The Good, the Bad and the Ugly
Turning Ambivalence into Possibility
by Bill O'Hanlon
Nearly a decade ago, I treated a man named Abel, who was severely obsessive. He taught in a college communications program and loved words, but he'd become so obsessed with how human beings communicate that he could no longer put together words and meanings. He loved to read, but he could no longer concentrate because he obsessed about page margins and typefaces. He obsessed about art, sex, and his own writing. If one obsession went away, another took its place, from the moment he woke up till the moment he went to sleep. Nothing he tried brought any relief.
I thought hypnosis might help with his symptoms, but Abel, who'd unsuccessfully tried practically every form of therapy, including hypnosis, didn't think so. I assured him that I used a different approach to hypnosis, and he agreed to give it a try. During our second hypnosis session, he was symptom-free for about 15 minutes, and he continued to be for about 2 hours afterward. Even though he didn't entirely believe he'd been in trance, he was impressed and happy that something finally had helped.
In the third session, I began once more with hypnosis: "Okay, you can keep your eyes open, or you can close them, or they might open and close on their own," I said. Abel closed his eyes. "And as you're sitting there, you may be thinking you're not going to be able to go into trance. You can have that thought--that's okay. You may be thinking that this trance isn't going to work. You can think that--that's okay. You may be distracted by one of your symptoms, maybe by the tension in your jaw or your neck. You may even think you're too tense to go into trance--that's okay. You can be tense and you can still go into trance and you might relax as the moments go on. You don't have to relax to go into trance. You may be obsessing--that's okay. You can just let yourself feel what you feel, think what you think, experience what you're experiencing, and not think what you don't think, not experience what you don't experience, not feel what you don't feel, and you can still go into trance."
At that point Abel's eyes popped open. "That's it," he said. "Do more of that. That's what helped me last time."
"You mean do more trance?" I asked.
"No, no. I don't think I'm going into trance. But what you're doing now is exactly what I need. Do more of that."
"What do you mean?" I asked again.
"The way you're talking now is what's helping me. Because, somehow, when you talk that way, I get the sense I can't do anything wrong. It's the only time in my life when I can't do anything wrong. I long for that sense."
While Abel's symptoms didn't completely disappear, from this point on, he began to make progress in therapy. For the first time in years, he could relax his obsessive vigilance and begin to live his life instead of endlessly worrying about the details around life's edges.
Erickson and Not-Doing
I first learned this permissive approach watching Milton Erickson's work in the late 1970s, particularly the way Erickson used hypnosis and challenged standard ideas about hypnotic techniques and affects. Many considered hypnosis a rigid procedure, which could be effective only if certain exacting conditions were met: a person had to be physically and mentally relaxed to go into a trance; once in a trance, the person was supposed to be unaware of his or her surroundings except for the hypnotist's voice. So rigid were the requirements for succeeding at being hypnotized that many people believed they didn't have the ability to "go under" the hypnotist's spell.
Erickson's view was different. For him, trance was more of a not-doing than a doing. He understood that the hypnotist had to take the pressure off people, and make them realize that they didn't have to experience specific mental and physical stages in a particular order to go into trance. He invited people to just allow their own experiences to happen as they happened, without having to force anything. He used language that neutralized the mind's tendency to break experience down into dualistic opposites--this or that, right or wrong, correct or incorrect.
In a sense, he gave his clients permission to experience simultaneously or in rapid succession contradictory emotions and states of mind and body, emphasizing that no reaction excluded any other, and that all were "right." From Erickson, I learned to make statements like: "You can listen to and hear everything I say and you don't have to. You may remember what I say and you may not. You don't have to believe anything about this."
Abel's response to this approach--that it made him feel he couldn't do anything wrong--crystallized something for me. Here was a way to break up unconscious logjams; permissions enabled clients to experience two seemingly contradictory states simultaneously. The structure of hypnotic language freed people from the tyranny of having to choose, and choose correctly, what to feel and how to proceed. I began to appreciate the extraordinary power of permission, with or without hypnosis, particularly with my most challenging cases.
