utilizing ericksonian hypnosis in psychiatric

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Utilizing Ericksonian Hypnosis in Psychiatric-Mental Health

Nursing Practice

Zahourek, Rothlyn P., Perspectives in Psychiatric Care

TOPIC. Ericksonian hypnosis conceptual framework.

PURPOSE. To acquaint psychiatric-mental health nurses with hypnotic principles and how these can beintegrated into their practice.

SOURCES. Published literature and author's clinical experience.

CONCLUSIONS. Ericksonian hypnosis offers an array of potential interventions for psychiatric-mental health

nurses to integrate into their practices in a framework familiar to nurses: holism, honoring and respecting

individuality, and capitalizing on an individual's strengths.

Search terms: Communication, Ericksonian hypnosis, indirect suggestion, psychiatric-mental health nursing

practice, suggestion

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Clinical hypnosis is a therapeutic tool and not a therapy in itself. Thus, it can be incorporated into nearly any

form of therapeutic communication or psychotherapy modality. Clinical hypnosis is a process of observing and

co-creating states of consciousness with another person and participating in a relationship in which the purpose

is some sort of change for that client. Contrary to how Hollywood might present it in a sci-fi movie, hypnosis is

not done to another and is not a manipulative power play. If hypnosis were so powerful, we would have a

foolproof method to help people change unwanted behaviors and perceptions. Hypnosis differs from relaxation,

imagery, and biofeedback modalities in focusing on how and when suggestions are incorporated into the

intervention.

Hypnosis' long legacy in psychiatry really began with Freud in his development of psychoanalytic theory

(Zahourek, 2001). Freud's contemporaries used hypnosis successfully to provide surgical anesthesia before the

development of chemical anesthesia. Hypnosis was later used in World Wars I and II to "cure" soldiers

experiencing "battle fatigue" (post-traumatic stress disorder) so they could return to the front. To date we still

do not know exactly what hypnosis is and why it is successful with some and not others. Theories abound, and

well-controlled research continues to yield contradictory and confusing results regarding one form of hypnosis

being more effective than another (Mathews, 2000). Most clinical practice continues to rely on theory that has

been derived from the many published anecdotal case reports rather than on double-blind controlled studies.

Researching hypnosis with its many individualistic and uncontrollable variables is similar to researching

psychotherapy itself.

Ericksonian hypnosis, developed by psychiatrist Milton Erickson (1901-1980), offers psychiatric nurses a

unique opportunity to expand their repertoire of practice. Ericksonian hypnosis is both simple in being an

intentional form of communication, and complex in its capacity to help individuals learn self-soothing

techniques and to restructure ego defenses and strengths in psychotherapy. The framework is useful for both

long-term psychodynamic therapy and for shorter-term, solution-oriented treatment.

Ericksonian psychotherapy can be employed with clients who have various diagnoses including anxiety,

phobias, habit disorders, depression, and post-traumatic stress. This article explores some of the basic

approaches of Ericksonian therapy and offers examples for integrating these into psychotherapy. The focus is

on integrating these techniques without formal induction techniques. I hope psychiatric nurses will respondwith "aha," stating to themselves, "I already do some of that naturally." A goal subsequently is for nurses to use

these tools more intentionally, skillfully, and purposefully in their practice. Further, this approach to

psychotherapy and hypnosis draws on a basic psychiatric nursing tenet I was taught in a foundations of nursing

class: "All behavior is meaningful, purposeful, and can be understood."



Ericksonian Hypnosis

Milton Erickson, considered the father of American hypnosis, developed his unique brand of hypnosis based on

approaches he called naturalistic, utilization, and indirect (Erickson & Rossi, 1979). These approaches

incorporated the waking trance and the appreciation of such seemingly negative characteristics in

psychotherapy as resistance (Yapko, 1995).

