Blog Posts

  • Using Rituals in Psychotherapy

    ritual

    The term “ritual” can bring to mind many different images and preconceptions. Rituals are powerful actions that are all around us in both religious and secular settings. One can consider standing for the national anthem as a ritual. Having a funeral after a loved one passes is a ritual. Weddings and graduation ceremonies can be considered rituals.

    According to many researchers the use of rituals is designed to cause a shift in one’s consciousness. It is a method to open up to other ways of being in the world. The great mythologist Joseph Campbell believed that rituals can put one in direct touch with mythic reality. Rituals can, if done correctly, be powerful methods of setting intention in one’s life. Rituals can also be used to facilitate healing, mark important transitions in one’s emotional development and signal new beginnings in one’s life journey.

    From the psychotherapy perspective rituals can be very effective at assisting individuals (and families) in creating new patterns of responding to and interacting with the environment. Many times people feel stuck in a certain pattern and not sure how to change it. In his book “Rituals in Psychotherapy: Transition and Continuity”, psychotraumatologist Onno Van Der Hart writes that he feels the use of rituals to work through significant psychological distresses can result in major shifts in ones’ cognitions and emotional patterns. He feels rituals can create the process of healing in a manner that few other interventions can demonstrate.

    The field of family therapy is full of great case studies of therapists giving clients odd rituals to perform that indirectly creates a change in the previous patterns the family exhibited. In other cases families may need to hold on to their rituals during difficult times to ensure their connection to each other. I read an article recently in the New York Times that cited the importance of the family dinner as a ritual in preserving the emotional health of the family.

    When a therapist gives a client a ritual to perform it is often geared toward giving the client more flexibility and resources in working through the present issue being faced. If a client feels stuck he or she is merely lacking experience of a new action to take. Once the action has been taken in the form of a ritual the client will now know (at the unconscious level) that he or she has more options than previously considered.

    An example of this happened in a session I recently had with a male client who was seeking therapy due to an upcoming divorce. His wife had a consistent pattern of infidelity and seemed to have no desire to reform and become part of a monogamous team in a marriage. My client was hurt and depressed by his wife’s actions. He did feel divorce was the right thing to do in this situation but he was totally stuck in moving forward with his life. He really felt he loved his soon to be ex-wife and had trouble even envisioning a life without her. He could not even bring himself to begin getting rid of some things that belonged to his wife that she had left behind at his home. Seeing those items and not having a vision of a life without her led to his feeling more depression and heartache.

    After we covered the important points of what brought him to therapy, I decided to enact a ritual to help him move forward. I asked him if he would be interested in doing a small action that could assist him in feeling better. He replied he was very interested. I told him that what I was going to ask him to do may seem a little strange but it was in his best interest. His curiosity was peaked but he still was open to what I was going to recommend.

    I sat quietly for a minute. I then looked him directly in the eyes with some intensity and told him, “I think you need to perform an exorcism!” This was not what he had expected to hear. “An exorcism?” he asked to make sure he had heard me correctly. “Absolutely.” I told him, “You need to exorcise a room in your house.” At this point he was all ears. “I think you have a real issue that needs a different approach. The exorcism you will perform is not for ridding your home of the devil but rather the pain of this relationship. I want you to take all of your wife’s belongings out of one room in your house. Put these in the garage for three days. After you take her things out of the room I want you to go get yourself some incense from your local store. Choose the kind that you like the best. Light the incense and face each wall of the room which you removed her belongings and make the sign of the cross (this client was a devout Christian). After you make the sign of the cross say out loud four times, ‘I ask for peace and love in the name of the Father.’ Do this ritual seven times each day for three days. After three days you can feel free to bring in your wife’s belongings and put it back where it was in the room.”

    exorcsim
    My client did not expect to hear this kind of thing from a psychotherapist. In spite of him being surprised by my odd directions, a part of him appeared to be excited and energized to begin this assignment. I was not telling him to get rid of his soon to be ex-wife’s belongings but rather just to put them somewhere else for a few days. This action gave him the flexibility and experience of moving her things to the garage which could possibly lead to moving them out of the home. Making the sign of the cross invoked within him a feeling of connection with his religion which previously had given him comfort when life was tough. He reported back with a new feeling of possibility and hope that even though he was very sad, he could go on and create a new future with someone who would be faithful to him.

    I certainly could have spent our time together working on his illogical beliefs about the future, his family of origin issues or his self-esteem troubles but I felt that in that moment a ritual would do more for him than the traditional therapy. The action I directed him to take was so different than what he was doing that he had no choice but to have a new experience. His experience of taking charge of moving things in his house and asking for help from his God gave him the necessary resources he needed to create new changes in his patterns.

    I think we as psychotherapists need to ask ourselves what are some ways in which we can help our clients move through their trials and tribulations other than just talking with them (although that alone can be pretty powerful). What actions can we take to shake things up and give our clients the resources and experiences they need to solve their own problems? What rituals can we perform for ourselves that will make us more effective healers?