So I began focusing on how to most productively include the good, the bad, the ugly, and the in-between of my clients' experience to help them expand their sense of possibilities in life. But this was the mid-1980s, the height of the popularity of various forms of solution-based therapy, and people would sometimes come up to me at my workshops and say, "I really like your positive approach," thinking they were complimenting me, in spite of the fact that I wasn't particularly interested in accentuating the positive.
Around the same time, therapist David Nylund told me that the staff at his clinic had noticed a problem with therapists who were too focused on highlighting the positive. As they watched from behind the one-way mirror, they were struck by how often they saw therapists straining relentlessly to keep clients focused on solutions and solution-talk. Often, the effect was that clients became more and more frustrated and alienated, while the oblivious therapists continued asking about what was going better. Nylund and his colleagues named this phenomenon solution-forced therapy.
So, in my training workshops, I began emphasizing the importance of not excluding those thoughts and feelings that didn't look like solutions to anything. As valuable as it is to help people focus on solving their problems, it's equally important to validate people's experiences, however negative. The essence of good therapy is to be able to descend with people into their hell and at the same time keep one foot in the land of hope and possibility. I once heard a radio interview about research conducted with people who'd survived jumping off the Golden Gate Bridge. The only common factor among them seemed to be that on the way down each of them had had more or less the same thought: Hmmm. Maybe this wasn't such a good idea.
As therapists, we must recognize the complexity and ambivalence at the core of human experience. Inevitably our therapy theories invite us to oversimplify, and solution-focused therapists aren't the only ones guilty of that: the client's problem is "cathected introjects"; she needs to "express her feelings"; he needs to "take responsibility for his life"; clients have to "reexperience their abuse to heal from it." Whatever ideas we therapists get are going to be helpful in some situations with some clients, but they necessarily diminish and impoverish our clients' inner realities. Recognizing this, we need to remind ourselves that whatever conclusions we come to about our clients, it's always more complicated than that.
The Power of Permission
People run into problems when their lives are dictated by rigid beliefs that make the stories they're living out too restrictive. One common set of beliefs is about what you must or should do. For example: "I must always be perfect," or "I should always smile and be happy," or "Females should take care of others' needs." Another common set of beliefs is about what you can't or shouldn't do: "I can't be angry," or "Big boys don't cry."
Permission counters these commands and prohibitions. The therapist who offers permission goes beyond accepting clients as they are and moves into encouraging them to expand their life stories and their sense of themselves. In effect, the therapist who offers permission is saying, "There's more to you than this story you've lived out up to this point." Permissions can introduce choice and possibilities into circumstances that have been limited by necessity and impossibility.
How do permissions work in practice? Some years ago, I worked with a woman who'd been sexually abused by a cousin in childhood. He routinely brought her to orgasm, which she liked and felt bad about--because she didn't like him and felt manipulated and coerced by him. As an adult, she never got sexually excited or had orgasms until she became involved in S&M in her early twenties. After a frightening experience in which she was almost killed, she left the S&M scene.
Now, after many years of therapy, she lived with her fiance and was still unresponsive sexually. She'd begin to get sexually excited, and then get frightened and go numb. She'd accepted that this was the way things were with her. Once, at a professional conference, she'd started chatting with a fellow attendee and had gone into an elevator with him. As the doors closed, sparks seemed to jump between them and they had sex in the elevator. She was surprised that she was doing this wild thing, and even more surprised to have an orgasm during the short encounter.
In our therapy, she realized she was operating under two beliefs: "You shouldn't enjoy sex, because it's bad," or, "You're bad if you're sexually excited or have an orgasm." Because she'd been coerced to be sexually aroused, she'd developed the idea that she had to be sexually aroused and have orgasms in any sexual situation, whether she felt like it or not. I gave her two permissions: "It's okay to have sexual pleasure and not be punished. It's also okay not to be sexually aroused and okay not to have sex." I started interspersing into our conversations permissions such as, "You can be a good person and be sexual." And "You don't have to be bad to be aroused." But also, "You don't have to have sex, if you don't feel like it." And, "You don't have to have orgasms when you have sex."