Naturalistic approach. Erickson had polio as a child and spent time in an iron lung, from which he watched his baby sister learn to walk. He developed acute observational skills that he later used in his theory and clinical

practice development. For example, he used his observations of how his sister learned basic skills in his later

trance-induction techniques. According to Erickson (Erickson & Rossi, 1979), we learn skills such as walking,

bike riding, and swimming one muscle and one step at a time. When we learn these skills, the steps are

indelibly imprinted in our nervous systems and become automatic and unconscious behaviors. To become

mentally aware of such minute steps takes concentrated work and effort, employing both visual and kinesthetic

recall of when and how we learned them. The early learning was so concentrated that it occurred in an altered

state of consciousness. As a result, it can be more readily remembered in a trance state. Incorporating such

universal and natural experiences into what Erickson believes is a naturally occurring process of altered states

of consciousness or trances is called the naturalistic approach (Yapko, 1995).

Utilization approach. Erickson believed that everyone's level of awareness--consciousness--varied throughout

the normal passage of time. These variations, or circadian and diurnal rhythms, provide a continuum or

consciousness from alert waking, to semialert but usually focused trance, to sleep (Rossi, 1991). Stress or crisis

alters the level of awareness, catapulting the individual into a trance state in which he or she is more susceptible

to new ideas or suggestions. In Ericksonian theory, a formal induction of a trance state that characterizes more

traditional forms of hypnosis is not necessary for the individual to become more susceptible and suggestible. In

a waking trance, the individual may be as receptive to suggestion as in a deep trance. The utilization approach,

basic to Ericksonian hypnotherapy, reflects the theory's tenet, which is to accept the client as a unique

individual and appreciate where he or she is. This statement summarizes an important Erickson principle that

values individual characteristics, including such phenomenon as resistance and how resistance can be used in

psychotherapy.

Indirect approach. Another hallmark of Ericksonian hypnosis is the indirect approach, which is distinguished

from directive and authoritarian approaches in traditional hypnosis. In such traditional forms, specific

suggestions for a behavior change or an outcome usually are given in an authoritative manner. Suggestions such

as "relax and soften your muscles; become aware of your breathing; stop smoking now; let the blood flow more

easily to your feet; remember a time when you felt in control" are examples of direct approaches. Suggestions

constructed indirectly may be unusual in nature. Erickson is known for such indirect interventions as

paradoxical intent (Haley, 1973), therapeutic metaphors (Kopp, 1995), and story telling (Lankton & Lankton,

1988; Larkin & Zahourek, 1988), and the creation of a positive atmosphere through "yes sets."

The core ideas of Ericksonian hypnotic psychotherapy--utilization, naturalistic approach, the waking trance,

appreciating resistance, and indirect suggestion--differentiate it from traditional hypnosis and are also familiar

concepts in nursing. Hildegard Peplau (1957/1982), in her classic paper "Therapeutic Concepts," states that

psychiatric nurses must have "an understanding of the concepts of awareness and unawareness, attention and

inattentions, especially with regard to relations between feelings, thoughts and actions.., to grasp the hidden

meaning of symptoms and other forms of communication used by patients ..." (p. 102).

Basic Concepts of Traditional and Ericksonian Hypnosis

Consciousness. Consciousness is viewed as a highly variable subjective mental state of awareness, and as

fundamental neurological processes of perception, sensation, movements, and cognitions (Erickson, 1980).Consciousness varies according to one's interpretation of experience, which in turn depends on one's previous

experiences and sociocultural background. Consciousness may be altered purposefully though one's will, or

change spontaneously as a result of environmental stimuli. Emotionally charged events and boredom both are

associated with such alterations. Alterations occur naturally and are part of everyone's normal experience.



Trance. Trance is a changed state of awareness or consciousness. It varies naturally and continuously. Most

people have experienced at least a light trance, such as becoming completely absorbed in a good book and

losing track of time and orientation to place. According to Erickson (1967/1989), the degree of trance in a

therapeutic situation depends on rapport in the hypnotic relationship, and on the client's need and the

circumstances of the interventions. In the trance state, the therapeutic work is done but a deep level is rarely

necessary for the success of that work. In Ericksonian hypnosis, change is less dependent on depth than on

desire, motivation, and the receptivity to accept the suggestions from another on either a conscious or an

unconscious level.

A trance is characterized by catalepsy, suggestibility, dissociation, time distortion, and amnesia or

hyperamnesia.

