Posts Tagged ‘Metaphor’

by Hideo Tsugawa Estimated reading time: 7 minutes, 34 seconds.

Editor’s Note: The following is a summary and English translation of an award-winning article published in Japan: Tsuawa. (2000). Play as therapeutic metaphors: Ericksonian play therapy. The Japanese Journal of Brief Psychotherapy, 9, 18-38.

 “Why are children born? They might be born to play. They might be born to romp,” these words are found in Ryojinhisho, an old Japanese song book. Throughout history and across varying cultures, childhood and play have been closely associated. During play, children naturally strive to develop solutions to problems. Play facilitates the expression of emotion and the focusing of attention. Even more importantly, play is a metaphorical device producing rich experiences that add to the life and skill of children.

Play therapy is an approach that incorporates these features of play. Axline (1947), the originator of Child-Centered play therapy, presented eight principles of play therapy, one of which requires the therapist to adopt a non-directive attitude. Many schools of play therapy have adopted this non-directive style of interaction. This approach provides children with the experience of behaving freely. For some, non-directive participation is a useful metaphor that brings changes and solutions. But for others, it is not sufficient. For example, children who have experienced trauma or abuse are not likely to initiate their own healing and instead require the direct participation of the therapist (Gil, 1991). While non-directive play is an important experience, this approach is not useful as a metaphor for all problems and symptoms.

Ericksonian approaches to therapy recognize the metaphorical quality of problems and symptoms. In a like manner, the Ericksonian practitioner provides therapeutic experiences in the form of metaphor. Zeig (1992) calls this process “gift-wrapping.” A gift is presented to the client in which the therapist wraps up the goals and solutions. Symbols, anecdotes, tasks, and hypnosis are generally chosen as the “wrapping.” When working with children, play is used as a gift, a wrapping used to present goals or solutions.

Respect for individuality is another key principal in the Ericksonian approach. Ericksonian therapists tailor their interactions in accord with the unique situation of the client or family. When therapists use tailoring in play therapy, their participation in play becomes more flexible and more effective. An example of an Ericksonian approach to play therapy is illustrated in the following case example.

Naomi, a seven-year-old girl, was brought to therapy by her mother. Her mother explained, “She can not attend school because she is unable t0 separate from me.” Naomi was invited to play and during the following conversation she indicated that she feared arriving to school late and having her class mates stare at her. Whenever Naomi was delayed, she would enter the classroom bent down behind her friends. The initial intervention consisted of an indirect suggestion to her mother to take Naomi to school early. In a follow-up phone conversation, her mother reported, “For the rest of the spring semester, l have taken her to school early in the morning and she goes to school easily.” During the next session, the therapist told Naomi a story about a boy who feared being stared at while riding the bus. As a solution, the boy was instructed by his doctor to walk onto the bus backwards. By presenting this story, the therapist suggested an understanding of her predicament. At the same time, the story implied change is possible. Next the therapist asked, “Naomi, have you had the experience of walking into your classroom backwards?” Naomi was surprised; her expression showed that she noticed something. All the chairs in the playroom were arranged like her classroom with stuffed dolls as her classmates. Her mother and the therapist also sat in the chairs as classmates.

So she tried to go into the playroom/classroom backwards, after which she said, “No problem!” The therapist reinforced her   progress stating, “Great!  But don’t you feel a little fear?” to which she replied, “No, i’m okay.” The therapist then asked solution-focused questions (de Shazcr, 1985) such as, “How were you able t0 do so well? How did you cope with the fear?” She answered, “I watched my feet only.” The playroom was compared to her classroom and a game of entering the classroom was begun. Naomi, her mother and the therapist played going into the classroom using various strange and unique techniques such as coming in with a skip, while spinning, imitating a fashion model, imitating a gorilla, watching only her nose, and while doing a somersault. This produced laughter and suggested to Naomi the possibility of distraction (Erickson & Rossi, 1976). This play provided the opportunity to practice catering the classroom. The purpose of this type of rehearsal is to reduce anxiety and tension in the problem situation. Because it was done as play, it yielded superior results. During a follow-up meeting, Naomi reported, “Now when I go into class room, I laugh unconsciously. Because I remember the games for how to go into the classroom.”

