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Making Quick Work of Lasting Change

© 2017 Psychotherapy Networker magazine, March/April

Steve Andreas

Imagine that your car is smoking, shaking, and making ugly noises. When you take it to a repair shop, the manager is unusually direct. “We charge $100 an hour, and you’ll have to bring it in weekly so we can develop a working relationship,” he says. “We can’t tell you how long we’ll take to repair it, and we don’t provide estimates or guarantee our work, even for simple repairs like a flat tire or a bad alternator. Since the dropout rate is 20 to 40 percent, overall 30 to 50 percent of cars leave the shop no better than when they came in, and 10 to 20 percent leave in worse shape.”

You’d probably take your car somewhere else for service.

Yet that scenario is a pretty accurate picture of the state of psychotherapy. No wonder that for many suffering people, going to a “shrink” is a desperate and unaffordable last resort. Someone earning minimum wage would have to work a day and a half to pay for an hour of therapy. Not many jobs I can think of pay so well for such mediocre results.

I’ve been a participant-observer of the therapy scene for almost 60 years, and I know that the majority of therapists are sincere, hardworking, and well intentioned. I also recognize that some clients’ difficulties remain intractable to even the most skilled clinicians. The problem, in my view, is that most therapists haven’t been equipped with sufficient perspectives and behavioral-change skills to help people with even the simplest issues.

Moreover, most therapists have no idea how ineffective their work actually is. In a 2012 study of 129 therapists by Steven Walfish and colleagues, published in Psychological Reports, the researchers found that most of their subjects suffered from the “Lake Wobegon effect,” the tendency to overestimate one’s capabilities. More than 90 percent self-rated their psychotherapy skills at the 75th percentile or higher, and all of them rated themselves above the 50th percentile. In fairness, I should note that people in the general population also tend to believe that their intelligence and skills are higher than average. Nonetheless, in his research on therapists, Walfish used a much larger sample size than most such studies do, making the Lake Wobegon effect for clinicians likely to be significant. As I see it, this indicates a lamentable lack of self-awareness and minimum of motivation to improve skills.

It’s widely believed that therapy is generally effective in helping clients over an extended period of months or years. However, the validity of the research often used to back up this view has come under intense scrutiny since Stanford professor John Ioannidis’s article “Why Most Published Research Findings Are False” was published in PLoS Medicine in 2005. He writes, “A research finding is less likely to be true when the studies conducted in a field are smaller; when effect sizes are smaller; when there is a greater number and lesser pre-selection of tested relationships; where there is greater flexibility in designs, definitions, outcomes, and analytical modes; when there is greater financial and other interest and prejudice; and when more teams are involved in a scientific field in chase of statistical significance.”

More recently, a team led by Brian Nosek, a social psychologist at the University of Virginia, reviewed research published in 2008 in three major psychological journals, and tried to replicate a hundred of them. The resulting article, published in the August 2015 issue of the journal Science, found that only 36 of 100 replication attempts were successful, with most of those at a lower level of significance than in the original study. Further, William Epstein’s The Illusion of Psychotherapy (1995) scrutinized the research available at that time and identified a blizzard of uncontrolled factors that could account for all the evidence for the effectiveness of psychotherapy. In his 2006 book, Psychotherapy as Religion, Epstein went even further to argue that therapy is an ineffective cultural ritual.

Of course, many therapists freely admit that their years of graduate school didn’t really train them in the skills they need for helping clients in a concrete, expedient way. Most of us spent plenty of time studying theories of therapy, personality, developmental stages, learning, and motivation. But even if we assume those theories are valid, how are we supposed to translate such general knowledge into what to actually say to a client in therapy? We need specific, practical, hands-on training. This means giving therapists a chance to see clinical work in action — the real-time encounters between therapists and clients, the therapists’ interventions and the clients’ responses. Also, rather than reviewing videos of students’ work with clients, most therapy supervision is just discussion of what a student remembers about a session — which is inevitably biased and doesn’t include opportunities for the students’ clients to offer their input.

Study after study has repeatedly shown that the therapist-client relationship is by far the most important indicator of client satisfaction. But the same studies show that the therapist’s theoretical orientation, training, experience, and skill are negligible factors. That suggests to me that what’s called the therapeutic alliance is little more than a popularity contest, in which a successful therapist is perceived to be more caring, accepting, and understanding than anyone else in the client’s life. Since many clients come from difficult backgrounds and the therapist only sees them for an hour or two each week, this is usually not too difficult to achieve.

So here’s what we know so far: the evidence for the effectiveness of psychotherapy is weak; therapy is vastly overpriced for the uncertain results it produces; and therapy education rarely teaches us how to actually work with clients and improve what we do, especially since few therapists release videos of their in-the-moment work with clients. In my view, at best, much of psychotherapy is a pseudoscience, promising far more than it can deliver. At worst, it’s a group of psychotheologies competing for market share, with buzzwords like mindfulness, self-compassion, and neuroscience.

Discouraged? Nettled? Exasperated? Bear with me. There’s good news, too.

 

The Dance of the Nonverbal

What if there were a few basic principles and methods that make therapeutic change far simpler and easier — and much more enjoyable for both client and therapist — than most people think is possible? And what if we could often bring about that change in a very short time by modifying a few unconscious processes? Not only is this possible, but there’s already a coherent body of knowledge and practice to guide us in eliciting change in the moment, confirmed by longer-term follow-up in the real world.

I’ve deliberately refrained from naming this approach to keep it from being dismissed as yet another of the thousand or so named models out there, most of which are only different rebrandings of existing therapies with slight variations. If we must have a name for this way of working with internal processes, let’s call it essentials of therapeutic change. It’s a rich tapestry woven from many different threads, from cognitive linguistics to clinical hypnosis, developed by studying the work of therapeutic greats such as Milton Erickson, Virgina Satir, and Fritz Perls, as well as the work of a few outstanding researchers, like Daniel Kahneman’s two systems of thinking and Thomas Gilovich’s work on regret. Developed largely outside of mainstream academia, many different practitioners have been involved in its growth over at least four decades. Few of us could be called originators; most are fieldworkers or adapters.

