Ericksonian Hypnosis

Milton Erickson in his therapeutic practice can be characterized as a playwright who plans a little play for each patient and then leads that patient to accept and enact the assigned role. This arrangement permits him to be authoritarian as playwright and director by providing the staging and the strategy, while the patient then provides the tactics by carrying out the assignment in his or her own way.

Milton Erickson’s strategic interventions illustrate how expectancies […​] and a variety of response sets can be manipulated to produce constructive changes by mechanisms that operate outside the patient’s field of awareness. […​]

Contrary to more standardized or formal approaches to clinical hypnosis, Erickson 's "utilization" approach (Erickson, 1959; Haley, 1973) involves the observation and facilitation of patients' thoughts, feelings, and behaviors in response to therapeutic communications. Indeed, one of the keys of the Ericksonian approach is to judge whatever behaviors the patient emits as emblematic of cooperation and involvement with the hypnotic proceedings, thereby reinforcing response expectancies of a successful outcome.

Erickson rarely questioned or refuted the patient’s reality. This created the impression that it was the patient who directed the interaction. The classic example is the patient who claimed to be Jesus Christ. Erickson simply accepted this and communicated to the patient the assumption that he must know a lot about carpentry. How could the patient deny it? Soon Erickson had the patient engaged in productive woodworking.

As this example implies, Erickson often avoided telling patients how to think about events: Direct interpretation and confrontation can provoke resistance. Instead, Erickson would allow patients to interpret and perceive things "on their own." He would simply set the stage (by techniques such as priming) to increase the likelihood that patients would make attributions and interpretations consistent with treatment goals.

Far from being "theoretical fluff," constructs derived from social and cognitive psychology can provide a foundation for understanding a wide variety of therapeutic techniques, and for generating creative psychotherapeutic interventions such as those pioneered by Milton Erickson. To be sure, Erickson fully appreciated the importance of establishing rapport with patients; inculcating positive beliefs, attitudes, and expectancies; the need to tailor suggestions to the unique needs and understandings of the patient; and the importance of establishing lenient performance standards and fail-safe procedures that minimized critical evaluation of suggested actions. Erickson’s ingenious methods reflected an acute awareness of the importance of creating, maintaining, and strengthening response sets that trigger a wide variety of behaviors, thoughts, and actions consistent with therapeutic objectives.

Unfortunately, many of the remarkably creative techniques that Erickson innovated have not been subject to careful, well controlled research, even though they have entered the mainstream of clinical practice. Anecdotal reports, no matter how intriguing and fascinating, do not constitute a sound rationale on which to base clinical practice. We stand on firmer ground when a particular technique or approach is supported by theory and research. […​]

Extensive reviews of psychotherapy outcome (e.g. Lambert and Barley, 2002) have concluded that common factors (i.e. elements of the therapeutic relationship) that bridge disparate approaches account for as much as 30% of the variability in therapeutic outcome, whereas particular psychotherapeutic techniques account for only 15% of outcome. Rather than limit our discussion to the common factors that are typically identified in the literature (e.g. feedback, empathy, therapeutic alliance), we maintain that Erickson’s success, and the success of many therapeutic endeavours, can be attributed, at least in part, to the therapist’s ability to manipulate response expectancies, prime therapeutic responses, strengthen positive response sets and intentions, remove impediments to the automatic execution of desired behaviours, and disrupt or modify negative or undesirable response sets. […​]

Erickson’s utilization approach (Erickson, 1959; Haley, 1973) enabled him to gain the cooperation and trust of many of his clients and to establish a rapid and strong therapeutic alliance. The two basic components of utilization are: 1) the observation and facilitation of clients’ thoughts, feelings, and behaviours in response to therapeutic communications; and 2) the demonstration of acceptance and respect for the client’s reality. The examples that follow imply that radical acceptance engendered the impression that the client directed the interaction, thereby minimizing resistance to therapeutic interventions. In referring to a psychotic patient, Erickson (1983) states, ‘Why should I dispute that patient’s delusions and hallucinations? They were hers. I had better respect them in the same way I respect a broken leg or a broken jaw’ (p. 116).

