by Roger Fritz, Fall 1998
PART 1: BACKGROUND (as related to the development of the theory)
Milton Erickson (1901-1980) learned hypnosis from Clark Hull, an American behaviorist, when Erickson was an undergraduate student in psychology at the University of Wisconsin. Hypnosis from the time of Mesmer had consisted of progressive relaxation and direct suggestion. Erickson pioneered the clinical use of hypnosis and demonstrated a style which came to be known as indirect suggestion and utilization. (Lankton, 1984, pp. 5-6, and Haley, 1993, p. 2)
Erickson founded the American Society of Clinical Hypnosis in 1957 and edited the American Journal of Clinical Hypnosis from 1958 to 1968. He hypnotized over 30,000 people in the course of research and treatment. Some of his techniques, such as paradox, metaphor, therapeutic double binds, and symptom prescription, are now well known and used in non-hypnotic therapies. (Lankton, 1984, p. xiii) He had a profound influence on the development of brief therapy, and on men like Don Jackson (founder of the Mental Research Institute), Gregory Bateson, John Weakland, Jay Haley, Steve de Shazer (co-founder of the Brief Family Therapy Center), Richard Bandler, John Grinder, and Moshe Talmon (author of Single Session Therapy (1990)). (Capuzzi, 1999, p. 349) His influence on reality therapy can be seen in the emphasis on behavior change, the present orientation, the use of parradoxical techniques (relabeling, redefining and reframing) and the way metaphors are used. (Capuzzi, 1999, Ch. 12)
Erickson didn't value the psychiatric beliefs of his time: insight for repressed material, an unconscious considered to be filled with unsavory impulses and buried hostilities, "working through," long-term non-directive therapy, focus on the past,refusal to focus on the problem, and non-involvement of the therapist. Hypnosis wasn't allowed to be taught in medical school. He considered the unconscious to be positive, promoted brief therapy, the use of directives, focusing on the problem, family therapy, use of hypnosis with amnesia, encouragement rather than confrontation, and utilizing resistance. And Erickson used his personal self as much as possible to influence the client.
He would persuade, joke, demand, cajole, play, threaten, make telephone calls, or do whatever was necessary to achieve the therapeutic goal. (Lankton, 1984, p. 6, and Haley, 1993, pp. ix-xiv)
PART 2: HUMAN NATURE: A DEVELOPMENTAL PERSPECTIVE (how the theory defines individual developmental processes over time)
Erickson didn't have a theory of personality. He used a theory of change rather than a theory of the structure of personality to form his interventions. (Lankton, 1984, pp. 6 & 23) He believed that people operate out of internal maps rather than out of sensory experience. Each person has a unique point of view and frame of reference. Therapy can edit, expand and elaborate the map. Relabeling as positive what the client considers negative is one way to alter the map. Teaching new choices is one way to expand the map. People are considered to make the best choice for themselves at any given moment. Even problem behaviors and feelings are the best choice the person has learned to make in a particular circumstance. This idea is incompatible with the idea of resistance. Erickson wrote, "Sick people do want to try; usually they don't know how." (Collected Papers IV, p. 60) Erickson disagrees with transactional analysis that people play games and advance life scripts. (Lankton, 1984, p. 14) Erickson did believe that people are mastering different challenges at each new stage of their life. Children must learn to accept care, to respond to supervision, to follow directions. They must learn to have obedient relationships with their parents, even while learning to behave as equals with others in preparation for the day they leave home and start their own families. (Haley, 1963, p. 107) As an adolescent, the challenge is to separate from the parental home without cutting off ties. In a marriage, each partner must learn how to negotiate the rules of living together as well as negotiate who is to make the rules, and deal with the power struggles that arise. (Haley, 1963, p. 123) When children are born, new challenges arise, and in the transition to being grandparents there are fresh difficulties.
As an example of how Erickson helped some people in the transition to grandparenthood, a young woman came to Milton Erickson because she was alarmed about her possessive parents. What as most upsetting to her was that they'd built rooms onto their house so that when she married she could live there. Erickson saw the parents together, and they had a series of pleasant talks. He praised them for their solicitude, for being available as babysitters. He asked if they'd soundproofed the walls so the babies crying in the night wouldn't bother them. It so happened they hadn't. He congratulated them on being willing to put up with toddlers, with the way toddlers get into everything, and everything breakable has to be put away.
