The following is the written text of the Conference Address delivered at the 4/17/98 Seminar in Hickory, NC entitled:
“APPLICATIONS OF HYPNOSIS IN PSYCHOTHERAPY“
EXTENDING THE ENCHANTMENT: Reflections of a Second Generation Ericksonian
By Mickey Skidmore, ACSW
My formal training in clinical hypnosis began in Raleigh, North Carolina in October of 1990 — a decade after the passing of the late Milton H. Erickson, MD; and on the weekend of my 31st birthday. Somewhere I heard (or read?) that on average, most clinicians “experiment” with hypnosis for five years or less before moving on to other approaches or paradigms. However, for me, nearly a decade after I was exposed to the teachings of Milton H. Erickson, my hypnotic growth and development continue to unfold in ways that enrich my personal and professional life.
I refer to myself as a “second-generation” Ericksonian therapist. Jeffrey Zieg defined this term as one who never met Milton Erickson, but one who instead learned hypnosis from reading and studying his works and from studying with Erickson’s disciples. It has been suggested by some, that the Ericksonian legacy has played out. However, I submit that the fact that we’re here today is evidence to the contrary, and in fact is powerful testament that the contributions Erickson made to the fields of hypnosis and psychotherapy continue to influence another generation of professionals.
Having studied and/or trained with many of Erickson’s disciples during the 90’s, it has been my obervation that each of my mentors has skillfully developed an identifiable aspect or style which in some way promulgated intracate models and explanations of Erickson’s contributions. Ernest Rossi emphasizes the Mind-Body connection/relationship; Kaye Thompson takes a special interest in the Languages of Hypnosis; the Lankton’s focused on the structure and strategic delivery of metaphorical approaches; Jeffrey Zieg transformed the technique of Utilization into a concept of orientation; and Steve Gilligan has successfully articulated the aesthetic dimensions of Erickson’s teachings.
Ultimately, these and many others (Jay Haley, Joeseph Barber[?], Steve de Shazer, William O’Hanlon, Sidney Rosen, Michael Yapko, Yvonne Dolan, Michelle Ritterman, and Carol Kershaw, to name just a few) contributed to the movement in mental health arena which we have come to recognized as Brief Therapy or Solution-Oriented/Focused Therapies. Without question, many of Erickson’s disciples have earned professional distinctions in their own right.
So, a question I’m always mindful of is: As a second-generation Ericksonian, what distintion or new contribution do I make (if any) to the Ericksonian legacy? And in the true spirit of the Ericksonian tradition, I’d like begin to address this question with a few anedotes:
After several years of attending hypnosis workshops, I began to hear grumblings from collegues and various attendees. “I was dissappointed with (insert a presenter of your choosing); there was nothing new. It was the same thing s/he did at the last conference”. “They just re-organize and rehash their same stuff in a slightly different format”. While there was clearly some validity to these observations, I intentionally decided for myself that if I continued to hear certain things over and over, it was probably because this was core material that was a fairly important foundation to practicing hypnosis.
Not long after that I was preparing to present a workshop in western North Carolina. After a public speaking engagement where I had plugged this event, a professional woman approached me to let me know she would not be attending my seminar because “I’ve already done your workshop last year”. While at some level I was flattered that she had appartently associated me with some of my Ericksonian teachers, she didn’t know what I’d like to convey to you now — which is what I believe I do in response to my earlier question.
Simply put, my own style as a second-generation Ericksonian is to offer a blending of the aspects from each respective mentor, in conjunction with my own uniqueness. This means several things to me. First, the vast quantity, quality, and variety of learnings I have aquired from several Ericksonian teachers and numerous writings prohibits me from reducing any distinct contribution I might make susinctly or simply. Second, maintaining a repertoire of therapeutic strategies and approaches lends itself to succesful intervention with patients more so than any single approach would permit. Third, for me at least, learning the endless applications of hypnosis (in my respective discipline) is an unfolding and hopefully unending process. Thus, when I present a workshop it may focus on one particular aspect of hypnosis, or even a blending of several frameworks, while the next seminar may emphasize an alternative approach, completely different.
