Creating Ethical and Effective Directives

I received a question the other day about the use of directives in psychotherapy due to my having written other posts about applying absurdity and paradox as effective therapeutic directives. The question I received is “How do you do directives in an ethical manner”? This question caused me to pause as I usually do not think about how I do directives as being unethical at all. Upon further reflection I think the question came about because of the power distribution within the session in which directives arise. In order to give directives, the therapist has to become the “director” of the session and cannot be merely a passive onlooker. This can create concern for those who are uncomfortable with having a larger amount of power and control in their therapy sessions. I completely understand this concern.

 

Ethics

 

To address this concern, first, I must state that if you are a therapist it is crucial that you adhere to the ethical guidelines set forth by the organizations who are involved in your licensing (APA, ACA, NASW, etc.). Thoroughly knowing what is appropriate and what is not in the ethical codes is an important part of being a professional therapist. If there is uncertainty on one’s part about a course of action, I recommend consulting with a colleague or supervisor to bounce ideas off of so that one can have a better perspective on a directive. The allure of power can be seductive so it is imperative that we in the healing profession proceed with caution. At the same time, we need to not be so uptight and worried about what we are doing that we lose our spontaneity and creativity.

Secondly, I think the best way to use directives is to simply ask yourself, “Would I be willing to do what I am asking my clients to do?” If the answer is “yes”, then implement the directives. If the answer is “no”, then do not implement the directive. If we are unwilling to do what we are asking of our clients, then not only are we not congruent with the therapeutic offering, but we are also putting unnecessary burdens and expectations on the people we are trying to help. By approaching directives with this mindset, it creates an opportunity for us to expand our own comfort zones. If we ask our client to do an odd action to change his or her patterns of interaction, then why not implement that same pattern in our own lives? It may help us become less regimented and more creative in how we approach our own problems. I have a rule that I never ask any of my clients to do anything that I would not be willing to do. This helps keep me mindful of the issue of power in the therapeutic relationship and also reminds me that there are areas that I need to work on and expand in myself.

A recent example of this occurred when I had a client who was very anxious about having things in order. She specifically was bothered by the idea of germs in her home. I was able to get her to agree to not wash one of the pans she used in cooking for two days (it was no small feat to get that agreement!). This allowed her mind to observe that not having everything perfectly clean would not automatically lead to excessive germs and sickness. As I gave this directive, I noted that I can be a bit of a neat freak in my own home. I make my bed and wash my dishes daily and do not like things out of order. As a result of giving her the directive to not wash a pan for two days, I decided to implement a similar directive for myself. I did not wash a pan for two days nor make my bed. This may seem like it is not a big deal to some of my readers, but for me it was an annoyance to alter my usual routine. It did pay off as I reminded myself that routines are sometimes made to be broken and it also gave me a level of congruence with my client.

If you direct your client to stand up more for himself in situations where he would previously back down, then make sure you are willing to stand up for yourself in a situation where you usually back down. If you want your client to expand her comfort zone by try something new, then make sure you are willing to try something new outside your comfort zone.  By being willing to do what we ask of people we can defend against potential ethical issues.

 

That’s Absurd!: Using Absurdity to Create Change

Performing odd, unexpected and absurd actions in psychotherapy is not something one usually learns in graduate school. In fact, in my many years in training, giving absurd directives was never covered. There were examples of various leaders in the field doing strange things to create change but this was never followed up with explanations or encouragement on how to perform such actions. In really examining the use of absurdity and paradox in therapy we find that it is the unexpected that creates a sense of confusion in clients which opens the space for new possibilities to emerge.

Even though great therapists such as Whitaker, Haley, Erickson, Palazzoli, etc. have used absurdity and paradox in their work, as of late there does not appear to be much information in the literature about how or why to perform such maneuvers. I personally believe that being open to absurdity not only makes you a better therapist, but also allows you to have a happier life. The nature of life itself is absurd, so why not embrace this fact? Absurdity can be utilized for shaking up interactions in a way that forces clients to find a different way of relating to the situation which originally brought them to therapy.