The parents decided they really didn't want their daughter living with them. They decided to rent the rooms to a quiet person and bank the money for their grandchildrens' future education. Erickson commented, "Is it essential to feel guilt? I don't believe in salvation only through pain and suffering." (Haley, 1973, pp. 280-282)
PART 3: MAJOR CONSTRUCTS (structural components of the theory)
CONSCIOUS MIND: Erickson believed the conscious mind primarily contains biases, rigid beliefs, and inflexible patterns of perceiving. (Collected Papers III, p. 90) He often went to great lengths to keep the therapeutic work from being examined and destroyed by the client's conscious mind. (Erickson & Rossi, 1979, p. xii)
UNCONSCIOUS MIND: Erickson's idea of the unconscious wasn't the same as Freud's. Erickson thought of the unconscious as a complex set of associations, automatic patterns which calculate, regulate, modulate and guide routine conduct. The degree of "out of awareness" of these patterns varies due to personal history, intensity of learning, subtlety of discrimination, and social sanctions against being aware. (Lankton, 1984, p. 8) He thought of the unconscious as a positive force which held more wisdom than the "conscious." If a person let their unconscious operate, it would take care of everything in a positive way. Erickson emphasized trusting the unconscious and expecting it to fulfill the greatest good. (Haley, 1993, p. 54)
MULTI-LEVEL COMMUNICATION: There are several simultaneous levels occurring in any communication. When the social level (usually in words) contradicts the psychological level (usually in
voice tone, emphasis, or body-language), the psychological level will determine the outcome. This principle is used to keep the therapist mindful and purposeful, to evaluate the client and to respond to all messages being sent by the client. Metaphor and indirect suggestion are capable of facilitating change without the client's conscious awareness. (Lankton, 1984, p. 26)
FUNCTION OF THERAPY: Erickson's approach to people was to teach the mind to concentrate on the countless learnings, potentials and resources that lie within. (Lankton, 1984, p. xiv) Often he would surprise, challenge or even shock the resource into the foreground. (Lankton, 1984, p. 18)
RESISTANCE: Clients aren't thought of as resistant. Erickson shaped the therapy to the client. He wrote: "If they bring in resistance, be grateful for that resistance. Heap it up in whatever fashion they want you to-- really pile it up.... Whatever the patient presents to you in the office, you really ought to use." (Erickson & Rossi, 1981, p. 16)
THE SOCIAL FUNCTION OF SYMPTOMS: Implicit in Erickson's way of working with clients is that a psychiatric problem is interpersonal in nature. The ways the client deals with other people and they with him cause his feelings of distress and restricted ways of behaving. Given this view, the problem of how to change the person often becomes one of how to change his relationships with others. (Haley, 1993, p. 33)
Relationships are either based on cooperation or power struggle. The most visceral level of power struggle is over who defines the relationship, who makes the rules. Haley (1963, p. 15) points out that "....the crucial aspect of a symptom is the advantage it gives the client in gaining control of what is to happen in a relationship with someone else. A symptom may represent considerable distress to a client subjectively, but such distress is preferred by some people to living in an unpredictable world of social relationships over which they have little control.
"A client with an alcoholic wife once said that he was a man who liked to have his own way but his wife always won by getting drunk."