However, three days before the next appointment, her mother called the center in a distressed state of mind. Naomi  had  been  attending school successfully but after being lectured by her grandmother for her previous absences, Naomi developed the hallucination that a bug was crawling into her ear. By the next morning, she felt that insects went inside her body and refused to go to school. The therapist was encouraged by the fact that she had not had any previous episodes of hallucination and that it occurred in response to situational factors (i.e., the interaction with grandmother). Furthermore, Naomi thought her experience was strange, thus indicating that she had the mental facility from which to judge the appropriateness of experience. Because Naomi was ashamed to talk to the therapist about the insects, the therapist chose not to take the problem up directly. Zeig (1980) has suggested the amount of indirection is directly proportional to the perceived amount of resistance. Playing with a large white ball, the therapist told stories of cold  hands and fingers becoming numb. These stories suggested that humans  have the ability to change sensations. A competition was begun to see who could experience the most numbness. The hypnotic induction was accomplished naturally, through play. The hypnotic anesthesia was also introduced using a naturalistic technique (Erickson, 1958). Later, during a phone conversation, her mother told the therapist, “Naomi hasn’t been talking about insects since the last session. She seems to have forgotten about it. I have kept your instruction and have said nothing to make her remember it.” During her fourth and final visit, Naomi confirmed that she no longer had concerns about  going to school. The therapist validated this idea by indicating that there was no longer a problem and the therapy was ended. 

The concept of play is wide and ambiguous. It contains elements such as games, playing with toys, creative activities, and sports. Caillois (1958) systematically classified play using four major principles: competition, chance or luck, imitation and giddi­ness. However, these classifications define play only in terms of external behavior. In contrast, Henriot(1973) views play not as activity but as states of consciousness. From this perspective, it is the experience of play that determines its significance. For example, even when presented with fascinating toys, a child may not want to play. When it is understood that play is determined by the subject’s consciousness, the importance of the therapist’s participation is more apparent. The experiential possibilities for play are not fixed but can be changed by including the child  in play constructed by the therapist.

In the clinical setting, it is important to recognize that the reality of play is derived in part from the interaction between memory and feelings, but equally as important, includes the interaction of therapist and client.

When the therapeutic approach is based on this understanding, play therapy is no longer limited to the use of a playroom or toys. While these can lead to play, it is important to construct therapy as play through human interaction. This allows the child to develop a practical understanding of pertinent situational factors and his or her role in relation to others. While it can be said that play therapy is the approach that utilizes the reality of play for therapy, Ericksonian play therapy is the approach that builds on the reality of the child while permitting the therapist the flexibility to provide assistance when and where it is needed.

References:

Axline, V. M. (1947). Play Therapy: The Inner Dynamics of Childhood. Boston: Houghton Mifflin.

Caillois, R. (1958) Les jeux et les hommes. Paris: Gallimard

de Shazer, S. (1985). Keys to Solution in Brief Therapy. New York: Norton.

Erickson, M. H. (1958) Naturalistic Techniques of hypnosis. The American Journal of Clinical Hypnosis, 1, 3-8.

Erickson, M. H., & Rossi, E. (1976). Two-level communication and the micro-dynamics of trance and suggestion. The American Journal of Clinical Hypnosis, 18, 153-171.

Gil, E. (1991). Healing Power of Play: Working with abused chil­ dren. New York: Guildford.

Henriot, J. (1973) Le jeu. Presses Universitaires de France.

Zeig, J. K. (1980). Teaching Seminar with_ Milton H. Erickson, M.D; New York:.Brunner/Mazel.

Zeig, J. K. (Ed.) (1992). The virtues of our faults: A key concept of Ericksonian psychotherapy.  In pp. 52-269, Evolution of Psychotherapy: The Second Conference. New York: Brunner/MazeI.

Sep 18

The Boxer

By Dan Short, Ph.D Dallas, TX Estimated reading time: 4 minutes, 30 seconds. 

The 21-year-old client did not want to be in therapy . Charged with assault on his girlfriend, he had been ordered to counseling as a condition of probation. The intake, conducted by another therapist, noted, “Client is reluctant to focus on violence related issues.” The client, muscular and sullen, entered the first session in silence and sat slouched in his chair with a cap concealing most of his face. He had described himself as “a boxer” and had explained that counseling should not interfere with his “career,” which consisted solely of daily sparring at a local gym.

