz, Karuza, et al. (1982) hypothesized that “many of the problems characterizing relationships between help givers and help recipients arise from the fact that the two parties are applying models that are out of phase with one another” (p. 375).
Building on Erickson’s tradition of utilization, the Mental Research Institute (MRI) (Watzlawick, Weakland, & Fisch, 1974) developed the concept of position, or the client’s beliefs that specifically influence the presenting problem and the client’s participation in therapy (Fisch, Weak land, & Segal, 1982). The MRI recommended rapid assessment of the client’s position so that the therapist could tailor all intervention accordingly. Similarly, Frank and Frank (1991) suggested that “ideally therapists should select for each patient the therapy that accords, or can be brought to accord, with the patient’s personal characteristics and view of the problem” (p. xv).
Held (1991) separates therapist and client beliefs into two categories. Formal theory, held by therapists, consists of predetermined explanatory schemes (e.g., fixated psychosexual development, triangulation) addressed across cases to solve problems. Informal theory, held by clients, involves their specific notions about the causes of their particular complaints. Held suggests that strategies may be selected from any model based on congruence with the client’s informal theory. Duncan, Solovey, and Rusk (1992) clinically demonstrate such a selection process in their “client-directed” approach.
Duncan and Moynihan (1994) assert that utilizing the client’s theory of change facilitates a favorable relationship, increases client participation, and, therefore, enhances positive outcome. Duncan, Hubble, and Miller (1997) view the client’s theory of change as holding the keys to success regardless of the model used by the therapist, and especially with “impossible” cases. Similarly, Frank (1995) concludes: I’m inclined to entertain the notion that the relative efficacy of most psychotherapeutic methods depends almost exclusively on how successfully the therapist is able to make the methods fit the patient’s expectations” (p. 91). Scholars representing a wide variety of clinical orientations tend to agree that the client’s perceptions about a problem’s etiology and resolution are likely to affect the process and outcome of therapy. Do these hypothesized impacts have empirical support?UTILIZATION-RELATED RESEARCH: A BRIEF SAMPLE
Attribution research has an important bearing on the theoretical issues raised above. Claiborn, Ward, and Strong (1981) placed clients in conditions that were either discrepant or congruent with the therapist’s beliefs about problem causality. Clients in the congruent condition showed greater expectations for change, achieved more change, and rated higher levels of satisfaction than did those in the discrepant condition. Tracey (1988) investigated attributional congruence with regard to responsibility for the cause of the problem, and found that agreement between the therapist and client was significantly related to client satisfaction and client change, and inversely related to premature termination. Two studies (Atkinson, Worthington, Dana, & Good, 1991; Worthington & Atkinson, 1996) found that clients’ perceptions about the similarity of their causal beliefs to those of their therapists were related to ratings of therapist credibility and how satisfied the clients were with therapy. Similarly, Hayes and Wall (1998) found that treatment success depends on congruence between clients’ and therapists’ attributions concerning client responsibility for a problem. They suggest that attending carefully to clients’ attributions and tailoring interventions accordingly enhances effectiveness. Client expectancies and beliefs about the credibility of specific therapeutic procedures may be an important factor in predicting who will benefit from therapy. For example, Hester, Miller, Delaney, and Meyers (1990) compared traditional alcohol treatment with a learning-based approach. Clients who believed that alcohol problems were caused by a disease were much more likely to be sober at six-month follow-up if they had received the traditional alcoholic treatment. Clients who believed that alcohol problems were a bad habit were more likely to be successful if they had participated in the learning-based therapy. It was the congruence between client beliefs and expectations and therapeutic approach that proved crucial. Finally, Crane, Griffin, and Hill (1986) found that how well treatment seemed to “fit” clients’ views of their problems accounted for 35% of outcome variance. It seems to be a recurring finding that the degree of credibility of the intervention, or fit, or match with the client’s theory of change is a variable worthy of attention. The alliance provides further support of the importance of utilizing the client’s theory of change to effect a positive outcome.ALLIANCE
