Therapy with Tough Clients: Exploring the Use of Indirect and Unconscious Techniques
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About this ebook
George Gafner
George Gafner, MSW, LCSW, is director of the hypnosis training program and director of the family therapy training program at the Southern Arizona Veterans Affairs Health Care System, Tucson. He is the author of four previous books on hypnosis and hypnotic inductions.
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Therapy with Tough Clients - George Gafner
Praise for Therapy with Tough Clients
As Gafner takes the reader through the therapy of two of his most challenging clients, he presents what he calls directed unconscious therapy and often transcends the translucent membrane
between hypnosis and non-hypnotic therapy. This book is intended as a hand-son resource and is replete with clinical wisdom. Wonderful-Serious-Wise, this is the work of a true master, Therapy with Tough Clients should be required reading for all entry level therapists and most seasoned therapists as well.
Stephen R. Lankton, MSW,
author of Tools of Intention
Therapy with Tough Clients was primarily written to be of help to the clinician by offering a variety of approaches to treating challenging cases. But the book does much more than this: Gafner challenges us to recognize and transcend our own limitations, encouraging a personal growth that will no doubt spill into performing more creative and effective psychotherapies. Read this book and you will be better in more ways than one!
Michael D. Yapko, Ph.D., author of
Trancework and Depression is Contagious
When searching the bookshelves it is evident that there is virtually no literature available devoted to exploring the tricky subject of handling challenging clients, especially from a hypnotherapy perspective. Not afraid to meet this difficult aspect of the therapeutic relationship head on, George Gafner has written a thought-provoking book that admirably fills this glaring void. Espousing a refreshing pluralistic approach to therapy he explores working with overt and covert resistance, whilst openly discussing the often taboo subject of the therapist’s personal cognitive and emotional reactions.
One of the many highlights of this engaging book is that approaches are illustrated through on-going case studies, which are constructively dissected, affording the reader the opportunity to fully get to grips with every nuance. Ostensibly based around PTSD, there is much to learn for those not versed in the treatment of trauma as each approach is adaptable to any client that presents a challenge to the therapeutic process.
Gaffner is an expert in therapeutic story telling and therefore this book is unashamedly based around metaphor. That said, other aspects of hypnotherapy, including the use of paradox, are effectively demonstrated in situ in the abundant therapy transcripts. The author also includes informative discussions on the potentials and pitfalls of using cultural metaphors, whilst reviewing hypnotic language and hypnotic phenomena for those new to hypnotherapy. With therapists from every background in mind, the author discusses how approaches can be applied both hypnotically and non-hypnotically. He also explores their application in a diverse range of settings, from couples therapy to those working with people held in correctional facilities.
This is a well-rounded book that holds something for everyone, irrespective of their therapeutic background.
Peter Mabbutt FBSCH, CEO/Director of Studies London College of Clinical Hypnosis
Fans of Milton Erickson and his work with metaphors will love George Gafner’s new book, Therapy with Tough Clients. From the very beginning, it is obvious that the author has mastered the use of metaphors as he discusses different categories of metaphors: darkness, weight, captor, and descent. In addition, he refers to overused metaphors
as well as misunderstood cultural metaphors and he also listens to his clients’ metaphors even before the hypnotic experience begins.
The book focuses on two case histories, Maggie and Charles, both veterans who are suffering from a number of problems since their return from combat. They are introduced in the first chapter, and we get to follow their progress throughout the book, but the book is not limited to only Maggie and Charles. One interesting case was how he successfully handled a potentially volatile situation when an angry spouse burst into the middle of her husband’s session.
Although the book is filled with various metaphors, the author also believes in the value of ego strengthening, and devotes an entire chapter emphasizing it. At the same time, he shows his human side by sharing a couple of ooops
comments to let us know that he also makes mistakes. Gafner says, therapy is more of an art than science,
and I totally agree. It is obvious that he is a master of the artistic use of metaphors in therapy, and his book is easy to read.
Roy Hunter, FAPHP, DIMDHA,
author of The Art of Hypnotherapy
George Gafner is a seasoned clinician who provides a variety of creative ways to use hypnotic procedures and storytelling to treat diverse clients. He uses case vignettes effectively to illustrate the process of therapeutic decision-making. Anyone who is a follower of the Milton Erickson mode of intervention will find this book engaging and informative.