A woman sought therapy because she was compelled to ritually wash her hands many times every day. Classically, her ritual washing would be seen as a defense against various ideas. However, in this case, her husband was brought into the therapy and an examination of the interpersonal context revealed an bitter struggle between the client and her husband over the compulsion. The husband was tyrannical about all the details of their lives. Although the wife objected to the husband's tyrannical ways, she was
unable to oppose him on any issue except her handwashing. Almost anything he suggested, she could refuse to do, using the handwashing. He was dethroned by the simple act of washing a pair of hands. (Haley, 1963, pp. 13-14)
As a consequence of the interpersonal nature of symptoms it is often more effective to use an ecological approach, to treat marriages and families rather than treating individuals. For example, the relatives of a client can be brought in to enlist their cooperation in producing a change. Partners in a marriage and people in a family fight both about what the rules of living together are, and even more strongly about who makes the rules. Since most symptoms are embedded in a relationship, a change can
often be produced more rapidly by working with an intimate of the ostensible client. (Haley, 1963, p. 50)
On the other hand, Erickson believed that a therapist received from a client what he expected to. He didn't like having therapists expect people not to change because they were stabilizing a system. He considered resistance important to circumvent, but he didn't like having resistance built into the theory. Typically he would see family members separately or in groups of two. The individual was at the heart of Erickson's theory. (Haley, 1993, pp. 190-191)
PART 4: APPLICATIONS (goals, process of change, interventions)
GOALS: In general, Erickson liked to describe therapy as a way of helping clients extend their limits. He saw therapy as a way of intervening in the life of a client in such a way that the client recovered from his current dilemma and was shifted to a more successful level of functioning in the real world. Other goals are for the client to become responsible, and to exchange symptomatic behavior for functional behavior. (Haley, 1993, p. 29)
More specifically, Erickson set forth various brief-therapy goals, such as symptom substitution, symptom amelioration, symptom transformation, and corrective emotional response. (Lankton, 1983,
Another major goal in therapy is for the therapist to maximize his own freedom to maneuver with the client. Erickson might sit and listen, or offer advice, or give directives, he might require an ordeal, or be kind. He cheerfully worked both with clients who liked him and disliked him. (Haley, 1993, pp. 15-16)
THE PROCESS OF CHANGE: Erickson didn't help the client bring unconscious ideas into awareness, understand how he dealt with others, understand the relationship of his past to his present, understand why he is the way he is or how he relates to others. (Haley, 1993, p. 34) Erickson didn't encourage the expression of feelings. His technique for stopping someone from crying who had
gone on too long was to hand them a Kleenex and comment, "At Christmas I give out green Kleenex." (Haley, 1993, p. 194) Erickson didn't assume therapeutic change occurs as a result of more awareness or knowledge in the usual sense. He didn't teach the client what he didn't know. Instead, he arranged a situation which required new behavior and consequently engendered a new experience of living. He provoked the client into a kind of action that would bring about change. Insight comes about of itself after a therapeutic change. (Haley, 1993, pp. 36 & 112)
EXPECTATION OF CHANGE: Erickson approached each client with an expectation that change is not only possible but inevitable. He was willing to assume that some changes in life must occur slowly, but he also accepted the idea that lifelong habits can sometimes change overnight. He acted as though change for the better is a natural development. (Haley, 1993, p. 17)
EMPHASIS ON THE POSITIVE: Erickson didn't explore the maladaptive thoughts and desires of a client, or a couple's hostility. Instead he would appreciate their positive aspects. What the client saw as a defect, he would redefine. A woman's large nose became what gave her character. (Haley, 1993, p. 18)
ACCEPTANCE: Ericksonian emphasized accepting what the client offers. The acceptance can later be followed by a change, and the change is more likely if the way has been paved by the need or behavior first being accepted. (Haley, 1993, pp. 19-21) All messages from the client are respected, rather than sensitive areas being challenged. Body-language messages are answered with body language, metaphors with metaphors. (Lankton, 1984, p. 15)
A new client entered the office and said all psychiatrists were best described by a common vulgarity. Erickson's immediate reply was, "You undoubtedly have a damn good reason for saying that and even more." The last four words were an intentional suggestion to be communicative, and the encouragement worked. (Haley, 1993, pp. 19-21)
A woman said there was a giant bear trap in the middle of the floor. Whenever she was in the room, Erickson carefully walked around that spot. He was courteous to his clients. (Haley, 1993, p. 86)
EMPHASIZING MULTIPLE POSSIBILITIES: Erickson's approach assumes a multiplicity of ways to solve the client's problems. One of the ways he altered the client's views was to relabel as positive those aspects of life the patient saw as negative, but there were many others. Erickson tried not to use the same solution twice. He also used puzzles, jokes, and puns. (Haley, 1993, p. 21)
