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Case Study - Page 2

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Bad News

Sarah, a 72-year-old therapist in private practice, whom I’ve known for many years, called and asked if she could have a session with me to discuss a “health issue.”

She was tense and hesitant as she settled into her chair and began to tell me about her situation. Two years before, she’d felt some discomfort in her abdomen, and as part of the medical testing for this, she’d had a CAT scan of her lower torso and the lower section of her lungs.

In the follow-up appointment, her doctor, after telling her the scan had revealed no problems in her abdomen, showed her the image of her lungs and said in a distant, nonchalant tone of voice—“as if it wasn’t a big deal”—that she did have lung disease and had “two months to six years to live.” Sarah said she’d taken this as a “death sentence,” even though she hadn’t had any breathing problems other than a slight cough. Since then, she’d experienced intense fear about her health and a lot of anger at her doctor for his offhand, insensitive attitude; however, instead of trying to learn more about her ailment or its possible treatment, she’d tried to blot from her mind the entire experience of receiving the bad news—without much success.

Whenever someone is afraid—especially without an external stimulus—the fear is coming from their own internal images, along with the feelings, sounds, and thoughts that accompany them. To determine how Sarah created her fear, I asked her, “What do you see when you think about the doctor telling you about your lungs?”

As she described her memory of the CAT-scan image, she gestured with both hands directly in front of her face, about two feet away, outlining an area about a foot square. This image of her diseased lungs was literally “in her face,” where she couldn’t ignore it. Seeing the image of her diseased lungs right in front of her was the main reason that the unpleasant content of this picture made her so afraid. However, her memory of the original CAT-scan image had spontaneously changed in an interesting way from what she’d seen in the doctor’s office. She said that each lung now looked like “the big hoops with paper that clowns jump through at the circus, and afterward, you can see the torn edges of the paper where the clown broke through.” Since this torn image showed only parts of the image of her lungs, it wasn’t quite as disturbing as the original CAT scan had been, but it still bothered her.

Then Sarah reached into her purse and took out a small scrap of torn paper, folded in half. She handed it to me as if it were a poisonous snake that she wanted to let go of as fast as possible, saying in a tense voice, “This is what the doctor said I have. I don’t want to say or see the words.” As she handed me the paper, her upper body moved away from her outstretched hand. When I opened the paper, I saw that she’d written “interstitial lung disease.” The word disease was crossed out, and under it was written “condition.”

Seeing that Sarah barely wanted to touch the piece of paper, I respected her need to avoid the words on it for the time being. So as soon as I’d looked at the note, I refolded it, put it on the arm of my chair, and covered it completely with my hand, so that it was out of sight and wouldn’t bother her. When I did this, she relaxed slightly and moved back toward me a little. Because of this response, I kept my hand over the paper throughout most of the rest of the session, which lasted an hour and forty-five minutes.

Sarah was aware of her feelings of fear, but like most of us, she was only partly aware of how she created these feelings. Although many therapists would probably have asked her to say more about the feelings, I didn’t believe that would be useful. I could ask her to describe her feelings all day long, but the feelings themselves would remain unchanged, unless we could change the certainty that elicited the feelings.

One of the first things I did was to focus on weakening Sarah’s certainty about the negativity of this experience by questioning the authority of the doctor’s grim statement, and thus her acceptance of it. I laughed and said, “Doctors and their predictions! Do you know what I do when a doctor makes a prediction like that?” I paused briefly until she shook her head to be sure she was engaged. “I look around at all the diplomas on the wall —I elaborately pantomimed craning my neck to look around at all the walls of my office—and then I look at the doctor and ask, ‘Do you have a fortune-telling license?’” As I acted this out, I looked into Sarah’s eyes to bring the “story” into the immediate present and elicit a strong response.

She laughed, and then told me that her sister had had juvenile diabetes as a child, and the doctors had said she wouldn’t live past 40, but she lived to be 75. When her sister was in her sixties, Sarah had asked her what she’d thought when the doctors had told her that she’d die young. Her sister had replied in an offhand way, “Oh, I just thought they were talking about all those other people out there, not about me.” As Sarah said this last sentence, I noticed that she gestured with her left hand in a broad, sweeping motion away from her body, from the front to the side and back.