How did she begin putting these permissions into practice? She decided to let her partner know she became afraid or numb when they were having sex. She'd tell him she needed to stop and talk, or not have sex right then. He was understanding and appreciated that she was honest with him, rather than just forcing herself to go through the motions. The fact that he responded so well confirmed for her that she did not have to have sex or have an orgasm. Her new freedom actually enabled her to have orgasms with her fiance more often.
Although you can give the permission to or the permission not to, giving both permissions at the same is often most effective: "It's okay to be sexual, and you don't have to be sexual." If you give only one permission for one type of response, clients may feel pressured to experience only one part of the equation, or they may find the other side emerging in a more compelling and disturbing way.
In certain situations, it's important to give permission for feelings, not actions. For instance, "It's okay to feel like cutting yourself, and you don't have to feel like cutting yourself." Needless to say, never give permission for harmful, destructive behavior.
Other times, it's helpful to give a client permission to do two things at once. Such was the case with Josie, whom I'd seen for a few sessions when she came in very agitated. She said she had something to tell me, but was terrified to talk about it. I told her it was okay not to tell me until she was comfortable enough to do so. Josie responded that she had to tell me, or she felt she'd be wasting her time and money in therapy. I told her to go ahead and tell me in whatever way felt right.
She seemed to struggle for a while and then said, "I can't tell you. I'm too afraid." We went back and forth like that until I began to understand Josie's dilemma and said, "Okay, I know this may not make sense, but what I'm going to say can be understood somewhere deep inside. You can find a way to tell me and not tell me at the same time."
In response, Josie closed her eyes and her hands began to move in elaborate movements that reminded me of "hand dancing" I had seen done by Thai performers. After some time, she opened her eyes and smiled, obviously relieved. "There," she said, "you were right. I told you and didn't tell you at the same time. My hands told you the whole story of my abuse. Now I can tell you in words."
"That's good," I thought to myself, "because I didn't get the hand thing at all." Josie went on to tell me what had happened to her. Although she knew it was irrational, she'd feared that if she told me, she'd somehow be responsible if I had a car accident or a heart attack. Telling her story was a great relief to her. Once she could find a way out of her bind, she could embrace the possibility of breaking her "curse."
The Power of Inclusive Thinking
Sometimes the key to helping someone who seems hopelessly stuck is to invite them to experience two seemingly contradictory feelings or states without putting them in conflict. What's central is the use of the word and: "You can feel tense, and you could relax. You might think you can't change, and you might be surprised to discover that you're changing. You want to change, and you're so afraid to change." This contrasts with how most people unconsciously put things together: "I have to feel this or feel that. I feel this, but I should be feeling that." Instead of reinforcing one-dimensional definitions of ourselves, such permissions go beyond mere acceptance to actively encouraging clients to simultaneously experience thoughts and feelings that they consider irreconcilable. It's as if the therapist is saying, "Your story has become too small for you. Give yourself permission to begin to envision and live out a larger story."
I remember doing therapy with a woman who'd been severely and persistently abused as a child. She lived six hours away and we met every month or so for three-hour sessions. She'd struggled with suicidal impulses for years, and the work we were doing was leaving her emotionally raw. She called one day and told me she couldn't go on in the therapy. "You're getting too close, and I feel too vulnerable," she said. "Plus you're too far away, and I can't come easily for an emergency appointment if I need one."