Much of the development has come from eliciting overlooked, often unconscious, aspects of the before-and-after experience of clients who have recovered from a problem. For instance, people who were no longer depressed had internal images of the future that were large, bright, and colorful; but when they were depressed, their images were small, dim, and colorless. This suggested that helping a depressed client adjust his or her unconscious images of the future to be larger, brighter, and more colorful could be useful. It sounds far too simple to be true, but the videos and feedback from clients speak with authority.

Of course, some complex issues are still difficult to treat with this approach, but many common ones that clients bring to therapy — anxiety, phobias, grief, shame, guilt, self-judgment, critical internal voices, unwanted habits, and general overwhelm — can be dependably resolved with established procedures, usually in the course of a single session. Many readers will understandably doubt this claim, especially in light of my arguments above about therapy’s generally mediocre results. So my hope is to demonstrate how it works with a case study of resolving lifelong anxiety, backed up by short, unedited YouTube videos of complete sessions and three years of follow-up.

Watching the client’s nonverbal responses in the videos will be essential to an understanding of how different this approach is from most therapy. Learning how to do it doesn’t require studying a complex theoretical orientation. But it does involve paying close attention to the mostly unconscious, nonverbal process details of your clients’ experience of their problems, and learning how to ask questions that elicit additional process elements.

To make this approach as user-friendly as possible, here are seven practical principles for making sense out of the case study that follows. You can easily test and confirm each of these principles in your own experience, or in your work with clients.

  1. Many problems that bring clients to therapy are caused by unconscious processes over which they have no conscious control. By unconscious I don’t mean Freud’s seething cauldron of inhibited desires: I simply mean aspects of our internal experience that we don’t usually notice, like the size, closeness, and color of a troubling memory image, or the tempo, tonality, and volume of a critical internal voice. If our problems were the result of conscious processes, we could just stop doing them, as satirized in Bob Newhart’s short YouTube video in which the therapist listens to the client’s problem and then responds with his universal solution: a loud, emphatic “Stop it!” But since most problems are caused by unconscious processes, that’s where we need to direct our interventions.

For instance, a client might say, “That screw-up I made is right in my face,” while gesturing with his palm close in front of his face as his head recoils slightly. If you imagine having that experience yourself, you can notice that if that image of the screwup were smaller and farther away, or off to the side or behind you, the content of the image would be easier to deal with. It takes only minutes to ask clients to try these kinds of process changes, and to find out the extent to which they’re useful in changing their problematic response. I often tell clients, “I’m the authority on what might work; you’re the authority on what does.”

  1. Change the cause, not the symptom. Returning to the metaphor of a malfunctioning car, if your car is smoking, shaking, and making ugly noises, those are important signals of a problem. They may give you some indication about what the problem is, but they’re never what needs to be changed. Filtering the exhaust, using vibration dampers, or soundproofing won’t solve the problem in the car’s engine.

In the same way, unpleasant feelings are important signals that something is wrong, but they’re only symptoms of an unconscious cause. For instance, feeling depressed is often a signal that someone has an internal image of a bleak future. Or perhaps there’s a low, slow, internal voice saying, “It’s hopeless.” To change the feeling, he or she has to change the image or voice that elicits the feeling.

  1. Discover the unconscious processes that elicit feelings. These processes are mostly outside of our awareness, but they can become conscious if we pay attention to them. The client’s gestures, direction of gaze, and other nonverbal behaviors often reveal important aspects of their internal experiences. For example, if a client talks about a troubling memory while gesturing in front of her with hands two feet apart, this tells you where her memory image is, and how large it is. Once we’re aware of the process, we can try simple interventions. If the therapist reaches out in the same spatial location and says, “Tell me about that memory again” while moving his hands somewhat closer together and farther away from where the client gestured, that’s an unconscious invitation to see the memory as a smaller image, at a greater distance, which usually makes it less emotionally disturbing, and thus easier to address and learn from. Most of these processes are nonverbal — the sensory parameters of an image or inner voice, in contrast to the content — and eliciting them is often as simple as asking questions like, “Where is that disturbing image? How large is it? Is it in color or black and white? Is it moving or still? Is it 3-D or flat?”
  2. Adjust, don’t eliminate. Many approaches try to abolish a troublesome process by eliciting a competing response, such as teaching an anxious client to think of a soothing context, slow his breathing, or relax her muscles. It’s much easier and more effective to make small changes in the troublesome process itself. For instance, if you hear an internal voice saying, “We’re going to crash!” in a fast, high-pitched voice, you’re likely to feel anxious. Disputing the content of what the voice says will have little or no effect. However, if you hear the same anxiety-producing words — “We’re going to crash” — spoken in a slow, low, bored tone, with a hint of a yawn, you’re likely to experience full-body relaxation without any conscious effort. The process is almost always more important than the content. For example, a sarcastic tonality can completely reverse the meaning of any set of words.

Another example: someone who’s overwhelmed is typically trying to cope with too many images at once — often big, close, colorful, moving images with sound, like a movie. If you invite him to allow all those images to retreat into the background, dimming the color, muting the sound, and perhaps pausing the movie as a still, the sense of being overwhelmed is likely to diminish, or even disappear. Then you can suggest that he scan the still images and decide which one is most urgent to address. Ask him to bring that one into the foreground again. Then turn it back into a movie so he can see it in clear detail, process the content, and decide what to do about it, before doing the same with the next most important image.

  1. The importance of gesture and language. Since a major part of your communication with a client is nonverbal, it’s important to make sure that your gestures congruently specify and support the change you ask a client to make. If you say, “Move the image of that critical colleague in front of your face around to a location behind you,” many clients will be able to do that easily; they’d just never thought of doing it before. However, if you first gesture to where their image is, and then pantomime grasping it and moving it behind yourself with your hand, that will make it even easier for clients to succeed in following your instructions. Doing this is also a clear nonverbal message that you’re taking on their experience as if it were your own, signaling respect and empathy in a way that’s far more subtle and impactful than the formulaic verbal, “I understand.” As you gesture, you can even say, “Allow that distressing image to move around behind you,” which hypnotically presupposes that it will move.

If the image won’t move, you can use a hypothetical “as if” frame while gesturing appropriately: “If that image were to move around behind you, how would that change your response to it?” If the image moves but then returns to its original location, you can say, “Imagine that you put some Velcro on the back, so you can hear that soft sound Velcro makes as you push it down in place back there,” while gesturing to the new location.