The idea that successful therapy involves the establishment and maintenance of adaptive response sets and the elimination of undesirable response sets has not, to date, been discussed in terms of a ‘common factors’ conceptualization of the ingredients of successful psychotherapies, hypnotically facilitated or otherwise. Our proposal is that Erickson developed techniques that were effective to the extent that they harnessed principles of change and ‘common factors’ that served to create and fortify desired response sets while they minimized or eliminated counterproductive response sets. However, the threads of our argument are constructed around a core of anecdotal case material and evidence garnered in the laboratory, which is no substitute for a more systematic analysis of the independent and interactive effects of common factors in the context of psychotherapy. Indeed, the common factors that we identified should be regarded as largely hypothetical rather than proven contributors to the effectiveness of diverse psychotherapeutic approaches, despite their grounding in social and cognitive psychology. It would be of great interest to carefully examine the determinants of response sets (e.g. social learning), to devise measures of the strength and durability of response sets, and to relate the instantiation and elimination of response sets to therapeutic interventions and to changes in the client over the course of therapy, as indexed by self-report and objective measures.

As I have noted earlier, despite his strongly authoritarian position as playwright and director, Erickson typically set the stage and the strategy, but left the tactics up to the patient. What is not so evident is the role of many others in producing the therapeutic successes: Joe, who enhanced Harold’s use of the library beyond the reading of children’s books; the married couple who befriended him at the trailer court; the friend who taught him to drive a truck; the transcriber and annotator of rare manuscripts with whom he lived and talked for a year and a half; his teachers (shorthand and typing, piano, guitar [?]), and his college teachers-all of whom are missing from the case study except for the briefest of mention of the piano teacher because she was a woman. […]

Harold’s life away from Erickson may have been very different from the way he appeared in Erickson’s presence. We do not know how fond he became of his teachers or they of him. Although he occasionally asked about Harold’s daily activities in detail, Erickson appears to have been more interested in his own cleverness than in finding out how Harold was perceived in the context of his daily life.

Erickson claimed that by looking at the way a married woman crossed her legs he could tell whether she was having an affair or not. I can easily believe that Erickson had an extraordinary sensitivity for nonverbal cues, but this and other unquestioned examples of Erickson’s abilities strike me as farfetched. Did anyone actually evaluate whether many married women who were having an affair, and only them, crossed their legs that way (i.e., check for false positive and false negatives)? Or when Erickson mentioned that a hypnosis speaker he had publicly dressed down apologized to the audience for his own lack of knowledge, did anyone corroborate with that speaker or someone in the audience whether matters transpired exactly as Erickson stated? I doubt it, because throughout the years I have heard some followers of Erickson repeat these types of stories and those of almost miraculous cures without a hint about corroborating evidence, follow-ups, or other validating information. To muddy the waters even more, why have not some of the followers of a therapist known to fabricate false past stories to achieve therapeutic goals wondered whether he used that same technique in his writing and teaching?

I am convinced that many of the explanations that have been ascribed to him in later years were developed retrospectively by him, quite late in his life, because of the pressure put upon him by many of us to explain what and why he had done certain things. I question whether, when he acted in certain ways or said certain things, he always clearly had these explanations in mind, or even knew what they were immediately after his actions took place.

Erickson was particularly adept at capitalizing on anything the subject did and building it up into something more than it was. In not a few cases it has been my impression that he very subtly enticed and encouraged subjects in to role play. Erickson was also quite adept in turning failures into successes in the eyes of the onlookers. The well-known “induction of Ruth” which was filed in one of the laboratories at Stanford University in the lage 1950s and later used by Erickson as an example of the “reverse-set” (Erickson & Rossi 1981) was possibly one such failure.

Ruth was Hilgard’s and my secretary. She was a relatively poor subject by Stanford Scale standards. I did not know this when I asked her to be a volunteer subject for Erickson. By any standards as a demonstration it was anything but inspired. I felt more than once that Erickson was at a loss regarding what he could do with Ruth but was not going to admit it.

Erickson’s retrospective, much later explanation to Haley that he had demonstrated with Ruth, a “reverse set induction”, a method he had never previously alluded to, has always seemed to me to possibly have been invented under the pressure of giving Haley an explanation.

[…​] Full sessions with commentaries are to be found […​] One should keep in mind that the commentaries in the case of Bandler and Grinder are not Erickson’s.

