Toward a scientifically based understanding of Milton H. Erickson's strategies and tactics: hypnosis, response sets and common factors in psychotherapy

Contemporary Hypnosis (2004)Vol. 21, No. 2, 2004, pp. 63–78

TOWARD A SCIENTIFICALLY BASED UNDERSTANDING OFMILTON H. ERICKSON’S STRATEGIES AND TACTICS: HYPNOSIS,RESPONSE SETS AND COMMON FACTORS IN PSYCHOTHERAPY

Steven Jay Lynn and Michael N. Hallquist

State University of New York at Binghamton, New York, USA

Abstract

This article updates and extends earlier efforts (e.g. Sherman and Lynn, 1990; Lynn andSherman, 2000) to characterize Erickson’s work on the basis of the scientific literatureand Kirsch and Lynn’s (see Kirsch and Lynn, 1998) response set theory. It identifiestherapeutic mechanisms and learning processes inherent in Erickson’s work thatconstitute ‘common factors’ potentially responsible for the effectiveness of diversepsychotherapeutic and hypnotherapeutic approaches. We argue that many of Erickson’screative techniques were effective in establishing a strong therapeutic alliance and engen-dering, fortifying and maintaining positive response sets while removing impediments tothe automatic activation of positive response sets and altering or deautomatizingmaladaptive response sets.

Key words: common factors, hypnosis, psychotherapy, response sets

Introduction

The late Milton H. Erickson is renowned as a master hypnotist and as a therapist withoutpar. Since his death in 1980 his work, and some would say his legend, lives on, abetted bythe establishment of numerous Ericksonian institutes that have sprung up over the world,and many books and articles that have been inspired by his work. A skilled practitioner ofhypnosis lacking familiarity with Erickson’s approach to hypnosis is akin to a physicistlacking familiarity with quantum mechanics. Unfortunately, many of the remarkablycreative techniques that Erickson innovated have not been subject to careful, wellcontrolled research, even though they have entered the mainstream of clinical practice.Anecdotal reports, no matter how intriguing and fascinating, do not constitute a soundrationale on which to base clinical practice. We stand on firmer ground when a particulartechnique or approach is supported by theory and research.

With few exceptions (Matthews, Conti and Starr, 1998), neither Erickson nor many ofhis followers have articulated a scientific rationale for his approach. In 1984, the atheo-retical nature of Erickson’s work spurred Hilgard to observe that ‘the central core ofErickson’s varied practices is elusive’ (1984: 257). Since that time, Lynn and Sherman(Sherman and Lynn, 1990; Lynn and Sherman, 2000) have used concepts and researchderived from social and cognitive psychology to understand and evaluate Erickson’sapproach.

Con Hyp 21.2_crc 4/6/04 12:47 pm Page 63

The present article updates and extends earlier efforts to characterize Erickson’s workon the basis of the scientific literature, explicates the idea that Erickson’s approachcapitalizes on the automaticity of thought and action, and identifies therapeutic mecha-nisms inherent in Erickson’s work that we contend may be responsible for theeffectiveness of not only Erickson’s strategic interventions, but of many psychothera-peutic approaches as well (see also Kirsch and Lynn, 1999). Extensive reviews ofpsychotherapy outcome (e.g. Lambert and Barley, 2002) have concluded that commonfactors (i.e. elements of the therapeutic relationship) that bridge disparate approachesaccount for as much as 30% of the variability in therapeutic outcome, whereas particularpsychotherapeutic techniques account for only 15% of outcome. Rather than limit ourdiscussion to the common factors that are typically identified in the literature (e.g.feedback, empathy, therapeutic alliance), we maintain that Erickson’s success, and thesuccess of many therapeutic endeavours, can be attributed, at least in part, to thetherapist’s ability to manipulate response expectancies, prime therapeutic responses,strengthen positive response sets and intentions, remove impediments to the automaticexecution of desired behaviours, and disrupt or modify negative or undesirable responsesets. Accordingly, this article is written in the spirit of attempts to identify commonfactors (Norcross, 2002) in psychotherapy, or in this case, mechanisms, learningprocesses and strategies that play an important if not central role in diverse therapeuticapproaches. We will focus on elements of Erickson’s techniques and therapeutic approachthat have received empirical support from the social, cognitive, and clinical psychologyliterature, and suggest that despite the anecdotal base of evidence, Erickson’s techniquesmay hold promise for treating a broad clientele.

Response sets and automaticity

Kirsch and Lynn’s (Kirsch and Lynn, in press, 1997, 1998, 1999; Lynn, 1997) responseset theory emphasizes the important role of response sets in hypnosis, psychotherapy, andeveryday life. Response sets are comprised of mental associations linked by priorlearning, and refer to expectancies and intentions that prepare cognitive and behaviouralschemas, roles or scripts for efficient and seemingly automatic activation. There issubstantial support for the idea that positive expectancies can catalyze the effectiveness ofa broad range of psychotherapeutic interventions, including hypnosis (Kirsch, 1990,1997). The influence of response sets is so important that we are in essential agreementwith Michael Yapko’s (2003) statement: ‘If you were to ask me what single stage of theinteraction most influences the rest, the overall success of the hypnosis session, I’d say it’sthe stage of deliberately building response sets’ (p. 283). When asked how he was able tosecure seemingly incredible compliance from his clients, Erickson stated that he askedthem to respond with the full expectation that they would complete the task (see Haley,1985a). Clearly, Erickson had no reservations about using his charisma and authority toinstill confidence, channel clients’ associations and motivation, and activate positiveresponse sets by way of strongly worded, as well as more indirect or implicit, suggestions.

Indeed, Erickson was well aware of the ubiquity of automatic experiences and thepower of suggestions to activate and shape response sets. Erickson, Rossi, and Rossi(1976) stated that ‘most people do not know that most mental processes areautonomous... Hypnotic suggestions come into play when the therapist’s directives have asignificant effect on facilitating the expression of that flow in one direction or another’(p. 58). They further observe, ‘Much initial effort in every trance induction is to evoke aset or framework of associations that will facilitate the work that is to be accomplished’

64

64 Lynn and Hallquist


Milton H. Erickson’s strategies and tactics 65

(p. 58). Additionally, Erickson claimed that the most effective aspect of any suggestion isthat which stirs the listener’s own associations and mental processes into automaticaction, a notion compatible with the theory of spreading activation, which holds thatwhen a concept is encountered or imagined, the concept is activated and spreads itsconnections to associated concepts and activates those concepts.