One client experiencing significant feelings of being overwhelmed was confused because she couldn’t put her internal images of moving her family and possessions from one coast to the other into an orderly sequence. The images of the tasks involved in the move — many of which depended on first doing others — wouldn’t stay put; they wobbled, slipped, drifted around, and moved in and out chaotically. When I suggested putting Velcro on the back of each image, she could put her images into a sequence that stayed still, allowing her to examine the sequence, notice what was out of place, and move images until the sequence made sense and was less overwhelming.

  1. Our internal world is a representation of our external world. If a threat comes closer in the external world — let’s say you’re visiting Yellowstone and a bison approaches you at a good clip — you’ll react more fearfully than if you see it from a distance. The same is true in our internal world: when a threatening image moves closer and becomes larger, it evokes stronger feelings, and vice-versa. Imagine a snarling pit bull coming rapidly toward you. Now imagine the same dog, still snarling but backing up and moving away from you, and notice how your feelings are different. Knowing that the internal world is similar to the external lets us predict how a given internal change might help a client become less reactive. Asking a client to “put a frame around that image,” for example, will typically result in seeing the internal image as flat, rather than 3-D, since most framed images we’ve seen are flat. A flat image appears less real and is therefore less likely to elicit a strong emotional response.
  2. Point of view is a key process element. Any memory (as well as any image of the future) can be experienced either as being inside it (reliving it) or being outside it (seeing it as a detached observer). For instance, imagine sitting in the first car on a roller coaster just as it begins its first big descent. As you feel a breeze ruffling your hair, you can see your hands gripping the safety bar in front of you as you look down at the ant-sized people far below. Now imagine sitting on a park bench, looking up, and seeing yourself far away in the roller coaster. This is a choice in point of view that everyone has, but most people don’t realize they have this choice until it’s suggested to them.

When a client remembers a terrifying memory by being inside it, that experience elicits what’s called a phobia or a PTSD flashback. If he steps outside that experience and views the same event as an objective observer in a movie theater, his terror response will diminish. (A complete nine-minute video of this process, along with a 25-year videotaped follow-up with the client is available.)

Sometimes, however, we need to tell a client to reverse this process and move from an “outside” viewpoint to an “inside” one. For example, if a grieving client remembers her dead lover from an outside point of view, the feelings of affection and closeness that she shared with the lover will be absent, leaving only a horrible feeling of emptiness. To resolve her grief, she needs to step back inside the memory to regain the special feelings of love, warmth, and connection.

These examples highlight yet another important principle: every mental process can be useful or not useful, depending on the larger context and the client’s desired outcome. A big, bright, “inside” image of a party can motivate us to achieve a useful goal, such as being with friends. The same image, however, can lure us into harmful behaviors, such as taking drugs or drinking too much alcohol.

 

Resolving Lifelong Anxiety

As we all know, anxiety is one of the most common problems our clients present. Most currently used treatments — such as learning relaxation and breathing skills, medication, and exposure — are directed toward the symptoms, rather than the cause, and are typically only partially successful.

First, let’s look at anxiety in its larger context. Planning is our ability to forecast events and prepare a response to them. When we foresee an unpleasant event, we experience anxiety. (It’s important to note that this is structurally different from a phobic fear response elicited by past traumatic memories.) When planning reaches a satisfactory conclusion, anxiety stops. But when we can’t reach a satisfactory conclusion, we continue to search for a solution indefinitely. In short, we worry. When we worry about a future that appears unavoidably dangerous or unpleasant, we continue to anxiously search for a better outcome.

Sometimes anxiety is useful, because it warns us about an unpleasant experience that we can do something about. For example, if you’re worried about being in an airplane crash and your anxiety keeps you from buying a plane ticket, then it’s effective in avoiding that possibility. But once you’ve decided to fly, and have put your safety in the hands of people and machines over which you have no control, anxiety is no longer useful.

Quite often anxiety is only a habitual, learned response to a perceived challenge, even when you’re well prepared for it. That was the case for Joan, who’d suffered, in her words, from “lifelong anxiety.” What follows is a condensed description of my work with her. (To observe exactly what occurred, see the complete, unedited 14-minute YouTube video)

Anxiety didn’t prevent Joan from doing things; it just made her miserable. An accomplished professional in her mid-60’s, she had a PhD in business and had held several high-level positions in successful companies. Now she was in full-time private practice as a hypnotherapist specializing in treating PTSD. Petite and smartly dressed, with short graying hair and an impish smile, Joan told me she experienced strong anxiety whenever she was facing a challenge, particularly when she was alone and potentially helpless. A recent example: she’d driven alone more than 700 miles across the desert from Arizona to Colorado to participate in my workshop, and had been anxious during the whole trip. So when I asked for a volunteer to demonstrate a method for resolving anxiety, Joan had hesitated briefly and then raised her hand.

When I asked her to imagine being in a situation where she got anxious and to tell me about the experience, she reported hearing a fast, high-pitched, internal voice yelling, “I can’t do this!” over and over, followed by a flood of anxious feelings.

“Notice where the feeling of anxiety starts, and where it goes to,” I said. After some searching, she reported that it started as a feeling of tightness in the back of her neck, then came around her right shoulder, traveled down the right side of her body and into her groin. “As the feeling moves along this path, tell me a little bit about the size of the path,” I continued. “Does it start out small and get larger as it goes down, or is it all the same size?”

Joan replied, “It’s big, immense,” gesturing broadly with outstretched arms. Although it may seem strange that someone could feel a feeling that’s partly outside the body, that’s what many people report. When I asked what color it was, she told me it was white.

“This last question may seem a little bit weird,” I said. “As it goes from your neck down your body, which way does it spin?” Joan quickly gestured with her right hand.

At this point, we were finished with information-gathering and ready for the intervention. “Joan,” I said, “I want you to imagine yourself in one of these situations that’s made you anxious — like driving across the desert to get here — and feel it start in your neck and move down your body. But this time I want you to reverse the direction of spin, change the color from white to one you like better, and add some sparkles to it. Just do that, and find out what happens.”

After a few moments, Joan said, “It feels better. It feels a lot better.” She looked mystified. “It’s really nice. This whole side of my body is relaxing. I’m breathing better.” The change was instantaneous, and her verbal report was congruently confirmed nonverbally. “Would it be OK for you to have this response instead of the old one?” I asked. She immediately responded, “Oh, yes!”