* Catalepsy is a state of balanced muscle tonicity that allows individuals to remain in one position for long

periods of time. A waking trance occurs naturally and appears as an open-eyed glassy stare. The person is able

to carry on normal activities. People driving long distances often experience a sense of losing time and

wondering how they got from point A to point B; this is a classic example of the waking trance.

* Dissociation, while considered to be a characteristic of trance, may also occur naturally without trance

induction. It is a natural "ability to break a global experience into its component parts, amplifying awareness for one part while diminishing awareness for others" (Yapko, 1995, p. 115). O'Hanlon (1987) described

dissociation as a separation of psychological states: consciousness from unconsciousness, emotions from

thoughts, feelings, and behaviors. Erickson (1967/1989) viewed dissociation as a detachment.

Therapeutically, dissociation enables an individual to experience past, present, or future painful (physical or

emotional) experiences from a distance. It is characterized by a sense of distance, disconnection, numbness, and

disbelief.

* Time distortion, experienced as time expanded or shrunk, is also a hypnotic trance phenomenon. In hypnosis,

the value placed on a past, present, or future experience also can be altered.

* Amnesia or hyperamnesia is loss, or intensification, of feeling states and recall. These, too, may be altered in

one's present or past experience when using hypnosis. All these trance phenomena may be used therapeutically

to anticipate new experiences or to relive old ones in a revised manner.

Suggestion. Suggestibility is a central phenomenon of hypnosis. It is an enhanced receptivity to new ideas and

an altered responsiveness to stimuli. In order for a person to act on the content of the suggestion, it must be

acceptable to the individual. When suggestions are accepted, the person may experience profound changes such

as temporary hallucinations and dissociations, deafness, blindness, amnesia, or numbness. Again, these

phenomena may be used therapeutically to help people realize the numerous capacities that are available to

them in their own consciousness.

Giving suggestions is the means of hypnotic communication, which occurs in numerous forms. Direct or

indirect suggestions are the most basic forms. A direct suggestion provides specific information or directions

that usually includes an outcome (e.g., "You can go to that party tomorrow without feeling anxious"). An

indirect suggestion is less authoritative and allows room for interpretation (e.g., "When you attend the next

party, you may find you are increasingly comfortable"). In the last example, time (when) and degree of comfort

(may, increasingly) are both left vague. The previous suggestion might be made even more indirect by stating,

"When you decide to go to a party, you may find it interesting how your feelings have changed." The decision

of going to a party, the timing, and the responses anticipated to the whole process are framed positively but the

specifics are left nonspecific, allowing the client to fill in the gaps.

Because indirect suggestions are believed to bypass resistance, theorists contend that the frequency of using

these suggestions should be proportional to the degree of the client's resistance (Zeig, 1980). Indirect

suggestions may be integrated or interspersed in conversations and may be based on obvious truths that the



client will find agreeable. These are described in Ericksonian theory as interspersed, truisms, and yes set

suggestions. In practice, Erickson and most clinicians use a blend of direct and indirect suggestions.

In normal interactions, people use suggestions all the time. Suggestions are more powerful when the

individual's level of awareness has shifted (a trance state). Observing for these subtle changes provides

opportunity for clinicians to make therapeutic comments (suggestions) that have greater potential for realization

than those given in usual conversation. The therapist's tone, movements, change of cadence and rhythm of

speech, and demeanor can "anchor" or reinforce the suggestion (Bandler & Grinder, 1979). Anchoring provides

an additional nonverbal form of suggestion that evolves naturally out of the process of the interaction and isused intentionally by the therapist.

Basic Ericksonian Concepts of Hypnotherapy

The heart of Ericksonian hypnotherapy is the utilizationy concept, or "accept and utilize" (Yapko, 1986, 1990).