When I last saw Erickson in his home in 1975, he had become physically very weak, was easily fatigued, and most of the time he could barely speak above a whisper. My efforts at the time to enter into a dialogue with him regarding some of the material that was to appear in his and Rossi’s 1976 book met with failure. Erickson was willing, but not up to doing this. I doubt very much that, prior to publication, he had either the strength or inclination to go over the material he co-authored with Rossi, and certainly not carefully. At least, we do have verbatim reports of answers and comments made by Erickson, and it is, perhaps, important to note that frequently Erickson does not affirm the correctness of some of Rossi’s statements to him.

Rossi’s work is interesting and stimulating reading. It needs be kept in mind, however, that he has built a hypothetical edifice whose foundation and many of its bricks are nothing more than speculations. This does not produce a sound scientific structure. The mortar also shows weaknesses. Rossi has a tendency to confuse speculation with fact. […​Rossi] does generally ignore any data that contradict his position and he frequently misrepresents facts to suit his own purpose.

Another myth is that metaphors were Erickson’s primary therapeutic tool. According to this belief, the more esoteric, highly indirect and incomprehensible the metaphor, the better, and multiply embedded metaphors are unsurpassed.

Regarding the sloppy overuse of metaphor, Pearson (Note 5) recalled, "He told me within the last year before he died that one of the things that disgusted him was that so many people in trying to imitate him with embedded metaphor and parables were hiding behind that obscurity. He was very careful in what he told and why he told them."

[…​] Erickson laboriously wrote out suggestions for his patients. He even roleplayed and practiced them in front of a mirror (Thompson, Note 2). One of the ways that Erickson learned to trust his unconscious was through years of disciplined and careful preparation earlier in his career. In fact, the author believes that this compulsive, careful planning and the writing and rewriting of suggestions was a vital part of Erickson’s growth process in becoming a master clinician.

Haley (Note 4) recently lamented that, "It is unfortunate that what Erickson most disliked is being attributed to him. He objected to dilettante therapists, and to therapists who did not train properly, plan their work with care, or master the skills of interview technique. The one thing he did not believe was that one could cure by magic or by offhand wise pronouncements and stories" (p. I)

Haley (Note 4) expressed the opinion that "it is ignorance that makes therapists choose one or two of Erickson’s procedures and make a school of them, writing books about them as if that is Erickson therapy. Erickson therapy is, by definition, variety in technique" (p. 2). Erickson was afraid that this very thing would happen. In the week before his death, he prophesied that self proclaimed experts about his work "would come out of the woodwork" after he died (Pearson, Note 5).

The true legacy of Erickson was eclectic hypnosis and therapy, although unfortunately his eclecticism was intuitive and without apparent organization or easy replication. His approach was one of diversity, flexibility, and freedom to use a variety of methods. He was unwilling to be restricted by the artificial limitations of one therapeutic system, and so it is particularly unfortunate that some disciples would now create a restrictive “Ericksonian” school based on their interpretations of his work.

Lankton (2020) recently opined that Milton Erickson’s hypnotic approach evolved “and changed from being largely direct and authoritarian to egalitarian and indirect” (p. 11). […​] It is my belief that this proposition continues to perpetuate a distortion of Erickson’s hypnotic approach.

The work that Milton Erickson did day in and day out as a practicing therapist has been largely pushed aside. The range, complexity, and variety of therapeutic approaches that he worked a lifetime to develop and apply have been supplanted by a narrow, simplified view of his work as interpolated from the teaching seminars he conducted in his last few years. his work and, more importantly, narrows and distorts the work that those who try to follow him are now able to do…​ Erickson’s work thus has been simplified and narrowed to the point that I am quite sure he would not recognize it as his own.

One of his strongest beliefs was that all therapists must work to earn the necessary credentials of their field and must then continue to learn and to upgrade their skills and capabilities throughout their working careers… I’m sorry to say that we don’t hear much about appropriate training anymore.

Among psychotherapists there are some who worship Erickson with a reverence that borders on idolatry. Every word, sentiment, opinion, or act is presumed to have an inspired meaning. Such deification rooted in expectation of timeless power and omnipotence can ultimately lead to disillusionment. Equally prejudiced are those who regard Erickson as a maverick whose egregious methods are a passing fancy that will eventually be consigned to the dustbin of outmoded schemes. [Both] these attitudes do injustice to a highly creative and imaginative original mind…​ A poignant criticism of Erickson’s strategic therapy is that it is overvalued by those who believe that clever tactics can substitute for disciplined training.