“If you put yourself in the situation that used to make you anxious, what’s it like now?” I asked. Shrugging, Joan said, “It’s easy.” Her new response was qualitatively different, not just a reduction of intensity in her old anxious response. But would it last?

“Some people need a little bit more practice, and that’s what I’m checking for,” I told her, pointing out that if her new response wasn’t automatic in the future, she now had something that she could do on the spot, on her own, to ease the anxiety. Then I asked her to test her new response repeatedly in her imagination. “Think about other situations that you used to get anxious in, and see if you can get the old response back,” I suggested. I did this for three related reasons: to make sure that she had no objection to the new response, to be sure the new response was dependably automatic, and to see that it had generalized to all the different situations in which she used to be anxious.

As Joan imagined several of these, she mused to herself, “One would be in the future, looking at finances, and that’s fine now.” She paused, imagining another situation. “Driving back home, fine. If I get in a place where there’s no cell reception, well, there I am, and I’ll deal with it then.” At the end of the session she said, “What a wonderful gift!”

 

Transforming Negative Self-Talk

To further reduce the possibility that Joan might revert to her old response, I set out to help her change the anxious voice that repeatedly yelled, “I can’t do it!” If that voice remained loud, tense, high-pitched, and fast in tempo, it could re-elicit the cascade of anxious feelings. So I used a method I learned from Melanie Davis, a therapist in the UK, in which the tonality of a troublesome internal voice is changed and the sentence is re-punctuated into two or more separate messages. On the next day of the training, I wrote Joan’s internal sentence — I can’t do it — on a flip chart. Seeing the words on the chart is already an intervention, because it puts some distance between Joan and the words, externalizing them and making it easier for her to observe them dispassionately. More importantly, I knew that the written words, without italics or an exclamation point, were likely to omit or soften the tonal aspects (panicked yelling) of her self-talk. So when Joan reads the words on the flip chart, she’ll be able to hear it in the neutral tone of voice that she typically uses when reading.

I started with a useful reframe that I knew Joan already agreed with because of her previous training — that every part of her, even her anxiety, has positive intent. If she didn’t already have this understanding, I’d have elicited specific times in her life when her positive intent had resulted in behavior that had been less than useful, like yelling harshly at a child with the intent of keeping him or her safe.

Next I said, “Now let me show you something. Can’t is really can not, right?” (Separating can’t into can and not has the effect of shifting the meaning from inability to possibility and choice: she can always choose to not do it.) So I rewrote her sentence this way on the flip chart: I can – not – do it.

This new punctuation divided her sentence into three separate messages. Joan gazed at the words, looked a bit surprised, and then said softly, “Oh, wow. The whole world opened up.” She gestured with both arms in a soft expansive movement. Although she was aware of the sudden, qualitative change in her feelings — from helplessness to freedom and possibility — she had no idea how that occurred, even after I asked her repeatedly, and even though she was in a training that focused on tracking the elements of this kind of rapid change.

I went on to offer her further modifications of the tonal aspects of the three separate messages: saying “I can” in a confident tone, shifting “not” into a rhetorical question (“not?”), and using a command tone for “do it!” This further amplified the change she’d already made, and Joan responded, “Oh, I like that.” (You can watch this unedited four-minute session on YouTube).

The following morning, Joan reported to the group that her car had failed to start and that she’d calmly phoned for help, whereas previously she’d have felt helpless and panicky. After the training, she drove home alone across the desert, feeling centered and secure the whole way. Three years later, Joan reports that these changes remain in place. She’s been able to remain calm in finding solutions to a variety of significant life challenges, including dealing with her mother’s failing health. She recently wrote to me, “I’ve used this process successfully with my clients and friends. I even got a full night’s sleep before making a recent presentation. Prior to the work we did, my anxiety would’ve been way too high for that.”

 

                           *       *       *       *       *

 

This way of working with the largely unconscious structure of present experience — in contrast to working with the history that created that structure — makes therapeutic change much more like reprogramming a computer: just find out what isn’t working in the client’s experiential software and offer simple interventions to alter the process. This simplicity has made it easy for many to dismiss the resulting changes as superficial quick fixes, presupposing that they don’t address “deep” issues and won’t last. Though clients are often initially skeptical of this approach — and real-world results are the only way to test it dependably — I’ve never yet had a client complain, “That was just too fast. Couldn’t you have taken longer?”

As I mentioned earlier, some clinical issues are still difficult to resolve quickly with this approach, though the list gets shorter each year. For instance, complex PTSD is a tangled mixture of terrifying flashbacks, guilt, shame, regret, anxiety, disappointment, and depression, often compounded by years of self-medication with drugs and the consequences of poor decisions resulting from that. It’s hard to disentangle and address all those different aspects, even when there are dependable processes for each of them individually.

Other problems are intractable because the client has no motivation to resolve them. For instance, narcissism feels good and is often richly rewarded in business and politics. The structure of narcissism is fairly simple, and I’ve been successful in changing it when it hasn’t gone too far; after all, each of us has at least some of narcissistic qualities. But I have no idea how to convince a full-blown narcissist that such a change would be useful. Paranoia has a simple structure, and is also easy to change if it hasn’t gone too far. But again, I have no idea how to enter the tight and vigilant world of a full-blown paranoid person in order to convince that person of the value of changing.

Keeping these and other limitations in mind can be useful in maintaining a sense of balance and perspective. But they don’t overshadow the immense pleasure and importance of being able to resolve many simple client problems rapidly, making therapy much cheaper, effective, and more available to so many who need it.

Working with a shame-inducing internal voice

I got a lovely email recently from a therapist reporting on a session:

 

I did a client session in November 2016 regarding old and new traumas with a 30-year-old woman who was sexually assaulted when she was 18. She had cancelled and rescheduled several times, but she finally found a time she could come without her two small children.

We were discussing the phobia process and when I asked if she had any questions, she was tearful, voice shaking, and she shared a strong disturbing thought, “You are going to take this from me.” She had a strong belief that she “should” feel the reactions to the memories of the assault (hypervigilance, somatic symptoms when memories arose, discomfort with physical contact with her partner).