Contrast the position of utilizing the client’s theory with the stance of applying the therapist’s orientation across cases. For Erickson, theoretical loyalty could lead to oversimplifications about people, close off possibilities for change, and promote technical inflexibility: “Each person is an individual. Hence, psychotherapy should be formulated to meet the uniqueness of the individual’s needs, rather than tailoring the person to fit the Procrustean bed of a hypothetical theory of human behavior” (Zeig & Gilligan, 1990, p. xix). Rather than reformulating the client’s complaint into the language of the therapist’s orientation, the data suggest the opposite: that therapists elevate the client’s perceptions above theory, and allow the client to direct therapeutic choices. Such a process all but guarantees the security of a strong alliance. Gaston (1990) summarizes the alliance into four components: (1) the client’s affective relationship with the therapist, (2) the client’s capacity to work purposely in therapy, (3) the therapist’s empathic understanding and involvement, and (4) client-therapist agreement as to the goals and tasks of therapy. Whereas items 1 and 3 reiterate the importance of the relationship, the client’s participation in and agreement on goals and tasks refer to the congruence between the client’s and the therapist’s beliefs about how people change in therapy (Gaston, 1990). Utilizing the client’s theory, therefore, proactively builds a strong alliance by promoting therapist agreement with client beliefs about change, as well as about the goals and tasks of therapy. The therapist and client work jointly to construct interventions that fit the client’s experience and interpretation of the problem. In this way, interventions represent an instance of the alliance in action.UTILIZING THE CLIENT’S THEORY: PRACTICAL GUIDELINES
Within the client is a uniquely personal theory of change waiting for discovery, a framework for intervention to be unfolded and utilized for a successful outcome. To learn the client’s theory, therapists may be best served by viewing themselves as “aliens” seeking a pristine understanding of a close encounter with the clients’ interpretations and cultural experiences. Clinicians must adopt clients’ views on their terms, with a very strong bias in their favor. After direct inquiries about the client’s goals for treatment are made, questions regarding his or her ideas about intervention are asked. What the client wants from treatment and how those goals can be accomplished may be the most important pieces of information that can be obtained. Recall how Erickson asked Bob about his view of change and how he could be helpful to Bob. Client responses to similar questions provide a snapshot of the client’s theory and a route to a successful conclusion.
• What ideas do you have about what needs to happen for improvement to occur? • Many times people have a pretty good hunch not only about what is causing a problem, but also about what will resolve it. Do you have a theory of how change is going to happen here? •In what ways do you see me and this process as helpful to you in attaining your goals?
It is also of help simply to listen for or inquire about the client’s usual method of or experience with change. The credibility of a procedure is enhanced when it is based on, paired with, or elicits a previously successful experience of the client. Recall how Erickson utilized Kim’s previously helpful solution of containing the nude young men in the closet in his suggestion to put the psychotic episodes in an envelope.
• How does change usually happen in the client’s life? • What do the client and others do to initiate change?
Utilizing the client’s theory occurs when a given therapeutic procedure fits or complements the client’s preexisting beliefs about his or her problems and the change process. We, therefore, simply listen and then amplify the stories, experiences, and interpretations that clients offer about their problems, as well as their thoughts, feelings, and ideas about how those problems might be best addressed. The degree and intensity of our input vary and are driven by the client’s expectations of our role. The client’s theory of change is an “emergent reality” that unfolds from a conversation structured by the therapist’s curiosity about the client’s ideas, attitudes, and speculations about change. As the client’s theory evolves, we implement the client’s identified solutions or seek an approach that both fits the client’s theory and provides possibilities for change.THE CASE OF TOM
For five years, Tom, an 18-year-old college student, had been becoming increasing distressed by thoughts about having sex with young boys.Session One
C: I am physically attracted to children, but I haven’t acted on my thoughts. I’m a pedophile. I’ve done lots of reading about pedophiles. You can wean yourself out of your behavior if you’re young and willing to do it. But just in case, I’m looking into chemical castration. But I know if I got help from an expert, my chances might improve. You know, a normal person’s mind doesn’t function like that, dreaming about children. It’s programmed into my mind. Tom shared his beliefs about his problem (he is a pedophile), how change will happen (wean himself out of it), and the role of the therapist (expert). Although the therapist did not believe Tom to be a pedophile, she did not challenge his view.