This story about her sister, which was a great example of how doctors often make predictions inappropriately, offered Sarah an alternative behavioral choice of simply dismissing the doctor’s pronouncement. The fact that she’d recounted it told me that she understood me perfectly, and that I was on the right track. Since I wanted her to distance herself from the experience of fear induced by her doctor’s statement, I said, “Great, I want you to do the same thing that your sister did. Think of what your doctor said to you, and in the same casual tone of voice as your sister, say, ‘He was talking about all those other people out there, not about me.’ As you say this, use that same broad, sweeping gesture with your left hand.” When Sarah reenacted exactly what her sister had done—both verbally and nonverbally—she took on her sister’s attitude, mentally and physically, consciously and unconsciously. Of course if I’d asked her to do this and she’d had some objection or discomfort with it, that wouldn’t have happened.

After Sarah had spoken her sister’s words and used her gestures, she smiled and pointed toward her upper chest, saying, “That helps me breathe easier.” This spontaneous change in breathing was a good indication that change was occurring unconsciously as well as consciously, and it confirmed that what I was doing was useful to her. As John Grinder, a founder of Neuro-Linguistic Programming, used to say, “Any verbalization that is not accompanied by congruent nonverbal behavior should be treated as unverified rumor.”

At this point, some people might think that I was imposing my strategies on Sarah without consulting her; however, at every step of the way, I was using her nonverbal feedback to guide me. If she’d objected at any point, I’d have immediately adjusted what I was doing in response.

The Limits of Predictions

I went on to say, “It’s one thing for a doctor to be honest with you and give you whatever statistical information he has about a medical problem, but it’s quite another thing to make a prediction about a particular person.” Then I told her about a small parotid tumor that I’ve had under my right ear for about five years. The surgeons predicted that it would grow larger, and they wanted to take it out—which would require a four-and-a-half hour operation, because the main facial nerve goes right through the middle of it. I gathered information on the Internet and decided to wait and monitor it. In the last four years, the tumor hasn’t changed in size or been a problem. This gave Sarah another vivid personal example of a doctor’s incorrect prediction, further weakening her certainty about the validity of the “death sentence.”

To reduce her certainty about the doctor’s statement even more, I asked Sarah to close her eyes and return in her imagination to the doctor’s office and tell him how angry she was with him, and anything else that she wanted to tell him, both what she’d felt at the time, and anything she’d thought of later. This was to help her move from feeling like a passive victim of events to taking charge of them—what’s often called being “empowered.” When she was done, she said, “Oh, that felt gooood,” and again said that her breathing felt easier—yet another unconscious response that confirmed that I was on the right track.

Then she said she was still angry that the lung problem had been discovered by accident when the abdominal scan had been done. “If they hadn’t done that, I never would have known about it, and I wouldn’t be afraid.” In response to this, I told her of a story I’d read recently about a man who was in a similar situation. The tumor they discovered accidentally was still very small, and he felt very grateful and lucky to find out about it early, so that it could be removed before it spread, resulting in a complete cure. This story invited her to feel lucky and grateful (instead of angry) to have found out about her lungs—in contrast to not knowing there was a problem and being unable to do anything about it.

Next I said, “For two years now, you’ve been trying to avoid this experience, but it’s continued to terrorize you. I’d like you to be able to think about it differently, without fear—just as information. Does that sound useful to you?” Sarah considered this thoughtfully, but her expression wasn’t enthusiastic.

“Let me tell you my reasons for this,” I continued. “First, fear can be useful to get you out of a dangerous situation, but chronic fear isn’t good for your body, and interferes with health and healing.

“Second, when you don’t know about something, it’s much scarier than when you do know about it. For instance, you don’t know what’s in that closet (pointing to the closet in my office). If you were to worry about it, you could think of all sorts of horrible things that might be in there. But if you opened the closet, you’d see some clothes on hangers, some boxes on the floor, and other stuff that would be much less scary than your images.

“Third, even if you did find something dangerous in there, knowing what it is would give you information that you could use to protect yourself. If you don’t know about something, there’s no way to make informed choices and decide what to do. The more information you have, the more choices you have about what to do to make your life better.”

I mentioned how some women who discover that they have a dangerous breast cancer gene have decided to have their breasts removed, because they’d rather be alive without breasts than dead with them. This might seem like a somewhat grim example, but it was a good match for Sarah’s thinking about her lung condition as a “death sentence,” and it illustrated how accurate information is a basis for being able to make choices. Sarah pondered this and didn’t disagree, but her expression didn’t change much.