We had planned to use the movie theater/rewind method to address the phobic response to her traumatic memories, but instead we addressed this negative internal voice that thought she “should” have this reaction. We shifted to the Troublesome Internal Voice Transformation method from the online PTSD training. She quickly identified the negative voice as being that of the boyfriend she had at the time (not the person who assaulted her), who shamed and manipulated her when he found out about the assault. She had a very profound experience when she realized this — her affect changed dramatically, she was quiet and smiling and relaxed, so there was no need to do the phobia process.

She said she hadn’t realized that the voice was “not me,” and when she had this realization, she felt free to stop listening to it. We’ve met twice since that session, most recently in early March, and the results have held. Below is the email I got from her the next morning after our session.

—Susan Malcolm LCSW, Portland Maine

 

“I literally cannot explain it. I am happy. I could not fall asleep last night because I am happy. I feel like I am that girl that was lost 12 years ago that was once so happy and liked herself. I am a little in shock from it still, but to have this box that was gross and oozing yesterday be beautiful and dressed up today is just amazing. All my anxiety that I have been having about everything is gone. I want to spend time with my kids, I want to talk to my husband about all the weird crazy things in my mind, and I don’t even care about talking about building a house anymore. (Yes, it’s still overwhelming, but I am not scared about it anymore.) It is literally unexplainable and amazing all at once. I cannot say thank you enough. I want this to be available for everyone. This is the craziest thing that everyone with PTSD should go through. E.V.E.R.Y.O.N.E.”

 

Comments by Steve Andreas

Susan’s lovely example is a reminder that when someone says they have a phobia, or PTSD, or anything else, those words may not accurately indicate the structure of what is troubling them. Many people use the words “trauma” and “PTSD” for a very wide range of different troubling experiences. If Susan had gone ahead with the phobia cure, either it wouldn’t have worked at all, or it might have worked with her memory of the assault itself. But it wouldn’t have resolved her crippling shame induced by the voice of her old boyfriend. It’s only too bad that she had to suffer needlessly for 12 years from something was so easily resolved in a single session. When Susan asked her if she recognized the voice, the realization that the troubling voice wasn’t hers probably only took a few seconds — a sweet example of what I call “Briefest Therapy.”

Small-Scope Synesthesia

In response to my previous blog post on synesthesia, Gary Skaleski (MA, LPC, currently working as an EAP case manager) wrote the following:

 

“About 1976-77 John Grinder was teaching about modalities, and at one point came up with a technique which I had not heard anyone else talk about, not written up as far as I know, but which I found helpful. We started talking about synesthesia, and while discussing overlap, John suggested we spend time every day mapping from one modality to another, but at such a small level that we would never get overwhelmed.  Example: take a sound.  Not a word (big scope: “Amen”) but part of that word (‘Ah’) and turn that into a feeling (not emotion, but how and where that sound feels physically in or on your body), then take that feeling and turn it into a visual image (again, not a scene but a simple shape, color, etc.).

“The order is not important, and could start with a feeling, to visual to auditory, etc.  Just keep overlapping at this small level.  After a few weeks of doing this, I noticed a significant drop in my general anxiety — things that might have ‘gotten under my skin’ did not elicit as large a response as before.

“It’s an interesting and effective technique, and in this age of mindfulness and meditation, it’s also a way someone could take any experience, chunk it down, and use the small elements of that experience to remap at an equivalent level in all systems, so going back to thinking about the original experience is not as overwhelming as before.”

 

I wrote back: “Gary, thanks for your note. I remember Grinder presenting this ‘small chunk overlap’ as a way to work with schizophrenia about 1978 (and it may be mentioned in Frogs into Princes) as a gentle and non-threatening way to integrate modalities. I don’t know anyone (other than you) who has tried it, but it certainly sounds right, and I can’t see how it could possibly hurt. Boredom would probably keep me from spending enough time doing it to be worthwhile, but others might not be so encumbered.

 

Gary replied: “This was early NLP, so submodalities and spinning feelings were still in the distant future.  I would probably spend about 20-30 minutes a day doing this, and it was fascinating to concentrate on the smallest detail (a line, different parts of words with different sounds, pitches, volume, and feelings here and there (equivalent to the est technique of asking, ‘What color is your headache?  Where is it located?  What shape is it,’ asking this over and over until it changed or disappeared).  Anyway, we were still green in those days and John could have told me to put my head in a garbage can and yell to cure something and I probably would have done it.”

 

Steve wrote to John Grinder, asking him to look over the above to see if it accurately represented his memory and understanding, and/or suggest changes or additions; his reply is below:

 

John Grinder replied: “Your account strikes me as entirely plausible. I have no idea about the dates involved — it sounds close to when the period when we were exploring synesthesia. I have had good success in cases of clients who get triggered by X; if you elicit a reasonably well-specified description of the triggering stimuli, you can decompose them into their submodality components, and use small pieces of those components mapped onto other submodalities of other representational systems through synesthesia circuitry (e.g. swatches of color, small sounds, any of the submodalities kinesthetically) and either have the client’s unconscious (ideally) or in some cases, have the client deliberately present to him/herself these small chunk elements (and therefore meaningless and ineffective as a trigger), the triggers lose their ability to access the states that they have been historically associated with. In my experience, this has worked with the full range of clients, from chronic schizophrenics to off-the-street clients.

“I have used the small chunk approach with synesthesia mapping with many clients over the years — it works very well (for me, at least) with things like pain control. I remember taking a fall climbing and breaking a bone in my ankle. I had about one and a half miles to get back to my pickup truck. Because of my fascination with, and playing around with, such synesthesia mapping, I mapped the pain (important to maintain a sensing of the pain to avoid doing things that would exacerbate the injury) onto pressure and heat. By so doing, it was able to carefully return to my truck without further damaging my ankle.

“I have used it with women who want to be fully conscious during childbirth but not feel the pain. One striking example was a woman who has strong K > V circuitry. I had her practice for some weeks during her pregnancy. When she went into labor, the professional medical types wired her for contractions as well as the baby for heartbeat, breathing. She was walking around the room talking to her mom and friends, and the nurses were looking worried and constantly checking the instruments. Fortunately they were intelligent enough not to mention that according to the instruments, the woman should be in severe pain. The baby was born premature and was kept in a critical care unit because the brainstem breathing was not mature enough to safely maintain the breathing patterns. The mother decided to stay in the hospital to be close to her baby. Two or three days after the birth, she, the head nurse, and her mother walked in the room where she had been in labor. She stepped through the door, stopped abruptly and exclaimed, ‘They have painted the room!’ What had happened was that practicing the synesthesia patterning (K >V) kicked in unconsciously, and she had succeeded in remaining conscious and mobile by changing the colors in the room to one that served as a measurement of the pain without the requirement of experiencing the pain.