In practice this is an expanded version of accept the client where he/she is and plan and execute every

intervention based on that knowledge. The utilization approach depends on a knowledge and understanding of

the patient as a total psychosocial-spiritual-sociocultural being who has values and behaviors in concert with

that wholeness. Utilization is also a holistic process of "incorporating aspects of the client's existing behavior

and perceptions, current and past relationships, life experiences, innate and learned skills, and abilities into the

therapeutic change process" (Dolan, 1985, p. 6). The utilization approach is truly "walking in another's shoes."It is a way of both viewing and interacting with the client, and requires the therapist's respect of the person as

well as an understanding and acceptance of him- or herself. In this framework of respect, the therapist accepts

the meaning and value of the client's resistance and appreciates the unconscious need to keep symptoms even

when the client consciously wishes to be rid of them. The utilization approach helps the client transpose

symptoms into something more friendly, familiar, and manageable so that the individual feels more in control.

Yapko (1986) summarizes the characteristics of the utilization approach as follows: (a) each person is valued as

unique, (b) the client's experience is valid for him or her, (c) each person assigns meaning to his or her

experiences based on the person's unique frame of reference, and (d) a way to "accept and utilize" is to join the

person at his or her flame of reference. One manifestation of this is to use the client's form of language.

Reframing. As an Ericksonian approach, reframing reflects the principle of accept, utilize, and modify. A

common example of reframing is viewing one's situation in a different context (e.g., a crisis as both a dangerous

event and an opportunity for growth).

Ericksonian psychotherapy is inherently optimistic. It contends that change is possible and, in fact, inevitable.

"Ericksonian utilization, with its inherent perspective of optimism and non-judgmental posture, offers as

antidote for the demoralization that handicaps therapists working with clients labeled chronic and resistant"

(Dolan, 1985, p. 2).

Ericksonian naturalistic approaches focus on the here and now and everyday experiences. These common

experiences are used as precursors to trance. The client's "naturally occurring behavior in the here and now.., is

used to absorb attention, redirect it inward, and induce trance" (Edgette & Edgette, 1995, p. 9). The therapist's

incorporating natural internal experiences such as memories, images, and kinesthetic sensations to induce

trance facilitates that process. Using an Ericksonian approach, the therapist creates an optimistic future-

solutions orientation that is based on the recognition of the client's resources rather than on liabilities or past

problems (Edgette & Edgette, p. 9).

The Process of Ericksonian Hypnosis

The process of Ericksonian psychotherapy is similar to psychotherapy but emphasizes both client and therapist

awareness and subtle behaviors.

* The therapist learns about the client's background, culture, processes of learning, areas of stuckness and

resistance, desires and goals, strengths, and talents. This is essential for the process to begin.



* The therapist secures and maintains the client's attention by talking with the client about what brought him or

her to treatment, "telling absorbing stories that parallel the client's experience," or by doing "something

unexpected" (Yapko, 1995, p. 100).

* The therapist notices the increased signs of the client's focused attention (e.g., changed breathing, glassy-eyed

stare, catalepsy).

* The therapist can deepen the state using direct and indirect suggestions such as saying, "That's right; I can see

you are really contemplating this matter. Can you allow yourself to find a new way to view this situation--maybe something you did in the past or maybe from the ideal, or from the perspective of how you would like to

see the resolution, or maybe through the view of someone else that you care about? How would that person

interpret the situation?"

* The client engages in a mental internal search, using past experiences and the vision of a future resolution.

This internal search encourages the person to conduct a review of resources from within as well as from others

who are both idealized and valued or from those who may hold opposing views and values.

* The therapist paces with the client. He or she may breathe in the same rhythm or sit in the same posture. The

goal of pacing is to sense as much as possible how the client is feeling.

* The therapist leads the client into deepening the experience and considering new possibilities (e.g., "Allow

yourself to more deeply appreciate your experience. Can you enhance it even more?").

* The client experiences an unconscious search, and his or her perspective begins to expand.

* The client's imagery may be engaged, through which experiential, problem-solving, and behavioral rehearsal

is possible.

* The therapist reinforces the experience (e.g., "You have accessed a new part of yourself that has infinite

possibilities ...").

* The therapist provides posthypnotic suggestions (e.g., "You have accessed a new part of yourself that has

infinite possibilities ... to help you solve past, current, and future problems.... You may find newer solutions as

time goes on and you will find this experience accessible to you in your memory bank of problem-solving tools

that you can use any time you so desire."). According to Yapko (1995), posthypnotic suggestions form a

necessary bridge for the client to convert the internal, hypnotic-state, specific suggestions into external future

perceptions, cognitions, feeling states, and behaviors (p. 77).