"I understand," I replied, "and I think this isn't a good time to end treatment. So let's talk for a minute and see if we can get you through until the next appointment. You can find a way to be vulnerable and protected. And you can regulate the distance and closeness to make it work for you. I can be right there with you while I'm here. You can be right here with me while you're there. I can be as far away as you need me to be and as close as you need me to be. And I can be far away and close at the same time." I went on in a similar vein for a few minutes--trying to establish in her a direct feeling sense that she could have her cake and eat it, too. It seemed to work. "Okay. You're right," she said. "I can do that. I'll see you next appointment."
As therapists, we must always be sensitive to the enormous life-restricting pull of either/or thinking. This abused client believed she had to be either vulnerable or safe. But there were situations in which this particular client had been able to be both vulnerable and safe. She said she felt that I was getting too close. I suspected just the opposite as well: she felt that I was too far away, emotionally as well as physically. So I included both possibilities, instead of one or the other.
Typically, when people are stuck, it's like two people trying to go through a door at once. The two are present simultaneously: I want to change, and I'm afraid to change. Inclusion expands the doorway, leaving room for both--and perhaps more--aspects of self to move freely. Merely giving language to this double presence by inviting people to recast their life stories to match their expanded sense of themselves, is often enough to free them from the insidious internal demand to see themselves and their reactions monolithically.
Not long ago, I consulted at a hospital with a woman who was depressed, suicidal, self-mutilating, and defiant.
"How long have you been so depressed?" I asked.
"Since I was 8 years old," she said.
"That's a long time. I'm surprised you've lasted this long."
"Well, two times over the years I almost succeeded in killing myself."
I was curious about how she'd kept herself alive. She told me she'd struggled against the depression so long because in some ways she wanted to live and find a way out of depression. Nobody really understood that, she added, because she was always talking about killing herself.
A few weeks earlier, I'd seen Mike Wallace on 60 Minutes interviewing a woman with a degenerative illness, who was fighting through the courts for the right to die. Wallace asked her why she was suicidal. She replied, "I'm not suicidal. I just don't want to live like this, and I want the right to choose to die." Wallace insisted that, since she was fighting for the right to die, she must be suicidal. "No," she replied, "I love life. I just don't want to live like this. I love life."
I told the woman at the hospital the story and said, "You've lived all this time because you want to live. You've made it this far, by luck, or because the angels were watching over you, or because someone cared for you at times, but mostly because you just kept yourself going. You want to die and you want to live, but you definitely don't want to live like this."
"That's it exactly," she said. "No one has understood that. I'm suicidal and I'm not!"
Now you might say that these women really didn't want to die. But I think that's the cheap version of their reality. They did want to die in a certain way, and (there's that word again) they were still alive, which spoke powerfully for their desire to go on living. Only by recognizing the complex truth of the matter, taking it seriously, giving words to and accepting these dual realities can this permissive, inclusive method work. So clients really do want to live. And the reality that you must come to terms with is that they may really die.
Practicing What We Preach
If the approach I've been laying out here was purely a matter of logic, theory, and better clinical outcomes, its principles would be more widely demonstrated in therapists' consulting rooms. But embracing clients' multiple realities inevitably leads therapists to face emotional issues in their own lives, issues that make an inclusive approach much more than a merely intellectual exercise. At least that's what my own experience has taught me. It's been one thing to give clients permission to accept their ambivalence, but quite another to do that in my own life.
Some years ago, my wife Steffanie was stricken with a painful and life-threatening illness. By 1997, she was bedridden, gaunt, and in extreme physical pain. While the doctors could offer many diagnoses, they had no viable treatments. Many told her there was nothing more they could do. Others referred her for assessments or treatments she'd already tried. She was despondent and convinced she was going to die.
I would hear none of it and found it impossible to support her hopelessness. So I unswervingly emphasized the possibilities for treatments yet to be developed, and the need to keep a positive attitude to support her immune system. I thought, of course, that this would be helpful to her, but it often had the effect of sparking terrible arguments between us.
She would tell me, "You want me to feel better, and I don't feel better. What you're saying just makes me feel worse and more alone." But at some level, I felt that if I didn't expend all my energy in fighting her pain and hopelessness, I would be giving in to it, even making it worse. I was terrified that if I accepted her reality, she was doomed and I would lose her.