For Erickson et al. (1976), the ‘therapeutic aspect of trance’ occurred when ‘thelimitations of one’s usual conscious sets and belief systems are temporarily altered so thatone can be receptive to an experience of other patterns of association and modes ofmental functioning ... that are usually experienced as involuntary by the patient’ (p. 20).The dialogue with Jay Haley (1985b) that follows reflects Erickson’s appreciation of thefact that significant changes often bypass conscious awareness and do not require specialinsight or self-understanding: ‘Haley: “One of the things that I’ve come to conclude,somewhat reluctantly, is that helping a patient understand himself, become more aware ofhimself, has nothing to do with changing him.” Erickson: “Not one bit!”’ (Haley 1985b:10). Erickson noted that cultivating self-awareness is far less important than engenderingpositive expectancies and empowering behavioural change: ‘[Many therapists] make[patients] more self-aware, but they never do get the patient to become aware of the thingshe can do’ (Haley, 1985b: 10).

In conclusion, the establishment of positive response sets consistent with a person’sgoals and values is a paramount, if unstated, goal of virtually all therapies. Until negativeresponse sets are modified, it is reasonable to assume that they will continue to createobstacles to progress in psychotherapy. In the remainder of the article we illustrate howchange can occur by not only building desired response sets but by deautomatizing ordisrupting counterproductive response sets. We will provide numerous illustrations ofhow Erickson devised creative and ingenious therapeutic techniques that involve manipu-lating response sets and creatively exploiting common factors of behaviour change thattranscend a single therapeutic modality.

Building positive response sets

The utilization approachHorvath and Bedi’s (2002) comprehensive review of literature on the therapeutic allianceconcludes that establishing a strong alliance early in therapy is crucial to its ultimatesuccess. Wampold (2001) went further in stating that the alliance accounts for the largestproportion of systematic variance in psychotherapy outcome. Considerable evidenceindicates that rapport is also important in optimizing hypnotic responsiveness (Fraumanand Lynn, 1985; Gfeller, Lynn, and Pribble, 1987; Lynn, Weekes, Brentar, Neufeld,Zivney, and Weiss, 1991). Arguably, Erickson’s clinical proficiency was as attributable tohis ability to forge strong therapeutic relationships as to his use of particular techniques.

Erickson’s utilization approach (Erickson, 1959; Haley, 1973) enabled him to gain thecooperation and trust of many of his clients and to establish a rapid and strong therapeuticalliance. The two basic components of utilization are: 1) the observation and facilitationof clients’ thoughts, feelings, and behaviours in response to therapeutic communications;and 2) the demonstration of acceptance and respect for the client’s reality. The examplesthat follow imply that radical acceptance engendered the impression that the clientdirected the interaction, thereby minimizing resistance to therapeutic interventions. Inreferring to a psychotic patient, Erickson (1983) states, ‘Why should I dispute thatpatient’s delusions and hallucinations? They were hers. I had better respect them in the


same way I respect a broken leg or a broken jaw’ (p. 116). In his initial interview withsome clients, Erickson would acknowledge that there were some things that they wouldrather not share and he encouraged them to withhold such information: ‘There are anumber of things that you don’t want me to know about, that you don’t want to tell me.There are a lot of things about yourself that you don’t want to discuss. Therefore, let’sdiscuss those things that you feel free to discuss, and be sure that you don’t discuss thosethat you are unwilling to discuss’ (Haley, 1985a: 6). However, as the clients disclosed onething after another, they began to withhold less and to ultimately tell Erickson what theyhad set out not to mention. This rapport-building technique illustrates Erickson’s abilityto acknowledge clients’ ambivalence about entering therapy and also fits well with theaforementioned spreading activation model in which mentioning one concept causesother related concepts to be activated, thereby contributing to therapeutic momentum.

The psychotic client referred to above (Erickson, 1983) believed that she was beingfollowed by half a dozen nude young men who floated in the air behind her, and she wasconsternated by the presence of six nude dancing girls whom she believed Erickson keptin his office. When she mentioned that she was concerned that Erickson’s young womenmight fraternize with her young men, Erickson immediately assured her that he wouldask his dancing girls not to fraternize. Similarly, when she expressed concern about thebear trap she believed was set on Erickson’s floor, he said that something shoulddefinitely be done about the hazard and asked her to be cautious in stepping around thetrap. In accepting and utilizing this client’s highly distorted perception of reality, Ericksonbuilt a deep rapport with his client, which enabled him to have a successful therapeuticrelationship with her.

The following example illustrates that Erickson was not averse to using highlyunorthodox and arguably brutal means of demonstrating his acceptance of anotherperson’s reality. An obese woman came to Erickson (1980c) to use hypnosis to loseweight. After taking a brief case history, Erickson proceeded to deride the woman and toenumerate all of the ways she presented herself as an unattractive person, commentingparticularly on the polka dot dress she wore that accentuated her appearance of beingoverweight. In general, positive feedback is rated by clients as more credible and helpful(Martin and Jacobs, 1980). However, when individuals suffer from low self-esteem, theydo not judge positive feedback to be especially accurate, because it is not consistent withtheir negative self-perceptions (McNulty and Swann, 1991). In the case Ericksonreported, by making comments that aligned with his client’s negative body image, heshowed her that he appreciated her difficulties and that he would be as blunt with her asshe was with herself. In short, she could trust him to be honest and treat her problemswith the seriousness they deserved. Although the treatment of this client is outrageous byvirtually any standard, the woman developed a strong working alliance with Erickson,and she succeeded in losing weight, changing her clothing style, and improving the wayshe presented herself to others.

Consistent with the proposition that it is important for therapists to display respect forclients’ beliefs, Myers (2000) found that therapists who imposed their positions andperspectives while dismissing their clients’ positions were rated as less empathic thantherapists who paid close attention to details of clients’ positions. Relatedly, meta-analytic studies of therapist empathy (Cooley and Lajoy, 1980; Bohart, Elliot, Greenberg,and Watson, 2002) indicate that clients’ belief that they are understood contributes toboth positive therapeutic outcome and to the sense of active collaboration with thetherapist (Strupp, 1998).