T: Since you have given it much thought and research and you have your own diagnosis, have you given thought to how you would accomplish your goals? C: Yes. It will take time. All I want is to meet a woman who is very special to me. Someone who cares about me, someone with whom I feel comfortable and safe. But first I need to focus on the thoughts.
The client’s theory of change is crystallizing. He will wean himself off his thoughts of children by meeting someone who will care about him. But first, Tom said, he needed to focus on the thoughts; therefore, he was assigned the task of embracing his thoughts and learning from them.Session Two
C: I’ve learned there is something missing from my life. I need someone besides my family to share my life, a relationship. But I really don’t know where to start. T: So do you think that if you find a relationship, the thoughts of children will go away? C: Yes, I do-yes, I am convinced. Tom’s theory of change has unfolded. Finding a relationship is his chosen method of eliminating the thoughts. The therapist assigns another task that gives credibility to Tom’s beliefs regarding the problem and its solution. Building on Tom’s research skills and his success with therapeutic tasks, he is asked to observe relationships to identify the type that he would like to have.Session Three
C: I looked into relationships, talked to people, and found some interesting books. I wanted to tell you that if the situation were to present itself, I wouldn’t do anything with a child. Dreams are dreams and actions are actions. There has been positive change. I thought I was a pedophile. Now I know that I am a fantasizer. All I do is fantasize, and I could probably fantasize about anything. Tom, without confrontation of his belief, shifts his view of himself as a pedophile. The therapist amplifies and empowers the change and Tom discusses his plan to talk to women. The therapist follows the client’s lead.Session Four
C: I gave a girl a kiss! I was talking to her and she put her cheek down and I gave her a kiss. It was fun and felt good. I know I’m interested in girls and I think things are changing, but how can I be sure? T: Have your thoughts decreased? C: I think so, but I’m not sure.
Tom shared his exciting news and his uncertainty about the extent of the change. The therapist again highlighted the change and reinforced the connection between finding a relationship and reducing the thoughts. To measure Tom’s progress, he was asked to monitor and rate his thoughts.Session Five
C: I completed the assignment and I found that my thoughts have substantially decreased. If I dream of a kid, I can now immediately transfer my thinking to a woman. I get turned on by my thoughts of women. I’ve reprogrammed my thinking. It feels great. Tom had his own theory on how to resolve his problem, and honoring that theory created a space for him in which to employ his strengths. Throughout the therapy, the client’s ideas directed the process; the therapist utilized Tom’s theory of change to direct therapeutic actions. Followup revealed Tom’s continued attraction to, and pursuit of, women.ERICKSON WAS ON TO SOMETHING
This brief historical review revealed a rich theoretical tapestry made up of different orientations woven together by their consistent agreement on the importance of matching the client’s ideas about problem formation and resolution. We briefly sampled the attribution, expectancy, and alliance literatures and established that these disparate literatures are in concert in their empirical support for utilizing (matching, fitting, sharing attributions with, being credible to, etc.) the client’s theory of change. Historically, mental health discourse has relegated clients to playing nameless, faceless parts in therapeutic change. This attitude is changing. No longer interchangeable cardboard cutouts, identified only by diagnosis or problem type, clients emerge as the source of wisdom and the solution. They are the true heroes and heroines of the therapeutic drama. Unfolding the client’s map reveals not only the desired destination for the therapeutic journey, but also possible paths to get there. In that endeavor, our clients have shown us trails we never thought existed.