After the end of World War II, the serious efforts of scientifically trained researchers and clinicians have kept the field away from sensationalism, and hypnosis has been steadily and quietly investigated as a science and as a technique for carrying out responsible therapy. Currently, however, with great fanfare, a new period of “boom,” (which could lead to another “bust”) is sweeping over this country in the form of the Neo-Ericksonian movement. Neo-Ericksonians look down on research and attract much publicity by conducting their (large) meetings in the style of religious revival meetings.

Erickson himself was a virtuoso hypnotherapist who developed highly innovative communicational strategies. Although now hailed by his “disciples” as the greatest theorist in the field of hypnosis (see Kraft, Rodolfa, & Reilley, 1985), he really cannot be considered to be a theorist in the true sense of the word, because he never could or did explain in a scientificaIly clear manner what the role of hypnosis was in his highly varied and original psychotherapy (E. R. Hilgard, 1987). He was a charismatic man. During the last years of his life, he attracted many pupils from all over the world. After his death in 1980, some of his American “disciples” of the latter years put him on a pedestal and exploited and overpopularized his work.

The fostering of sensationalism with regard to hypnosis is not the only danger the Neo-Ericksonians have brought to the field of clinical hypnosis. In their desire to “spread the gospel,” they accept for training even those with a mere B.A. as an educational background (i.e., they frequently accept for training even those individuals who have had no prior psychotherapy or medical training). The amount of time Neo-Ericksonians require for certification as hypnotherapists often does not exceed a single 3 or 6-hour workshop.

Particularly since Erickson’s death in 1980, workshops, books and self-anointed experts on Ericksonian hypnotherapy are abounding. […​] There were many times when Erickson meant to communicate on multiple levels. However. because of his reputation for the use of subtle, indirect techniques, students came to his teaching seminars expecting this mode of operation. They recorded the seminars, afterwards analyzing and reading in a great deal. Unfortunately, what students witnessed was a retired, seriously ill, old man. Today many regard it as a badge of honor to say that one "studied" with Erickson. Even hypnosis centers aligned with people who strongly clashed with Erickson are now being named after him, thereby capitalizing on his reputation. In the vast majority of cases, having "studied" or been "trained" by Milton Erickson merely means that the person listened to him for several afternoons as part of a larger group. This does not, however, keep many of these people from authoring books and sponsoring training and supervision on "Ericksonian Hypnotherapy."

Thompson, an associate and friend of Erickson for over 27 years, feels particularly strongly about this. "I firmly believe that the people who are most profiting from his death are those who never would have done so from his life. Many people feel free to interpret him now that they can do so without fear of refutation. It appears to be mostly those individuals who only had exposure to Erickson in the later years of his life who feel the need to explain him and his theories. and to make a living from the explanations. Those individuals who 'knew him when' he was vibrant and powerful would not presume to do that" (Thompson, Note I).

The rest was equally as easy. In the nefarious world of quasi-credentialing and diploma scams, money talks. Or at least it meows. All I had to do was get Zoe her first credential, which I did by filling out an "application for certification" on a lay hypnosis association’s website. I charged her application fee, and within a few weeks, Zoe had her first piece of paper. Since most lay hypnosis associations have a reciprocity agreement respecting each others' certifications, it was a snap to obtain additional (and very impressive sounding) certificates.

Zoe is (or was, since I doubt I will pay certification maintenance fees) certified by the National Guild of Hypnotists, the American Board of Hypnotherapy, and the International Medical & Dental Hypnotherapy Association. She is a Professional Member of the American Association of Professional Hypnotherapists.

As the daughter of Milton H. Erickson, I get emails from people all the time about having me train them in hypnosis. Sometimes legitimate, sometimes I-lost-my-job-and-want-to-earn-money-with-hypnosis, but most of the time from people w/ Ph.D. and Master’s who want the credibility of me -a Master’s Level (earned degree, although I do have an honorary Ph.D. from Armenia because of my name).

To date, I am aware of no research on Ericksonian therapy (with or without the use of hypnosis) that would meet the criteria […​] of an empirically validated treatment. The lack of outcome research on effectiveness, coupled with the reliance on clinical anecdote or uncontrolled single-case study common in the Ericksonian literature, have created inescapable limitations for Ericksonian hypnotherapy in determining its efficacy and effectiveness.