A foot in the doorOne key to the utilization approach is to judge whatever behaviours the patient emits asemblematic of cooperation and involvement with the hypnotic proceedings or therapymore generally, thereby reinforcing response expectancies of a successful outcome. Infact, Erickson defined virtually anything the client experienced or reported as a sign thatthe individual was experiencing a ‘trance.’ Jay Haley (1973) has characterized thisapproach as ‘emphasizing the positive’, which is important for another reason. AsRichard Petty and his colleagues (Petty, Briñol and Tormala, 2002) have shown, whenpositive thoughts dominate in response to a message, increasing confidence in thosethoughts enhances persuasion.

Erickson capitalized on what social psychologists (see Dillard, 1991) have dubbed the‘foot in the door tactic,’ which begins by getting compliance with a small request andthen advances to a related, larger request. One way that Erickson got his ‘foot in the door’was to tie suggestions to naturally or frequently occurring responses, or, more broadly, towhatever response the patient made (Erickson, Rossi and Rossi, 1976). Certain naturallyoccurring responses, such as the lowering of an outstretched arm, provide immediatepositive proprioceptive feedback. Once clients cooperated with a relatively easy task, itbecame possible to engage them in more difficult tasks.

A ‘fail-safe’ inductionErickson often used what the client said or did as a starting place and built on it toestablish and preserve positive treatment expectancies and rapport. Consider the following ‘fail safe’ induction (Lynn, Kirsch, and Rhue, 1996) based on theaforementioned principle: ‘You may notice that one of your arms is just a bit lighter thanthe other, and your other arm is heavier. As we talk, your light arm may become evenlighter or your heavy arm may become even heavier. And I wonder just how light yourlighter arm will feel, and how heavy they other arm will feel. Will your light arm becomeso light that it lifts up into the air all by itself, or will your heavy arm become so heavythat it stays rooted to the arm of your chair? And I wonder which arm feels lighter. Is ityour right arm or your left arm? And where do you feel the lightness most? In your wristor in your fingers? In all of your fingers or especially in one of them?’ Overt signs ofupward movement in one hand or arm provide a signal to focus on suggestions for armlevitation. Otherwise, these are abandoned and suggestions for arm heaviness andimmobility are stressed. In our experience, this method can prevent perceptions of failure,maintain therapeutic rapport, and provide some indication of the client’s level of respon-siveness.

Establishing the hypnotic contextErickson capitalized on clients’ positive expectancies regarding hypnosis. T.X. Barber(1985) noted that clients often enter therapy with expectancies that hypnosis will enhancethe effectiveness of psychotherapy, an idea championed by Irving Kirsch who has arguedthat hypnosis can be thought of as a nondeceptive placebo that generates positivetreatment expectancies that, in turn, mediate positive treatment outcome in psychotherapy(Kirsch, 1994). Erickson often defined his work with patients as ‘hypnotic’ in nature,whether or not he used a formal induction, or whether his clients discussed their experi-ences in terms of a trance or ‘hypnosis’. There is substantial research support for the ideathat simply labelling procedures as ‘hypnotic’ can enhance treatment outcomes (Kirsch,Montgomery, and Sapirstein, 1995; Kirsch, 1997).



Altering the accessibility of response sets

PrimingPriming refers to the activation or change in accessibility of a concept by an earlierpresentation of the same or a closely related concept (see Reason, 1992). Erickson primedhis clients by introducing ideas and examples early in a therapy or assessment session sothat patients would think in certain ways later in the session or after the session. Bytalking to patients prior to hypnosis about various ‘nonhypnotic’ relaxing experiencesthey have enjoyed in the past such as listening to soothing music or watching waves on abeach, and by asking patients questions about what they would like to experience duringthe upcoming hypnosis session and gaining input from the patient about helpfulsuggestion-related scenarios, therapists can prime subsequent ‘hypnotic’ responses.Priming effects can be subtle. Even subliminally presented stimuli can affect interpreta-tions of events (see Bargh, 1994). Priming effects can also extend to complex socialbehaviours (Wilson and Capitman, 1982).

Imagination and explanation Asking people to think about or imagine possible situations or to explain hypotheticaloutcomes is an effective means of priming and altering the accessibility of facts inmemory. Erickson used these strategies to increase the salience of particular outcomeexpectations and to bring to mind concepts and ideas consistent with positive outcomesand inconsistent with negative outcomes (see Sherman and Lynn, 1990). When makingsubsequent judgments or decisions, these ideas will then be most accessible and willserve as a basis for action (Sherman, Skov, Hervitz, and Stock, 1981). For example,imagining negative outcomes of smoking and overeating and positive outcomes of notdoing so can make it easier to resist those urges. What happens when a person contraststheir fantasies about a desired future with reflections on present reality? According toOettingen’s fantasy realization theory (Oettingen, Pak, and Schnetter, 2001), this contrastleads to a necessity to act that leads directly to the activation and implementation of situa-tionally appropriate response sets (e.g. expectancies).

Erickson, like other solution focused therapists (de Shazer, 1985; Fish, 1996), directedthe client’s attention to exceptions to the problem (e.g. ‘Tell me when you do not feelanxious’), thereby priming adaptive thoughts and behaviours. Posing questions to clientssuch as, ‘how would your life change if you did X?’ or ‘what would you have to change inyour life in order for relinquish your fear of public speaking?’ are also likely to increasethe accessibility of adaptive activities (Kirsch and Lynn, 1998).

Erickson realized what social psychologists (Taylor et al., 1998) have known for sometime – that it is more effective to imagine implementing goal-directed behaviours (e.g.studying) in attaining a goal (e.g. getting an A in a course) than to imagine havingattained the desired outcome or goal. Gollwitzer’s (1999) work on implementation inten-tions also indicates that discussing and committing to behavioural change at a veryspecific level is advantageous. Rather than merely specifying behaviour in general terms,such as being assertive, Erickson recognized that actual behavioural responses and theirenvironmental cues should be specified.

In order to help a couple to become more equal in their relationship, Erickson (Haley,1985b) prescribed a complex, seemingly ridiculous behavioural experiment. He asked thehusband to take his wife out to dinner (which the couple enjoyed doing together), but tohave his wife give him circuitous directions, specifying in great detail on which streets toturn, though the path they took meandered. Once in the restaurant, Erickson had the wife



read his directions to her husband, which instructed them to walk past a certain number ofbooths, and to exchange menus at a certain point in the dinner such that the husbandordered the meals that his wife had chosen. The husband appreciated the meticulousnessand detail Erickson had included in his instructions, and the wife enjoyed the opportunityto give more input into the couple’s decisions. The couple enjoyed their experience somuch that they repeated similar experiments on their own and enjoyed a satisfyingadjustment thereafter. In summary, by guiding clients’ stream of consciousness, includingthe kinds of outcomes they think about, it is possible to establish response sets that affecthow clients behave when relevant situations arise.