(Hopefully other hypnosis seminars do this also in some way), but if this reasonates with you, and with any luck at all, perhaps this may begin to evoke some questions for you which we can explore today:
*Why attend a day-long workshop on hypnosis? (After all, there are lots of conferences and other trainings competing for your limited time and pocketbook). Or, what do I get from a hypnosis workshop that adds to my professional learning more than other potential learning ventures?
Tom Stanger, Ph.D., President elect of the North Carolina Society of Clinical Hypnosis (NCSCH) eloquently articulates my own similar sentiments regarding these questions in a recent address published in the Winter 1998 NCSCH Newsletter: “Learning hypnosis encourages me to challenge my developed notions of what therapy is or can be, to search for notions of what might be done, how I might be, that could be more effective. Hypnosis to me is a way of looking at how to enhance the therapeutic process. It is a way of communicating with clients that encourages accessing/cultivating more personal potential than they have managed before …” Perhaps then, such a response sets the tone for an exploration of a more basic question …
*What is hypnosis really anyway?
Anyone who uses hypnosis in their practice is confronted regularly with a seemingly endless barrage of distortions and attitudes about what it is and what it is used for. This is understandable considering some of the historical baggage hypnosis brings with it. However, today I’d like to present some refelctions and observations from a second-generation Ericksonian perspective as we explore our understanding of this question.
It would be tempting at a hypnosis seminar (such as this) to interpret the [above] figure/field distinction as the small circle representing the “conscious mind” and the larger circle representing the “unconscious mind”. (You may even recall being exposed to a similar representation in one of your early psychology courses). The basic idea is that one perceives something only against a background different from that something. Other examples of this figure/field relationship may include: the little circle as the “text” (the story or description of things) in contrast to the big circle (all the values, experiences, intentions of the observer/reader). The little circle might be an individual, while the big circle is the social system within which that person is in relationship. If the little circle is a single experience (i.e. a trauma), the big circle is the entire life experience of the person. If the little circle is a diagnostic category, ego-state, or frame of reference (i.e. depression or anxiety), the big circle is the larger context of all the person’s ego-states and frames of reference (Gilligan. In Zieg, 1994). And so it is with hypnosis — or at least the conceptualizations of what many think hypnosis is and is not.
HYPNOTIC FUNDAMENTALISM:(Myths; Misconceptualizations & Reductionism)
To the best of my knowledge, every hypnosis trainer I have learned from addressed the myths and misconceptions inherent with hypnosis. I’d like to do this today by broaching what Steve Gilligan refers to as a “fundamentalist approach to life” (or regarding the misconceptualizations of hypnosis, what I sometimes refer to as hypnotic fundamentalism). For purposes of clarification, the term fundamentalism is used generally in this context to describe any psychological approach that vehemently insists upon an unchanging text as the one and only “objective truth” (Strozier, 1994). In other words, what’s inside of one little circle is the right belief and what’s outside of it is dangerous and wrong.
Erickson repeatedly stressed that therapists traditionally operate as fundamentalists. We start with the premise that something in the client is wrong, broken, or pathological; we use our models and theories as fundamentalist text to “diagnose”; then we try to control the relationship with the intention of converting the patient to the light of mental health. In other words, we try to reduce the patient into the confines of our “little circle” and lose connectedness to the “bigger circle” of the Self and its unique values, experiences, and interests (Gilligan. In Zieg, 1994).
Psychotherapy has become the institution in our culture whereby therapists participate in the transforming of negative experiences through human consciousness. When successful, this is an important and precious gift to our culture. Consequently, I share Gilligan’s view that therapists must have compassionate understanding of how fundamentalism develops, and appreciate how the consequent reduction of identity to an image or an “ism” is a recipe for suffering and violence.