Finally, help came from an unusual quarter. We'd recently moved to Santa Fe, New Mexico, and rented a house out in the country. It turned out there were some problems with the well because of leaks and some toxic materials stored in the house. I called the landlady, explained the situation, and told her that we intended to move out. The landlady didn't want us to move and, in addition to making the needed repairs, had a suggestion that could only happen in Santa Fe (or perhaps Sedona): she proposed hiring a "house psychic" to do a reading on the house and deal with the problem at a more cosmic level. Skeptical and a bit bemused, Steffanie and I decided we had nothing to lose and agreed to let the house psychic do her thing.
After a few Feng Shui-type suggestions, the house psychic did a reading for us that revealed, she said, that in a previous life Steffanie and I had been a couple living on a large estate in ancient Italy. Steffanie was the heir and I, as the new husband, had taken over managing the estate. But because I had little experience in such things, I was running the estate into bankruptcy and stubbornly refusing to listen to Steffanie, who unsuccessfully kept trying to tell me what to do. In our past life, the psychic told us, our stalemate ultimately had led to tragedy for Steffanie and I'd spent the rest of my life regretting I hadn't listened to her.
I know, I know--only in Santa Fe! But whatever its value as a past-life story, the psychic's tale was so parallel to our situation that it had an electric effect on me. I realized that I hadn't been listening to Steffanie. However inclusive I'd tried to become as a therapist, at home, I'd been determined to screen out her "negativity." As I might have predicted had I had any distance from our situation, the more "positive" I got, the more desperate Steffanie became.
Something about the psychic's making me see how stubbornness can led to tragedy made me think about my own family story. I suddenly made the connection to growing up in a household in which the unwritten injunction was "don't get sick." We kids had to be essentially on our deathbeds to be allowed to stay home from school or work. If we did stay home, we were never coddled. There was no television or other distractions. My mother, a tough farm girl, would leave some 7-Up and soda crackers by the bedside and check back every few hours to make sure we were still alive. No doctors, no medications. It was as if sympathy would somehow reinforce the illness.
From fear that Steffanie might die, I'd been reenacting an old family drama. I saw that I had to quit trying so hard to make everything okay again. I needed to let myself just be with Steffanie in her hell. I remember going into our bedroom and just lying down and holding her for a long time, without saying much of anything. Then, we quietly spoke about the pain she was in. Later, she told me that it was the first time she hadn't felt left alone in her despair. From then on, something shifted between us. I realized that accepting her hopelessness didn't mean I had to give up my own hopes for our future. I could hold them both. Soon, Steffanie began to talk about future plans and other small dreams that indicated she hadn't given up. I could, in turn, speak to her about my fear of losing her and being left alone. She's still far from well, but the tension between us has been replaced by a sense of connection and an awareness of my tendency to "go positive."
It's relatively easy for most of us to think inclusively with our most functional clients, but much harder to do so with those who are difficult and demoralized, or when our own psychological hot buttons are being pushed. But being a therapist means taking the time to get all the pieces of people's reality, spoken and unspoken. At the most basic level, we must discover how to perform the balancing act of simultaneously giving up the need to see clients change while holding open the possibility of change. This attitude requires us to face our own fears (of lawsuits, suicide, failure) and be still with the client's pain, immobility, glaring absence of change, and , at the same time, we must be able to see the "and"--that something more, unrecognized and unspoken, happening beneath the dead calm of an apparently inert sea.
Bill O'Hanlon is a therapist, author, and workshop presenter. His latest books include Do One Thing Different; Try and Make Me; Collaborative, Competency-Based Counseling and Therapy; and Even From a Broken Web. His book A Guide to Inclusive Therapy is due in early 2003. Address: 551 West Cordova Road, Suite 715, Santa Fe, NM 87505. Website: www.brieftherapy.com.