After preliminaries, I began giving the client an explanation of the negative effects of emotional stress. I told him how “industrial psychologists are paid high wages to insure workers have their lives in order at home.” The role of sports psychologists was also described in detail with some impressive statistics about successful results. The client was then offered psychological training in order to benefit his boxing career. He responded with increased enthusiasm toward treatment.

First, the client was trained in hypnotic time distortion and rapid relaxation. This allowed him  to experience, subjectively, 15 to 20 minutes of rest in a three-minute period. This was important because it allowed him to “gather strength  more  quickly  between boxing rounds.” He also was given training for increased tolerance of frustration “to ensure clearness of thought while in the boxing ring.” The client was told to practice these skills at home with his girlfriend.

During the first few sessions, the client came with specific requests aimed at helping him with his boxing. For example, he said his coach told him he didn’t do as well while sparring with people he liked and that he needed to stop being “so nice.” We explored the concept of respect. Respect for a friend demonstrated by sitting at lunch and asking “how things are going” was differentiated from sparring in the ring “where one wants to show respect by doing one’s very best.”

In the following sessions, our topics changed from specific boxing tactics to more general principles. These included moral strength, responsibility for self and self-respect. The client was given both direct and indirect suggestions about transferring the abilities for the self-discipline required in boxing to the self-discipline required for healthy relationships.

After a few weeks, the client no longer mentioned his boxing career. Instead he began to ask for advice about his relationship with his female partner. He also talked extensively about his current relations with his extended family and his desire to be a son of whom his deceased mother “would be proud.” Toward the end of his counseling , the client was discussing plans to retire early from boxing and become an accountant. After the mandated ten visits, the client was given a letter of completion. Three months later, he returned for a social visit. A six-month follow-up revealed he had enrolled at a local junior college and has had no further reported acts of violence.

Commentary: The Boxer by Tina Foster Jansen, M.S.

Court-ordered clients are typically unmotivated. Faced with this type of client, Short used an opening strategy which would encourage the client to be involved in counseling to the “benefit of his boxing career.” As Cormier and Cormier state, “A productive assumption  in  converting  involuntariness into a  commitment  to be counseled  is that the client’s chief interest is himself.” (p.575) Short’s adroit therapeutic intervention began the changes that eventually alleviated further violence, and also had positive influences in other areas of the client’s life.

The treatment in this case is a study in reframing and utilization . Short used the strengths, weaknesses and temperament of the client to reframe inherent abilities so destructive behaviors could be changed. Haley (Nichols, 1984) maintains reframing is a necessary step in altering problem-maintaining sequences. Proper reframing changes a viewpoint to the meanings of interactions are changed  while  the  facts  of  that inter­action remain the same. Short reframed respect for the client. This new definition allowed the client to change behaviors while keeping and building on the client’s wish for personal  respect. Haley (1971) concludes that, on a general level, the goal of the therapist is to change the maladaptive behavior of the individual. An additional and subsidiary goal  is  to extend  the  client’s personal range of experience . By getting this client to change his violent behavior, Short was able to open the door for further  change  by  the  client.  The man’s personal range of experience could be extended. He could consider ways of obtaining respect other than through violence – he could consider becoming the son his mother “could be proud of.” He then could begin to extend  his  idea of a career and investigate choices.

Utilization is a cornerstone of Erick­sonian psychotherapy. Short demonstrated a superb ability to enter his client’s world and regard that world as having the material for productive change. He took the problem behavior, violence, and gave the client ways in which to reframe that behavior so his needs to be respected and strong were productively met. Short should be congratulated for his insightfulness and creativity in using negative behaviors as material for productive change.

References:

Cormier, W. H. & Cormier, L. S. 1985. Interviewer Strategies for Helpers. Brooks/Cole, Publishing Company. Monterey, CA.

Haley, Jay. 1973. Uncommon Therapy: The Psychiatric Techniques of Milton H. Erickson, M.D. W.W. Norton . NY.

Nichols, M. T. 1984. Family Therapy Concepts and Methods. Gardner Press, Inc. NY.

A Shift for Victim to Empowerment by Tim Baumgartner, Ph.D. Houston, TX

A 24-year old client who had been in therapy almost continually since her mid-teens presented a long history of sexual abuse and incest. Five years previously, she had been hospitalized for major depression and suicidal concerns.

