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Drama as a Proposal for Understanding Milton Erickson's Clinic

Updated: Feb 17

Maurício da Silva Neubern* Universidade de Brasília, Brasília, Brazil.


This paper seeks to offer, through the notion of drama, an initial framework for understanding Milton Erickson's clinic. As this author seemed to conceive, the notion of drama takes the theater as a metaphor for human subjectivity, conceiving that a person's actions take place in a lived scenario and are guided by symbolic plots that influence their relational plots, but generally remain unconscious. This notion refers to a complex relationship between the person and the world, in which actions, the production of meaning, roles and corporeality are permeated by culture, including the participation of the person who can become an actor and author of their destiny and of the therapist who can construct characters pertinent to the scenario experienced by the person.

The work of Milton H. Erickson, an American psychiatrist (1901-1980), is often highlighted as one of the main factors responsible for the revival of hypnosis in the 20th century, as well as for the birth of brief therapies and systemic family therapy (Neubern, 2009; Zeig & Geary, 2000). However, there are many doubts and controversies about it, especially when it comes to understanding its assumptions. There are those who liken it to cognitive and behavioral therapies (Erickson, 2002), neolinguistic programming (Bandler & Grinder, 1982/1986) or even strategic family therapy (Haley, 1993; Nichols & Schwarz, 2006), but these classifications fall apart on closer examination of Erickson's clinical practice.

It is enough to consider that the emphasis on relationship patterns, typical of strategic therapy, does not make room for an understanding of the person in their singularity and their internal world, points that are also important in this author's clinical conception (Erickson, 1983; Zeig, 2006). Similarly, his conception of the unconscious does not allow for a relationship with cognitivism, nor does the complexity of his vision of man reduce itself to the attempts to simplify neolinguistics, which greatly impoverish his proposal. In short, the impact that this author has had on the field of psychotherapy seems to contrast with the difficulty in understanding his proposals, which still seem nebulous to many authors (Hoffman, 1992). On the other hand, some readings allow for a more comprehensive understanding of his work, seeking to understand it not as the derivation of a school, but as an original clinical proposal (Erickson & Rossi, 1989; O'Hanlon, 1991; Zeig, 2006).

How the other is known from the clinical relationship, what observation is based on, how the singularity of the other is considered, how they can be conceived as a person, how to conceive of the unconscious, emotions and the use of language, how the therapist should place themselves and observe themselves in the relationship, in other words, the fundamental principles of their work (O'Hanlon, 1991) are some of the questions that need theoretical and epistemological deepening in order to be inserted and articulated in a set of meanings that are pertinent to Erickson's conception and clinical practice. The word drama refers to actions that take place in a specific social scenario that is permeated by symbolic plots, made up of various metaphors and which determine the ways in which relationships should take place. Drama, which involves everything from small gestures to the construction of therapeutic characters, is opposed to a clinic restricted to the verbal and the cognitive, as it refers to actions that mobilize corporeality, emotional processes and the production of meanings in the everyday contexts of people's lives.

In this sense, the work proposes two specific objectives, which are intrinsically linked. On the one hand, to give visibility to some of Erickson's clinical principles, not exactly in the sense of discovering what his original and implicit intentions were with regard to them, but with the aim of making them clearer, more understandable and more accessible to reflection, practice and clinical teaching. Obviously, it is important to emphasize that this objective does not consist of an arbitrary interpretation, since, in order to achieve it, a pertinent understanding of his work was sought through studies that addressed his epistemological origins, biography and historical moment (Erickson & Keeney, 2006; Neubern, 2004;2009; Zeig & Geary, 2000).


SCENARIOS AND PLOTS

One of the important references for understanding Erickson's practice, as proposed in this paper, is the notion of a subjective scenario, due to all its dramatic complexity configured in the subjectivity of people and the therapeutic relationship in which they took part (Zeig & Geary, 2000). This is because her reading of the people who sought her therapeutic help involved the concrete and symbolic relationship between people, a generation of particular subjective meanings, as well as a symbolic plot that guided the relationships and roles between the protagonists, but was unknown to them.

