A Path With A Heart

Ericksonian Utilization With Resistant and Chronic Clients

Yvonne M. Dolan

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317758594
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

First published in 1993. Historically, hypnotherapy has been assiduously avoided in the treatment of psychotics. One of the myths around this is that hypnosis is too all-powerful- that it can precipitate psychosis in patients with fragile egos. This myth was disproved by Milton Erickson, the master psychiatrist whose extensive work with hypnotherapy is the basis for Yvonne Dolan's work on the treatment of chronic patients. Erickson was the first practitioner to consistently demonstrate the efficacy of formal and informal hypnotherapy with schizophrenics, and now Dolan has advanced Erickson's naturalistic techniques with her practical and common sense techniques.

1

 

The Complexity of Working with Chronic and Resistant Clients

 

 

 

 

“Chronic” and “resistant” are two labels that can contribute to demoralization on the part of both therapist and client. Even if these terms are not directly voiced to the client, their presence is likely to be felt in the therapist's demeanor and nonverbal communication.

To the extent that therapists blindly accept the terms “resistant” and “chronic” as accurate current descriptions of the client, they will further contribute to the difficulty the client is experiencing. “Chronic” is actually a comment on the therapeutic community's long-term inability to effectively treat the client. “Resistant” is a comment on the therapeutic relationship and indicates the extent to which the therapist has been unsuccessful in accepting, communicating, and achieving trust with the client.

A MUCH-NEEDED PERSPECTIVE OF OPTIMISM

In order to succeed with “chronic” and “resistant” clients, the therapist must let go of the demoralization and negative expectations attached to those labels and develop an expectation of positive outcome.

Ericksonian utilization, with its inherent perspective of optimism and nonjudgmental posture, offers an antidote for the demoralization that handicaps therapists working with clients labeled chronic and resistant. The Ericksonian perspective emphasizes the value of symptomatic problems first being acknowledged and accepted, then utilized as therapeutic resources to lead the client to choose more rewarding behaviors and perceptions.

THERAPISTS WHO TREAT CHRONIC AND RESISTANT CLIENTS

The earliest years of many therapists' careers are spent seeing the clients whom the more experienced therapists choose not to see. It is an odd bit of irony about our mental health system that the most difficult clients are not infrequently given to the most inexperienced therapists.

There are some treatment advantages in assigning chronic and resistant clients to interns and novice therapists. What the novice therapist and intern frequently lack in experience and skill they sometimes make up for in optimism and enthusiasm, attitudes valuable in working with chronic and recalcitrant clients.

All too often a seasoned therapist will tell a novice not to become overly involved with the client. While this is technically accurate advice, a highly personalized and perhaps extreme measure is likely to be required in the case of most clients who have been labeled chronic. “Commonsense” and “common” therapeutic methods have already failed this client. Otherwise the chronic individual would not now be the person described in a five-inch thick treatment file with a ten-year history of recurrent inpatient psychiatric admissions.

Conversely, it is well known among experienced clinicians that rigidly expecting a client to change at the therapist's rate, rather than according to the client's own internal rhythms and personal abilities, is tantamount to setting that person up to fail. The overeager, enthusiastic, naive graduate intern may, if not warned, fall into the idealistic abyss of setting out to single-handedly empty the psychiatric units in short order. At worst, the overidealistic and zealous fledgling clinician may encounter an experience analogous to that of the man who tries to help a butterfly emerge from its cocoon.

The man, impatient with the butterfly's slow progress in “struggling” out of the cocoon, seeks to help the creature. He fails to recognize the protective nature of the constricting “resistant” cocoon. The butterfly, with the man's “help,” is set free in the cold air prematurely. Deprived of adequate time to make the necessary adjustments within the cocoon, it crumbles into a helpless suffering heap. The therapist must have reverence and appreciation for each client's personal rate of change, idiosyncrasies, difficulties, vulnerabilities, and resources.

On the other hand, if the therapist goes too far in the direction of avoiding stress in the interest of protecting a vulnerable client, he or she risks depriving the client of the very motivational factors that are needed for recovery.

In working with chronic and resistant clients, the path between these two extremes is sometimes very narrow. Clearly, good intentions are not enough! The skilled therapist needs much more.

In order to be effective, the therapist who works with chronic and resistant clients must find a way to preserve an initial perspective of confidence in the client's ability to respond favorably to treatment, while simultaneously seeing beyond the myopic oversimplifications that may plague and hamper the unseasoned therapist. This is no simple task.

THE THERAPEUTIC RELEVANCE OF INTEGRITY

In the demanding context of working with chronic and resistant clients, the Ericksonian approach offers much-needed values of pragmatism coupled with integrity and precision. Erickson viewed the “resistant” behavior as one more aspect of the client's symptomatology and devised precise strategies to utilize that symptomatology to lead to therapeutic change.

Therapists wishing to help their patients should never scorn, condemn, or reject any part of a patient's conduct simply because it is obstructive, unreasonable, or even irrational. The patient's behavior is part of the problem that brought him into the office; it constitutes the personal environment within which the therapy must take effect; it may constitute the dominant force in the total patient-doctor relationship. Since whatever patients bring into the office is in some way both a part of them and a part of their problem, the patient should be viewed with a sympathetic eye appraising the totality which confronts the therapist. (Erickson, 1965, in Collected Papers, Vol. 1, p. 213)

Erickson emphasized the quality of the relationship between therapist and client while viewing the client as a total human personality rather than simply a set of lingering diagnoses or symptoms. Earlier in the above quoted article, he states:

In dealing with any type of patient clinically, there is a most important consideration that should be kept constantly in mind. That is that the patient's needs as a human personality should be an ever-present question for the therapist to insure recognition at each manifestation. Merely to make a correct diagnosis of the illness and to know the correct method of treatment is not enough. Fully as important is that the patient be receptive of the therapy and cooperative in regard to it. Without the patient's full cooperativeness, the therapeutic results are delayed, distorted, limited, or even prevented. (In Collected Papers, Vol. 1, p. 212)

Admittedly, this approach will demand from the therapist a high degree of integrity, creativity, and continuing willingness to expand personal horizons in the interest of professional competence. In order to enable the chronic client to become cooperative and responsive, the client must be given the immediate experience of the therapist's acceptance of the client's “needs as a human personality.”