Anecdotes and metaphorsErickson’s use of priming by way of anecdotes, stories drawn from his own life, previouscase material, and metaphors allowed him to seed therapeutic change in clients in anondirective manner and to activate concepts and ideas consistent with therapeutic goals.For example, Erickson (Rosen, 1982) told the detailed story of precisely how childrenlearn to stand up and walk as a way of building a learning response set and suggesting toclients that they would accomplish difficult tasks in therapy by completing many smalltasks. In Erickson’s (Haley, 1973) conversations with Joe, a terminally ill florist, he intro-duced concepts relevant to plants and gardening and used concepts and ideas that Joemight later employ in thinking about his own life and situation in terms of growth,comfort, and beauty, rather than his deteriorating health and vigour. When Ericksonvisited this client a month later, he found that Joe was much more comfortable, and thathe had developed successful pain control techniques. Brown’s (1993) review indicatesthat metaphors implicitly structure experience and determine responses to events, oftenwithout explicit conscious awareness.

Generating therapeutic momentum and fortifying response sets

Cuing response sets and scriptsAccording to Mischel and Shoda’s (1995) cognitive-affective system theory of person-ality, individual differences in personality are associated with distinctive and meaningfulprofiles of situation-behaviour relations. Over time, situations come to evoke strong andpredictable responses. In terms of response set theory, situations can trigger response setsthat influence thoughts, feelings, and actions. Similarly, Aarts and Dijksterhuis (2000)observed that behavioural repertoires typically unfold in the same physical and socialenvironment and take on a habitual character. Accordingly, the majority of actions areexecuted on a routine, habitualized basis. Habits are response sets that can be adaptivewhen they facilitate the performance of desired actions in an automatic, effortlessfashion. As William James (1981) said: ‘We must make automatic and habitual, as earlyas possible, as many useful actions as we can’ (p. 122). Suggestions that call to mindspecific situations or feelings associated with events and actions can likewise triggerresponse sets that unfold in a seamless, mindless, automatic manner.

The automatic effects of response sets on behaviour can be demonstrated simply bycueing response sets that have been transmitted culturally in the form of implicitknowledge of social roles or scripts. Scripts range from baking cookies to ordering foodin a restaurant. Social psychological research indicates that once immersed in a script, anindividual tends to get carried along with the behaviours in a mindless, automatic way. Ifa person can be engaged in a script, the rest of the sequence will run off automatically,



and substantial behavioural control can be achieved (Sherman and Lynn, 1990). Erickson found this technique to be useful in engendering a ‘yea saying’ response

pattern. He would start with questions with an obvious ‘yes’ answer; to establish a patternor response set, he would keep asking such questions. Patients would apparently agree tothings that they would not have agreed to in the absence of the response set. Ericksonwould induce behaviours and thoughts by subtly establishing the initial part of asequence, knowing that the patient would complete it (Sherman and Lynn, 1990). In onecase, Erickson wanted the patient to think about being warm-hearted and kind. Byreferring to her ‘cold hands,’ he knew that the entire response sequence would be estab-lished.

Yapko (2003) describes the creation response sets as building a momentum of respon-siveness. He stated, ‘If I offer four consecutive statements I know he or she will agreewith, what is that person’s most likely response to my next statement? For example, if Isay, “Each person is unique as an individual. Human experience is often complex. Peoplefrequently have more resources than they realize. Sometimes it feels good just to sit andrelax” – all agreeable statements – where does the momentum of responses carry theclient? Most likely into the realm of agreement for the next statement’ (p. 404).

Creating expectancies for gradual changeMomentum can be established and maintained by ensuring that positive feedback will beexperienced throughout treatment. This can be facilitated by the expectancy thatimprovement will begin with small, gradual changes. By focusing on clients’ smallchanges in respiration for example, and linking these small changes with statements tothe effect that it demonstrates the person is going into a trance, Erickson was able to buildpositive expectancies, and convey the idea that change begins with changes so small theymay escape notice. This allows small increments, such as those produced by randomfluctuations, to be interpreted as signs of therapeutic success. The assignment of easyinitial tasks ensures early successes, which bolster the client’s confidence in treatment(Lynn et al., 1996). As a rule, progress in therapy is not linear. Erickson would prepare forsetbacks by labelling them in advance as inevitable, temporary, and useful learningopportunities. In so doing, the client would be more accepting of them if they occurredand, if they did not, feel even more positive about their progress in treatment.

Effort justification: strengthening response setsIn addition to establishing therapeutic response sets, it is important to strengthen andmaintain them. According to Bem’s (1967) self-perception theory, people sometimesobserve themselves in action and make inferences about the type of person they must be.When people observe themselves working hard to achieve a particular goal, they arelikely to conclude that they are committed to the goal. The role of effort was not lost onErickson. He assigned homework to patients that could require a great deal of effort tocomplete: climbing Squaw Peak, carrying a heavy rock for a week, or looking up manyarticles in the library. Expending such effort can presumably enhance commitment totherapeutic goals (Sherman and Lynn, 1990), independent of other benefits derived fromthe homework.

Homework is important for two additional reasons. First, clients must have the skillsnecessary to achieve what they expect will happen, so that expectancies are not merelypromises that are unfulfilled (Yapko, 2003). Ideally, positive expectancies must be culti-vated in a realistic framework that empowers clients so that they are able to achieve theirgoals. Second, when clients and therapists are involved cooperatively and clients work



hard outside of therapy, research shows that outcome is enhanced (Burns and Spangler,2000; Persons, Burns, and Perloff, 1988).

Removing roadblocks to activating response sets

Permissiveness and acceptanceIt may be as important to remove impediments to the automatic activation of responsesets and their execution as it is to create facilitative conditions for the expression ofdesired behaviours. Erickson realized that direct suggestions or injunctions to relinquish,suppress, or control longstanding symptoms are often doomed to failure. Ironically,attempts to suppress or control a particular thought or action can increase the propensityto engage in the thought or action (Wegner, Schneider, Carter, and White, 1987).Research indicates that excessive control efforts, such as attempts to rigidly suppresscompulsive or food related thoughts or images (Polivy and Herman, 1987; Strauss,Doyle, and Kreipe, 1994), depressive thoughts (Segal, Williams, and Teasdale, 2002), andanxious moods (Mellinger and Lynn, 2003), can have quite the opposite effect. Hayes andGifford (1997) have argued that poorer clinical outcomes eventuate when peoplefrequently use ‘coping strategies aimed at avoiding or suppressing negative emotions orthoughts’ (p. 170).