* The therapist helps the client associate this experience with future problem-solving capacities.

Ericksonian Techniques

Within the above process, Ericksonian techniques of therapy are evident. Many have been described in the

literature. The following are illustrative clinical vignettes.

Utilization. Ms. Paul is relating how much she did not want to take a midwinter trip to visit her parents in a

Florida retirement community. She states, "I should be grateful. Everyone wants to leave the ice and snow and

go to Florida. But I'm dreading it. I feel guilty. Lots of people would love this opportunity." She sat quietly

staring off into space, her breathing more shallow as she appeared to be visualizing some aspect of the trip.

The therapist responded, "Well, maybe some people would be grateful to get away from the cold [agreeing with

the client and not countering her experience; joining the resistance], but how many people do you know find itfun when they're in their 30s to visit a retirement community even if it is warmer [adding an element of doubt;

creating a yes set]?" She thought about that and stated, "Gee, I don't know anybody who would want to do that!

Maybe I'm not so different." This is a very brief example of not confronting the resistance, "I need to feel guilty



and ungrateful. And I am surely different form everyone else," with "Maybe I am not so different; is that

possible? Maybe I don't need to feel so guilty."

Reframing and utilization. A client in a dual-diagnosis program for substance abuse and mental illness had been

encouraged to take Antabuse to curb his relapsing course with drinking alcohol. He was resistant and stated he

was too anxious. The therapist stated, "You know, this medication does not only react badly with alcohol; it is

also an antianxiolytic." The client looked at the therapist as if she were crazy, knowing full well that the

medication was not classified as antianxiety. The therapist had his full attention and stated, "You know that if

you don't have to worry so much about drinking that you will be less anxious; antabuse is an antianxiety med inthat sense." The client laughed and still resisted. Two weeks later he stated, "I want to take that antianxiety

medication you talked about." This is an example of reframing and utilization of the client's resistance and

using humorous metaphor.

Metaphors. A metaphor is a term that stands for something other than its usual meaning. Metaphors can be

powerful psychotherapeutic tools. Often, metaphors help clients circumvent resistance and help them see things

in a different light. They may be used as a tool to enable a reframing process. When perceptions change, feeling

states are likely to change as well. Clients then are more able to think about new approaches and behaviors.

Common metaphors act as lenses and filters for viewing reality. Seeing the glass `full' or `empty' is a common

metaphor for optimism and pessimism. Learning basic skills and progressing normal processes such as the

seasons or growth and development are common metaphors for change.

Metaphors of machinery and maintenance of machinery may be metaphors for self-care and survival under

adverse circumstances (Larkin & Zahourek, 1988). For example, Sally had suffered a brain injury in an

accident and had been trying to adjust several years to her inability to withstand stimuli. She described feeling

flooded and overwhelmed, and that her filter no longer worked. The therapist felt the filter metaphor would be

useful to help her develop increased capability to withstand stimuli. The therapist asked the client to describe

the filter as she experienced it in the present. Sally concentrated on the image and exhibited a glassy-eyed stare

as she described the filter as "It's like an old wire mesh kitchen sieve; it has holes in it and it's rusty and

dilapidated." The therapist asked, "What would a brand new one look like that you just bought at the hardware

store?" Sally responded, "It's shiny stainless steel, very strong, and all the holes are uniform and even; it's easy

to work with because it has a nice sturdy wooden handle." The added metaphor of a sturdy handle indicated a potential for her having control over "her new mental metal filter." She enjoyed the image and the metaphor of

being able to screen out stimuli when she needed. She used this successfully in many situations when she felt

potentially overwhelmed.