Donald Meichenbaum, Ph.D., Distinguished Professor Emeritus, University of Waterloo, Ontario, Canada and Research Director of the Melissa Institute for Violence Prevention, Miami, Florida
George Gafner has devoted his professional career to refining his approach to hypnosis to benefit the clients with whom he worked. This book provides a distillation of years of exploration, study, and clinical practice that George shares with us in an engaging and highly readable manner. He presents interesting and complex cases and aptly demonstrates how hypnosis is often the treatment of choice due to the wide variety of options it provides. The book is clear and comprehensive, insightful and illustrative. Readers will find a depth of knowledge and analysis in these pages that will stimulate valuable ideas that can be utilized in their own work.
Brent B. Geary, Ph.D., co-editor of
The Handbook of Ericksonian Psychotherapy
THERAPY WITH
TOUGH CLIENTS
The Use of Indirect and Unconscious Techniques
George Gafner, MSW, LCSW
To Sam Atterbury
Foreword
George Gafner is a storyteller and all of his clients know this. It is not unusual for his clients to ask him to tell them stories during a session. He is also a hypnotist, and has had many years of experience as a therapist. Storytelling and hypnosis seem to go seamlessly together for him (as they do for me). When the story is sufficiently engaging the listener goes into a kind of reverie state, there is focused attention, and most therapists would recognize that their client is in what can be described as a natural everyday trance. This interaction between therapist and client is comfortable and provides a useful instantaneous rapport. What better way for a therapist to help a client work through difficulties?
George has worked with many clients during his professional career in institutional settings such as the Veterans Administration (V.A.) system and jails. These settings and clients are amongst the most difficult to help with psychotherapy. Many of the veterans have PTSD; prisoners and others in institutional settings may be sociopathic and abuse themselves with drugs and alcohol. Yet, somehow, stories and the metaphors embedded within them are so universal that they become the royal road
to establish a productive therapeutic alliance. People appear to be more receptive to suggestions when listening to stories. In that sense the therapist is communicating directly with the client’s unconscious or inner mind. The more possibilities the therapist builds into the story, the more likely it will be that the listener will latch onto one or more of the embedded suggestions, and use them to reframe themselves out of their stuckness. George is well aware of this, and especially the need to put into the storytelling sufficient pauses so that the listener can process information in his/her own unique way. He also understands that in the interpersonal interaction time in his office that he has to be himself and from time to time share some personal things. (The latter, of course, is done cautiously and with conscious design!)
In this volume, there are many clients whose concerns are discussed in detail. They illustrate George’s experience in working with a diverse population and the ways he chooses to help them. As a kind of leitmotif he focuses on two clients—Maggie and Charles—who appear repeatedly in the book. Most therapists would regard them as being difficult to work with, and George illustrates this in detail, including his own mistakes. He worries about these sessions and mistakes, and we all learn along with him as he freely lets us participate in his progress with Maggie and Charles. It is almost like looking over his shoulder as he ponders what to do next—stories seem to come to the rescue time after time! And he is not afraid to be directive from time to time.
This book is strewn throughout with gems of wisdom and practical things to do, and it is well worthwhile studying. As an added bonus, Chapter 14 contains a number of useful story transcripts which can be adapted to many different circumstances.
Rubin Battino, MS
Yellow Springs, OH
Contents
Title Page
Dedication
Foreword by Rubin Battino
Introduction
Chapter 1. Initial sessions with Maggie and Charles
The Case of Maggie: a referral for individual therapy
Pandora’s Box
Notes for practice
The Case of Charles, another referral for individual therapy
The Three Lessons
Notes for practice
Chapter 2. Metaphor, story and other invaluable devices
Cultural issues: Missing the point
Research on metaphor
Metaphorical examples
Metaphors for depression
Hackneyed metaphors and Easy Street
Concrete metaphors
The Story and the anecdote
Hypnotic language
Hypnotic phenomena and elegant indirect techniques
Time distortion
Amnesia
Dissociation
Catalepsy
Taking advantage of hypnotic phenomena in the session
Integration through discussion?