Erickson used permissive suggestions with clients who placed too great a premium oncontrolling the responses they wished to suppress (Wegner, 1997). Erickson’s emphasison permissiveness was a little acknowledged and appreciated precursor of acceptance andcommitment therapy (see Hayes, Jacobson, Follette, and Dougher, 1994), a behaviouralapproach that is designed to circumvent avoidance tendencies by accepting, rather thanchanging or eliminating, vexing thoughts and feelings. Acceptance has also been a keycomponent of: a) humanistic-existentialist approaches since their inception (L.Greenberg, 1994); b) rational-emotive therapies, addiction treatments, and approaches totreating sexually abused individuals (see Hayes et al., 1994); and c) mindfulness andmeditation approaches to the treatment of anxiety (Mellinger and Lynn, 2003) anddepression (Segal, Williams, and Teasdale, 2002). By avoiding, rather than accepting andcoping with aversive feelings and situations, fears tend to become exaggerated, asindividuals become preoccupied with the need for control, engendering or perpetuating avicious cycle of fear and avoidance.

Paradoxical approachesErickson grasped this relationship between fear and control and avoidance and devisedparadoxical approaches to work with resistant clients who seek to block or prevent thera-peutic change. On one level they may seek such change, but on another they may fear it.A good deal of research indicates that resistant clients achieve less positive treatmentoutcomes and are at risk of prematurely terminating from treatment (Beutler, Goodrich,Fisher, and Williams, 1999). A paradoxical tactic that Erickson used to counter thepatient’s self-defeating strategy of blocking or preventing therapeutic change is toprescribe the symptom. That is, the person is asked to intentionally produce the unwantedfeeling, thought, or behaviour. In this way, resistance facilitates a therapeutic response.Another paradoxical approach, akin to Erickson’s methods, which has recently become amainstay of cognitive-behaviour therapy of generalized anxiety disorder, is prescribingthe symptom of worry. Worry is either postponed to a definite time or confined to aworry period of, for example, 30 minutes a day, providing the client with a measure of



control over excessive worry. In their study of resistant clients in psychotherapy, Beutler,Clarkin and Bongar (2000) found that therapists who authoritatively instruct resistantclients to continue problematic behaviours often succeed in effecting therapeutic change.

Exploiting reactanceSocial psychologists have long known that people resist responding when they believetheir perceived freedom is threatened. The term for this behaviour is ‘reactance’ (Brehm,1966). Erickson did more than devise techniques to undercut reactance – he exploited it.On occasion, early in therapy sessions, during the induction of hypnosis, he would askpatients for a response that they failed to give. Having expressed their freedom, they weremore likely to comply with requests that were far more important to Erickson.

In a similar way, Erickson (1980b) instructed a couple struggling to consummate theirmarriage that they would have intercourse on any night the following week, but that hewould prefer Friday. The couple returned the next week and reported that they hadconsummated their marriage on Thursday night. Of course, it was irrelevant to Ericksonwhen the positive experience occurred, but his technique allowed clients to achieve asense of control. To teach clients that they could control their symptoms, Erickson wouldarrange for patients to have different symptoms than usual or to exhibit them at a newtime. Likewise, Erickson would present clients with a choice of two or more alternatives(e.g. they could take one or two or three deep breaths), any of which would be acceptableto Erickson. He assumed that the act of choosing a particular alternative would fortifycommitment to it (Sherman and Lynn, 1990).

ReframingMany clients are not actively resistant to change, yet there are times in therapy andeveryday life when response sets will not unfold in a seamless way because they are inter-rupted by feedback or information that implies that a particular thought or action is ‘offtarget’ or inconsistent with treatment goals. When this occurs, it can dampen responseexpectancies and engender negative response sets that activate thoughts and behavioursthat are inconsistent with treatment objectives. Erickson pioneered ‘reframing’techniques as a means of reinterpreting events that are not consistent with therapeuticgoals. For instance, a newlywed’s failure to maintain an erection could be taken as a greatcompliment of his wife’s overwhelming beauty (Haley, 1985b). Or a yawn that occursprior to the induction of hypnosis, and that might ordinarily be interpreted as a sign ofboredom or disengagement from therapy, could be interpreted as a signal that the personis ready to ‘enter hypnosis’ and tied to a suggestion to that effect. Erickson used this sortof reframing to turn the patients’ deficits into assets (Sherman and Lynn, 1990; Lynn andSherman, 2000). An inability to work or to travel could be seen as an opportunity to enjoyone’s life at home. Reframing is a valuable technique insofar as objective facts are oftenunchangeable, but the framing of facts is subject to alteration (Sherif and Hovland, l961;Sherman and Lynn, 1990).

Deautomatizing response sets

ExposureThe principle of exposure is central to many contemporary behaviour therapy techniquesincluding desensitization, flooding, and implosive therapy. Exposure provides a powerfulway of modifying well-established, maladaptive response sets (see Mellinger and Lynn,



2003) and involves remaining in contact with feared stimuli and emotional reactions inorder to process emotionally reactions to events that trigger anxiety. Elements ofexposure techniques are apparent in Erickson’s (Rosen, 1982) treatment of a patient whoexperienced severe claustrophobia as a result of her mother locking her in a closet as achild. Erickson asked her to sit in his closet during their sessions and she said that thedoor would have to be wide open for her to do so. Erickson then suggested that he wouldleave it one millimetre less than wide open and then proceeded to help her work up toseveral centimetres . Finally, she found that she could sit in the closet with the door closedso long as she could look out through the keyhole. By exposing the woman to increas-ingly claustrophobic conditions, he succeeded in helping her to overcome her fear ofenclosed spaces.

The principle of exposure is also evident in Erickson’s (Haley, 1985a) treatment of aman with a driving phobia who feared fainting while driving. Erickson first asked theman to drive to the furthest point that he could without feeling like fainting. Ericksonthen had the man drive on the hard shoulder to the next telephone pole and, if faintingoccurred, to get out of the car and go lie in the ditch until the fainting spell passed. Theman continued these actions until his fear of driving outside the city limits had passed.Eventually, the man was able to drive several hundred miles to a nearby city, after whichhis driving phobia was no longer problematic.