At that time she reported abusive treatment by her psychiatrist. Complaints involved isolation when she refused medication, verbal insults, and suggestions of memories that she did not have. She reported that the psychiatrist subsequently lost his license.

Prior to seeing me, she was in therapy with another psychiatrist for five years. The client reported feelings of resentment and distress toward this psychiatrist. She reported that he insisted that she had engaged in specific sexual acts with her father. These acts were not consistent with her recollections. Therapy had included confrontation of the father.

The client was now married and had not been troubled by suicidal depression or drug abuse over the last three years. However, her history combined with her reported abuse by family, boyfriends, employers and treatment providers contributed to her depression, post-traumatic stress, and “victim” self-image.

Treatment began with the setting of clear boundaries and focusing on the client’s rights and expectations . Her abuse history was gradually disclosed, accompanied by expressions of fear and anger. The client agreed to the use of trance to shift her focus from the perspective of victim to one of curiosity and empowerment. She responded well to conversational inductions. The therapeutic focus was on learning and development as opposed to remediation. As she learned to express her feelings of anger and frustration, she began to express the need to “get away somewhere.” Her fantasy was to take an island vacation, but she believed that she required psychiatric inpatient services to stabilize her thinking.

In our discussion, she expressed that the dollar price of the short hospital stay would be about the same as the desired vacation, however, she was concerned about her husband’s “emotional price tag” that would result if she took a vacation. In therapy, I suggested that some people “prepay” vacations so they can enjoy the entire experience knowing that there would be no legitimate bill waiting on their return. She was challenged to determine all “hidden” costs and experience them affectively and inter­personally, as soon as possible, so she could begin anticipating her trip.

The client accepted this suggestion, and shifted her focus from anticipation of hospitalization to planning for the trip. She took the vacation while her husband stayed home. Upon her return, she reported that she had successfully set boundaries with her husband and did not assume any emotional debt for her trip.

The metaphor of the vacation was used to reinforce her inner strength and independent action. The client reported successful goal planning, boundary setting, calculated risk taking, initiation of interpersonal relationships, and a feeling of inner courage and empowerment. Over the following months, she remained in therapy and reported that the vacation provided a “turning point” for her. The client enrolled in college and performed well. While the change from “victim” to responsibility was rapid, and occasional slips into the former role occurred, the resources for change were integrated within her.

Suggested readings Otani, A. & Koska, M., (1992). “The dialogue technique of hypnotic induction.” American Journal of Clinical Hypnosis, 35, 1, 20-28.

Phillips, M., (1993). “Turning symptoms into allies: utilization approaches with post- traumatic symptoms.” American Journal of Clinical Hypnosis, 35, 3, (179-189).

Rosen, S., (1982). My Voice Will Go With You. New York: W.W. Norton

Discussion by Gene Davita, M.D.

Baumgartner  focused on present­ing issues in the past as well as present boundary violations and abuse from numerous sources including professionals. Establishing a therapeutic relationship with clear expectations, respect for the rights of the patient and opportunity for her to express her emotions was paramount. This established a fluid, process focused therapy in which change could be promoted.

The patient seemed adept at trance since conversational induction worked well. She was able to move from the victim position to one of empowerment rapidly. More traditional therapeutic approaches that encourage hours of exploring victimization experiences can further crystallize that role. Such a shift in the therapeutic paradigm for a patient allows responsibility, self-assertion and creativity that universalizes to all areas of living.

The patient’s concerns with the cost of hospitalization presented Baumgartner with an opportunity to employ an Ericksonian approach and the patient’s fears then could  become a useful part of therapy. The vacation metaphor allowed the patient to experience “getting away” and to create an experience that furthered her responsibility, assertion and individuation . This created even more encouragement for further growth and development in living by using the skills developed while turning a dream into a reality. She was further empowered by beginning to create a life of self hood rather than perpetuating the life of a victim.

Baumgartner’s work with this patient, who presented with a multi­tude of serious problems, demonstrates therapeutic elegance in his work with one aspect of her problems. The assistance of movement from being reactive in her life to being the source of creating her life was important. This resolution can serve as a springboard for future therapeutic advancement.