 

absurd

In order to create absurdity in the therapy room, clinicians must be one hundred percent willing to abandon any rigid ways of interacting with clients. They should be prepared to act in a spontaneous and creative manner. To be absurd we need to not make any sense. This statement will clash with the prevailing paradigm of logical, left brained therapy which appears to engulf much of the evidence based research. We are often taught that we need to teach our clients to think and act rationally in order for them to change. Certainly these are good objectives, but I will raise the point that it is in learning to deal with the absurdity of life where we really learn to be happy. When we become confused by things we naturally search for understanding. While we are trying to make sense of certain absurd actions, we automatically are being stretched out of our habitual ways of relating to our world. With this stretching process we become open to new resources in how to respond to the absurdity of the moment and of life in general.

 

Some examples of using absurdity to create change:

1. I once saw a couple who were having issues due to the wife’s unwillingness to let her husband have any power in the relationship. She was very controlling but at the same time wanted her husband to “step up” and take some control in the household. The husband wanted to do this but every time he attempted to “step up” she would create a fight because it triggered her control issues and he would back down. He was stuck in a “double bind” situation (which was absurd to begin with). Even though both the husband and the wife logically knew what the situation was, nothing was changing. When they came to their first session, I got their approval for them to do anything I asked them to do as long as it did not violate any safety, security or ethical boundaries. I then told them to go home and on the next day that they were home alone with nowhere to go (which was the upcoming Saturday), they were to wear each others’ clothing for the whole day. The husband was to wear one of his wife’s dresses and she was to wear one of his suits. They were instructed to do whatever they wanted to do that day but they were not allowed to talk about how they felt about the change of clothing. They reluctantly agreed. On the next session, three weeks later, it was revealed that the wife had begun to allow the husband to take on more responsibility in the home.

2. A man in his late 50s came to therapy stating that he was emotionally wounded from the constant “destructive” criticism he received growing up. He stated that he was in a wonderful marriage and his wife rarely ever criticized him. He said the problem was anytime she would offer anything that was “constructive” criticism; he would emotionally withdraw because it would activate his old fears and emotional pain from his past history of “destructive” criticism. He was open to trying anything to get past this problem. His wife was called during the session and put on speaker phone. I directed her to constantly criticize her husband for the next three days about everything. I told her to let him know that he was breathing incorrectly eating incorrectly, sleeping incorrectly or anything else he naturally did. Clearly confused, both parties agreed to do it. When the husband returned in a week he told me not only had he not been upset at any criticism, but both his wife and daughter began to open up more to him to let him know how they felt about certain private things. The dialogue in the home was more emotional in a positive way and he felt closer to his family. He was clearly confused how getting criticism from loved ones for three days created the ability for a family to become closer and more loving toward each other.

 

In order to be effective at performing absurd actions in therapy we need to be sure that we have our clients’ best interests at heart and that we are asking them to do things which we would be willing to do ourselves. We are creating an alive” Zen Koan” in our therapy room when we allow absurdity in. By being open to absurdity and paradox we also free ourselves to become more creative in our interventions. There is not fixed pattern when we utilize absurdity. To do this we are jumping off into the unknown. This may be frightening to some practitioners who cling to standardized regimentation. To me, that is absurd!

 

For a case study of the absurd I offer the following clip from the Marx Brothers. Get out your notebooks and watch how literally everything within this clip is absurd, yet it creates a wider perspective of what could happen.

How to Become an Irreverent Therapist

I recently came across an old article while doing some research that really got me thinking in a different direction. The article was written by Cecchin, Lane and Ray and published in the Journal of Marital and Family Therapy in 1993. It is entitled “From Strategizing to Nonintervention: Toward Irreverence in Systemic Practice”. The article discusses the shifting of focus in systemic therapy away from cybernetics and directive interventions and towards nonintervention and a focus on narrative (this shift was a huge mistake in my opinion). In the article, the authors suggest that in order to avoid the trap of being constricted in any way, therapists may want to embrace irreverence in their clinical work. This will enable them to avoid any potential limitations. It is a fantastic article that still has applications today. I was so inspired by the authors’ ideas that I wanted to share them, along with my own thoughts about how to become an “irreverent therapist.”