There are three basic assumptions that underlie Ericksonian hypnosis. These assumptions are: (a) hypnosis is an altered state of consciousness with markers that are distinguishable from the waking state; (b) hypnotizability of the subject/client is primarily a function of the hypnotist’s skill (i.e. utilization strategies) and less a function of the subject/client‘s hypnotic ability and; (c) the use of indirect hypnotic suggestion is, at least in some instances, more effective in producing hypnotic responses than is direct suggestion.

The research reviewed simply does not support long-held beliefs by Erickson or those who practice Ericksonian approaches to therapy. There is no definitive evidence for a trance state, the existence of a wise unconscious, the importance of indirect over direct suggestion, or the universality of hypnotizability. Although there are impressive and dramatic clinical anecdotes cited in the literature about Erickson and his work, there is no compelling need to invoke any sort of special curative processes active in Ericksonian approaches beyond those already documented as active in any form of effective psychotherapy (e.g., relationship, expectancies, construction of a compelling narrative, active client involvement). Unlike hypnosis as an adjunct to cognitive-behavioral therapy, it is not clear that hypnosis adds anything to this approach.

This misemphasis has led, I believe, to the relatively superficial training (hypnotic and otherwise) of many clinicians who call themselves "Ericksonian" and are largely naive about both the work of clinicians other than Erickson and relevant hypnosis research. Furthermore, I think this narrow clinical training lends itself to an uncritical acceptance of Ericksonian (1) lore.

Although I enthusiastically share Matthews’s attitude toward empirical support for the assumptions he explores, I prefer a restatement of his conclusion in order to accommodate the credibility that Ericksonian assumptions have acquired through drama and repetition. Because these assertions are based only upon impressive and dramatic clinical anecdotes about Erickson’s work, they should be considered to be hypotheses until empirical evidence is found to support them. […​] Until that bright future, Matthews and I will share our pessimistic view of the current lack of rigor of things Ericksonian.

Footnote 1. I use the term "Ericksonian" to distinguish those who have developed models or hypotheses based on their interpretation of Erickson from the assertions of Erickson, himself, who shunned such model-making. It may prove useful to distinguish Erickson and his claims from those of "Ericksonians."

The empirical research reviewed in this article, found little support for the traditionally held Ericksonian beliefs in hypnosis as a state with identifiable markers, the universality of hypnotic suggestibility, or the increased effectiveness of indirect as compared to direct hypnotic suggestion. Instead we have argued that the effectiveness, creativity, and ingenuity of Milton Erickson can be understood in terms of his seemingly intuitive grasp of the importance of expectancy, belief, and motivation for both the client and the therapist. There is considerable empirically based support for this viewpoint. Matthews (21) suggested a cybernetic or interactional frame from which to consider the work of Erickson rather than a simple linear or causal frame. Matthews (21) in moving away from a hierarchical model (i.e., therapist as expert, client as passive recipient), suggested the client informs and influences the therapist as does the therapist with the client. It is our contention that essence of the Erickson’s approach was to create an expectancy for change, disrupt, distract or otherwise occupy the limited conscious mind, and thereby create a context for the client in which a change in his or her self narrative can occur. Within this perspective, hypnosis is used as a social interaction constructed by the therapist and client in which different multiple realities for the client can emerge.

Erickson himself, however, never offered a formal theoretical formulation of his work. There are no entries entitled ‘theory’ in the indexes of Erickson’s collected writings, nor in Erickson’s collected lectures and seminars (Rossi et al., 1983; Rossi and Ryan, 1985), nor in any book written by him (Cooper and Erickson, 1954; Erickson et al., 1961, 1976; Erickson and Rossi, 1979, 1981). This is primarily due to Erickson’s desire to avoid structural theories for working with individuals and families in favor of formulations about the process of change itself.

It is possible for anyone to use the term Ericksonian to describe his or her particular orientation. Lacking a precise definition of the term, many studies have been conducted that would not qualify in the present authors' minds as being representative of Erickson’s approach. These studies range from simply having a group exposed to self-hypnosis and calling it the "Ericksonian group" (Larkin, 2001) to studies that administered numerous interventions, including what was called "Ericksonian metaphors" among a list that also included the following: self-hypnosis, meditation, guided imagery, music therapy, neurolinguistic programming, breath control, thought distraction, unconditional acceptance, cognitive challenging ofthe idealized self-image, assertiveness training, inner-child work, and gestalt therapy (Edwards, 1999).