Perhaps the single most pressing example of reductionism can be found in the consequences which result from our current managed care/insurance industry. During recent years there has been a profound reduction of mental health treatment (both inpatient and outpatient) resulting from the payment and/or reimbursement practices of managed care and insurance companies. Inpatient psychiatric admissions are forced to emphasize crisis stabalization rather than inpatient treatment due to the rapidily decreasing lengths of stay. In this setting, professional nurses are reduced to clerks stuggling with mounds of paperwork associated with admissions and discharges. Masters prepared social workers and therapists find it difficult to provide family, group, and individual therapies amidst the intensive case management involved in shorter lengths of stay, where discharge planning begins at the time of admission (if not before). Even following discharge, third party payer sources may agree to only 5 or 6 outpatient sessions to treat vastly complicated cases. Every indicator today strongly suggests that the notion of therapy as a relationship-mediated event is a thing of the past. Based on current trends, we may very well be witnessing the systematic genocide of anything resembling long-term therapy, or psychotherapy as we know it.
Throughout the 90’s, it has also been my experience that there are many limiting and false fundamentalist ideas in regards to hypnosis. And while the consequences of these fundamentalist views may have yet to manifest in suffering or violence, they continue to contribute to stereotypical limitations, misrepresentations, and fear, which undermines the potential effectiveness of hypnosis, and exposes it to further reductionism.
TECHNIQUES vs. THERAPY
As I reflect on my hypnosis training over the years it occurs to me that when one is referring to “hypnosis training”, what they are primarily referring to is the emphasis on the mechanics and techniques of hypnosis. And while it is an absolute necessity to have a solid working knowledge of the techniques and mechanics of hypnosis, it is an oversimplification and disservice to reduce hypnosis to a cluster of techniques. In fact, it has only been within the last two years that I gradually became aware that when people were coming to my workshops or requesting hypnosis supervision that were mostly interested in the “double inverse — conscious/unconscious — dissociative — full-body leviation — catalepsy techinique” with post hypnotic suggestion for amnesia. They were also hyper-focused on the ingenuity and cleverness frequently involved in structuring the indirect suggestions and binds, which in turn led to the development of metaphor constructions.
Meanwhile, as that realization was beginning to take shape in my awareness, there remains the constant fear-based responses from the nay-sayers within organizations whenever they hear of the possiblity of someone “doing” hypnosis in their agency. As a Clinical Social Worker specializing in Ericksonian approaches to hypnosis and psychotherapy, I have encountered many distorted attitudes and false ideation’s about the use of hypnosis. While hypnosis is not considered a therapeutic paradigm or theory, it is a tool much older than any school of therapy and can be one of the most powerful therapeutic agents available to a clinician. Unfortunately, despite its endorsement by the American Medical Association in 1956 as a legitimate aid to therapy, hypnosis remains associated in the minds of many with charlantary (Lankton & Lankton, 1983).
So, in order to disavow the limitations and misconceptions frequently imposed on hypnosis I’d also like to share some reflections of what contributions hypnosis can offer to the fields of psychotherapy, and speak a little about how I conceptualize hypnosis. Milton H. Erickson, M.D. (1901-1980) made vast and profound innovations in psychotherapy which have been called by some parallel in scope to those of Freud’s. While Freud was a major contributor to the theory of personality structure, Erickson’s contribution was in methods and techniques of intervention and change. Given the limitations of our time today, I will emphasize three features of hypnosis, all of which are influenced by Ericksonian methods. They include: Formal and Informal Ericksonian Approaches; the impact of emerging hypnosis frameworks on psychotherapy; and the four enduring ideas of Erickson’s contributions and retorical considerations for the future.
Formal & Informal Ericksonian Approaches
Ericksonian approaches include both formal and informal inductions. In general, Ericksonian methods refers to influencing communication whereby all patient behaviors are utilized as resources to gain the patient’s cooperation. What constitutes a formal Ericksonian induction typically involves the use of the term hypnosis, and the expectation from the patient that something new and/or different (beyond what they’re accustomed to) will occur within the context of their therapy. Erickson also developed, named, and pioneered the “Naturalistic Approach” or what he referred to as hypnosis without formal induction (informal). Hypnosis without formal induction is particularly useful in dealing with resistance. It is worth noting however, that even the formal Ericksonian induction may appear to incorporate a natural, conversational style, utilizing unique and relevant material for the patient in contrast to a standardized induction employed by researchers. Later today I look forward to sharing and discussing with you some examples of how informal approaches can be utilized in hospital and other settings.
