The Missing Theory of Strategic Psychotherapy

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The Missing Theory of Strategic Psychotherapy

• John O. Beahrs, M.D.
• Professor Emeritus of Psychiatry, Oregon Health
  Science University
• for 10th Ericksonian Congress
• December 9, 2007

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Conceptualizations

• 1. Milton H. Erickson, 1959 Utilization
• 2. Jay Haley, 1973 Social Influence Skills
• THERAPIST evaluates ? enacts strategy
• ? monitors ? re-evaluates adapts
• 3. Palo Alto Group (1967, 1974, 1982)
• VS. Problem-Maintaining Behaviors
• What is Happening? Toward What Ends?

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Theory Problematic for Tx.

• 1. Limiting (Procrustean straight-jacket)
• (a) weakens predictive skill
• (b) lowers flexibility scope of tx.
• (c) in contrast to physical theory
• 2. How and Why? What is Theory For???
• 3. Tradeoffs in Rejecting Theory
• (a) treatment rationale? (theory)
• (b) protective grounding? (values)

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Milton Erickson Anomaly

• 1. Subject of a Scientific Discipline
• 2. Violates Hypnosis Research Consensus
• (a) subject gt hypnotist locus of control
• (b) hypnotizability stable trait
• 3. Blurs Therapeutic Meta-Theories
• (a) contextual model adapt tx. to client
• (b) medical model specific, theory-driven

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How Anomalous was Erickson?

• 1. Methodology Master Hypnotist
• (a) unequivocal, vs. established wisdom
• 2. Direction Good Person
• (a) beneffectance, traditional family values
• 3. Impressive Case Anecdotes
• (a) what was their place in his caseload?
• (b) commonalities differences with others?
• Whats Good Therapist? Can it be Coached?

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Contextual Model

• 1. Contrasted with Medical (Wampold, 2001)
• (a) nonspecific gtgtgt theory-driven
• (b) therapist variation gtgtgt specific technique
• (c) adapt treatment to clients world views
• 2. Why do Therapists DO nonspecific factors???
• (a) while explaining them otherwise?
• (b) concealing whatever really happens?
• Missing Theory Common Sense Psychology

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Milton H. Ericksons Common-Sense Psychology

• 1. Individual Psychologies are Intermeshed
• mutual suggestion
• influence increases with rapport, prestige
• 2. Speaking Individuals and Families Unique
  Languages ? RAPPORT
• enters clients in-group
• establishes common interest

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3. Utilization Triad (Erickson, 1959)

• (a) Join clients system ? Rapport
• (b) Modify the system ? Control
• (c) Utilize control ? Therapeutic Ends
• restructure the social context
• so that good things likely to just happen
• probabilistic upping the odds of change

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4. Consciousness/Volition Complex,
Context-Dependent

• Treat All Levels with Respect
• VS Selective Attention to Overt Request,
• (risks enmity with hidden levels,
• creating unnecessary resistance)
• Gain Rapport at Hidden Levels
• -positive reframing
• -paradoxical quality not too fast

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5. Resistance Often Arises at Conscious Level

• -less from rational counter-motivation
• -more from need to save face
• -evidence everyday tact, timing, diplomacy
• De-Potentiating Consciousness
• Empower Unconscious Striving to Health
• Creative Face-Saving

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Inherent Questions

• 1. Nature of Social Influence
• 2. Function of Individuals Languages
• 3. Nature of Reframability Utilization
• 4. Nature of Complex Consciousness
• 5. The Perplexing Role of Face
• 6. The Tx. Place of Moral Values

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How/Why is C.S.P. Missing?

• Effective People Sense and Utilize It
• But Explain it Otherwise
• Denials Possess a Ritualistic Quality
• Most Acknowledge When Confronted
• Theory Present Shallowly Hidden

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The Human Nature Question

• 1. Tacitly Recognized by Everybody
• (a) life skills, all human sciences
• 2. Easily and Often Abused
• (a) tyrants, cult leaders, deniers
• (b) conceal hidden agendas
• 3. Missing Question of Values
• (a) in-group vs shared human norms
• (b) theory must encompass values

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Hypnosis Social Influence

• 1. Hypnosis/Non-Hypnosis Inseparable,
• -data apply to all waking mentation
• -multilevel intentionality
• 2. Illusion of Conscious Will
• -not causal (Wegner, 2002)
• -social regulatory functions
• -applies to all psychodynamics?
• 3. Context Dependence (Reframability)