How to become an Irreverent Therapist

To be able to act without any restrictions on effectiveness, irreverent therapists need to take 100 percent responsibility for the actions they take and the directives they give. They must be willing to do anything within ethical guidelines to create the conditions for change to occur. If a therapist needs to be silent for the whole session in order to create change, she will. If a therapist needs to be confrontational in order to create change, she will. If a therapist needs to jump up and down on the couch singing songs from the 1960s to create change, she will. An irreverent therapist has an incredible amount of flexibility because her client is the focus of the session, not her theory.

 

Jester-_Joker_Card001

 

This will mean that the therapist will have to abandon any concepts, ideas, theories, or beliefs which could hamper the successful outcome of treatment. To quote Cecchin, Lane, and Ray, “therapists should maintain a healthy disrespect for any idea which restricts therapeutic maneuverability and creativity.” If you want to be an irreverent therapist, it is crucial that you successfully overcome any desire to stick to predetermined theory or technique that is regarded as the gospel truth. Any allegiance to a dogma is to quickly be rejected in order to flow with the moment as you and your client interact.  Practice laughing maniacally when you hear that a specific theory or technique is labeled “the best”.

An irreverent therapist will go out of his way to undermine and create havoc in the rigid beliefs and patterns of his clients. The order of the day is to embrace playfulness and see what happens when an inspired, uninhibited shrink gets to have fun. The irreverent therapist is also expected to poke holes in his own beliefs and patterns as he weaves a web of possibilities in his interactions with his clients. Uncertainty is not only embraced but encouraged in the therapy room. Any viewpoint the therapist or client takes as an absolute certainty in the session must be disregarded and discarded in favor of pure spontaneity and aliveness. Any certainty that the problem the client brings is unsolvable needs to be immediately dismantled in the therapy session. Spend time observing mastery of the absurd by watching a Marx Brothers movie or a Samuel Beckett play (these are much more enjoyable and teachable than most therapy textbooks).

An irreverent therapist pays little attention to how problems got started. He or she will be mostly focused on how things can shift and change. Investigation into past history and narrative explanations are kept to a minimum as the therapist redirects focus away from problem investigation and towards an exploration of client strengths and resources. Diagnostic labels are regarded with much suspicion and even disdain (maniacal laughter can be used here as well).

Try on the mantle of “Irreverent Therapist” for a week. Put it on your business cards. For this title there are no expensive, long term trainings to attend in order to obtain some silly certification. All that is needed is an openness to absurdity, an embracing of compassion, and a sense of humor.

principles

Interviewed by Rob McNeilly

I was recently honored to have been interviewed by Dr. Rob McNeilly. Rob is a medical doctor, a direct student of the late therapy wizard Dr. Milton H. Erickson and the founder of the Center for Effective Therapy in Tasmania. Our quick interview covers such topics as the role of expectancy in therapy, research into the therapeutic use of hoodoo, and how clients can be therapists’ best teachers.

 

Rob is a masterful trainer in Solution Oriented Therapies and Ericksonian Hypnosis. As a matter of fact, he is now offering a new comprehensive and hands-on online program “Easy Hypnosis – A Common Everyday Approach after Erickson”. This great program has text, audios and videos so the principles can be readily learned and easily incorporated into one’s clinical practice (whatever your previous experience of hypnosis may be). It includes 6 one hour video coaching calls. I highly recommend this experience and urge you to explore the possibilities. Rob tells me that registration will only be open until April 25th, so if you’re interested, don’t wait.

If you are interested in learning the Ericksonian approach to hypnosis from a true expert and direct student of Dr. Erickson, there are details here.

Theoretically speaking…

A theory is a generalized explanation and body of knowledge about how something operates. These explanations are used to predict and assume outcomes for specific actions. A theory stands if the results can be consistently replicated by researchers under similar conditions.