Evolving Client-Directed, Outcome-Informed Discourse
While a client-directed discourse is familiar landscape to many, it remains uncharted as to how that discourse may legitimize our efforts to third-party payers. We believe that further utilization of the client’s ideas and perceptions holds the key. The assessment and utilization of outcome information as defined by the client may be the best possibility for proving the value of our services to managed care. Developing such an outcome-informed discourse need not be complicated or time-consuming. Therapists can simply choose from measures already in existence that are standardized, take only minutes to administer, and are accompanied by normative data for comparative purposes. Rather than repeating the failures of the past and attempting to determine “what approach works for which problem,” these methods focus on whether or not a given encounter is working for an individual client at a given point in time. They focus on the factors that research has shown really do make a significant contribution to outcome: incorporation of client strengths and ideas and the development of a strong therapeutic alliance (Hubble, Duncan, & Miller, 1999). Using standardized measures would also eliminate “treatment plans” containing sensitive and potentially damaging personal information. Information learned from these instruments is “fed back” throughout the therapy process itself (Duncan & Miller, in press). This radical departure from the traditional use of assessment instruments gives clients a new way in which to look at and comment on their own progress and their ongoing therapy. The process is simple: clients who are informed, and who inform, feel connected to their therapist and the therapy process; their participation is courted and utilized as a pivotal component of change itself (Duncan, Sparks, & Miller, in press). The client has been woefully left out of the loop regarding outcome and service accountability. Using measures that acknowledge the client’s experience of progress and satisfaction would allow clients to really direct their therapy. The client’s voice would be formally utilized in all aspects of therapy, thereby establishing an entirely different discourse-not a pathology or treatment approach, but the discourse of the client.UTILIZING THE CLIENT’S THEORY OF CHANGE
• Think of oneself as an alien seeking a pristine understanding of the client and his or her culture of change. • Explore client stories, experiences, and interpretations particularly relevant to the problem and its resolution. • Ask about and listen for the client’s goals for therapy and ideas about change. • Ask about and listen for how change has previously happened, including previous attempts at change. • Ensure that the therapy amplifies, fits, or complements the client’s preexisting beliefs about the problem and the change process.References
Asay, T., & Lambert, M. (1999). The empirical case for the common factors in therapy. In M. Hubble, B. Duncan, & S. Miller (Eds.), The heart and soul of change. Washington, DC: APA Books.
Atkinson, D., Worthington, R., Dana, D., & Good, G. (1991). Etiology beliefs, pref erences for counseling orientations, and counseling effectiveness. Journal of Coun seling Psychology, 38, 258-264.
Bachelor, A., & Horvath, A. (1999). The therapeutic relationship. In M. Hubble, B. Duncan, & S. Miller (Eds.), The heart and soul of change. Washington, DC: APA Books.
Berg, I. K.& Miller, S. D. (1992). Working with the problem drinker. New York:Norton.
Brickman, P., Rabinowitz, V., Karuza, J., Coates, D., Cohn, E., & Kidder, L. (1982). Models of helping and coping. American Psychologis 37, 368-384.
Claiborn, C., Ward, S., & Strong, S. (1981). Effects of congruence between counselor interpretations and client beliefs. Journal of Counseling Psychology, 28, 101-109.
Crane, R. D., Griffin, W., & Hill, R. D. (1986). Influence of therapist skills on client perceptions of marriage and family therapy outcome: Implications for supervision. Journal of Marital and Family Therapy, 12, 91-96.
Duncan, B., Hubble, M., & Miller, S. (1997). Psychotherapy with “impossible” cases. New York: Norton.
Duncan, B., & Miller, S. (in press). The heroic client. San Francisco: research: Intentional utiliza tion of the client’s frame of reference. Psychotherapy, 31(2), 294-301.
Duncan, B., Solovey, A., & Rusk, G. (1992). Changing the rules: A client-directed approach. New York: Guilford.