WILLINGNESS TO TAKE RESPONSIBILITY: Erickson assumed that he would influence the client's life, so the questions were how to do it effectively and label it appropriately. However, the goal is for the client to develop into taking responsibility for their own life. (Haley, 1993, p. 22)
Erickson didn't compliment clients for acting normal. He assumed that clients should take responsibility for their own actions. If a person did well, Erickson responded as if that behavior belonged to the person, not to him guiding the person. "He who reinforces takes the power." But if he didn't use positive reinforcement, clients knew when Erickson was pleased. His compliment was in action or in other ways than verbal reinforcement. (Haley, 1993, p. 185)
BLOCKING OFF SYMPTOMATIC BEHAVIOR: This is the centerpiece of the process of change. Erickson would ease the client into a different style of behaving, or he would block the symptomatic behavior by relabeling, by "taking over," or with an ordeal. At the same time he would provide the client with new experiences which would prove more successful and satisfying than the old behavior. Erickson maintained that clients who recovered from a symptom didn't develop something worse, that the bump-under-the-rug metaphor isn't true. He said that recovery from a symptom promoted improvement in other areas. (Haley, 1993, pp. 22-23,35)
CHANGE OCCURS IN RELATION TO THE THERAPIST: Erickson established an intense relationship with his clients. Then he could bring about change using either cooperation or rebellion. If the issue of winning was important to the client, Erickson let the client defeat him. Then the client would go along on other issues that led to change. (Haley, 1993, pp. 23-25)
One way he got participation was by trailing off in the middle of saying something, so the client had to finish the sentence. When the client finished it, he was participating. (Haley, 1993, p. 94)
USE OF ANECDOTES: Erickson taught with the use of anecdotes that were related to the client's problem in some way, though usually in a way that wasn't obvious to the client. He sometimes used anecdotes to "peg" an idea so the client wouldn't forget it. (Haley, 1993, pp. 25-26)
WILLINGNESS TO RELEASE CLIENTS: Erickson didn't see the goal of therapy as a total clearance of all the client's problems. And so he gave them up to continue on their own, once obstacles were removed. Disengagement was built in from the beginning. (Haley, 1993, p. 27)
Observation and diagnosis are complex. Interventions themselves are simple. (Haley, 1993, p. 94)
Erickson said, "People come for help, but they also come to be substantiated in their attitudes and they come to have face saved. I pay attention to this, and I'm likely to speak in a fashion that makes them think I am on their side." (Haley, 1973, p. 206) "An attitude of empathy and respect on the part of the therapist is crucial to achieve successful change." (Erickson & Zeig, Collected Papers IV. p. 336)
"In therapy, you are very careful to use humor, because your patients bring in enough grief, and they don't need all that grief and sorrow. You better get them into a more pleasant frame of mind right away." (Zeig, 1980, p. 71)
"I dislike authoritative techniques and much prefer the permissive techniques as a result of my own experiences. What your patient does and what he learns must be learned from within himself. There is not anything you can force into that patient.... But there are times when the patient comes to you because he wants you to take responsibility, and there are times when you should take on such a responsibility, so you need to be aware of authoritarian techniques and be willing to use them.... There are some patients who cannot understand unless you take a figurativebaseball bat and hit them over the head with it, and in this case you ought to do it. But I think you have the privilege of whether the bat shall be of soft wood or of hard wood." (Haley, 1993, p.16)
"Teach choice; never attempt to take choice away. Create situations where the client willingly changes his thinking." (Erickson & Zeig, Collected Papers IV, p. 335)
A client's commitment to a change is established as quickly as possible. Erickson was once asked what information he would want from a woman who entered therapy because she had lost her voice four years previously and was unable to speak above a whisper. "For brief therapy," said Erickson, "I would immediately pose her several questions. 'Do you want to talk aloud? When? What do you want to say?'..." (Haley, 1963, pp. 42-44)
It is not enough to explain a problem to a client or even to have the client explain a problem himself. What is important is to get the client to do something. Erickson pointed out that it is insufficient to have a client with an oedipal conflict discuss his father. Yet, one can give the client the simple task of writing the word "father" on a piece of paper and then have him crumple it up and throw it in the wastebasket, and this action can produce pronounced effects. (Haley, 1963, p. 45)
In Erickson's approach, there is always an emphasis on the presenting problem. When a symptom is what the person seeks to recover from, Erickson worked directly on the symptom, and through it he made whatever changes in relationships were necessary. He argued that the symptomatic area is the most important and intense to the person with a problem, and therefore it's in this area that the therapist has the greatest leverage for change. (Haley, 1963, p. 179)
One of the characteristics of Erickson's therapy was the use of imagery. He would have a client imagine scenes in the past, present or future and use those to induce change. (Haley, 1963, p. 130)
Erickson said that he invented a new theory for each individual, and his flexibility and creativity were legendary. (Lankton, 1984, p. xv) Nevertheless, several features typify an Ericksonian approach:
(1) Indirection: indirect suggestions, binds, metaphors, and resource retrieval.