Moments of dissociation in a session
Embedded suggestion
The Wok
Waterfalls and enormous soft drinks
Security anecdote
Balloons everywhere
Tony’s Balloons
Frankie’s Balloons
Seeding
Sound seed and split suggestion
Misspeak
Interspersal—another elegant indirect technique
Indications for use
Chapter 3. Irritable bowel syndrome (IBS) and continued therapy with Maggie and Charles
Irritable bowel syndrome
Healing stories
White sand beach (Benson, 2011)
The Molasses Reef story
IBS-specific anecdotes
The Burglary
The Great Vowel Shift
Notes for practice
Charles’ second session
The Garden, a story by Charles
Notes for practice
Chapter 4. Ego-strengthening
Albert Bandura
Direction versus indirection within hypnosis
Many tools in the toolbox
I need to know I ‘went under’
Influence of Erickson
Ego-strengthening within hypnosis
Improvement with ego-strengthening alone
But didn’t Mussolini make the trains run on time?
Different people, different conclusions
Ego-strengthening outside of hypnosis
Group anger management
Conveying suggestions
Major ego-strengthening techniques
Story, anecdote and short-burst
The Greenhouse
Anecdotes
245 Feet High
Lodgepole Pine
Strong cactus
Matchstick girl
Short-burst ego-strengthening
Mixing techniques in a session?
Don’t forget Albert Bandura
Chapter 5. Maggie and Charles continued
The Case of Maggie
Recent losses
Making sense of it all
Earlier life—and a detour
A night at PP’s
Notes for practice
The case of Charles
Automatic writing
Notes for practice
Chapter 6. Perturbation and pattern interruption
Stirring the soup
Perturbation in daily life
Perturbation with new clients
Say uncle
in the ante room, write in the drawing room, or go far in the waiting room
Generating an evergreen epiphany
Patterns in daily life
Pathologic routines
The case of Kathryn
The Rationale
Were the target something else
Sequencing
Other ways to perturb
Pills story
Instigative anecdotes
Robert Frost
Rings in a Dream
The Shipworm
Painting Landscapes
Amplifying the metaphor technique
Let’s see how Dr. Tracten gets traction with this technique
Amplifying both metaphors
Notes for practice
Fish again
Recovered memories
Earl the Pearl
Chapter 7. Maggie and Charles are back
Case of Maggie
Alternating Stories: The Good Spirit and Simple Rooms
The Good Spirit
Simple Rooms
(The Good Spirit concluded)
Notes for practice
The case of Charles continues
Charles’ wife bursts into the session
Pineapple anecdote
Notes for practice
Slot Canyon story
Instigative anecdotes (Gafner, 2004)
Helen Keller
Labyrinth
After the Pond
Post-It Notes
Mark Twain
Chapter 8. PTSD and war
Persian Gulf War (383 U.S. Dead)
Barriers to treatment
PTSD treatment in the V.A.
World War I (116,000 U.S. Dead)
World War II (405,000 U.S. Dead), Korea (92,000) and Vietnam (58,000)
Vietnam War
Help from medication
Substance abuse
Psychotherapy and PTSD
Intrusive images
EMDR and cognitive-behavioral therapy (CBT)
Trauma-focused psychotherapy is practiced world-wide
Watching part of a movie over and over again
EMDR
Culture and EMDR
Current V.A. treatment
Therapy as we know it may not be for everyone
Finding help in affinity
The Performative
In conclusion
Chapter 9. Using story techniques
Alternating stories with Maggie
Charles and Bernadette
Active role of the therapist
What needs to happen with couples early on
Patrick’s relationship
Couple dynamics and marital therapy
Couples and themes
Back with Charles and Bernadette
Cactus story
Two days later Charles is back
Road 302 story
Tyranny of Ten story
Notes for practice
Story techniques
A story for a 64-year old man with heart failure
Storm Clouds story
Adding on with a behavior prescription
Unethical treatment?