“I was amused by Gary’s statement about yelling into a garbage can — it is certainly accurate that congruency on the part of the agent of change is a powerful aspect of doing change work.”

What is Synesthesia?

One problem that crops up repeatedly in NLP is imprecision in the meaning of a word, creating an ambiguity about what kind of sensory experience a word refers to. Since most NLP works directly with changing sensory experience, it’s crucial to know what that is. The word “synesthesia” has been used in NLP for two very different kinds of experience, and this often causes confusion — whether or not that confusion is noticed. Below is an online definition of what the wider world means by the word synesthesia:

Synesthesia is a condition in which one sense (for example, hearing) is simultaneously perceived as if by one or more additional senses such as sight. Another form of synesthesia joins objects such as letters, shapes, numbers or people’s names with a sensory perception such as smell, color or flavor. The word synesthesia comes from two Greek words, syn (together) and aisthesis (perception). Therefore, synesthesia literally means ‘joined perception.’ ”

I want to point out three crucial criteria embedded in this quote: two (or more) sensory perceptions are joined simultaneously, in the same location in space and time. When someone sees a number in a particular color, they see a colored number — they don’t see a number adjacent to a swatch of color, or a number followed by a color, or a color followed by a number.

Synesthesia is often described as something rare and unusual, and it’s true that seeing letters or numbers in color is uncommon. Years ago when Connirae and I were investigating different spelling strategies in great detail, we found one woman who saw each letter of the alphabet in a specific individual color. When she spelled a word, she knew it was correct if all the letters changed to one color! Although this was a complex way of spelling words, and I wouldn’t recommend it over the “good spelling strategy” discovered in the early days of NLP, it did work for her.

Another aspect of synesthesia is that while it may seem unusual to those who don’t experience it, I have never heard of it being a problem for those who do. It is fairly common among “autistic savants” but it isn’t a cause of their limitations. Rather it is always a useful part of some amazing skills that are far beyond what most of us can do, such as quickly noticing if a large number is prime or not, or multiplying two large numbers. I have never heard of anyone for whom a synesthesia was a significant problem; rather it is an interesting embellishment of experience, and it is often credited with contributing to creativity. Here is a short TED talk by a synesthete; search online for “synesthesia savant” for other descriptions.

Actually we all experience synesthesia in ways that are so commonplace that it’s easy to overlook, and not realize that it is fundamentally the same process. As I type these words, the feeling in my fingers occurs at the same time — and in the same location — as the sight of my fingers moving on the keys, and the clicking sound of the keys. The same is true if I close my eyes and imagine typing — I see and feel my fingers moving on the keys, and hear the clicking sound that the keys make.

This is only an example of how our brains integrate the information coming from the different senses into a single coherent experience.

Imagine how weird and disconcerting it would be if those three different perceptions occurred in different locations and at different times! The feedback information from each sense would be out of synchrony with the others, making it difficult to learn even the simplest of motions, like bringing a glass to my lips to take a drink.

 

Overlap

When someone has a representation in only one modality, an early basic NLP intervention is to overlap from that modality to others, in order to add information from other senses. “When you hear those words in that tonality, what image comes to your mind?” “When you see that image, what sounds can you hear?” That kind of question is a deliberate instruction to elicit synesthesia in order to enrich someone’s experience by accessing relevant useful information that they may be ignoring. An image of a future event may look wonderful, but when you add in sounds and/or tactile kinesthetic feelings, it may be much less desirable. With more information, we always make decisions that are more accurate and balanced predictors of future satisfaction.

In everyday conversation we often speak of a sharp sound, a sour smell, a sweet spot, a flat color, or a loud shirt. While some of these expressions may be only metaphoric, often they indicate synesthesia that is below awareness, or on the edge of what we usually notice in our internal experience. For instance, when I hear music or voices, I always have a visual experience of abstract transparent 3-D shapes moving from left to right. Like any other skill, it has advantages and drawbacks. I have always preferred simpler melodies or small ensembles, because it is easier to visualize a smaller number of sounds. When there are too many sounds, as with a large orchestra or a big band, my images become cluttered, tangled and unpleasant. I also have trouble understanding conversations in noisy rooms, and if I’m looking for an address in unfamiliar territory, I need to turn the car radio off or I begin to have symptoms of ADHD.

To summarize, the widely accepted meaning of synesthesia is to experience two or more sensory perceptions simultaneously in the same location in space. This is an enrichment of experience that is generally useful, and only very rarely a problem.

 

What is the other definition of synesthesia?

In Robert Dilts’ Encyclopedia of NLP the entry titled Synesthesia states:

“Sometimes various sensations become connected and overlapped so completely that it is not possible to easily distinguish one from the other in a causal relationship. Feeling deeply moved by a piece of music would be an example of this. The feeling cannot really be distinguished or separated from the sound of the music. The same could be said for the sense of fear or pleasure that people experience when they see certain types of images.”

These “hear-feel” or “see-feel” causal linkages were called “fuzzy functions” in the early days of NLP. They are very important to us — sometimes problematic; sometimes very useful — but they are radically different from the previous definition of synesthesia in several ways:

  1. The causal relationship mentioned by Dilts presupposes a passage of time between the cause and effect, so the joining of the two sensations is sequential rather than simultaneous — even if it is very rapid.
  2. The two sensations are in different locations in space. The sound or image causing the feeling is typically heard or seen in a location outside the body, while the feeling is felt inside the body, mostly along the midline of the chest and/or belly. Even when the sound is heard in the ears, or the image is seen inside the head, that is still a very different location than the emotional feeling of “feeling moved,” “pleasure,” or “fear.”
  3. Finally, the emotional feeling in response to the sound or image is an evaluative feeling that is very different from a perceptual tactile feeling in the skin or fingers. Tactile feelings provide information about what is touched — its size, temperature, pressure, texture, etc. In contrast, emotional feelings provide information about the values of the person having the feelings.