In the case of most chronic clients, words alone will not adequately communicate the therapist's acceptance. Generally, it will be necessary for the therapist to join the client, either on a metaphorical or literal level, in doing what the client is already doing. This will serve to undeniably communicate acceptance and appreciation. While this is a demanding task, there are fortunately many strategies and techniques available to the therapist.

The best techniques and strategies will fail even the most competent therapist, however, if the therapist does not genuinely feel a sense of goodwill, acceptance, and appreciation towards the client. A crucial requirement for success is the therapist's integrity.

2

The Nature of Ericksonian Utilization

Too many psychotherapists take you out to dinner and then tell you what to order. I take a patient out to a psychotherapeutic dinner and I say, “You give your order.” The patient makes his own selection of the food he wants. He is not hindered by my instructions which would only obstruct and confuse his inner processes. (Erickson & Rossi, 1973)

The utilization of the client's presenting behavior as an integral part of therapy (Erickson, 1955, 1965) and the utilization approach to trance induction (Erickson, 1958, 1959) are among Erickson's most important contributions to the field of hypnosis and psychotherapy (Erickson, Rossi, & Rossi, 1976).

The utilization techniques described in the following pages will frequently lead to the development of hypnotic trances. The specific focus of this book, however, is on utilization of the client's existing behavior, perceptions and resources to elicit therapeutic change. A comprehensive account of Erickson's utilization approach to hypnotic trance induction is beyond the scope of any single volume.

Utilization is the process of incorporating aspects of the client's current behavior and perceptions, current and past relationships, life experiences, innate and learned skills, and abilities into the therapeutic change process.

Both as a way of looking at the client and as a way of interacting with the client, Ericksonian utilization is a perspective of optimism and confidence in the client's ability to respond to treatment. The concept of utilization implies that every part of the client's behavior, personality, relationships, personal beliefs and situation is potentially valuable and useful in enabling the client to achieve more rewarding choices.

The concept of utilization is an essentially nonjudgmental way of looking at human behavior. Gilligan (personal communication, 1982) relates an anecdote in which Erickson says, “You cannot rigidly assign human values to human behavior. They're always changing.”

It is crucial that the therapist maintain a nonjudgmental attitude if he or she is to succeed in enabling the client to become unstuck from rigid symptomatic patterns of behaving and perceiving. Direct or implied criticism of the client's behavior and perceptions are criticisms of the client's model of the world. Such criticism will serve only to strengthen the “resistance” patterns of an already chronically resistant client. If directly challenging a psychotic's belief system were a successful intervention strategy, it would have worked long before the client became a chronic client with a three-year or longer treatment history and no symptomatic relief. Erickson, (with Zeig) writes:

Concerning psychotherapy, most therapists overlook a basic consideration. Man is characterized not only by mobility but by cognition and emotion. No two people have the same ideas whether they are psychotically based or culturally based. When you understand how man really defends his intellectual ideas and how emotional he gets about it, you should realize that the first thing in psychotherapy is not to try to compel him to change his ideation; rather you should go along with it, and change it in a gradual fashion and create situations wherein he himself willingly changes his thinking (Erickson & Zeig, 1980, p. 335)

Particularly when working with chronic clients, it is crucial that the therapist be willing to meet the client where the client is currently at. Before any behavior or perception can be utilized (incorporated into the change process), three requirements must be met:

1) The therapist must accept and appreciate the problematic resistant behavior or perception as a legitimate piece of communication from the client regarding the client's current inner state and the client's model of the world.

2) The therapist must be willing to view the client's problematic resistant behavior or perception as a potentially valuable therapeutic resource.

3) The therapist must communicate this acceptance and appreciation to the client in an undeniable way.

Joining a chronic client in his symptomatic model of the world in order to therapeutically utilize the client's behavior and perceptions is an exacting and oftentimes a personally demanding task for the therapist. Since no two human beings are alike, each case requires a willingness to extend the therapist's personal limits in ways that may not yet be a part of the therapist's personal repertoire. However, to the extent that a therapist is unable or unwilling to do this, he or she will be handicapped in attempts to help the client.

It is crucial that the therapist's acceptance and appreciation of the client be real and not merely an attempt to “trick” the client into giving up his problematic resistant behavior or perception. Particularly in the case of the client who has been involved with th...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Foreword
• Table of Contents
• Acknowledgments
• Introduction
• 1. The Complexity of Working with Chronic and Resistant Clients
• 2. The Nature of Ericksonian Utilization
• 3. A Naturalistic Perspective for Hypnotic Trance
• 4. Bypassing Conscious Blocks Through Interspersals and Presuppositions
• 5. “Yes” Sets and “No” Sets
• 6. Strategies for Communicating Acceptance in an Undeniable Way
• 7. Establishing New Therapeutic Resources Through Associational Cues
• 8. Reframing Chronic Symptoms—A Utilization Approach
• 9. Metaphors: Communicating with Chronic and Resistant Clients Through Stories
• 10. Using Metaphors with Psychotic Clients
• 11. Changing Chronic Problem Behaviors into Therapeutic Resources
• 12. Ericksonian Utilization in Group Settings
• 13. The Therapist as an Instrument
• Appendix A
• Appendix B
• Appendix C
• References
• Index