Rather than strive for complete elimination of a problematic behaviour, Ericksonwould conduct exposure with the goal of reducing the behaviour. For example, in treatinga young man who bit his fingernails until they bled, Erickson (1983) suggested that theman had never had the pleasure of chewing a long fingernail and that surely, the mancould allow one fingernail to grow. Over the course of therapy, Erickson graduallyreduced the number of nails that the man chewed until the man no longer felt it necessaryto bite his fingernails.

Modifying the symptomErickson was also adept at taking control of when and where a patient experienced aparticular behaviour, thereby weakening the habitual reaction and modifying theundesired response set. For example, Erickson would expose an individual to situations orconversations that were greatly feared and which would induce the symptom in thepatient. However, before the patient could exhibit a symptom such as fainting, Ericksonwould take control of the symptom by suggesting that the client could experience thesymptom in a different way. For example, a patient who was afraid to enter a particularrestaurant and would faint upon entering came to Erickson for treatment (see Haley,1985a). Erickson arranged a date for the man, and had the man take his date, Erickson,and Erickson’s wife out to the restaurant. While they were approaching the restaurant,Erickson pointed out several places where the man might like to faint. By eliminating thespontaneity of the symptom and disrupting the client’s habitual fear response, the manwas able to enter the restaurant without fainting and have a mastery experience. Thisbehavioural intervention closely resembles exposure and response prevention techniquesused by modern behaviour therapists.

At times, Erickson suggested that a client amplify or exaggerate, rather than reduce, aproblem behaviour as a way of increasing the absurdity of the behaviour and promotingextinction of the undesired behaviour. In treating a 16-year-old girl who habitually suckedher thumb, Erickson (1980a) made it plain to the girl that she was free to suck her thumb,and that she ought to annoy her parents and her teacher even more than she already had.After securing her parents’ promise not to reprimand their daughter for her behaviour for



one month, and thereby depriving her of attention for her behaviour, Erickson told her tosuck her thumb noisily while her father read the paper and her mother sewed. The girlfollowed Erickson’s instructions to the letter, only sucking her thumb when following hisinstructions. Over time, Erickson’s client became bored with following his instructionsand decided not to suck her thumb at all.

Creating ‘worse’ situationsAnother way that Erickson deconstructed habitual response sets was by creating insolubleor alternative situations that were more aversive than the presenting symptoms orproblems themselves. In one case, Erickson (Haley, 1985b) saw a woman who experi-enced speech difficulties following a mild stroke. In order to help her overcome thesedifficulties, he instructed her husband to buy a large fish tank and stock it with tropicalfish. Each night, the couple, who did not like fish whatsoever, was instructed to sit andwatch the fish for half an hour without saying a word. The woman experienced an intensedesire to ask her husband why they were forced to go through this ridiculous ritual eachnight, but had to remain silent so as to comply with Erickson’s instructions. Over time,however, she began to speak more easily during the day because she knew that she wouldhave to sit quietly and stare at the f ish in the evenings. Such techniques have beendescribed as ‘ordeal therapy’ by Haley (1984). By creating a difficult, if not ‘impossible,’situation, Erickson essentially forced his client to respond in a way that required imple-menting a nonhabitual response set.

Conclusions

The idea that successful therapy involves the establishment and maintenance of adaptiveresponse sets and the elimination of undesirable response sets has not, to date, beendiscussed in terms of a ‘common factors’ conceptualization of the ingredients ofsuccessful psychotherapies, hypnotically facilitated or otherwise. Our proposal is thatErickson developed techniques that were effective to the extent that they harnessedprinciples of change and ‘common factors’ that served to create and fortify desiredresponse sets while they minimized or eliminated counterproductive response sets.However, the threads of our argument are constructed around a core of anecdotal casematerial and evidence garnered in the laboratory, which is no substitute for a moresystematic analysis of the independent and interactive effects of common factors in thecontext of psychotherapy. Indeed, the common factors that we identified should beregarded as largely hypothetical rather than proven contributors to the effectiveness ofdiverse psychotherapeutic approaches, despite their grounding in social and cognitivepsychology. It would be of great interest to carefully examine the determinants ofresponse sets (e.g. social learning), to devise measures of the strength and durability ofresponse sets, and to relate the instantiation and elimination of response sets to thera-peutic interventions and to changes in the client over the course of therapy, as indexed byself-report and objective measures.

With the exception of different suggestion types (e.g. authoritative/direct vs.permissive/indirect), few of the techniques used by Erickson have been subject toempirical analysis. The literature supports the conclusion that suggestion type is far lessimportant than participants’ understanding of the meaning and intention of the suggestionand individuals’ willingness to respond to what is suggested (Lynn, Neufeld and Mare,1993). This finding is consistent with the idea that the important aspect of a suggestionhas less to do with the subtleties of wording, than with the activation of a response set in



the participant consistent with successful response to the suggestion. However, thehypothesis that indirect or permissive suggestions may be especially effective with highlyresistant individuals in the clinical setting has not, as yet, been subject to a rigorous test.

Questions can be raised about whether Erickson’s work with clients represents adistinct type of psychotherapy, rather than an amalgam of techniques applied to clients ona less than systematic basis. Indeed, it would be difficult to manualize ‘Ericksoniantherapy’ and subject it to rigorous analysis at the present time. Nevertheless, we dobelieve that it is possible to: a) systematize and operationalize Ericksonian methods to agreater extent than has been done in the past; b) study Erickson’s methods in relation tothe treatment of different disorders; and c) conduct controlled, comparative outcomeresearch on treatments based on Erickson’s methods. Empirically supported techniquesshould be the f irst line treatments of any disorder (Barlow, 2000), and Erickson’s‘uncommon therapy’ lacks a strong evidential base. However, knowing that Erickson’stherapeutic tactics have a basis in research and theory, as we have illustrated, shouldprovide comfort to therapists who use or contemplate using interventions derived fromErickson’s body of work.

Author Note

This article is based on a keynote address entitled ‘Understanding Milton H. Erickson’shypnosis: insights from cognitive, social, and clinical psychology’, presented to theAnnual Conference of British Medical, Clinical, Dental and Experimental Hypnosis,London, England, July 17–20 2003.