I’d like to point out that I was using both my words and my nonverbal behavior to create experiences to elicit alternative, new, unconscious responses in Sarah. Even when I offered her broad generalizations about fear, knowledge, and choices, I was tracking how she responded and using this feedback to adjust what I did next. Those generalizations were useful in creating a frame of understanding, but it was the experiences that I helped her have—through stories and the actions she took in response to my suggestions—that elicited new, more useful responses.

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13 comments

  • Comment Link Wednesday, 11 July 2012 15:18 posted by S. Andreas

    Reply to Steve Green:
    Firstly, what I did with the client was not hard work at all. It was an easy and enjoyable exchange that was delightful.

    Secondly, yes, it certainly would have been "simpler and much more straightforward" to do what you suggest.

    There is only one small problem with a direct approach--no matter how true that might be—and I do agree with what you write. Actually creating that realization takes more than just telling someone that "that they are just thoughts, stories, fantasies, and not true. They are just made up." That is conscious mind talk, and rarely effective. (When I worked in the oilfields in the 1950's this was described as "pissing into the wind.")

    Creating that realization requires changing the internal images, sounds and feelings that a client uses to determine what is real and what is not. This can be done directly ("Make that image transparent; hear that voice as if it is coming from an old tape recorder" etc.) or conversationally by telling and acting out relevant stories behaviorally so that they are processed as real, which is what I did in the session.

    Daniel Kahneman's excellent book, Thinking Fast and Thinking Slow presents a huge variety of experiments that his "Dual system" theory is based on:
    -System 1 is fast, relatively primitive and prone to error, and is what many people have called the "unconscious," or "right brain."
    -System 2 is slower, and more work, using logic, mathematics, language, often described as "left brain."

    Most clients are troubled by feelings, addictions, and behaviors that are generated unconsciously by system 1 thinking.

    System 2 thinking has little effect on this UNLESS it utilizes images, metaphors, narratives, etc. to communicate in a way that system 1 can respond, which is what I did in the session described.

    One of the main points in my article was the difference between just talking logically to someone about their problem which unfortunately is what most therapists do, and communicating appropriately with the client's system 1 that is creating the problem.

    I think every therapist (and anyone else who wants to understand how our minds function) would benefit enormously from reading Kahneman's book.

  • Comment Link Wednesday, 11 July 2012 09:33 posted by Maria

    Great article, thank you!

  • Comment Link Wednesday, 11 July 2012 09:33 posted by Maria

    Great article, thank you!

  • Comment Link Thursday, 05 July 2012 06:52 posted by Neil

    Brilliant, thankyou for this, there are so many applications of NLP, and self management certainly is the big one for me!

  • Comment Link Tuesday, 15 May 2012 06:13 posted by Dr. Michael of Grantham Therapy

    Well worth reading Steve and thank you. When our perception shifts, it immediately provides a new vision of the world. Regards, Michael

  • Comment Link Monday, 14 May 2012 17:07 posted by John D Lentz

    How wonderful to read the work of a master, weaving so elegantly words, emotions, and associations so that the client feels better and has more options.

  • Comment Link Friday, 20 April 2012 22:10 posted by Eugenie

    What elegant, skilled work! I especially appreciate the step-by-step explanation and rationale for each strategy used; so useful for us learners out there. You are a great
    ego-free teacher. Thank you for ministering to Sarah!

  • Comment Link Thursday, 19 April 2012 14:43 posted by Ron Klein

    As usual, Steve, you are a wizard!!

  • Comment Link Thursday, 19 April 2012 08:08 posted by Larry Iverson PhD

    Steve, Your weaving through the situation is beautiful. Thanks for sharing in a way that assists me in being ever more effective.
    Best to you, Larry Iverson

  • Comment Link Thursday, 19 April 2012 07:55 posted by Steve Green

    Phew! Blimey! I am sweating from reading all of that!

    That's a lot of hard work there.

    Would it not have been simpler and much more straightforward for the client to realise that it's all just a story, just thoughts, and there's nothing to it?

    Thoughts, both positive and negative, pop up automatically, but whether they are positive or negative, you save a lot of time, effort, energy and stress when you realise that they are just thoughts, stories, fantasies, and not true. They are just made up.

    And that there is no need to replace negative thoughts with positive thoughts, 'cos they are made up too!

    Just realise that they are thoughts, and leave it at that.

    Job done!

    Apply this to your life and your practice and life will be much simpler, happier and stresss free.

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