Anecdote within a story
The Playing Field story
It can be continuous, mutual, without an ending, or within a story
Mutual storytelling technique
Story without an ending
Chapter 10. A curse and the Greek chorus amidst continued therapy
Maggie returns and her mother reveals the curse
Notes for practice
Dora and Antonio
Fausto and Carmen
Charles and Bernadette are back
The Pond
Charles returns by himself
Greek Chorus
Notes for practice
Chapter 11. Therapy nears its conclusion
Maggie is back
Charles’ surprise visit
Notes for practice
Chapter 12. Farewell to Maggie and Charles
Maggie’s priest
Father Sean visits the V.A. a week later
Finishing up with Maggie
Seeing Things Differently
Maggie’s therapy is concluded
Bernadette leaves a phone message
Chapter 13. Employing indirect techniques in various treatment settings, and more
Other indirect techniques
Confederate outside the door
Rustling some papers
An unconventional story application: Strange but true
Can chickens be incorporated into a treatment plan?
Back to the basics with a story
Hypnotic techniques in hospitals, residential treatment, and correctional facilities
Ramon the screamer
Young Indian woman
Milling around
I need my meds now!
Offal in the shower
Enter the tweakers
93-year-old pedophile
I deserve to die
Blind and deaf
Maybe I’m interested
Tomato story
Organized crime
Another view behind bars
Generating your own material
Balloons may have been a fantasy
Refining your therapeutic voice
What is a good hypnotic voice?
A good hypnotic voice goes with the client
Contrasts are your friend
Your voice in a story and other scripts
Chapter 14. Favorite inductions and stories
Story inductions
Glen Canyon induction
Rumination Induction (for insomnia)
The Magic Theater: A guided imagery induction
Ego-strengthening stories
The Maple Tree
The Little Cactus
The Lighthouse
The Balloons
Instigative stories
African Violets
Pauly the Pufferfish
Silver Fox
Eating Dirt
In the Freezer
Glossary of Terms
References
For Further Training and Reading
Index
Copyright
Introduction
An enduring teachable moment
When we do unconsciously-directed work with clients we are privileged, as they open for us that window to the deepest part of them. When we direct therapy through that window—with story, anecdote, hypnotic language, pacing of ongoing response, or various other techniques—I call this an enduring teachable moment, as it is a time of heightened receptivity. But this is not a one-way glass like we used in the 1970s to view trainees doing therapy. We, as therapists, also have an ongoing process, much of it unconscious, reflected back through that window, and in this book I try to capture both sides of that window as I take you through therapy with two engaging and multidimensional people, Maggie and Charles. They represent two of the most complicated and challenging clients I ever had, and by working with them I demonstrate a host of techniques that you may find useful in doing therapy with your toughest clients.
Once I heard someone say that a delight in poetry is discovering something I didn’t know I knew.
Now, recalling that discovery is an example of this enduring teachable moment, and I’d bet that whatever that person read that day in a poem continues to sit there deep within, waiting to be triggered in the future by a like association. So, too, an enduring teachable moment is evident when I run into a client I saw 15 years ago and she mentions, You know, that old woman in the woods you told me about, I still think about her.
Something triggers the memory of the woman in the story. It may be mention of a cold day, a forest, or of some other aspect of The Three Lessons story she heard from me years ago, all inextricably linked to the meta-message of the story, that people have resources within to help themselves with their problems. That memorable tale, which I adapted from a story of the same name by Lee Wallas (1985), is an example of what you can do in your practice, borrowing from a story or technique in this book, adapting it to your needs, and fashioning it for whatever clinical scenario you encounter.
Luis, back from Afghanistan
As the unconscious is certainly the aegis of hypnosis, and as this book deals in part with hypnosis, let me share a clinical example that opened up this window to me as much as the client. Around 2005, I was referred a young Hispanic soldier, Luis, who had recently returned from Afghanistan. His problem was erectile dysfunction. He was in perfect health, on no medications, did not have depression or PTSD—despite months of harrowing combat—and like many hypnosis referrals, it came out of frustration after all else had been considered. Luis was married, of average intelligence, spoke good English, and said he didn’t drink or use drugs. He was calm, in no distress whatsoever, and said he wasn’t bothered at all about the war. His only concern was that he was impotent.
The next session we began hypnosis. He responded with deep trance and amnesia to a conversational induction and The Three Lessons story, which embeds the suggestion that people have resources within to help with their problem. The next session I employed a similar procedure but added an ego-strengthening story and set up finger signals for unconscious questioning. Using age regression, I asked him to go back in time to any time in the past that might have to do with the problem … and when you’re there, Luis, you may let your ‘yes’ finger rise.