Duncan, B., Sparks, J., & Miller, S. (in press). Recasting the therapeutic drama:Aclient-directed, outcome-informed approach. In F.
Datillio and L. Bevilacqua (Eds.), Comparative treatment in couples relationships. New York: Springer.
Erickson, M. (1980). The nature of hypnosis and suggestion: The collected papers of Milton H Erickson on hypnosis (Vol. 1, E. L. Rossi, Ed.). New York: Irvington.
Erickson, M. H., & Rossi, E. L. (1979). Hypnotherapy: An exploratory casebook. New York: Irvington.
Fisch, R., Weakland, J., & Segal, L. (1982). The tactics of change: Doing therapy briefly. San Francisco: Jessey-Bass.
Frank, J. D. (1995). Psychotherapy as rhetoric: Some implications. Clinical Psychology: Science and Practice, 2, 90-93.
Frank, J. D., & Frank, J.B. (1991). Persuasion and healing (3rd ed.). Baltimore: John Hopkins University Press.
Gaston, L. (1990). The concept of the alliance and its role in psychotherapy. Psychotherapy, 27, 143-152.
Hayes, J., & Wall, T. (1998). What influences clinicians’ responsibility attributions? The role of problem type, theoretical orientation, and client attribution. Journal of Social and Clinical Psychology, 17, 69-74.
Held, B. S. (1991). The process/content distinction in psychotherapy revisited. Psychotherapy, 28, 207-217.
Hester, R., Miller, W., Delaney, H., & Meyers, R. (1990, November). Effectiveness of the community reinforcement approach. Presented at the 24th annual meeting of the Association for the Advancement of Behavior Therapy. San Francisco.
Hoch, P. (1955). Aims and limitations of psychotherapy. American Journal of Psychiatry, 112, 321-327.
Miller, S., Duncan, B., & Hubble, M. (1997). Escape from Babel. New York: Norton. Rossi, E. L. (1980). Innovative hypnotherapy by Milton Erickson. New York: Irvington.
Tallman, K., & Bohart, A. (1999). The client as a common factor. In M. Hubble, B. Duncan, & S. Miller (Eds.), The heart and soul of change. Washington, DC: APA Books.
Torrey, E. (1972). The mind game. New York: Emerson Hall.
Tracey, T. (1988). Relationship of responsibility attribution congruence to psycho therapy outcome. Journal of Social and Clinical Psychology, 7, 131-146.
Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change: Problem formation and problem resolution. New York: Norton.
Wile, D. (1977). Ideological conflicts between clients and psychotherapists. American Journal of Psychotherapy, 37, 437-449. Worthington, R., & Atkinson, D. (1996). Effects of perceived etiology attribution similarity on client ratings of counselor credibility. Journal of Counseling Psychology, 43, 423-429.
Zeig, J. K., & Gilligan, S. G. (Eds.). (1990). Brief therapy: Myths, methods, and meta• phors. New York: Brunner/Maze!.
Suggested Readings Dolan, Y. (1985). Ericksonian utilization and intervention techniques with chronically mentally ill clients. In J. Zeig (Ed.), Ericksonian psychotherapy (Vol. 2). New York: Brunner/Maze!
Duncan, B., Hubble, M., & Miller, S. (1998). Is the customer always right? Maybe not, but it’s a good place to start. Family Therapy Networker, March/April, 81-90.
Duncan, B., Hubble, M., Miller, S., & Coleman, S. (1998). Escaping the lost world of impossibility: Honoring clients’ language, motivations, and theories of change. In M.A. Hoyt (Ed.), Handbook of the constructive therapies. San Francisco: Jossey-Bass.
Gilligan, S. (1987). Therapeutic trances. New York: Brunner/Mazel.
Stern, C. (1985). There’s no theory like no-theory: The Ericksonian approach in perspective. In J. Zeig (Ed.), Ericksonian psychotherapy (Vol. 1). New York: Brun-ner/Mazel.