However, breaking with the dominant perspectives in psychology (González Rey, 2005), the scenario is not restricted to an individual or social territoriality, nor real or imaginary (1), but consists of a lived space (Merleau-Ponty, 1949) that can integrate, at different times and in different ways, the relationship between these dimensions without diluting them. Although these dimensions interpenetrate, complement each other and also oppose each other, clinical situations can lead them into different configurations, where the focus can favor one of them at a given moment without, however, exhausting the other. Thus, in one of his most complex works, Erickson (Erickson & Rossi, 1989), leads the therapy into a scenario with a greater focus on the imaginary dimension, inducing a young patient into a hypnotic trance to review a series of events in her history. She was a phobic young woman with serious emotional deprivations in her childhood and adolescence, who feared that these problems would have repercussions on the upbringing of her future children.

In a hypnotic trance, accompanied by a very supportive imaginary friend produced by Erickson - the man from February - she was able to review the dramas of her story, interact with the characters present and modify their subjective meanings without this implying any direct and linear relationship with their concrete social contexts or any discursive production of the social world. The social, in such cases, represented by scenes with historical characters such as father, mother, family employees, pets, classmates and teachers did not make direct and isomorphic references to concrete people and situations, but consisted of images, emotions, words, perceptions, characters and beliefs whose symbolic content implied the way in which these experiences were subjectivized by the young woman, mainly in unconscious terms.

This process was able to promote concrete changes in the person's attitude in the real dimension, whether in terms of their perception of themselves, their history, the elimination of their symptoms or the raising of their children. At the same time, the focus of therapy could also extend the notion of scenario to real relational contexts, from which symbolic and imaginary processes also emerge, and which allow for a more comprehensive view of the system of relationships, going beyond the experience of a single person. Faced with a couple with a domineering husband and a wife who felt suffocated by his authoritarianism, Erickson (quoted in Haley, 1985) prescribed a task in which the couple had to go to a restaurant following a map previously drawn up by the therapist. The husband was not to be aware of the confusing and impractical map, but only to follow the guidelines dictated by the wife who, when she sat down at the restaurant table, was to go ahead of the waiter and place her order without the husband imposing on her what she should eat. Taking the city and the restaurant itself as settings and the members of the couple and the people in the restaurant as concrete characters, the prescription gave the wife the possibility of also being in charge, making her husband obey her and having the space to express and be accepted in something of her preference.

It is curious to note that such forms of intervention in the real dimension can produce significant changes in processes that are highly imbued with the imaginary dimension, such as marital projects, dreams and family transmissions. As these are mostly unconscious processes, the person finds themselves trapped in such references that seem to precede their consciousness or their deliberation to get out of them, so that they just carry them out without being able to disentangle themselves from the complex network of meanings and actions in their plot and without realizing that their own attitudes reinforce and confirm them.

The symbolic plot, in such circumstances, is generally organized in such a way as to offer little or no options for people who feel paralyzed, powerless, unsuccessful and with no prospects of finding a way out of their respective situations. At this point, Erickson's proposal (Erickson & Rossi, 1980), in contrast to many modern or even contemporary therapists, is not to explicitly denounce the influence of the storylines, in order to produce insights that lead to awareness. He proposes that the person gets rid of these references by experiencing them from new positions, meanings and actions that they take on in the execution of their plots. To do this, the therapist can use storytelling, in the normal or trance state, which in some way repeats the symbolic plot, with all its richness in terms of experience and expression, but adds new possibilities for the person to act, who can move in other ways through the plots in order to substantially modify their participation in the process.