  • Psychotherapist as Shaman

    Shaman

    One of my interests is in studying various traditional healing traditions around the world. Ancient people had a wide variety of methods to assist people in their culture to heal from physical and emotional wounds. I find that the more I learn about their work the more I sense that we may be missing something in our therapy work. This week I have been reading the book “Spirit Versus Scalpel: Traditional Healing and Modern Psychotherapy” published by Bergin and Garvey.

    In the forward Dr. Uwe Gielen writes,

    “The traditional healer must simultaneously cure the body and soul; otherwise, society will perceive him or her as a failure……It also helps if the healer succeed in staging a highly dramatic performance, since traditional healing typically takes place in the presence of impressionable spectators. Healing does not merely consist of the recovery of physical strength and health but must also result in the reintegration of the patient into his or her social group. The medicine man or voodoo priestess is not only a psychotherapist but equally a transmitter of culture. Everywhere, successful healers must learn to speak the psychological/spiritual/cultural language of their patients; they must enter the patients’ minds through a process of empathy and become sensitive to the emotional preoccupations that accompany their physical illnesses. They must evoke in the patients a sense of faith, hope and trust in the healer’s power.”
    As I read this passage I began to wonder if we as psychotherapists are fully utilizing all the elements we could when working with people.

    Do we give our clients hope just by walking in the room or is there a sense of uncertainty when we greet them?

    Do we create an alive, exciting environment that facilitates change or do we quietly work with lifeless diseased based models of therapy?

    Do we show our clients unwavering faith in the positive outcomes of our work or do we unconsciously send out the message that our work will be a long, tedious and unclear process?

    We can learn a great deal form studying the Shamans of the world. What if we began to see our work as therapists as that of a modern shaman? What if we began to believe that we have great power to bring about sometimes inexplicable healing in our clients? I wonder if that alone could shift the manner in which therapist and clients traditionally interact and create surprising results for the people who seek us out in order to heal?

  • What is a resource?

    In my work I define a resource as any emotion, event, belief or behavior that a client has experienced that can assist him or her in healing. If a therapist is working from a resource perspective he or she is constantly seeking what the client already possesses that can help move the client to positive outcomes in therapy.

    Often these experiences are in different contexts to what the client is presently experiencing. If a client is seeking therapy due to anxiety, then somewhere in his or her life he or she has also experienced being relaxed although in a different context. As one client told me that he had never been happy, I replied “How do you know? The only way you know you are not something is if you have some experience of the opposite. How can you know if you never have been happy if you haven’t been happy at least once?”

     Someone who I believe was a master at this approach was the late Milton H. Erickson. Erickson was a psychiatrist best known for his legendary skills as a hypnotherapist. Erickson was also an amazing therapist whose interventions often seemed odd, bizarre or confusing. However, if we approach his work with the mindset of seeking resources, many of his cases become more enlightening. He was truly amazing at helping his clients access their own inner resources in unexpected ways.

     The following two cases involving bed wetting serve as examples that show that even indirect accessing of resources within the client can have dramatic effects. I pulled these from O’Hanlon’s classic book, “An Uncommon Casebook: The Complete Clinical Work of Milton H. Erickson, M.D.” published by Norton.

     
    Case 1
    Erickson worked with a 10 year old boy named Jimmy who had an issue with bedwetting. Jimmy’s parents had gone to extreme lengths to get him to cease wetting the bed. Some of the things they did to attempt to cure jimmy was to have Jimmy confess to the congregation of his church about his bedwetting and wear a sign around his neck proclaiming that he was a bed wetter. None of this did any good and probably did much harm to Jimmy.
    When Jimmy met with Erickson to work on the problem of bed wetting, Erickson did not even discuss the presenting problem. Instead he commented on Jimmy’s athletic build and discussed what sports Jimmy was good at playing. One of Jimmy’s favorite sports was baseball. Erickson continued to talk about the muscles necessary to play something like baseball and went into detail about the fine motor control that is required to catch and throw a ball. He spent time talking about which muscles of Jimmy’s were most important in being able to close the glove after he caught a ball Erickson then went on to discuss in depth how the muscle at the bottom of the stomach has the ability to stay closed until it is time for the food to come out. After three sessions Jimmy reported he had ceased wetting the bed.

    Here we see Erickson reminding his client about the resource that he already possessed. Jimmy already was successful at controlling his muscles in caching a ball and digesting his food. Erickson provided Jimmy with the resource for competence which resulted in his new ability to cease wetting his bed.

    Erickson

    Dr. Milton H. Erickson (1901-1980)

    Case 2
    A woman brought her 12 year old son to see Erickson due to the son’s constant bed wetting. Upon learning that the boy also had issues at school with having bad handwriting, Erickson gave the woman a prescription to follow. The woman was directed to awaken at four or five in the morning and go in and check to see if her son had wet the bed. If he did not wet the bed she was directed to leave him alone and return to bed. If, however, he had wet the bed, the mother was directed to get the boy up from bed and have him copy out of a book to improve his handwriting until it was time to start the day. Over time the boy wet the bed less and began enjoying connections with other children more. He eventually ceased wetting the bed altogether and his grades improved.