Yapko, M. (1985). The Erickson hook. Values in Ericksonian approaches:In J. Zeig (Ed.), Ericksonian psychotherapy (Vol. 1). New York: Brunner/Mazel.
A common theme that I remember Erickson discussing during our time together was his fascination with how the unconscious was able to use current events and experiences to conjure past learnings.
I experienced this first hand during my second session with Matt, a ten-year-old boy, and his parents. Matt, an only child was going to have to redo the fourth grade because of poor grades. Matt had felt like an outsider in the fourth grade and had no motivation to do school work. The thought of repeating the fourth grade again after “flunking” made him feel even less motivated. His parent tried “everything.” Unfortunately, each parent felt that his or her strategy-of-choice had been good enough to motivate each of him or her as a child, so it should motivate Matt. Their unyielding assumption was that if their strategy did not work, the problem was in Matt, not the appropriateness of the strategy.
To adapt a key concept from Ellyn Bader’s work with couples: “A lot of times, [parents] are so invested in the other person changing that they don’t want to look at themselves.” I had to take it easy since both parents had a history of taking their son out of therapy if the therapist demanded that the parents change.
It was during the second session that I remembered how Erickson would talk to us as a group when he wanted to avoid triggering a specific person’s self-protections. In that memory, I heard Erickson tell us his classic story about the parents who could not stop their seven-year-old daughter from sucking her thumb.
In that story Erickson told the daughter that she was about to reach a milestone in her life, her eighth birthday. Erickson instructed the daughter to enjoy sucking her thumb and to memorize it because after her eighth birthday, she will have passed the age of thumb-sucking and move onto more interesting things that are more appropriate for an eight year old. By giving the instructions in the presence of the parents, Erickson was indirectly challenging the parents’ assumptions that they had to change the daughter.
Change was a natural part of life. If you let it, the mind moves forward by itself. And at the same time, the communication to the daughter affirmed that the parents were not the targets of change. (For a verbatim account of this story, see Zeig, J., A Teaching Seminar With Milton H. Erickson, Brunner/Mazel, NY, 1980.)
With echoes of Erickson’s words in my head, I addressed Matt, “I am so very glad that your parents brought you in to see me at this time. If they had waited until your eleventh birthday in six weeks, you would have taken care of the problem yourself and I would not have been able to get any of the credit.”
I told Matt about the significant brain changes that naturally occur as we grow. “One of the most significant changes occurs at the age of eleven when the nerve connections between the right and left sides of your brain become insulated. Nerve signals move quicker and more effectively. At that time, we are better able to see old things with new eyes. And along with this wonderful gift comes a terrible burden. [Long dramatic pause].”
I remembered that Matt had said that he had longed for a younger brother so he could “show him how it was done.” With that in mind, I continued, “Matthew, in returning to the fourth grade, you will be going through this change before others in your class do. This means that your classmates will naturally want to look up to you as a role model. It will be as though you are the older brother that leads the way, showing the younger brothers how to do it right. While you will have the advantage of being familiar with what your teacher is presenting, your mind will be different and you will have to learn it ‘brand new’ as an eleven-year-old who has had the brain-change.”
“Before you turn eleven, I want you to memorize how it feels to not want to do homework and to not be particularly interested in learning. You need to remember how this felt so you can let your classmates know that you understand how some of them might feel. You used to feel that way yourself before you had the brain-change.”
I continued for twenty-five minutes, repeating the same message in many different permutations. Within the first ten minutes, Matt and his parents were in a comfortable trance state, hearing future-pictures described of Matt moving forward on his own.
That was the last session I had with Matt. His father called to cancel the next session because Matt “discovered” that he got his “brain-change” early, and started taking an interest in schoolwork. They no longer needed my services.
I met the parents two years later for some couple counseling. They reported that Matt had been successful academically and socially in both the fourth and now in the fifth grade. The parents said that they wished that they had known about the brain-change earlier so they would not have had to work so hard to get him to do his work.