This distinction between tactile and evaluative feelings is clearest when we have an evaluative feeling in response to a tactile feeling. If you are enjoying a loving touch, you experience both tactile feelings in the skin and underlying tissue (pressure, temperature, etc.) and also your emotional experience of enjoyment along the midline. But if someone unwelcome touched you in exactly the same way, you would have a very different emotional response to the same set of tactile sensations.

These three differences point out how very different this second definition of synesthesia is from the more widely accepted one. When a NLPer says that a client has a “synesthesia,” they are almost always using this second meaning of the word. They are also usually talking about a synesthesia that a client complains about because the resulting feeling is unpleasant, or has problematic consequences.

 

Does this distinction matter?

Since any ambiguity can lead to confusion, it’s always useful to be very clear what a word means, especially when the wider world has a different meaning for it. One way to avoid the ambiguity of the word “synesthesia” is to simply not use it at all, which is what Connirae and I have done for many years. Most clients who seek personal change do so because of unpleasant evaluative feelings. Since usually they have little or no awareness of how those feelings are generated by mostly unconscious visual images, auditory sounds, tactile feelings — and/or less often, smell or taste — we don’t find any advantage in using a special word for it. Furthermore the word “synesthesia” is a nominalization that turns a process into a noun, and tends to distract and obscure the specific sensory experience it refers to. Keeping in mind that the emotional feeling is in response to a perception or memory in one or more of the sensory modalities helps us focus on adjusting those in order to change the resulting feeling.

But before making any such adjustments, it’s important to think about the “problem” feeling in a wider context of space and time, to be sure that a change is “ecological.” A “bad” feeling of shame or guilt may be very useful in motivating us to make apologies or amends to repair a relationship that was damaged by something we did, or failed to do. If this positive function is not incorporated into any change, it will be very difficult to make any change, and it isn’t likely to last.

The flip side of this is that some “good” feelings lead to destructive consequences, such as overeating, drug use, or other compulsive behavior. In those cases it can be useful to make adjustments that result in “bad” feelings that are more useful in the larger context of space and time.

25 April 2017: Also see the followup to this blog post, Small Scope Synesthesia.

Sometimes an intervention doesn’t work because something else needs to happen first. Putting on your pants before putting on underpants just doesn’t work very well, unless you just want to get attention at a party. Other times a “great” intervention might not quite fit the circumstances. You may see a nice-looking shirt in a store window, but when you try it on, you may find that it just doesn’t fit your body.

There is a widespread misunderstanding that a particular experience will be a resource for any problem or outcome, in any context. However an experience that is a wonderful resource in one situation can be a disaster in another. A “resource” experience may not fit at all, or it may be a close fit, but not close enough. Sometimes a “resource” experience is inappropriate because it’s too specific.

Recently a therapist sent me a detailed description of her work with a friend, asking me some questions about what she did. The exceptional detail in her description gave me some confidence that my responses will be relevant. (This definitely wasn’t a case of, “I tried X method but it didn’t work; what should I do?”) Her letter provided a rich opportunity to point out examples of a number of different “fine points” in NLP work. My responses are interspersed in brown italics.

 

Hi Steve:

I was using your Resolving Grief technique from Heart of the Mind on a friend recently. I had some questions regarding the process. I was wondering if I could get your take on this?

My friend expressed a loss of a friendship; it wasn’t a death, but a termination without any closure. So she had mixed feelings — anger, anxiety and sadness — since the loss of friendship wasn’t on her own terms.

Interestingly, when I had her access the presence of this person, she created an entire scenario in her head that has never happened. She said it’s the scenario she generally creates about this friend, which causes anxiety. The friend (who is in color/moving) is sitting down in a chair that my friend normally sits in during class, and she’s located 2-4 feet in front of my friend. My friend is standing and the ex-friend is to the right of her sitting in the chair. The ex-friend then says some snarky comment to my friend. My friend says she hears her ex-friend’s voice first, then sees her, and then panics.

 

Steve:

It’s useful to disentangle your friend’s three different feelings. Her sadness is in response to the loss of the relationship, and anger indicates that there is some “unfinished business” that needs to be resolved using the forgiveness process before doing the grief process. You’ll find more detail on resolving grief than we put in Heart of the Mind in a later article.

I assume that her scenario elicits panic because she anticipates having a difficult talk with the lost friend, so she’s anxious about how that might turn out.

For those interested in such things, the sadness and anger are at the same logical level (the relationship), but the anxiety is at a higher logical level because it is in response to how she imagines the discussion of the sadness and anger with her friend might turn out (about the relationship).

        

I contemplated doing the phobia cure, but I wanted to see how changes in the submodalities would affect her.

 

Since the scenario your friend is imaging “never happened,” it’s a future forecast, in contrast to a past memory. This means the phobia method isn’t likely to work. The phobia method is great for a response elicited by a past memory. However, panic and anxiety are in response to a future event, not a past one, so different methods are appropriate for that.

 

I then asked her to think of someone who is no longer in her life but who she thinks fondly of.

 

This is an example of asking for a resource counterexample that is too specific. When you’re doing the grief process, the instruction is to “Think of someone who is no longer a part of your daily life, but when you think of them, you experience them as a resource.” This lets her choose from many different kinds of “resource” and doesn’t box her in to a specific one.

I’m nearly certain that “fondness” is an inappropriate resource for your client, because her anger hasn’t yet been resolved — fondness and anger are opposites. It might (or might not) be appropriate for her to be fond of her ex-friend after forgiving her, but it’s certainly a mismatch when she’s still angry.

For another example of the importance of choosing an appropriate counterexample resource, check out the following article. In the example in this article, even though I was careful to ask for a general outcome, “Think of someone she had hated in the past, but now felt OK about; she no longer hated him,” she chose an example of someone she now felt that “she had come to care for him and trust,” which was inappropriate for her. Here is the relevant part of the article:

 

“When I asked her how she felt with this image moved to this new position, she said it was somewhat better, but her feelings of anger ‘dragged along with the image,’ a strong indication that this was not an appropriate change for her. I thought there might be something about her resource experience that didn’t quite fit, and that probably if I had stopped here, or insisted that she continue, it would not have been good for her.

