By Dennis L. Doke M.S.
Estimated reading time: 6 minutes, 45 seconds.
Tom, a young adult, has had a bipolar mental illness with episodes involving complex paranoid delusions. He had been hospitalized four times during the eight-year interval since his diagnosis and the time I saw him. Tom’s latest admission followed a trip, with his parents, in December 1991. Tom’s delusions intensified, on that trip, and he believed the name of a town where they had stopped (Winslow, Arizona) held a special message for him. He walked the streets through the nights, “circling around a U-turn exit and ending back at the hotel.” Tom said he could “…WIN the battle if he went SLOW.”
After his admission, I met with Tom to discuss that experience. He spoke frankly and with a look of fear in his eyes. I remembered an example in which Erickson discussed the choice of not confronting a patient (1) and decided not to confront Tom’s delusions at that time. After his improvement and release, Tom was tapered to monthly sessions. Two years later, he continued to have thoughts about returning to Winslow despite his overall absence of symptoms. I gave him an assignment of writing the Chamber of Commerce of Winslow, utilizing the reality of Winslow to confront his delusional memory. The following month, he reported he had not done this homework assignment, and that he “had not thought much about Winslow. Reality catches up with you. I guess I’m enjoying reality. Why should I take a trip down memory lane when I could take a real trip to Key West?” Currently, Tom is stuck in a new dilemma which is more reality-based and more congruent with post-adolescent searching. “I’m living a mundane existence. I’m living in the present and not in the future. However, I have started going out with my friends after work. I have accomplished one of my major goals which were to move out of my parents’ home and live independently.” I concluded this session by waving my hand towards the end of the couch and asking him if he could imagine a little baby learning to walk, leaning against the arm of that couch right there.
He nodded affirmatively. I carefully helped him visualize that child learning to take his first step. I emphasized that the adult knows what the child will do in the future, but the child doesn’t. At first the child tries to stand, ever so cautiously, staggering and falling on his bottom. Learning occurs through trial and error. I told him, “I know you soon will be able to walk. You try to take a step and falter, but you try over and over again. And then you learn to walk. As you continue growing and changing, more self-confidence is gained.”
The next month, Tom returned to my office saying he needed to return to Winslow in order to go ”full circle and bring closure to that episode.” He added that he always returned to the sites of his psychotic episodes. At this time he held a job as a waiter, but had been thinking about leaving the position stating: “I can’t be a waiter all my life.”
I inquired how long he wanted to be a “wait-er?” He didn’t know so I asked again. “How long are you going to be a WAIT-er?” Returning the emphasis, he replied “I guess I’ll have to be a WAIT-er until I make the trip and go full circle.” At the conclusion of the session, he reflected “I feel like I was in a tribulation stage for several years. I have now been in a waiting stage for nearly three years. I’m not sure when this waiting period will be over, but the next stage will be a moving-on phase. Maybe I’ll move to another city and settle down. Maybe it’ll be Winslow.”
(1) Erickson, M. (Rossi, E., Ed.). Innovative Hypnotherapy: The Collected Papers of Milton H. Erickson on Hypnosis, Vol. 4 1980. New York. Wiley & Sons. pp 70-74.
Comment on the Case of Tom
by Harriet E. Hollander, Ph.D.
The Milton H. Erickson Institute of N.J.
Tom has been diagnosed with a Bipolar Mental Disorder and exhibits its classic features. His illness began in late adolescence, and he has short-term psychotic episodes following psychosocial stress. Trips to strange cities and the disruption of significant relationships with family are characteristic symptoms. Delusions may persist in remission and are seldom treatable by direct confrontation.
Medication, along with psychotherapy, is the current treatment of Bipolar Disorder. Many of Erickson’s colleagues and students believed that Erickson had little use for medication even in the treatment of major mental illness. In her speech to the Ericksonian International Congress, 1994, Mrs. Erickson clarified Erickson’s view on psychopharmacological interventions to mental illness. She told the audience that Erickson, whose strategic interventions with psychotic patients were deservedly famous, placed little faith in the use of medication, mostly because the medications then available didn’t work. Certainly, she indicated, he would have prescribed medications that were effective and could help the patient.
Many individuals who might benefit from psychopharmacological treatment refuse it for a variety of personal reasons, leaving the therapist to rely on behavioral strategies. This history does not state whether or not Tom was on medication for his disorder. The psychotherapeutic approach taken by the therapist stands on its own as a thoughtful and empathic strategy to stabilize the psychosocial stresses that might have triggered further manic episodes.
The therapist gives his attention to the patient’s age-appropriate effort to individuate and separate from his parents and become an autonomous adult. He makes use of a metaphor with many levels of meaning when he suggests hypnotically to Tom that he imagine a little baby learning to walk, imagine the little baby learning to fall, and succeeding through trial and error. He draws the analogy with Tom’s courage to take the natural steps in his development even if he can’t anticipate where his steps will lead in the future. Tom had the delusion that the town name “Winslow” has a special message for him-“win slow”. Doke did not deal with this directly. The homework assignment of writing the Chamber of Commerce was designed to allow Tom to understand, on his own, and willingly, that ”Winslow” was merely the name of a town.
Doke kept “win slow” in his mind. When Tom began talking about returning to Winslow, Doke used Tom’s play on words that had created the “special message” as a base for intervention. As Tom talked about his job and his future, Doke asked, “How long do you want to be a ‘WAITer’?” The meaning was created on both the rational and irrational levels in Tom’s own style of communication. The question, which Doke wisely did not explain further, was loaded with a directive for action. The patient’s response testifies to the efficacy of Doke’s intervention. Erickson’s rationale for not confronting a patient’s delusions directly and aggressively is set out in an article coauthored with Jeffrey Zeig in the Volume referred to by Doke: (pp 34-35).
Man is characterized … by cognition and emotion, and man defends his intellect emotionally. … All people defend their ideas whether they are psychotically based, culturally based, or nationally based or personally based… the first thing in psychotherapy is not to try to compel him to change his ideation; rather, you go along with it and change it in a gradual fashion and create situations wherein he himself willingly changes his thinking.
The case presented above shows a thorough grasp of this principle and is part of the therapist’s respectful approach to his client and his willingness to protect the patient’s personality while also making change inducing treatment interventions. The patient begins to conceptualize his journey through life as stages in which he moves forward.
Editor’s Note: Tom had been under the ongoing care of physicians since his initial hospitalization. He had received a variety of medications, none of which was entirely successful in controlling his symptoms. Following this case report, Mr. Doke reported that Tom drove through Winslow and talked about the event as if it was unremarkable. Even though Tom remains seriously ill, his psychotic episodes have become less frequent and his social development has continued.