ReferencesAarts H, Dijksterhuise A (2000) Habits as knowledge structures: automaticity in goal-directed

behavior. Journal of Personality and Social Psychology 78: 53–63.Barber TX (1985) Hypnosuggestive procedures as catalysts for all psychotherapies. In: SJ Lynn

and JP Garske (eds) Contemporary Psychotherapies: Models and Methods. Columbus, Ohio:Charles E. Merrill, 333–75.

Bargh JA (1994) The four horsemen of automaticity: awareness, intention, efficiency, and controlin social cognition. In: RS Wyer Jr and TK Srull (eds) Handbook of Social Cognition (2ndedn). Hillsdale, NJ: Erlbaum, 1–40.

Barlow DH (2000) Evidence-based practice: a world view. Clinical Psychology: Science andPractice 7: 241–2.

Bem DJ (1967) Self-perception: an alternative interpretation of cognitive dissonance phenomena.Psychological Review 74: 183–200.

Beutler LE, Clarkin JF, Bongar B (2000) Guidelines for the Systematic Treatment of theDepressed Patient. New York: Oxford University Press.

Beutler LE, Goodrich G, Fisher D, Williams OB (1999) Use of psychological tests/instruments fortreatment planning. In: ME Maruish (ed.) The Use of Psychological Tests for TreatmentPlanning and Outcome Assessment (2nd edn). Hillside, NJ: Erlbaum, 81–113.

Bohart AC, Elliot R, Greenberg LG, Watson JC (2002) Empathy. In: JC Norcross (ed.)Psychotherapy Relationships That Work. New York: Oxford University Press.

Brehm JW (1966) A Theory of Psychological Reactance. New York: Academic Press.Brown P (1993) Hypnosis and metaphor. In: JW Rhue, SJ Lynn and I Kirsch (eds) Handbook of

Clinical Hypnosis. Washington: American Psychological Association, 291–308.Burns DD, Spangler DL (2000) Does psychotherapy homework lead to improvements in

depression in cognitive-behavioral therapy or does improvement lead to increased homework



compliance? Journal of Consulting and Clinical Psychology 68: 46–56.Cooley EJ, Lajoy R (1980) Therapeutic relationship and improvement as perceived by clients and

therapists. Journal of Clinical Psychology 36: 562–70.de Shazer S (1985) Keys to Solution in Brief Therapy. New York: Norton.Dillard J (1991) The current status of research on sequential-request compliance techniques.

Personality and Social Psychology Bulletin 17: 283–8.Erickson MH (1959) Further clinical techniques of hypnosis: utilization techniques. American

Journal of Clinical Hypnosis 2: 321. Erickson MH (1980a) The Collected Papers of Milton H. Erickson on Hypnosis, Volume I (ed. EL

Rossi). New York: Irvington.Erickson MH (1980b) The Collected Papers of Milton H. Erickson on Hypnosis, Volume II (ed.

EL Rossi). New York: Irvington.Erickson MH (1980c) The Collected Papers of Milton H. Erickson on Hypnosis, Volume IV (ed.

EL Rossi). New York: Irvington.Erickson MH (1983) Healing in Hypnosis: The Seminars, Workshops and Lectures of Milton H.

Erickson, Volume I (eds EL Rossi, MO Ryan, FA Sharp). New York: Irvington.Erickson MH, Rossi EL, Rossi SI (1976) Hypnotic Realities: The Induction of Clinical Hypnosis

and Forms of Indirect Suggestion. New York: Irvington.Fish JM (1996) Prevention, solution focused therapy, and the illusion of mental disorders. Applied

and Preventive Psychology 5: 37–40.Frauman D, Lynn SJ (l985) Rapport factors in hypnosis: a literature review. In: G. Guantieri (ed.)

Hypnosis in Psychotherapy and Psychosomatic Medicine. Verona, Italy: Post-UniversitarieVerona.

Gfeller J, Lynn SJ, Pribble W (l987) Enhancing hypnotic susceptibility: Interpersonal and rapportfactors. Journal of Personality and Social Psychology 52: 586–95.

Gollwitzer PM (1999) Implementation intentions: strong effects of simple plans. AmericanPsychologist 54: 493–503.

Greenberg L (1994) Acceptance in experiential therapy. In: SC Hayes, NS Jacobsen, VM Folletteand MJ Dougher (eds) Acceptance and Change: Content and Context in Psychotherapy, 68–72.

Haley J (1973) Uncommon Therapy: The Psychiatric Techniques of Milton H. Erickson, M.D.New York: Norton.

Haley J (1985a) Conversations with Milton H. Erickson, M.D. Volume I: Changing individuals.New York: Triangle Press (Norton).

Haley J (1985b) Conversations with Milton H. Erickson, M.D. Volume II: Changing couples. NewYork: Triangle Press (Norton).

Haley J (1984) Ordeal Therapy: Unusual Ways to Change Behavior. San Francisco, CA: Jossey-Bass.

Hayes SC, Gifford EV (1997) The trouble with language: experiential avoidance, rules, and thenature of verbal events. Psychological Science 8: 170–4.

Hayes SC, Jacobsen NS, Follette VM, Dougher MJ (eds) (1994) Acceptance and Change: Contentand Context in Psychotherapy. Reno, Nevada: Context Press.

Hilgard ER (1984) A book review of M.H. Erickson (EL Rossi, ed.) The collected papers ofMilton H. Erickson on hypnosis (Vols I-IV). International Journal of Clinical andExperimental Hypnosis 32: 257–65.

Horvath AO, Bedi RP (2002) The alliance. In: JC Norcross (ed.) Psychothera py RelationshipsThat Work. New York: Oxford University Press.

James W (1890/ 1981) The Principles of Psychology. Cambridge: Harvard University Press.Kirsch I (1990) Changing Expectations: A Key to Effective Psychotherapy. Pacific Grove, CA:

Brooks/Cole.Kirsch I (1994) Clinical hypnosis as a nondeceptive placebo: empirically derived techniques.

American Journal of Clinical Hypnosis 37: 95–106.Kirsch I (1997) Response expectancy theory and application: a decennial review. Applied and

Preventive Psychology 6: 69–79.Kirsch I, Lynn SJ (1997) Hypnotic involuntariness and the automaticity of everyday life.