The Impact of Emerging Hypnosis Frameworks on Psychotherapy
Earlier we considered a diagram of two circles. This simple figure exposed some outdated ideas and misconceptions for some, while providing a broader context to consider alternatives for others. Having served its initial purpose, I’d like sibmit this next diagram for your consideration:
This diagram is used as a backdrop to briefly introduce a Self-Relations approach to psychotherapy developed by Steve Gilligan, one of Erickson’s disciples. The premises of this approach include: (1) Each person has an indestructible “tender soft spot” (or center) at the core of their being; (2) The river of life runs through you, except when it doesn’t; (3) Life is great, but sometimes it hurts like hell; (4) There are two of you: What is the basic relationship principle?; (5) An intelligence greater than you exists in the world; (6) You are an incurable deviant and it’s just going to get worse: The path that is yours alone.
These principles suggest three orders of intelligence: (a) the center of the somatic self (the principle of beingness); (b) the sponsorship of the cognitive self (the principle of relatedness); and (c) the field of the relational self (the principal of belongingness). In experiences and times of well being, all are present: center, cognitive complementarity and sponsorship, and connection to the field. In problematic experiences, there is a “break in beingness,” a “break in relatedness,” and/or a “break in belongingness”. Thus, therapy endeavers to return attention to the center; sponsor differences and mend mental relations; and reunite self with the larger field. [For a more comprehensive review of the Self-Relations approach, the reader is directed to: Gilligan, Stephen. The Courage to Love: Principles and Practices of Self-Relations Psychotherapy. New York: Norton, 1997].
While this alternative may initially seem uncharateristically strange or rather involved, it serves as an excellent example to convey several key points. First, it clearly does not rely soley on cognitive constructs. It is aesthetic by nature and it reasonates deeply with many therapists exposed to these principles. Second, it is not mechanical. It is profound in its complexity and incorporates somatic expression and community in its approach. Third, it is but one of many examples of how an Ericksonian orientation can extend beyond the limitions of inductions and techniques to influence the field of psychotherapy.
The work of Ernest Rossi, Ph.D., (also one of Erickson’s disciples), is another departure from the over-emphasis on the cognitive expression in psychotherapy today. He has worked diligently in his career to develop a mathmatical formula or equation which would empirically prove his emerging theoretical paradigm: “… the flow of information between our psychosocial world, mind and body, down to the cellular-genetic level is the general domain of hypnotherapy” (Rossi, 1994). A sample of intriguing questions from Rossi’s contribution to the fields of hypnosis and psycotherapy include: When / where does the body end / mind begin? mind end / body begin? And, how much effect does consciousness have physiology (somatoformation)?
We’ve talked considerably today about Erickson’s contributions. Yet, when we acknowledge the significant influences of his disciples it becomes clear that many gifted practitioners have moved well beyond mechanics and techniques. In fact, many of Erickson’s students were monumental in the emerging of entirely new fields (Ericksonian Psychotherapy; Brief Therapies; Solution-Oriented/Focused Therapies to name a few) which proliferated at a dizzying rate not all that long ago. It seems reasonable that the next generation will also make their mark in extending the enchantment and influence of the Ericksonian tradition.
What follows then are some “second-generation” reflections about the emerging conceptualizations of hypnosis. One of the primary values of hypnosis seems to be re-connecting the mind with somatic expression. While cognitive approaches have strengths in the realm of research, and are effective with a substantial portion of the population, what about people who navigate the world in other ways? There are other significant portions of the population who interpret the world primarily in alternative fashion: auditorally, kinesthetically, spiritually, aesthetically, intuitively, or somatically. Hypnotic approaches offer a broader spectrum and added depth to meeting the patient on their terms and speaking their language (whatever that might be).