In the field of psychotherapy, research seems to come out daily promoting one theory of therapy over another. Each theory proponents pushes their theory to be the most effective and often have substantial research as evidence to its effectiveness. The rigor shown by these researchers can be impressive and their work has created shifts in, not only the content of educational training, but also funding for programs which are designed to assist the public with mental health issues.

I remember talking with one therapist who told me that the only real reason he started using his theory of therapy was that it was “evidence based”. He had not tried any other forms of therapeutic interventions because he felt there was not as much research to back up other theories. He said close to seventy five percent of his clients got better using his approach. My question to him was, “What about the other twenty five percent who don’t change?” He politely changed the subject at that point.

 

theory

 

Even though there are some great aspects to having a solid theory of how to do therapy, these theories can sometimes become cumbersome and limiting if we think each individual will automatically fit into our theory. Our clients may not have received the memo that they are to respond a certain way at a certain time due to a certain intervention. When the client does not fit the theory presented by the therapist sometimes the client is then labeled “resistant”. When a client is seen as resistant due to his or her inability to conform to the will of the therapist, the therapist may then become frustrated, angry, feel ineffective or become burned out due to his or her strict adherence to their theory.

The best way to handle the “resistant” client is to throw away your theory. This may be blasphemy to many who cling to their theories in a dogmatic, evangelical way. Many times our theories are good for some clients but not good for others (the twenty five percent). If all we have is one way to assist others we may find ourselves surrounded by “resistant” clients who make us work too hard, feel defeated and uninspired in our vocation. When we allow ourselves to create new interactions in the moment with each new client without a set scripted theory, we may find that every therapeutic encounter can feel much more exciting and creative. What if every client needed his or her very own theory of therapy?

The great scientist Karl Popper believed that theories by nature are abstract, and can only be tested in reference to their implications. Popper asserted that a theory is irreducibly conjectural and brought about by our imagination to solve problems that have come about in a distinct cultural and historical context. He felt that the truth of any theory cannot be verified by scientific testing. It can only be falsified.

To quote the brilliant family therapist Carl Whitaker: “I have a theory that theories are destructive.” Whitaker argued that too much reliance on a theory can cause a loss of objectivity for each unique person and situation. He felt this could result in a loss of compassion and care for the client. He argued that clinicians should consider give up strict adherence to theory and become alive as a real person in their sessions. As he eloquently put it, “Part of the problem is the theoretical delusion that science is curative; that enough knowledge, enough information, the right kind of facts will bring about the resolution of life’s doubts, the resolution of all distress.” I think Carl got this one right.

Are You Ready to be Creative?

If you have spent any time reading my blog or listening to my podcasts you know that I am a big proponent of using creativity in psychotherapy. I see too many good therapists who could be amazing therapists if they would just allow themselves to be more creative in their work. The straight jacket many therapists put on themselves by strictly sticking to the textbook can inadvertently dampen their effectiveness.

But it doesn’t have to be that way. It’s time to fall back in love with your work, have more fun, and gain the confidence to embrace more playfulness in your practice. This is why I am excited about this upcoming  event.

I’m speaking at a virtual event ­­ Create Fest 2016 ­­ that you can attend from the comfort of your home.

Create Fest is all about empowering therapists like you to awaken your creative spirit and reignite your passion for your work. What we do as mental health professionals is vital to healing in the world, so my fellow speakers and I are passionately committed to helping you revitalize and enhance your practice.

 

Createfest

 

Join me and a dozen of my “outside­ the­ box” colleagues. Each of my fellow speakers brings a wealth of experience, insight, and one­ of­ a­ kind creative thinking to the mental health field. Come discover some new approaches.

Each day, you’ll get to watch 6 fun and inspiring interviews PLUS 6 live experiential activities, designed to help you integrate and prepare to apply what you learn. This is not your average professional development conference! Create Fest 2016 will be 2 days of powerfully playful and practical ways to invite more creativity into your practice.

To sign up for this unique event, go HERE

If you are ready to have fun, be inspired and learn to expand your effectiveness as a therapist, then I know that I will see you there.

