A Seminal Contribution, a Family of Ideas,
and a New Generation of Applications
By, Barry L. Duncan, Scott D. Miller, & Susanne T. Coleman
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 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 the 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 a rapid assessment of the client’s position so that the therapist could tailor all interventions 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 the 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 a 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 learning-based therapy. It was the congruence between client beliefs and expectations and the 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 for the importance of utilizing the client’s theory of change to effect a positive outcome.
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:
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 increasingly distressed by thoughts about having sex with young boys.
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 the 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.
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.
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.
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.
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
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 a 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 the 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.
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