Milton H. Erickson - Ericksonian Therapy

Ericksonian Therapy

Erickson is most famous as a hypnotherapist, but his extensive research into and experience with hypnosis led him to develop an effective therapeutic technique. Many of these techniques are not explicitly hypnotic, but they are extensions of hypnotic strategies and language patterns. Erickson recognised that resistance to trance resembles resistance to change, and developed his therapeutic approach with that awareness.

Jay Haley identified several strategies, which appeared repeatedly in Erickson's therapeutic approach.

• Encouraging Resistance - For Erickson, the classic therapeutic request to "tell me everything about..." was both aggressive and disrespectful, instead he would ask the resistant patient to withhold information and only to tell what they were really ready to reveal:

I usually say, "There are a number of things that you don't want me to know about, that you don't want to tell me. There are a lot of things about yourself that you don't want to discuss, therefore let's discuss those that you are willing to discuss." She has blanket permission to withhold anything and everything. But she did come to discuss things. And therefore she starts discussing this, discussing that. And it's always "Well, this is all right to talk about." And before she's finished, she has mentioned everything. And each new item - "Well, this really isn't so important that I have to withhold it. I can use the withholding permission for more important matters." Simply a hypnotic technique. To make them respond to the idea of withholding, and to respond to the idea of communicating.

Some people might react to a direction by thinking "why should I?" or "You can't make me", called a polarity response because it motivates the subject to consider the polar opposite of the suggestion. The conscious mind recognizes negation in speech ("Don't do X") but according to Erickson, the unconscious mind pays more attention to the "X" than the injunction "Don't do". Erickson thus used this as the basis for suggestions that deliberately played on negation and tonally marked the important wording, to provide that whatever the client did, it was beneficial: "You don't have to go into a trance, so you can easily wonder about what you notice no faster than you feel ready to become aware that your hand is slowly rising....."

• Providing a Worse Alternative (The 'Double Bind') - Example: "Do you want to go into a trance now, or later?" The 'double bind' is a way of overloading the subject with two options, the acceptance of either of which represents acceptance of a therapeutic suggestion.

My first well-remembered intentional use of the double bind occurred in early boyhood. One winter day, with the weather below zero, my father led a calf out of the barn to the water trough. After the calf had satisfied its thirst, they turned back to the barn, but at the doorway the calf stubbornly braced its feet, and despite my father's desperate pulling on the halter, he could not budge the animal. I was outside playing in the snow and, observing the impasse, began laughing heartily. My father challenged me to pull the calf into the barn. Recognizing the situation as one of unreasoning stubborn resistance on the part of the calf, I decided to let the calf have full opportunity to resist, since that was what it apparently wished to do. Accordingly I presented the calf with a double bind by seizing it by the tail and pulling it away from the barn, while my father continued to pull it inward. The calf promptly chose to resist the weaker of the two forces and dragged me into the barn.

• Communicating by Metaphor - This is explored extensively in Sydney Rosen's My Voice Will Go With You, but an example is given in the first chapter of David Gordon's book Phoenix:

I was returning from high school one day and a runaway horse with a bridle on sped past a group of us into a farmer's yard looking for a drink of water. The horse was perspiring heavily. And the farmer didn't recognize it so we cornered it. I hopped on the horse's back. Since it had a bridle on, I took hold of the tick rein and said, "Giddy-up." Headed for the highway, I knew the horse would turn in the right direction. I didn't know what the right direction was. And the horse trotted and galloped along. Now and then he would forget he was on the highway and start into a field. So I would pull on him a bit and call his attention to the fact the highway was where he was supposed to be. And finally, about four miles from where I had boarded him, he turned into a farm yard and the farmer said, "So that's how that critter came back. Where did you find him?" I said, "About four miles from here." "How did you know you should come here?" I said, "I didn't know. The horse knew. All I did was keep his attention on the road."

Erickson's metaphorical strategies can be compared with the teaching tales of the Sufis (those of for example the Nasreddin) and the Zen tradition of Koans, each also designed to act on the unconscious mind.

• Encouraging a Relapse - To bypass simple short-lived "obedience" which tends to lead to lapses in the absence of the therapist, Erickson would occasionally arrange for his patients to fail in their attempts to improve, for example by overreaching. Failure is part of life, and in that fragile time where the patient is learning to live, think and behave differently, a random failure can be catastrophic. Deliberately causing a relapse allowed Erickson to control the variables of that failure, and to cast it in a positive therapeutic light for the patient.

• Encouraging a Response by Frustrating It - This paradoxical approach acts directly on the patient's own resistance to change. Obese patients are asked to gain weight, or in a family therapy session, a stubbornly silent family member is ignored until the frustration obliges them to blurt out some desperate truth. Once again, this approach has its roots in Erickson's hypnotic language patterns of the form "I don't want you to go into a trance yet".