 

Brief Reflections on Erickson Congress 2015

I recently was able to attend and present at the 12th International Erickson Congress in Phoenix, Arizona. My trip was very enjoyable and was a moving experience for me. Getting to see old and new friends was great as usual. I enjoyed connecting with people such as Bill O’Hanlon, Bob Bertolino, Michael Hoyt, Mike Munion, Suzanne Black, Rachel Hott, Bob and Sandie Wubbolding, Eric Greenleaf, Betty Alice Erickson, Richard and Susan Hill, Rob McNeilly, Gabrielle Peacock, and far too many other people to list. It was a lovely time to be around like minded practitioners whose high skill level was only matched by their deep desire to help others.

 

Bill keynote

Bill O’Hanlon during the keynote address

The primary thing that I gained from the conference was a reinforcement of my belief in the importance of focusing on the potential each client brings to his or her therapy session. Every presenter I talked with shared my views that a constant focus on pathology rarely leads to change. Dr. Eric Greenleaf said it best in one of his sessions, “Psychotherapy seems to be the only profession in which constantly discussing the history of the problem is seen as somehow contributing to solving the problem. You don’t find this in any other profession. If a plumber has a problem, he or she just makes adjustments in how the plumbing operates. There isn’t all this long drawn out examination of the history of how the plumbing issue started”.

Greenleaf

Dr. Eric Greenleaf

I have attended many conferences in the past but the Erickson Congress is my favorite as it feels so much like a family reunion. Even people I did not know at first quickly became friends. Having a common goal for utilizing client resources over emphasizing diagnostic dysfunction seems to draw us together in a way that I don’t find at many other psychotherapy related conferences. The staff did a great job at helping everyone connect and enjoy the event. Dr. Jeff Zeig, the head of the Erickson Foundation, and his team made a wonderful occasion even more wonderful by exhibiting much care and professionalism to ensure everyone had ample opportunities to learn and interact.

 

zeig

Dr. Jeff Zeig

On a personal note, I was honored to have been able to have a small, private tour of Dr. Milton Erickson’s home and office. His home has been turned into a private museum and kept how it would have looked if he were still living there. I was accompanied on the tour by some of my friends, including Dr. Suzanne Black and Dr. Rachel Hott. We all enjoyed seeing many of Dr. and Mrs. Erickson’s personal items and getting a sense of how humble Dr. Erickson really was. Just standing in his home I felt a sense of awe mixed with sadness. In some way I could sense the physical pain Dr. Erickson was constantly in toward the end of his life due to polio. At the same time I was overwhelmed by the feeling of how much he loved being alive and helping others. Just being in his office was inspiring for me and several of us were able to sit in his chair and soak up the ambiance of where he worked. Being in his home gave me a deeper sense of who Dr. Erickson was as a person. Even though I had written a book about his work, I didn’t have that personal sense of connection with him until after visiting his home.

 

Erickson backyardGetting a quick group photo in Dr. Erickson’s backyard

suzanne erickson

Dr. Suzanne Black in Dr. Erickson’s office

There is a certain feeling of sadness I had as the conference came to a close. I know it will be another year or so before I get to see my therapy friends and mentors. Having had several days surrounded by people who share my passion gives me a renewed feeling of possibility for my profession. I encourage anyone who works in the mental health field to make sure you are able to have some time throughout your year to interact with like-minded souls as our profession can be a very lonely one. By interacting with our peers (friends) we can share new ideas which can help not only us but also our clients. I am grateful not just to be able to attend but also to be invited to present a short course. I am anxiously looking forward to the next one and I hope to see you there.

You are part of the action!

When we are conducting therapy it is not uncommon for many of us to feel as if we are outside observers as to what is going on with our clients. We think we have a different perspective as we are not directly experiencing what they are experiencing. We often hold that we can be objective as we are outside the action that is taking place in our clients’ lives. Even though this view sounds logical, it may be that this view is limiting our ability to create change for clients.