    Again, Erickson supplies his client with a resource. This time it is also about muscle control. By having the boy learn to control the muscles and coordination needed to write more neatly, the boy indirectly gains a resource that aids in controlling his body in the area of bed wetting.

    I have found that approaching  therapy with an intention to focus on and utilize client’s resources not only makes therapy more fun it can also make it more effective.

  • Focus not on the problem

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    Too often therapists ignore the positive resources that clients brings with them to therapy. Graduate school counseling programs hone students’ ability to spot problems and disorders while labeling behaviors with codes that define more about insurance billing than the client healing.

    Many times this history of training sets the therapist’s brain in the pattern of looking for problems instead of seeking client resources. If a client has a resource that can assist them in healing and changing it should be utilized in session.  Sometimes the very “problem” the client brings in can have a positive intention that can activate the client’s own ability to change.

    Here is a personal example:

    I  worked with a young woman in her early 20s named Erin (not her real name). She came to seek help due to the encouragement of her mother that she speak to someone concerning her repression of her emotions. Erin stated that she often times was the person who her family came to when they were angry and upset as she would listen to them and not outwardly be affected by their anger. When people did things to make Erin angry she would shut down and not acknowledge how she felt and would never address her anger with the offending party. Her constantly bottling up of her emotions was beginning to cause some health issues for her which is why her mother began to notice that she might need to talk to a professional.

    When asked what the motivation for swallowing her anger was, Erin replied that she was scared that she would lose her temper to the point that it would make life unpleasant (or worse) for her and her family. She was uncomfortable with any expression of anger which was why she would work hard to calm people down in her home. At the same time she was growing tired of feeling caught in the middle of the many family battles that were taking place.

    At this point many therapists would be either examining Erin’s family history, challenging Erin’s irrational belief that something terrible would happen if she showed anger, or invite Erin to feel the feelings she has avoided feeling within the therapy session. All of these are good interventions but are still rooted in the context of a problem directed approach.

    Coming from a resource directed approach I found out that Erin’s emotion swallowing behavior had a positive intention. The positive intention I found was that she felt by doing this action she was trying to protect her family from her anger.

    At that point I praised her desire to protect her family and cited it as a resource she can use. Erin was then instructed to make a name tag that she only wears at home that reads “Anger Protection Specialist”. I informed her that she should be proud of the fact that she has decided to care more about the safety of her family than her own emotional state. She is then sent home to begin her new “work” as an Anger Protection Specialist.

    On returning to the next session, Erin informed me that over the past week she got so angry that she went into another room of her home and kicked a box. She was surprised that she showed any physical response to her feelings and admitted to feeling better after she kicked the box. She also reported that she was not wearing the name tag anymore. I made sure to comment to her that it must be nice that she can stop being an “Anger Protection Specialist” when she wants.

    On her third session Erin reported that she was no longer feeling extremely stressed and her health had improved. She stated that her family had noticed a major shift in how she related to them and also began to notice that she was occasionally getting angry but in “a good way”. Erin was feeling more comfortable expressing her anger and sadness to her family and others. At this point she did not feel she needed to come back to therapy for this issue.

    Erin had all the resources inside to change her behavior and emotions. By looking through the lens of resources instead of the lens of problems I feel we were able to have faster progress in our work that was on her terms.

  • Challenging the need for insight

    therapy-main

      I have sensed a shift backwards in the practice of psychotherapy over the past few years. In many cases the field has become a lifeless, empty process where therapists spend much of their time attempting to guide clients into insight and understanding of where their problems began. This noble endeavor is a hold over from the days of Freud who believed that insight was crucial to therapeutic change. While insight is not necessarily a bad thing, I assert that it often has little to no bearing on whether a client changes his or her life.    

    In spite of exciting new discoveries in the field over the past several decades, in many cases therapy has gone backwards and become a process where therapists have clients go on a psychological archaeology expedition of their lives. These therapists hope that by having clients see where their patterns of behavior originated they will obtain a new insight that will cease their pain. This occasionally may work but I think more often than not it doesn’t.

    If we want our clients to become transformed we as therapists need to be transforming! We need to get our clients DOING something different rather than just searching for causes. In the 1960s and 1970s amazing therapies (and therapists) began to show up that shook the foundation of established past oriented approaches to change.  The work of people such as Milton Erickson, Jay Haley, Virginia Satir, Salvador Minuchin, and many others gave the field a shot in the arm. There was aliveness and creativity in their sessions with very little exploration of where client behaviors originated. These therapy masters got results by changing what their clients were DOING not spending excessive time exploring and interpreting the history of why their clients behaved as they did.

    How many times have we had  a session with a client who seemed to have a wonderful, life changing moment of insight into why he or she exhibits certain negative patterns only to see them two weeks later complaining of the same emotions, behaviors, or situations? It is far too common. I think more therapists need to move away from solely encouraging insight and instead begin to find creative ways clients can begin DOING something new and different.  If the process of therapy is not much different from what clients are already doing what is the point of coming into session?