(2) Conscious/unconscious dissociation: multi-level communication, interspersal, double binds, and multiple embedded metaphors.
(3) Utilization of the client's behavior: paradox, behavioral matching, naturalistic induction, symptom prescription ("taking over" and directives), ordeals, and strategic use of trance phenomena. (Lankton, 1984, p. 6)
Indirect suggestions: Direct suggestion doesn't evoke the re-association and reorganization of ideas, understandings and memories so essential for an actual cure. (Erickson & Rossi, 1979, p. xii)
Erickson liked to direct clients in such a way that they could not recognize that they were being directed and so could not resist the directive. At times he would do this by dropping a casual comment, at other times he would arouse the client emotionally on one topic and then mention another, apparently unrelated topic at that moment. The client will "unconsciously" connect the two topics.
Another way Erickson would use to get over a suggestion indirectly was to tell anecdotes to clients. Often they would include an idea which the client could recognize and defend himself against, but while defending himself against that idea he was accepting others which encourage change. (Haley, 1963, p. 50)
Erickson communicated indirectly through choice of words and vocal inflections, as well as posture and movement. He emphasized certain words in a sentence and so was saying one thing while suggesting another, and perhaps offering a third suggestion with body movement. (Haley, 1993, p. 184)
Metaphors: Although Erickson communicates with patients in metaphor, what most sharply distinguishes him from other therapists is his unwillingness to "interpret" to people what their metaphors mean. He does not translate unconscious communication in to conscious form. Whatever the patient says in metaphoric form, Erickson responds in kind. By parables, by interpersonal action, and by directives, he works within the metaphor to bring about change. He seems to feel that the depth and swiftness of the change can be prevented if the person suffers a translation of the communication. (Haley, 1973, pp. 28-29)
Double bind: This is a paradoxical communication where a message at one level conflicts with a message at another level, and the client has to respond and can't leave the field. A classic example is the directive, "Disobey me." (Haley, 1993, p. 149) A therapeutic double-bind is one where no matter what the client does, he gets better.
Paradox: One use of therapeutic paradox is the client's rebelling against the therapist by not doing the problem behavior. (Haley, 1993, p. 69) Another is that Erickson had the client experience a distressing symptom deliberately. (Haley, 1993, p. 65) Reframing, redefining and relabeling are paradoxical tehcniques.