The next observation centers on defining hypnosis (a dubious task at best). Rather than be shackled by historical baggage, close-minded viewpoints, and outdated ideas, the next generation of Ericksonian practitioners can contribute to Erickson’s legacy by conceptualizing clinical hypnosis as the process of working with attention. This view is consistant with Erickson’s “Naturalistic Approach” and enables a therapist to intervene hypnotically and therapeutically in virtually any clinical setting.
Perhaps the final observation is the most important, because it speaks to the process of therapy itself. An overview of an Ericksonian approach would likely emphasize “de-framing” rather than “re-framing”. This process begins by identifying the needed or desired change(s), as well as the language of trance needed to facilitate the therapy. A simple example might be a required change due to a developmental demand or transistion. Preferably, rather than re-framing this sequence, the patient might be better served with no frame; thus the therapy process would focus on co-creating a (safe) container (or what the Greeks referred to as Temenos), and opportunity where they can build a new frame — identity — sets, etc.
Long before I received any training in hypnosis or Ericksonian approaches, I was taught that psychotherapy was both science and art. But most importantly, I was taught that it was a process. An experience based on the establishment of trusting rapport. As I became more seasoned with experience I reflected on having learned the wisdom of following the patient at their pace in the therapy process. Yet managed care and insurance carriers give little acknowledgement any more to that credo. Moreover, it is somewhat paradoxical and ironic that the very development of Brief Therapy and Solution-Oriented Therapies spawned out of the Ericksonian tradition has served as powerful ammunition for these companies to decrease and reduce outpatient visits to the point that establishing a trusting therapeutic relationship is seriously threatened.
It is unfortunate that Brief and Solution-Oriented Therapies are being pushed as part of managed care systems, and not as a respectful and effective mechanism of psychotherapy. Furthermore, it is disturbing that insurance companies have increasingly persuaded us that Brief Therapy and managed care are synonymous. In my mind, nothing could be farther from the truth, and a distinction should be made between Brief Therapy and time/session limited therapy. Brief Therapy distinctly promotes respectful and effective methods of therapy, contrasted with time, money or constraints of “session limited therapy,” which is imposed by managed care systems from outside.
I commend managed care and insurance systems for successfully pulling in the reigns of run away health care costs. Furthermore, I applaud the increase in accountability and procedures for accountability as a primary benefit stemming from the influence of managed care. Yet I believe that managed care companies are not paying attention to quality, but to the bottom line. It is simply bad news having accountants and business managers making clinical decisions. The endless beuaracratic forms and paperwork is another piece of bad news (some therapists need three sessions to fill out the damn forms!). And another aspect which deserves special attention is the increasing push to pharmacological solutions. Managed care and insurance companies are big on prescriptions; they are easy to track and pay for. When paying attention to the bottom line however, using general practice physicians as gatekeepers also biases to medical rather than psychological solutions. Lastly, managed care companies frequently discourage innovation — a reality unlikely to change with the increasing size of managed care companies into larger monopolies.
So, while the overall association between managed care systems and Brief Therapy is inaccurate, there are possibilities to utilize features of both to forge the “best case managed care system”. In this collaborative scenario, Brief Therapy is oriented towards quality. Brief Therapy approaches are client oriented, and focused towards an immediate beginning to the therapy process. Clear definitions of the problem and the solution are helpful. Yet, both consumers and practitioners alike should advocate complaining when a system compromises the process of psychotherapy. Nothing short of this will engender change. And while past or current experiences with managed care may evoke viseral reactions in you, I suggest that a measured response is perhaps the most prudent. Don’t panic. Pay attention to respectful, effect therapy. Be creative and innovative. Pay attention to what works, and use what works. And chose your battles with care — challenge the system where possible and necessary.