From a whole structure of meanings suggested by the story (frame), she creates her own solutions in terms of meanings, senses, perceptions and emotions that will subsidize a new way of acting in this plot, which can also be transformed under her influence. Such was the case with the man, a highly intellectual 25-year-old PhD, who asked for his help with a problem of premature ejaculation (Erickson, 1935). Inducing him into a hypnotic trance, Erickson told him that the client had once met a very important researcher who had offered him a partnership in a research project of great interest. The researcher arranged to meet him at his home at a certain date and time and the client was kindly received by his wife, who told him that her husband would soon be returning from an unexpected engagement. She introduced him to her beautiful daughter, with whom she left him alone to talk about art. The girl showed him some vases she had painted and also a delicate glass disk, artistically painted, which was an ashtray that would have belonged to her father, but, because it was so delicate, it was more of an ornament than an ashtray.

Here's how the story goes: You really admired that ashtray and felt a strong desire to smoke. Because of the girl's youth, you were hesitant to offer her a cigarette. Also, you didn't know how your father would feel about such things and that you should be aware of whether smoking was polite or not. Thinking about it, you became more and more impatient...[...]. Finally, in desperation you asked her for permission to smoke, to which she readily agreed and took a cigarette without offering you anything. As you smoked, you looked at the ashtray she had painted and the girl, noticing your gaze, suggested you use it. Hesitantly, you used it and continued talking about various things. As you talked, you became more and more worried about your father's return.

You quickly became so impatient that you no longer enjoyed the cigarette and, instead of placing it gently in the ashtray, you placed it there, lit and abruptly, and continued talking to her. Apparently she didn't notice your gesture, but after a few minutes, you heard a noise as the cigarette continued to burn and broke the ashtray. You felt bad about it, but the girl told you that it was okay, that she hadn't given it to your father yet and that he wouldn't know anything about it. However, you felt more and more guilty about the rudeness of breaking the ashtray and wondering how her father would react to it [...] after that, her father phoned, saying that he couldn't come and that he would arrange another day with you. And you left the house feeling very well, feeling better about the situation and realizing that, in fact, there was nothing in that situation that you couldn't handle. (Erickson, 1935, pp. 323-324)

This process, which lasted a single session, developed from the singularity of this young man's subjective meanings and, in a way, repeated the symbolic theme he was experiencing: when he felt interested in someone, he had an erection, felt very aroused, but was overwhelmed by worries and tensions, so that he ejaculated quickly. This gave rise to a strong sense of guilt and failure that tormented him every time he became interested in a woman. Being with a sexual partner was governed by a theme in which, in the same experience, configurations of arousal, desire and erection emerged, permeated by failure, worry and guilt that culminated in the production of premature ejaculation and with a partner who also felt bad about the process. However, in the story told, it is possible to observe a strong metaphorical dimension, due to the similarity of the elements at play, but which also led to a different outcome than usual.

There is the waiting for the meeting with the researcher (waiting for something important, such as sexual expectation) and also the surprise, marked by the interest in a beautiful girl who is linked to this important event. He develops a relationship of complicity with this attractive girl, staying alone with her, in a condition where he can't be seen by others (which, in this case, highlights the erotic and exciting content of the moment). When he comes across a delicate and artistic object made by the girl - the ashtray (in this context, the girl's body and vagina), he feels a great desire to smoke (which reminds him of his sexual desire and his erection) and is undecided as to whether or not to place the lit cigarette (his erect penis) in the ashtray.

With the girl's permission, he carries out his desire (sexual intercourse) and is very worried about breaking the delicate ashtray (the consummation of the act) and the possibility of his father arriving and finding out everything (he relives his intense anxiety during the sexual act). But at the end of the process, there was a different outcome in which he felt good and realized that there were no problems in that situation that he couldn't deal with. It's worth noting that, after a few months, the young man only had the problem a few times and began to experience his sexuality in a much more pleasurable, comfortable and peaceful way.


BUILDING THE CHARACTER

An unavoidable question, within what has been discussed so far, refers to the way in which the therapist, from Erickson's perspective, enters the patient's lived scenarios. In this sense, it is necessary to consider that the therapist enters the relationship as a person, with his or her own subjectivity and body, which start to interact with the other in a form of intense communication that has a not insignificant materiality (Csordas, 2002; Roustang, 2006).