Behavioral matching: Some forms of behavioral matching are: posture, body language, breathing rate, blink rate, tone and rhythm of voice, vocabulary, syntax, style of relating, apparent-age, attitudes and beliefs. It can also be done with metaphor. This is for initial rapport-building. This refers to meeting the client at his or her model of the world, not staying or living there. The goal is to teach the ability to make new choices. (Lankton, 1983, p. 18)
Symptom prescription: Give directives to clients, accepting the client's behavior, but in such a way that a change is produced. For example: a client came to Erickson reporting that he was lonely and had no contact with other people. All he did was sit alone in his room and waste his time. Erickson suggested he should go to the public library where the environment would force him to be silent and not have contact with others. At the library he should waste his time. The client went to the library and, since he was an intellectually curious fellow, he began to idle away his time reading magazines. He became interested in articles on speleology, and one day someone at the library asked him if he was interested in exploring caves too, and the client became a member of a speleological club which led him into a social life. (Haley, 1963, p. 46)
Erickson was a master at getting his suggestions followed. One factor was his sureness. Often the client was encouraged to follow Erickson's suggestions to prove him wrong. Erickson also encouraged clients to follow his directions by emphasizing the positive aspects of the client's life so that they were pleased to cooperate with him. Besides this context, he made suggestions which the client could easily follow and, in fact, emphasized how the client was doing this anyway. (Haley, 1963, p. 46)
Erickson would persuade a client to accept a suggestion by making it seem quite minor in nature. He would induce a cumulative change but base it upon so small a change that the client could accept it. He might ask a client with insomnia to report next time that he believed he slept one second longer one night. (Haley, 1963, p. 50)
Ordeals: People with strong will-power can be given ordeals. If one makes it more difficult for a person to have a symptom than to give it up, the person will give up the symptom. The best self-punishment is that which is of benefit to the client. If a man who feels he should exercise more is required to get up in the middle of the night and do a number of deep knee bends whenever he experiences his symptom, then he is benefiting whatever he does. (Haley, 1963, p. 56, and Haley, 1993, p. 64) The therapist can say, "I know how hard it is to get up in the middle of the night like that, because I myself so enjoy sleeping soundly all night through." (Haley, 1993, p. 72-73)
Strategic use of trance phenomena: One does not use hypnosis to suggest away a pain, but to establish a certain kind of relationship and to convince a patient that his symptomatic behavior can be influenced. Erickson's work is replete with examples of relieving a symptom in trance and then suggesting that it recur later under controlled circumstances. For example, in patients with functional pain, he will accept the pain as real and necessary but shorten the time of it, change the moment of occurrence, shift the area in which it occurs, or transform it into a different sensation. (Haley, 1963, pp. 44-45)
PART 5: EVALUATION (supporting research, limitations)
SUPPORTING RESEARCH: Erickson researched hypnotic phenomena extensively. He investigated such questions as whether he could influence a person to be unable to hear, unable to seem unable to see colors, unable to experience physical sensations, unable to resist anti-social influences, and unable to be aware of the thought processes behind his behavior. He also examined how much could be achieved in the increase of sensation, as well as a person's subjective perception of time and space. When it was assumed that the words and behavior of a patient were a product of certain types of unconscious mentation, he tested this notion by providing subjects with ideas and emotions, rendering these amnesic, and then observing the outcome behavior. The series of research papers reporting these investigations represent some of the most solid work ever done in the field. (Haley, 1993, pp.10-11)
Gregory Bateson, John Weakland, Jay Haley, Don Jackson and William Fry researched Dr. Erickson's work from 1952 to 1962. They published over seventy articles and books, on subjects ranging from schizophrenia and hypnosis to therapy and paradox. (Haley, 1973, p. ix)
LIMITATIONS: Ericksonian Therapy doesn't seem to have any limitations if you happen to be Milton Erickson. His career covered the full range of human problems. He eased the strains of birth, helped terminally ill clients deal with pain, worked with childrens' problems, adolescent difficulties, marital struggles, dilemmas of middle age and retirement. Not only did he work with the neurotic and psychotic, but as well with the brain-damaged and physically handicapped. He treated individuals, couples and family groups. He was known to have family sessions with only the client present by having the client in trance hallucinate the other family members.(Haley, 1993, p. 13) Some of his few failures occurred when he joined a child against the parents and didn't think the parents had to be helped to help the child. He was so fond of children and so irritated with parents who behaved badly that at times he would set out to save children from parents. (Haley, 1993, p. 197)
But if you don't happen to be Milton Erickson, the limitations are the same as those for Zen or any art form. All forms of therapy are both art and science, but for this one more than most, one is limited by one's level of expertise, by one's attainment.
PART 6: CASE STUDY
(Describe Maria's behavior and circumstances using the terminology and constructs from the theory. Then for the treatment plan list the goals for the course of treatment you would provide for Maria. Under each goal, VERY BRIEFLY describe each intervention you would employ to achieve the goal.)