Compare this with "Prescribing the Symptom" (below).

• Utilizing Space and Position - Hypnosis and therapy are experienced subjectively by the patient, and any part of their total experience can be used to reinforce an idea. The physical position or even the posture of the patient can be a significant part of the subjective experience. Manipulating these factors can contribute to a therapeutic transformation.

If I send someone out of the room - for example, the mother and child - I carefully move father from his chair and put him into mother's chair. Or if I send the child out, I might put mother in the child's chair, at least temporarily. Sometimes I comment on this by saying, 'As you sit where your son was sitting, you can think more clearly about him.' Or, 'If you sit where your husband sat, maybe it will give you somewhat of his view about me'. Over a series of interviews with an entire family, I shuffle them about, so that what was originally mother's chair is now where father is sitting. The family grouping remains, and yet that family grouping is being rearranged, which is what you are after when changing a family."

This may be directly compared with Fritz Perls' use of an "empty chair" as a context for imagined interactions (where the client was often invited to occupy the chair and thus take on the role of the person imagined to be sitting there); Bert Hellinger's approach, which requires the client to arrange family members (played by volunteers) in a row or pattern which matches the client's internal understanding, and then to reorganise the row; and Virginia Satir's work with tableaux and posture.

• Emphasizing the Positive - Erickson claimed that his sensory "disabilities" (dyslexia, colour blindness, being tone-deaf) helped him to focus on aspects of communication and behavior which most other people overlooked. This is a typical example of emphasizing the positive.

Erickson would often compliment the patient for a symptom, and would even encourage it, in very specific ways. In one amusing example, a woman whose in-laws caused her nauseous feelings in the gut every time they visited unexpectedly was "taught" to vomit spectacularly whenever the visits were especially inconvenient. Naturally the in-laws would always sympathetically help her clean up the vomit. Fairly soon, the annoying relatives started calling in advance before turning up, to see if she were "well enough" to see them.

The subject of dozens of songs, "emphasizing the positive" is a well known self-help strategy, and can be compared with "positive reformulation" in Gestalt Therapy.

• Prescribing the Symptom and Amplifying a Deviation - Very typically, Erickson would instruct his patients to actively and consciously perform the symptom that was bothering them (see the nailbiting example under #Resistance), usually with some minor or trivial deviation from the original symptom. In many cases, the deviation could be amplified and used as a "wedge" to transform the whole behaviour.

INTERVIEWER: Suppose someone called you and said there was a kid, nineteen or twenty years old, who has been a very good boy, but all of a sudden this week he started walking around the neighborhood carrying a large cross. The neighbors are upset and the family's upset, and would you do something about it. How would you think about that as a problem? Some kind of bizarre behavior like that.
ERICKSON: Well, if the kid came in to see me, the first thing I would do would be to want to examine the cross. And I would want to improve it in a very minor way. As soon as I got the slightest minor change in it, the way would be open for a larger change. And pretty soon I could deal with the advantages of a different cross - he ought to have at least two. He ought to have at least three so he could make a choice each day of which one. It's pretty hard to express a psychotic pattern of behavior over an ever-increasing number of crosses.

• Seeding Ideas - Erickson would often ensure that the patients had been exposed to an idea, often in a metaphorical form (hidden from the conscious mind) in advance of utilizing it for a therapeutic purpose. He called this "seeding ideas", and it can be observed to occur at many levels both coarse and fine grained, in many of his case histories. In a simple example, the question "Have you ever been in a trance before?" seeds the idea that a trance is imminent - the presupposition inherent in the word before is "not now, but later".

• Avoiding Self-Exploration - In common with most brief therapy practitioners, Erickson was entirely uninterested in analysing the patient's early psychological development. Occasionally in his case histories, he will briefly discuss the patient's background, but only as much as it pertains to the resources available to the patient in the present.

INTERVIEWER: You don't feel that exploring the past is particularly relevant? I'm always trying to get clear in my mind how much of the past I need to consider when doing brief therapy.
ERICKSON: You know, I had one patient this last July who had four or five years of psychoanalysis and got nowhere with it. And someone who knows her said, "How much attention did you give to the past?" I said, "You know, I completely forgot about that." That patient is, I think, a reasonably cured person. It was a severe washing compulsion, as much as twenty hours a day. I didn't go in to the cause or the etiology; the only searching question I asked was "When you get in the shower to scrub yourself for hours, tell me, do you start at the top of your head, or the soles of your feet, or in the middle? Do you wash from the neck down, or do you start with your feet and wash up? Or do you start with your head and wash down?"
INTERVIEWER: Why did you ask that?
ERICKSON: So that she knew I was really interested.
INTERVIEWER: So that you could join her in this?
ERICKSON: No, so that she knew I was really interested.