In addition to the words themselves that are exchanged in this interactive game, there are gestures, facial expressions, body choreography, tone of voice, cadence of words, minimal signs and bodily reflexes (contraction of muscles, pupils, eyelids, for example) which, in addition to the meaning they have in a culture and in social exchange, affect the protagonists in a concrete way, anchoring themselves in the therapist's own being embodied in their body. In other words, the relationships developed with the patient leave real marks on the therapist that refer to the position he or she occupies in the lived process, which tell us how these marks affect him or her, and can also point the way for the therapy to progress.

Given the intensity of this experience, which cannot go unnoticed in the clinical relationship, Erickson's practice (Erickson & Rossi, 1979) allows us to conceive that the therapist should use this influence received from the relationship in favor of the process, constructing characters that could address that specific patient in a pertinent way, with their particular themes and productions of meaning. However, such a construction should not be based on a manipulative attempt to influence, but on a process in which the therapist feels coherent with him/herself and faithful to the processes experienced within him/her, as described in the following passage, where Erickson makes a rare reference to this working principle that he used so often:

"To do this kind of therapy you have to be yourself as a person. You must not try to imitate anyone, but you must proceed in your own way, in your own manner. " (Erickson & Rossi, 1979, p. 276).

In other words, similar to the construction of a character in the theater (Stanislawski, 2006), the therapist draws from their own subjectivity and in coherence with it, the raw material for the construction of the character that will be created in such a way as to assume, without the patient realizing it, postures, roles and an entire gestalt capable of promoting a fruitful progression of the therapeutic process. Permeated by this role, the therapist's actions in the relationship with the person become powerful instruments of influence capable of mobilizing them to change their own roles and subjective processes in the social scenarios in which they take part, although there are situations in which the therapist themselves can become crystallized in roles that paralyze the therapeutic process (Zeig, 2001).

The dramatic nature of these actions is precisely because they touch, mobilize and impact the person through the transmission of subjectivity, with meanings and emotional processes, at a given moment and in the symbolic context of the therapeutic relationship. On one occasion, Erickson (1977) received a woman who wanted to know the reasons for her asthma attacks, which only occurred in the cold of winter. She sought therapeutic help against her will, because for her, her attacks were organic and not subjective, as several doctors had suggested. In her sad story, she told of a history of verbal attacks from her father, who always wrote her aggressive letters, claiming the inheritance from the patient's deceased mother, all year round, except in hot weather.

Erickson then, with a certain provocative attitude, asked her if she would accept him demonstrating that her asthma was psychological, as they were in a desert place, Phoenix, to which she nodded ironically. After a series of hypnotic suggestions, he tapped her lightly with a pencil, which was followed by a strong asthma attack, administered by suggestive techniques, which allowed the patient's breathing to return to normal. With the repetitions of this procedure, she began to conceive of the subjective dimension of her illness and to take a more active stance in the face of her father's attacks and injustices.

Thus, the light but dramatic strokes of the pencil (corresponding to the letters written by her father) led her to answer her question (the origin of her asthma) and to take on new roles in her suffering family life. Pietro came from an Italian family where his intensely authoritarian father decided that his first son should become a great musician. To this end, he chose an instrument and drew up a plan of musical studies for Pietro for several years, with 10 hours of activity a day, under the guidance of demanding teachers until, over the years, the young man became a soloist in a renowned orchestra. However, after resigning from the orchestra due to disagreements with the new conductor, his lower lip became swollen and, in desperation, the musician sought various medical treatments that did not lead to any satisfactory results. During the very first psychotherapy sessions, he complained to Erickson that he needed hypnosis, something that would solve his problem, not conversations about his history. After the fifth session, while the young man was in a light trance, the therapist suggested to him in an authoritative and emphatic way that his problem was psychological in origin and could be cured, since it was the expression of something that had been repressed, ignored and forbidden in his eyes. Awakening him from his trance, he dismissed the patient without letting him ask anything and went home to let his unconscious do the work, preparing him for the next session.