MARIA'S BEHAVIOR: She relates easily and expresses herself well, showing that she has social and intellectual resources that can be recovered. Her body appears tense and her voice is strained, suggesting that her choices (while the best she can make) are taking a personal toll. She says she is depressed and has "unexplained" crying spells, is unable to eat, has insomnia and is suffering from nightmares. She has thoughts of suicide. She says she's losing control of her children, suggesting that they want strength from her and are acting out in search of boundaries. Her depression keeps her away from people, suggesting that the function of depression for her is providing a feeling of safety. She has difficulty with her parents, suggesting that the adolescent challenges of leaving home while remaining a member of the family are unresolved. She's frequently absent from her teaching job. She's unable to maintain relationships with men she's been dating, afraid to trust them, suggesting that she hasn't completed grieving for her ex-husband's loss. She's pessimistic about her future. She says, "I have nothing to live for. No one cares about me. I've ruined my life and the life of two families, and I'm currently hurting my children."
MARIA'S CIRCUMSTANCES: She is 32, Hispanic, and Catholic, suggesting that she has resources of youth, culture and religion to draw on. She's a single mother raising two children, without asking for the help she needs. Her principle is recommending a leave of absence, which would mean moving back in with her family, which would be a failure of her task of establishing her independence. Her relationship with her parents was strained by attending college 200 miles from home and by marrying outside her religion and culture. Maria didn't reconnect with her parents till her children were born, and her parents are involved with their grandchildren. Her husband was physically and emotionally abusive. Maria and her husband have been divorced for three years, and he has no contact with Maria or his children.
(0) Provide Maria with new experiences which are more successful and satisfying than her old behaviors. Her old behavior is defying and abandoning her parents and culture, cutting herself off from support. She needs support and feelings of safety. She needs directives that give her these while still feeling that she's being defiant and independent, and at the same time teach her new choices.
It's important that Maria not feel overwhelmed. One of these interventions would be plenty to start with, perhaps (1), (7), or (8). Once Maria is started, she will develop momentum and fix her life on her own.
(1) Establish rapport.
INTERVENTION: with matching. One way is to say, "You have nothing to live for. You're alone and uncared for. You've unfortunately ruined your life and your children's lives. Given that that's the situation, what do you want to do?" Ask her what treatment she'd recommend for someone like her.
(2) Deal with depression.
INTERVENTION: Encourage her to talk about it, relabel it as concern for herself and her children, ask her to create images of a future without depression, or schedule feeling depressed for a certain time of day, perhaps efore going to bed. Ask her to review her life and criticize the "good girl" she tries to be. Explore whether referral to a priest is appropriate to re-establish her relationship with her church.
(3) Deal with crying spells.
INTERVENTION: encourage them as healthy, schedule them for certain time of day, perhaps after sending the children to school or before going to bed. Have her try cursing instead of crying.
(4) Deal with insomnia.
INTERVENTION: ask her to report next session that she slept one second longer. Ordeal: if can't go to sleep, get up and pray for an hour or have something to eat.
(5) Deal with suicidal thoughts.
INTERVENTION: explore how bad it has to get before she would do that, in order to deal with confusion, and then ask her why not do things differently as long as she's going to die anyway.
(6) Deal with inability to eat.
INTERVENTION: directive to fast for a day.
(7) Deal with absences from job.
INTERVENTION: directive for Maria to request several days off from work and rest.
(8) Deal with distance from parents.
INTERVENTION: direct her to "trick" her parents into taking the children for awhile; have her begin by appreciating them for caring about the kids.
(9) Deal with staying away from other people.
INTERVENTION: directive to stay totally away from others for a day or two, and then to spend some fun time with her friends and family.
(10) Deal with losing control of children.
INTERVENTION: directive to spend queality time with the kids, perhaps take them on a trip. Or perhaps a directive to ask them to lay down face-down on the floor and sit on them, one at a time, playfully. Once they realize they can't get up let them up.
(11) Deal with distrust of men.
INTERVENTION: Have her write her ex-husband's name on a piece of paper and tear it up. Give her a directive to continue dating in a light-hearted way and observe how many ways other men are different from her ex-husband. Ask her to future project and describe a good relationship.
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