American Journal of Clinical Hypnosis 40: 329–48.Kirsch I, Lynn SJ (1998) Social-cognitive alternatives to dissociation theories of hypnotic involun-

tariness. Review of General Psychology 2: 66–80. Kirsch I, Lynn SJ (1999) The automaticity of behavior and clinical psychology. American

Psychologist 54: 504–15.Kirsch I, Lynn SJ (in press) Hypnosis and will. Behavioral and Brain Sciences. (Commentary on

The Illusion of Conscious Will, by Daniel Wegner.)Kirsch I, Montgomery G, Sapirstein G (1995) Hypnosis as an adjunct to cognitive behavioral

psychotherapy: a meta-analysis. Journal of Consulting and Clinical Psychology 63: 214–20.Lambert MJ, Barley DE (2002) Research summary on the therapeutic relationship and

psychotherapy outcome. In: JC Norcross (ed.) Psychotherapy Relationships That Work. NewYork: Oxford University Press.

Lynn SJ (1997) Automaticity and hypnosis: a sociocognitive account. International Journal ofClinical and Experimental Hypnosis 45: 239–50.

Lynn SJ, Kirsch I, Rhue JW (1996) Maximizing treatment gains: recommendations for the practiceof clinical hypnosis. In: SJ Lynn, I Kirsch, JW Rhue (eds) Casebook of Clinical Hynposis.Washington, DC: American Psychological Association.

Lynn SJ, Kirsch I, Rhue JW (eds) (1996) A Casebook of Clinical Hypnosis. Washington, DC:American Psychological Association.

Lynn SJ, Neufeld VR, Mare C (l993) Direct versus indirect suggestions: a conceptual and method-ological review. International Journal of Clinical and Experimental Hypnosis 41: 124–52.

Lynn SJ, Sherman SJ (2000) Clinical implications of sociocognitive models of hypnosis: responseset theory and Milton Erickson’s strategic interventions. American Journal of ClinicalHypnosis 42: 294–315.

Lynn SJ, Weekes J, Brentar J, Neufeld, V, Zivney O, Weiss F (1991) Interpersonal climate andhypnotizability level: effects on hypnotic performance, rapport, and archaic involvement.Journal of Personality and Social Psychology 60: 739–43.

Martin L, Jacobs M (1980) Structured feedback delivered in small groups. Small Group Behavior11: 88–107.

Matthews WJ, Conti J, Starr L (1998) Ericksonian hypnosis: a review of the empirical data. In: WJMatthews and JH Edgette (eds) Current Thinking and Research in Brief Therapy: Solutions,Strategies, Narratives. Philadelphia, PA: Brunner/Mazel, 239–64.

McNulty SE, Swann WB (1991) Psychoherapy, self-concept change, and self-verification. In: RCCurtis (ed.) The Relational Self. New York: Guilford, 213–37.

Mellinger D, Lynn SJ (2003) The Monster in the Cave: How to Face your Fear and Anxiety andLive your Life. New York: Berkeley.

Mischel W, Shoda Y (1995) A cognitive-affective system theory of personality: reconceptualizingsituations, dispositions, dynamics, and invariance in personality structure. PsychologicalReview 102: 246–68.

Myers S (2000) Empathic listening: reports on the experience of being heard. Journal ofHumanistic Psychology 40: 148–73.

Norcross JC (ed.) (2002) Psychotherapy Relationships That Work. New York: Oxford UniversityPress.

Oettingen G, Pak H, Schnetter K (2001) Self-regulation of goal setting: turning free fantasies aboutthe future into binding goals. Journal of Personality and Social Psychology 80: 736–53.

Persons JB, Burns DD, Perloff JM (1988) Predictors of dropout and outcome in cognitive therapyfor depression in a private practice setting. Cognitive Therapy and Research 12: 557–75.

Petty RE, Briñol P, Tormala ZL (2002) Thought confidence as a determinant of persuasion: theself-validation hypothesis. Journal of Personality and Social Psychology 82: 722–41.

Polivy J, Herman CP (2002) Causes of eating disorders. Animal Review of Psychology 53:187–213.

Reason JT (1992) Cognitive underspecification: its variety and consequences. In: BJ Baars (ed.)Experimental Slips and Human Error.New York: Plenum, 71–91.

Rosen S (1982) My Voice Will Go With You: The Teaching Tales of Milton H. Erickson. New



York: Norton.Segal ZV, Williams JMG, Teasdale JD (2002) Mindfulness-based Cognitive Therapy for

Depression. New York: Guilford.Sherif M, Hovland CI (1961) Social Judgment: Assimilation and Contrast Effects in

Communication and Attituted Change. Oxford: Yale University Press.Sherman SJ, Lynn SJ (l990) Social psychological principles in Milton Erickson’s psychotherapy.

British Journal of Experimental and Clinical Hypnosis 7: 37–46Sherman SJ, Skov RB, Hervitz EF, Stock CB (1981) The effects of explaining hypothetical future

events: from possibility to probability to actuality and beyond. Journal of Experimental SocialPsychology 17: 142–57.

Strauss J, Doyle A, Kreipe R (1994) The paradoxical effect of diet commercials on reinhibition ofdietary restraint. Journal of Abnormal Psychology 103: 441–5.

Strupp JH (1998) The Vanderbilt Study 1 revisited. Psychotherapy Research 8: 17–29.Taylor SE, Pharn LD, Rivkin ID, Armor DA (1998) Harnessing the Imagination: Mental

Stimulation, Self-regulation, and Coping. American Psychologist 53: 429–39.Wampold BE (2001) The Great Psychotherapy Debate: Models, Methods and Findings. New

Jersey: Lawrence Erbaum Associates.Wegner DM (1997) When the antidote is the poison: ironic mental control processes.

Psychological Science 8: 148–50.Wegner DM, Schneider DJ, Carter SR, White TL (1987) Paradoxical effects of thought

suppression. Journal of Personality and Social Psychology 53: 5–13.Wilson TD, Capitman JA (1982) Effects of script availability on social behavior. Personality and

Social Psychology Bulletin 8: 11–20.Yapko MD (2003) Trancework (3rd edn). New York: Brunner-Routledge.

Address for correspondence:Steven Jay Lynn, PhD, ABPPPsychology DepartmentState University of New York at BinghamtonBinghamton, NY 13902Email: [email protected]


Documents

Toward a scientifically based understanding of Milton H. Erickson's strategies and tactics: hypnosis, response sets and common factors in psychotherapy