At the next meeting, Pietro told him that he immediately wanted a drug to solve his lip problem, to which Erickson replied: "Shut up with your conscious mind about this drug nonsense and let your unconscious mind do its job. " (1977, p. 244). The young man reacted violently and aggressively, accusing the therapist throughout the session of being incompetent, a member of the professional scum (psychiatrist), something useless, profane and obscene. The therapist then said to him at the end of the session: "Your unconscious can shut up now and continue in the next session exactly where it left off and do a better and deeper job. Now leave my office and go away." (Erickson, 1977, p. 244). This style of session lasted nine months and Pietro's attacks on Erickson included his profession as a psychiatrist, the scum of medicine, his Norwegian ethnic origin, Vikings, pillocks and thieves, and even accusing him of being a bad family man. At this point, Pietro said to him: "If you were my father..." but paused and added more calmly and disconcertedly "... but you're not my father!" (Erickson, 1977, p. 245).

Erickson confirmed that it wasn't and said that the young man could say many things to his father, but in a way that the old man could understand and bear, which he did in a frank, polite and firm conversation over dinner. Within a month, his lower lip was back to normal and he continued practicing the flute, but from then on, without the severe demands he was used to. In this case, it is possible to conceive that Erickson assumed an authoritarian posture in different ways, in order to repeat the symbolic theme of paternal oppression experienced by the young man.

He used authoritarian and directive hypnosis (which was not common in his work), imperative expressions such as "shut up", "go away", "think", which sought to determine what the patient should or should not do in the therapeutic process, so that the therapy sought to reproduce the real-life storyline that intensely mobilized him in his emotionality, which produced the swelling in the region of the body - the mouth - necessary to play the flute, also initially imposed by his father. However, the warmth of the therapy and the subtle suggestions that he should "let his unconscious do the work" allowed for the creation of a space in the therapeutic setting in which Pietro could express all the anger and revolt he had repressed for many years, which he only gradually realized was related to his father's authoritarianism.

In other words, Erickson took on the role of this father in the symbolic storyline experienced by the patient, without him knowing what was happening, and provoked him to react, stepping out of the oppressed role and expressing the emotions that were configured as a problem. Perhaps because he didn't consciously realize that his authoritarian father was symbolically embodied there, he felt, influenced by the therapeutic context itself, that he could express the emotionality that had been repressed for many years, since it wasn't forbidden to attack a third party who wasn't his father.

However, with Erickson's performance in this role, in every gesture, word and expression, he realized the plots that existed around his suffering and was willing to change his relationship with it, modifying his role in the wider family plot, which culminated in a whole change in his subjective production and the return of his lip to a normal state. Pietro gave up the script written by someone else and became the author and actor, in other words, the subject of his own story.


FINAL CONSIDERATIONS: DRAMA AND CLINICAL KNOWLEDGE

The relevance of the notion of drama for understanding Erickson's practice is considered to be basically due to three reasons that are consistent with the work of this important name in 20th century psychotherapy. Firstly, because he seeks a human metaphor for understanding people's subjective processes, not giving in to the temptation to import metaphors from other fields of knowledge in order to guarantee scientific legitimacy, such as psychoanalysis with fluid mechanics and the psychic apparatus, cognitive and systemic psychologies with computing and experimental psychologies with laboratory animals (Neubern, 2004).

In deep harmony with Erickson's work, the notion of drama points to a human production as a way of understanding the human itself, emphasizing that man, in all his anthropological, symbolic and subjective richness, is the best metaphor for understanding man. This trend is confirmed to some extent by authors who highlight the field of subjectivity as a potential storehouse of metaphors and key notions relevant to understanding human processes (González Rey, 2007; Merleau-Ponty, 1949) and to a deeper understanding of science itself (Santos, 2000).