After about a minute his index finger twitched and he began to mutter some words that were unintelligible to me, but I did glean a fragment of a phrase, I-U-D, I-E-D.
I re-alerted him and discussed today’s session. It soon was apparent that his unconscious mind had mixed up the improvised explosive devices (IEDs) in the war with his wife’s new intrauterine device (IUD), and impotence resulted. Discussion normalized and integrated this phenomenon, the problem immediately resolved, he was seen one more time in a month and was doing fine, end of story. Now, how many sessions of talk therapy might have been needed to resolve that problem?
Peter in jail
Therapy with Luis was during a scheduled appointment in a comfortable office at the Veterans Affairs (V.A.) Medical Center. The conditions were optimal. But such conditions aren’t always necessary to elicit a similar response within unconsciously-directed therapy. For example, I am now retired, for the most part, but I used to work about four days a month at the local jail. The other day one of the psychiatrists grabbed me as I was walking by and asked me if I would see this very anxious client I’ll call Peter, a Black male being treated for bipolar disorder. I sat with Peter for a few minutes in a busy hallway outside the exam rooms in the medical section of the jail. The first thing I noticed was Peter’s very fast and shallow breathing.
I showed him deep breathing and asked him if I could tell him a little story while he practiced this better way to breathe. You can close your eyes or keep them open, whatever you wish,
I told him He chose to close his eyes and I told him The Three Lessons story, which I often use early on. People continued to walk by in handcuffs and chains, doctors and nurses were talking, and it was business as usual while Peter responded highly favorably to the story. In two minutes we were done, his anxiety was allayed, and he left with some tools to help him in the future. I have had similar responses in even worse conditions there, like talking to them through the food trap in the door in segregation, or standing in the corner of a busy day room with the curious walking by, straining to hear what was being said. In other words, a nice office with a recliner and wind chimes music is nice, but if you don’t have it, you can improvise, even in the midst of rapists and murderers.
Standing on broad shoulders
In my years in this business I have learned from many, from my family, colleagues, people in the field, and my trainees, who came from divergent backgrounds and theoretical perspectives. However, my clients probably taught me more than anyone. For 38 years I worked at clinics and hospitals, and for 28 of those years I directed a program in family therapy and hypnosis training in the V.A. in Tucson, Arizona.
I learned from people who had extraordinary experiences, like the men who had been prisoners of war in World Wars I and II, as well as in later wars in Korea and Vietnam. I learned from the reactant and hostile, like the spouses and children who involuntarily attended family therapy, or those who were directed to attend one of the two anger management groups I conducted for 20 years. One Vietnam veteran with florid PTSD said he was eager to attend because this is my 12th marriage and I intend to keep it.
He did well in the group and his wife was eternally grateful. Years after the group, when I encountered that man or many others, I asked them what they remembered about the group, and invariably they answered, To take a deep breath or a time-out … but what I liked best was the stories you told.
Indeed, stories and anecdotes, both indirect, or unconsciously-directed techniques, have been my allies for many years.
I learned from my long-term therapy clients and I learned from the ones I saw only once or twice, like the paranoid personality disorder who defied me to try and help him. The V.A. is a fascinating place to work because you encounter a wide diversity of people with every kind of clinical problem. The youngest veteran I saw was 19 and the oldest 102. The oldest couple I saw had been married 76 years. Their recipe for a successful marriage? Always talk things out and never go to bed angry.
I learned from the elderly schizoid woman whose eyes I never saw because of her mirrored sunglasses. I learned from the overly compliant and passive, the therapy addicts who lived in their heads and were resistant to all change however small. I learned from the 200 trainees I had over the years in psychology, psychiatry, nursing, social work and other disciplines. I estimate that over the years I had to do with some 10,000 clients that I either saw directly or whose cases I supervised. In this business we quickly learn that some we help, some we don’t, and some we never know because they just fade away.