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Evolutionary Biology

• 1. Kin Altruism ? Family Values
• 2. Reciprocity ? deceit/counterdeceit, memory,
• reputation, social emotions, police functions
• 3. External Enemies ? selective in-group
  altruism,
• indirect reciprocity, punishing self-interest
• 4. Self-Deception evolves to protect
  self-interest
• if shared ? new psychosocial reality

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Shared Self-Deception Hypothesis

• 1. Contracting for Self-Interest (freedom)
• (a) ? new common interest ? cooperation
• 2. Concealed by Shared Self-Deception (privacy)
• (a) emergent conscious-unconscious duality
• -idealized image ? Cs volition
• -intrinsic causation suppression ? Ucs
• 3. Enforced by Counterbetrayal Punishment
• ? new psychosocial structure (meme)

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Supporting Data

• 1. Whistleblower Retribution
• 2. Importance of Face-Saving
• (a) face as ideal image, perceived agency
• (b) reactance when threatened
• 3. Deceptive Functions of Language
• (a) in-group privacy, hierarchical levels
• 4. Paradoxes of Hypnosis, Common Psychology
• (a) multilevel Cs context-dependence
• 5. Social Equilibration and Destabilization

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Sociodynamic Implications

• 1. Largely Outside of Awareness, Our Brains
• (a) calculate our interests, assets
  liabilities
• (b) develop strategies
• (c) create psychodynamics 2o adaptations
• perceived as causal via shared deception
• 2. Psychological Entities as Social Contracts
• (a) Cs, volition, personal identity, part-selves
  
• 3. External gtgtgt Internal Causation
• (a) makes psychotherapy possible

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Sociodynamics of Consciousness

• 1. Emotion of Authorship
• (a) mediator of reputation, face
• 2. Criterion for Culpability
• (a) volition illusion of causation criterion
• 3. Executive Functions
• (a) long term planning
• (b) vetoing problematic behavior
• (c) calling forth alternative behaviors
• Calling Forth is Often Confused with Causation

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Confusion of Volition/Non-Volition

• 1. Inappropriate Volition (Be Spont! Paradox) ?
• (a) insomnia
• (b) minor dysphorias
• (c) sexual dysfunction
• (d) impaired complex purposeful actions
• 2. Proper Role of Volition
• (a) setting up the parameters
• (b) so desired outcome is more likely
• Time Structure, Veto Power, Calling Forth

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Creative Face-Saving

• 1. Depotentiating Consciousness
• (a) ? unconscious causal primacy
• 2. Indirect Communication
• (a) ? wiggle room, windows of doubt
• (b) ? reputation gtgtgt public knowledge
• 3. Preserving Illusion of Conscious Will
• (a) clients choice gtgtgt therapists influence
• 4. Paradox and Reframing

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Changing Third Parties

• Developmental Impasse Luxury Cruise
• -reframing and paradoxical attitude change
• Wife Nags EtOH Husbd Al-Anon Model
• -establishes locus of control
• -gains allies, social support
• -leverage what is under ones sole control?
• Family of Passively Controlling CMI
• -refer to CMHC, support for themselves

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Boundary Blurring Antitheses

• 1. Ambivalence Gain Rapport at Hidden Level
• (a) paradox prevents reactance
• 2. Games Yes But (Berne, 1964)
• (a) antithesis deflect back onto client
• 3. Regressive Potential (Beahrs, 1986)
• (a) dependency versus autonomy
• (b) rescuing ? regressive dependency
• (c) antithesis challenge autonomous skills
• The Paradox of Helping by Not Helping

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Psychosocial Theory

• 1. Not Predictive, Limits Technology
• (a) illusion of predictivity
• (b) parallels illusion of conscious will
• 2. We Actually Predict Behaviors by
• (a) innate heuristics
• (b) past behavior
• (c) categorizing and learned expertise
• 2. Theory Shared Self-Deceptive Idealization
• (a) promotes affiliation among believers
• (b) protective grounding via consensus

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Testing Psychosocial Theory

• 1. Problem of Unfalsifiability
• (a) effectiveness ? allegiance gtgtgt truth
• 2. Testable Through Behavioral Effects
• (a) behavioral effects of believing the theory
• 3. Effects of the Missing Theory
• (a) does strategic therapy work?
• (b) how does it compare with alternatives?
  
• 4. What is the Scientific Status of C.S.P.?