Secondly, the notion of drama opens up space for a complex understanding of the clinic, as developed in the work of Milton Erickson (Neubern, 2002, 2004). In contrast to the individualistic tendencies of the clinic, it favors a more dialectical understanding between the person and the social context, conceiving that the person is qualified in their scenario of action. Although this notion needs to be supported by contributions that refer to the internal symbolic productions of subjectivity, especially in terms of emotions, meanings and senses (González Rey, 2007; Neubern, 2009), by placing the scenario as a production that articulates the individual world with socio-cultural influences, the notion of drama, in line with contemporary reflections (González Rey, 2005; Morin, 2001) breaks with the traditional dichotomy between these poles and allows for a more comprehensive view of people in the clinical process.

This is partly because, even though the focus is on an individual process permeated intensely by the imaginary, as in hypnosis, the socio-cultural is present through characters, scenes, learning and symbolic plots that refer to each person's history and their way of fitting into everyday life; and partly because, even though the focus is on the real of social exchanges, there is considerable room for a deeper understanding and work on the person and the imaginary that runs through them. In the case of Pietro (Erickson & Rossi, 1979), on the other hand, there was intense work on the real level of the therapeutic relationship, which, however, had intense repercussions on the imaginary typical of a family (and therefore social) project passed down from one generation to the next.

Similarly, in the case of the young woman with asthma (Erickson, 1977), the imaginary processes worked on in hypnosis helped the young woman to have a different relationship with herself in real terms (better understanding her own body and the origin of her asthma), as well as a different perspective on acting in a concrete social situation. However, as a result of the clinical process, the patients' actions were able to produce new qualities of subjective processes in terms of senses, meanings and emotions that favored the creation of new attitudes and roles in relation to the plots in which they participated.

Thus, after nine months of intense work with repressed aggression, it was Pietro who perceived the situation in a new way and established a new type of relationship with his father; the young man with sexual problems learned to add a sense of well-being to his distressing reflections during sex, changing his performance; the oppressed wife took advantage of the space she was given to learn how to express herself differently in front of her husband, breaking out of her oppressed role; and the asthmatic girl came to realize important facets of her relationship with her father, so that she broke out of her victimized role and took up a stance of defending herself against her father's aggression and abuse. In short, these processes of change occurred because there was an appropriation on the part of these people who, from a different relationship with themselves, their processes, their bodies, their images of themselves, which allowed them to recreate the influences present in the therapeutic process.

In other words, the influence of the therapy setting meant that the small changes occurred from the inside out in such a way as to acquire a condition of legitimacy for these people, i.e. something that was integrated into their subjective productions and anchored in their bodies (Csordas, 2002). Analogically, it's as if each patient could review their symbolic storyline and, from their own subjectivity, build characters that are more coherent with a freer, more dignified and healthier position in their subjective scenario.

Thirdly, the notion of drama also places the therapist as an actor, in order to emphasize, above all, their potential for creation in the clinical relationship and in the production of knowledge therein. This is not just about the actions whose materiality acquires meaning in the therapeutic setting, but about the therapist's own subjectivity, which is put on the agenda in clinical practice and in the production of knowledge. This is because the construction of a character, as illustrated here, refers to the establishment of a relationship between the production of the therapist's subjectivity and the roles he or she develops in order to work with the patient. Far from suggesting a shallow subjectivism or the illusion of a neutral place, this perspective seeks to make the therapist assume the references from which he addresses the patient, which can imply not only a revision of his way of being, but also research into the theoretical voices that inhabit him (Morin, 1994).

In this proposal, there are possibilities for relevant discussions with some contemporary debates on the role of the subject in the construction of knowledge, both in terms of a look at their own subjectivity (Gaulejac, 1999; Morin, 2001) and their creative possibilities in the production of scientific knowledge (Hacking, 2000; Santos, 2000; Stengers, 1995).

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