Trying new things as we counter resistance
For years on Tuesday evenings I was a volunteer therapist at the refugee clinic of the University of Arizona where I saw victims of torture. These people from Central America, Africa and the Balkans had experienced all manner of cruelty, loss and humiliation. I’ve always done therapy in either English or Spanish, but sometimes at this clinic an interpreter was employed, usually a French-speaking medical student who had done a rotation in Africa. From those in the refugee clinic I learned how fleeting and precious life is, and how we need to make the most of those few minutes or hours we are with any client. Seeing people who were able to overcome the most awful circumstances somehow made it easier for me to help the majority of my clients, people whose problems were understandably dear to them but which paled in comparison to those of survivors of the Bataan Death March, or the lone survivor in a village where all were killed.
Along the way I learned patience. With patience you don’t give up on clients and you keep trying new things in order to make an impact. As we try new approaches and techniques we discover what may work in certain situations, but we especially learn what may work for us. From these successes we build confidence, and this confidence is immediately apparent to others. I intended this book to be not only an aid to your practice, but also an impetus for the growth and development of the clinician.
Scientifically supported treatments
Currently, in many quarters there is a strong push to practice only one modality for most disorders. Of course, this means some variant of cognitive-behavioral therapy (CBT). I support CBT as a front-line approach. However, I know many seasoned psychologists and other practitioners—not only those new to the field—who disdainfully throw up their hands and are at a total loss when the client says, I already had CBT and it didn’t work,
or "I believe my problem resides in my unconscious, and I want therapy directed at that. I had many clients who in the first few minutes said,
Please don’t ask me to list my dysfunctional thoughts; I already did that both in group and individual therapy." So what does one do with those clients? Well, please read on.
A hands-on resource to assist with the toughest of clients
I make the assumption that you have been trained in one of the major disciplines, that maybe you are licensed, and that in your counseling or therapy practice you are guided by a generally accepted therapeutic approach. You’ve heard the saying, When you buy a new hammer everything looks like a nail.
Well, I know clinicians whose average day consists of EMDR or hypnosis sessions, hammering one nail after another. I asked them, What if they have acute grief or a crisis?
You guessed it, EMDR is good for everything, they know because every client looks like a nail. I’m not denigrating EMDR, as I’ve used it for many years, but almost all the time for everyone?
For you, perhaps you practice some version of CBT, or a mindfulness-based therapy, or maybe your theoretical orientation is psychodynamic, NLP, or some other popular approach. Perhaps you employ meditation or relaxation and stress management with your clients. If you could use an extra hand with your toughest clients, I encourage you to read on.
When first conceiving this book I thought, What kind of resource can best assist clinicians irrespective of their approach?
As such, I intended this book to be a hands-on resource that offers you ideas, choices, and opportunities to employ as an add-on to your approach. I’m very familiar with clients who, early on, would set off alarm bells in my head, you know, where the hair on your neck stands up and your gut response is, Oh, no, not another one!
With such clients, you know you have your work cut out for you and maybe you even say to yourself, They don’t pay me enough to try and help people like this, let me think … hmm, how can I ensure that they WON’T return?
Believe me, I’ve thought those thoughts, but I kept them to myself, not wanting to be mean-spirited or disrespectful, and went ahead and did my best with people who were, as we say in the U.S., a sharp stick in the eye.
Now, that type of client is an obvious example of a person whose resistance and overall presentation are worse than challenging. Even with them there are techniques that can help.
Building a foundation before advancing to corrective measures
With many people, the challenges are more subtle. You think therapy is progressing well and all of a sudden they start canceling, or just don’t show up. Something is operating beneath the surface—the issues are too dear, or you failed to put your finger on something important. In any event, you need to identify and rein in resistance so that therapy can move forward. For sure, I realize that there are some clients who simply aren’t ready to address vital issues. They bolt from therapy early, but hopefully they learned something from a session or two so that this foundation can propel them to successful therapy in the future.
One thing I emphasize in this book is how we can till the soil before planting the seed
by building a firm base of ego-strengthening before moving on to corrective techniques. I explain this to clients as doing a mental building up first,
likening it to a debilitated medical patient who requires major surgery (Hammond, 1990). That patient can first benefit from rest and good nutrition, strengthening her ahead of time. In psychotherapy, I believe that far too often the client comes in and says, I need help with this problem,
and we unwittingly jump in with corrective measures. The client isn’t ready, we lose them, and once again we’re left ruminating on