Integrating suggestions into conversation. During the course of a therapy session in which John was struggling

with trying to decide what to do with his problematic marriage, the therapist asked him to stop for a moment

and sit quietly. She changed the tone of her voice, setting the stage for a change in the level of their awareness

and stated, "You have many options, and several are painful to consider. Have you in the past ever been

plagued with a decision and decided to just `sleep on it'? Isn't it amazing how the next morning, or maybe even

the next afternoon, you get a `mental flash' and you know exactly what to do? The decision is made and it just

`feels right.' I wonder if some night before you go to sleep you might consider trying that and see what

happens." This is a set of indirect suggestions that include establishing a "yes set" with a "truism" (you have

many options and if you "sleep on something" the answer comes). The process is permissive in asking the client

"if" he wants to try "some" night. It is left up to John to decide when, and if, he will try. The realization of the

suggestion is more probable since the suggestion is based on an already familiar experience.

Paradoxical suggestions. A paradoxical suggestion joins with the client's resistance and encourages the client to

accentuate what he/she has been trying to change. This often demonstrates to clients that they, in fact, do have

more power and control than they thought. Paradoxical suggestions have to be used carefully. A therapist would

not want to increase a behavior that is potentially life-threatening, such as drinking alcohol or taking illicit

drugs. Paradoxical suggestions might be used with an obsessive compulsive who is having trouble withrepetitive thoughts or behaviors. Initially the therapist can say, "You have struggled for years not to count every

book on my bookshelf. Why don't you take time now to count them twice and let me know when you are

finished."



Precautions for Integrating Hypnotic Techniques

While hypnosis is considered to be a safe intervention for most psychiatric disorders and for many medical

conditions, nurses should be cautious about using formal trance inductions and suggestions without formal

training in hypnosis and a background in psychiatric nursing. Novice clinicians should avoid clients who are

psychotic, severely character disordered, exceptionally dependent, or have suffered severe trauma and abuse,

and those who may develop an eroticized transference toward the therapist. These conditions are especially

risky because of the potential for the emergence of primitive and overwhelming affective states and subsequent

personality disorganization (Edgette & Edgette, 1995). Literature and research exist on hypnotic applicationsfrom both a clinical and a legal perspective (Scheflin & Shapiro, 1989). Training is available through numerous

resources, including the American Society of Clinical Hypnosis and The Milton H. Erickson Foundation in

Phoenix, AZ. Many universities and medical schools provide workshops, courses, and training. Few nursing

programs at present offer specific content in clinical hypnosis, although many teach relaxation and guided

imagery as well as techniques for communication.

Conclusion

Ericksonian hypnotic techniques offer an array of potential interventions for the psychiatric-mental health nurse

to integrate into practice. Furthermore, the approaches are based in a theoretical framework that is familiar to

nurses: holism, honoring and respecting individuality, and capitalizing on an individual's strengths rather thanweaknesses. An appreciation for alterations in level of awareness and the therapeutic use of suggestion may

enhance all caregivers' practices. Psychiatric nurses will find numerous opportunities to implement the concepts

and interventions described in Ericksonian hypnosis.

References

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Press.

Dolan, I.M. (1985). The path with a heart. New York: Brunner Mazel.

Edgette, J.H., & Edgette, J.S. (1995). The handbook of hypnotic phenomena in psychotherapy. New York:

Brunner Mazel.

Erickson, M. (1980). A special inquiry with Aldous Huxley into the nature and character of various states of

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Scheflin, A.W., & Shapiro, J.L. (1989). Trance on trial. New York: Guilford Press.

Yapko, M. (1986). Ericksonian hypnosis. In B. Zibergeld, G. Edelstein, & D. Araoz (Eds.), Hypnosis:

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Yapko, M. (1995). Essentials of hypnosis. New York: Brunner Mazel.

Zahourek, R.P. (2001). Trance and suggestion: Timeless interventions and implications for nurses in the new

millennium. Holistic Nursing Practice, 15(3), 1-10.

Zeig, J. (Ed.). (1980). Teaching seminar with Milton H. Erickson, M.D. New York: Brunner Mazel.

Rothlyn P. Zahourek, PhD, RN, CS, HNC, is a Junior Research Associate, New York University, Division of

Nursing, New York, and has a private psychotherapy consultative practice in Amherst, MA.

Author contact: [email protected], with a copy to the Editor: [email protected]

utilizing ericksonian hypnosis in psychiatric

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