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Strategic Psychotherapy Works

• 1. Case Anecdotes establish possibilities
• (a) Palo Alto 1/3 , 1/3 , 1/3 no effect
• 2. Masters Johnson forbid sexual performance
• (a) roughly 80 effective
• 3. Indirect Communication/Leverage by 3rd Parties
• (a) est. 70 effectiveness of Al-Anon model
• 4. Paradoxical versus Direct Interventions
• (a) equal at termination, better at followup
• (b) in more seriously disturbed clients
  
• (c) if accompanied by positive connotation

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Comparative Psychotherapy

• Group 1. Strategic Self-Therapy (SST)
• (a) non-intensive
• (b) client change agent, guarantees safety
• (c) therapist consultant
• -not change agent or crisis resource
• (d) independent systems as crisis resource
• Group 2. Exploratory Psychodynamic Tx. (EPT)
• (a) doubly intensive
• (b) therapist change agent crisis resource

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V. SST vs Exploratory Tx (EPT)

• 1. Measures (clinician estimates, 0-4)
• (a) Regressive Dependency (RDL,
  operationalized, r 0.89)
• (b) Regressive Potential (RPRS, composite
  estimates, r 0.80)
• (c) Pt. Self-Therapeutic Activity (STAL,
  composite, r 0.71)
• (d) Therapeutic Progress (TPRS, composite, r
  0.77, 0.82 )

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Differential Effectiveness

• 1. Equal Effectiveness, SST EPT
• (a) ergo, SST was doubly cost efficient
• 2. SST gtgtgt EPT in Dropouts 27 vs. nil
• (a) tradeoff cost effic. dropout rate
• SST ltltlt EPT in Regressive Effects
• (a) RDL RPRS correlate EPT gtgtgt SST
• (b) less absolute RDL in SST clients
• 4. No Correlation between RDL and TPRS
• (a) regressive therapeutic effects separable

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Therapeutic Progress Varies With Patients Helping
Themselves

• 1. TPRS correlated with STAL
• (a) almost linearly
• (b) equally so in both modalities
• -Implic Tx Optimally Stimulates Pt Self-Tx
• 2. Relevance of a Pseudocorrelation
• (a) STAL and TPRS share common elements
• (b) STAL gtgt TPRS is experienced as voluntary
• -Implic effec. tx reframes TPRS as STAL

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Selected References I.

• Alexander RD The Biology of Moral Systems.
  Hawthorne, NY
• Aldine DeGruyter, 1987
• Beahrs JO Limits of Scientific Psychiatry The
  Role of Uncertainty
• in Mental health. New York Brunner/Mazel, 1986
• Beahrs JO A social brain interpretation of
  psychotherapy. Psychiatric Annals 2005
  35(10)816-822
• Beahrs JO Assessing attributive causation
  therapeutic results
• correlate with self-therapeutic activity.
  Clinical Neuropsychiatry 2006 3(2)154-161
• Beahrs JO, Butler JL, Sturges SG, Drummond DJ,
  Beahrs CH Strategic self-therapy for
  personality disorders. J Strategic Systemic
  Therapies 1992 11(2)33-52
• Berne E Games People Play. New York Grove
  Press, 1964
• Erickson MH Further clinical techniques of
  hypnosis utilization techniques. Am J Clin
  Hypn 1959 23-21
• Erickson, M.H. (E Rossi, Ed) The Collected
  Papers of Milton H. Erickson, M.D. New York
  Irvington, 1980

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Selected References II.

• Fisch R, Weakland J, Segal L The Tactics of
  Change Doing Therapy Briefly. San Francisco,
  CA Jossey-Bass, 1982
• Haley J Uncommon Therapy The Psychiatric
  Techniques of Milton H. Erickson, M.D. New
  York Norton, 1973.
• Masters WH, Johnson VE Human Sexual Inadequacy.
  Boston, MA Little, Brown, 1970.
• Shoham-Salomon V, Rosenthal R Paradoxical
  interventions a meta-analysis. J Clin Consult
  Psychol 1987 5522-28
• Wampold BE The Great Psychotherapy Debate
  Models, Methods and Findings. Mahwah NJ
  Lawrence Erlbaum, 2001
• Watzlawick P, Beavin JH, Jackson DD Pragmatics
  of Human Communication A Study of Interactional
  Patterns, Pathologies, and Paradoxes. New York
  Norton, 1967
• Watzlawick P, Weakland J, Fisch R Change
  Principles of Problem Formation and Problem
  Resolution. New York Norton, 1974
• Wegner DM The Illusion of Conscious Will. MIT
  Press, 2002