“So I gathered information, asking her about the person whom she had once felt anger toward, but now felt OK about. ‘What was it about that person that allowed you to let go of your anger?’ She said that she had come to care for him and trust him. I said, ‘It certainly wouldn’t be appropriate to care for and trust the man you still hate, would it?’ to which she heartily agreed. This told me that we needed to find a somewhat different resource experience, someone whom she had forgiven, but still didn’t care for or trust.” For more detail about this kind of careful resource selection, read this article.

 

The submodalities of the image of this person were really similar to that of her ex-friend. This fond person (color/moving) was sitting to the right of her. Both were seated on a couch. And the first thing my friend noticed was, again, the voice, but this time it was laughter. The only differences I noticed was that this person was very close in distance (nearly touching) and the quality of tonality was laughter (and not snarkiness). Another difference was the position of my friend. This time she was seated next to her friend in this representation.

When the submodalities are that close in comparison what would you do to create a pleasing shift?

 

Since both images are of friends, it’s not surprising that they are quite similar. However, you have described two very significant differences in location; in the resource experience they are both sitting, and they are much closer (“nearly touching”). Either one of these differences by themselves could easily elicit the different sound (laughter instead of snarkiness). There is a similar example in my transcript of a shame session, in which unpleasant cackling turned to the pleasant sound of a merry-go-round in response to changing location.

 

I had her take the ex-friend and replicate the exact motions, laughter, position of her fond friend who’s no longer in her life. She said it felt a little better, but that she still missed her ex-friend. She appeared sad and affected by the loss. Did I neglect to do something here? Or were the representations of the two losses just too similar?

 

As I’ve already mentioned, the representations are significantly different, so that’s not the problem. It would be better to start with shifting position alone, and find out what difference that process change makes. Asking her to replicate motions and laughter include changes in content, so those generally won’t be as useful. The key thing is that her anger needs to be resolved first in order for the grief process to work, so she’s still stuck in her two responses of sadness and anger. Very few people spontaneously think of forgiving as a resolution. (Many will think of expressing their anger or revenge instead.) Also very few are initially “ready” to forgive someone else. A major part of the forgiveness process is to satisfy (not “overcome”) the objections that most people have to reaching forgiveness — and some people have a lot of them!

 

I followed through with getting the values of that friendship, and she placed those values in an image in a location (as quotes on her wall in her bedroom.)

I then asked her to give those values form, whether abstract or vague. She wanted to use a person she knew, who she said embodies all of those qualities. What are your thoughts on that?

 

I think that is fine, as long as you go on to make that image more symbolic/abstract, which you do. However, proceeding with the grief resolution process won’t be very productive until the anger is first transformed into forgiveness.

 

Instead I asked her what form those values would take if symbolic or a visual representation. (I didn’t think it was prudent to have those values represented in a person in case this person ever left her life in the future; then there disappears the values.)

 

I agree. The main reason for making the values symbolic/abstract is to separate them from the image of the specific person in her past, so that they can be found in other people in her future life.

 

She then said the values were now inside a book she was the author of.

 

Her seeing the values inside a book that she is the author of is a nice metaphoric indication that your friend’s unconscious mind is participating fully. And her being the author of the book implies taking an active part in satisfying her values.

 

I then had her multiply the book, stack them, change each book a tad different from the previous one, and scatter them into her future, allowing each to drop at different locations. I explained how those values would be represented by friendships and experiences in her future, etc.

 

I realize that you may have done it, and just not mentioned it, but making the books glow is an important part of the process. When they glow, they are like lights beckoning the client, drawing her into the future (in contrast to the loss in the past). Instructing her to “change the story a little” in each book would have been a nice additional touch, preventing her from just changing the color of the cover or binding of the book, which wouldn’t be as useful. Later on you could utilize her metaphor by casually mentioning that some people are an “open book,” or that it’s useful to “close the book” on some past events.

 

Since she felt marginally better, but a tad underwhelmed, I asked her to play more with the submodalities.

 

I’m glad that you noticed that she was “underwhelmed,” so that you could go on to offer her more choices.

 

She made the ex-friend into a still black and white photo that was placed on the ground and any voice that emanated from her was a cartoon-like voice. In an instant all of her anger, sadness and anxiety dissipated. I even had her picture the friend sitting and saying the snarky comment, then pushing that image way back into the distance and the image that would come to the forefront was the one of the black and white still photo. Obviously this is not a visual squash, but I don’t know what to call it.

 

No, it’s not a visual squash; you asked her to chain two images together sequentially. The visual squash integrates two images into a simultaneous image — after finding a common outcome, or a joint outcome. (Heart of the Mind, chapter 13.)

 

but I had her play with rotating the images in quick succession. This alone made her crack up. She made the black and white photo really absurd, which seemed to shift her entire experience of the loss.

 

The kind of submodality shifts you explored with your friend (in the previous two paragraphs) to shift her experience are all fine, and got nice responses. However, without knowing her outcome/intention, so that you can satisfy it, it is really unlikely that they would be effective or lasting. In this case, her outcome is her need to resolve her anger, and none of the submodality changes you offered her accomplished that.

 

She said when she thinks of her friend now she can feel her presence, but the image of her face is obscured and vague, which she says she prefers because it has decreased the unpleasant feelings. Any value judgment on the fact she no longer sees the ex-friend’s face upon recalling her? She said when she tried to see the ex-friend’s face in her mind her feelings began to regress so she preferred not to.

 

That is a pretty clear message that she can’t “face” her friend without feeling the unpleasant feelings of anger and sadness, which are both still unresolved.

 

Sorry for the long email peppered with all of these questions! Though my friend seems ecstatic with the results, I’m not. LOL!

 

I applaud your noticing the difference between your experience and your client’s report. You did help her have a new and more satisfying response to her ex-friend. And I agree with you that those results are not complete. Using the forgiveness process will complete it — though you might have to repeat the grief resolution process after you do.

 

I feel like I took numerous missteps with the Resolving Grief process. I’m constantly trying to examine the feedback I receive, and the areas I went wrong, to improve what I can do in the future.

 

Your ability to notice when your work isn’t fully satisfying, and your willingness to ask for and receive feedback, is wonderful — and all too rare!

 

Anyway, if you read this entire email, I salute you! And appreciate it.

 

Thanks; it was a pleasure to respond.

When I sent this article to the therapist to look over for accuracy, she wrote back:

“Thanks again! This was excellent. It assuaged many of my concerns and answered so many questions. Beyond appreciative.”

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