When we have this perspective as being outside the interaction our clients are engaging in, we can sometimes struggle to adjust their behaviors and thoughts in order to create a shift in clients. If, on the other hand, we view ourselves as being part of the interaction, we find that our very presence can create openings for change to occur. Let us consider how being a part of the interaction is different from interpreting clients’ actions.

If we are interpreting clients’ actions as an “outside observer”, we can only give clients our perspective. This can sometimes be helpful but it can also just take the form of merely giving information. Having information can be helpful but it does not guarantee that our clients will change anything in their lives. Just knowing information does not create an experience for clients to feel firsthand what the adjustment to the pattern of interaction is like. Some clients may take the information they are given and run with it but many will hear it, think about it and find that nothing changes as the patterns of interaction have not been altered.

In contrast, by assuming that you are now part of the pattern of interaction, it becomes much easier to create therapeutic shifts in clients by the use of your own behavior. If your therapy session is an interactive process that now incorporates you the therapist (which it is), anything you do on your part to adjust the interactional patterns can result in shift in those patterns. By no longer believing you are outside of the interaction, you now have the ability to adjust the patterns clients bring to therapy by merely adjusting yourself.

 

interaction

 

As Keeney wrote in the classic text, “Aesthetics of Change” (1983):
“The traditional view is that a therapist treats a client through a given intervention. However, it may be useful for a therapist to imagine a client’s behavior as an intervention. His interventions, so to speak, attempt to provoke the therapist to come up with a useful directive or solution. In this reverse view the therapist’s behavior is problematic when he fails to help the client. Treatment is successful; when the client provokes the therapist to say or prescribe the appropriate action.”

Essentially, the patterns of interaction involve the therapist and to believe the therapist is not a part of the interaction is limiting to the ability of the therapist to create changes in those patterns. By changing yourself in the session, your clients cannot help but be impacted. Any action you take to shake up the pattern will be felt by your clients, unless all you are doing is giving them more and more information.

Since you are a part of the interaction, imagine how freeing this can be to you as a therapist! You no longer have to rigidly adhere to treatments and theories. No matter what therapeutic orientation you have you can become more effective as your mere presence in the session is able to open the doorway to new possibilities.

Are you a Lazy Therapist?

Are you a lazy therapist? If not, could you try to become one?

To me a lazy therapist is one who does only what needs to be done. He or she will relax and let the therapy session move into whatever direction it needs to take without feeling like he or she has to control it. Lazy therapists go with the flow and even sometimes shift the flow in surprising ways.

Most of us have been taught that if we are working harder than the client then something is not right. It may be that we want to the change in the client more than the client wants it. It could also be that perhaps we are attempting to get the client to fit into our therapy model. If we are lazy therapists we just let new therapy models happen all by themselves. We take whatever the client gives us and we use it to create new possibilities for the client. If we are trying to force a client into a model it feels like “hard work” and that means you aren’t being a lazy therapist.

lazy therapist

To be a lazy therapist does not mean you have to be an ineffective therapist. Quite the contrary. You may find that the more you let go of control and let the client do whatever he or she is going to do, often magical openings appear for you to do great therapy. These openings may not appear if you are working hard to get the client into a set pattern of interaction.

 
To be an effective “lazy” therapist I believe you need to do two things:

 
Improvise and Utilize

 
When we improvise we let the client takes us on a journey. We see what magically appears and we do things which seem natural in that specific moment.
After that we then utilize what has occurred in our improvisation to move our clients toward new resources for healing.
This is so different from “working hard”. This can be quite a fun, lazy way to help people.

 
Instead of badgering a client to change their thinking, why not start a discussion about something they enjoy which could lead to an experience of interaction which might shift their thinking in ways beyond anything you might have thought possible?

 
Instead of pushing a client into facing his or her fears, why not do an out of the ordinary activity where he or she can feel in charge of the situation and access the resource of confidence?

 
Instead of working hard to label a client, why not pull out your DSM and ask the client what label they would like to have, which could start a great discussion about the power each of us has to choose our own labels?

 
You could easily do all these kind of things but you may feel you are being lazy. That is a good thing.