So, as you can see, over the years I have reflected on many topics and aspects of both hypnosis and psychotherapy. These observations have attempted to extend the enchantment of Erickson’s teachings by expanding the traditional views, definitions and boundaries of hypnosis; by exposing the violence of fundamentalist ideology of psychological or medical paradigms; and by punctuating the ethical standards necessary to appropriately advocate against any (mananged care or insurance) system that threatens the essence of the therapy process. Although I leave room for the possibility of somehow (eventually) arriving to these views in some other way, I credit my Ericksonian experiences for broadening and enhancing my views regarding psychotherapy.
The Enduring Ideas of Milton H. Erickson
So, rather than bringing closure … it makes more sense to me, that the enchantment of Erickson’s work is extended to a second generation and beyond by contemplating the following rhetorical questions:
*What do you call the “other-than consious?”
*Where is intelligence located? (Unconscious? Mind? Body? Soul? …)
*What is the Therapist’s role?
*Is trance really all that common?
*Is trance always helpful?
*Is indirect communication helpful?
*Are failures crucial? (The hallmark of good therapists)
*Is LOVE a force to be reckoned with?
Regardless of your personal responses to these questions. They all speak in one way or another to core values and ethics, but perhaps most importantly, to the new directions the second-generation Ericksonian practitioners will take us to as we … “remember the future…”
So, while that’s a lot to ponder, it might be simplier for me to share what Steve Gilligan characterized as the Four Lasting Ideas of Milton H. Erickson:
(1) Uniqueness: of the individual.
(2) Utilization: as a core value and orientation, rather than a technique.
(3) Balance: inner (hypnotic) experience vs. social/behavioral.
(4) Enjoy life: JOY!
As a second-generation Ericksonian I would also include a short addendum of two items which has helped to keep me grounded in gratitudeand humility during my hypnotic journey:
First, a basic recognition that most change occurs outside of therapy. Therapy just sparks the change. The client’s outside life is more important than therapy. The second is without a doubt the most important to me, and is an idea far older than me, but an idea I have endeavored to mentor to anyone who would allow me to pass it on. It is an idea which is best presented and understood as a story, much like this Souix fable:
The Creator gathered all of creation and said,“I want to hide something from the humans until they are ready for it.It is the realization that they create their own reality.”The eagle said, “Give it to me, I will take it to the moon.”The Creator said, “No. One day they will go there and find it.”The salmon said, “I will hide it on the bottom of the ocean.”“No. They will go there too.”The buffalo said, “I will bury it on the great plains.”The Creator said, “They will cut into the skin of the earth and find it even there.”Then Grandmother Mole, who lives in the breast of Mother Earth,and who has no physical eyes but sees with spiritual eyes said,“Put it inside them.”And the Creator said,“It is done.”
Dolan, Yvonne. A Path With a Heart: Ericksonian Utilization with Resistant and Chronic Patients. New York: Brunner/Mazel, 1985.
Gilligan, Stephen. The Fight Against Fundamentalism: Searching for Soul in Erickson’s Legacy. In Zeig, Jeffrey K. (Editor) Ericksonian Methods: The Essence of the Story. New York: Brunner/Mazel, 1994.
Gilligan, Stephen. The Courage to Love: Principles and Practices of Self-Relations Psychotherapy. New York: Norton, 1997.
Lankton, Stephen and Lankton, Carol. The Answer Within: A Clinical Framework of Ericksonian Therapy. New York: Brunner/Mazel, 1983.
O’Hanlon, William H. The Perils and Possibilities of Brief Therapy in the Era of Managed Care. Keynote Address of the 4th Eastern Conference on Ericksonian Hypnosis & Psychotherapy, sponsered by the Institute for Advanced Clinical Training, Inc., of Philadelphia, PA, 7/07/95.
Rossi, Ernest. Training Seminar: The Psychobiology of Mind-Body Healing Houston, TX. Co-sponsored by The Milton H. Erickson Institute of Houston & The University of Houston Counseling & Testing Service, 4/15-17/94.
Stanger, Tom. Why Bother With Another Hypnosis Conference? The North Carolina Society of Clinical Hypnosis (NCSCH) Newsletter. Winter 1998, Vol. 30, Number 1.
Strozier, C. Apocalypse: The psychology of fundamentalism in America. New York: Beacon, 1994.