Ericksons Interspersal Technique for Pain

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Particularly in cases of resistance and when he did not know a patient well, Milton Erickson would "seed" ideas through interspersing words or phrases within the context of a story or discussion. These embedded suggestions were typically set off by the use of a slightly different voice tone or a very brief pause.

Erickson (1966) masterfully used embedded suggestions in treating the cancer pain of a patient named "Joe." Joe was a retired farmer who had turned florist. Facial cancer had resulted in the loss of much of his face and neck due to surgery, ulceration, maceration and necrosis. He experienced intolerable pain for which medications were not very effective. A relative was urgently requesting that hypnosis be used, but Joe disliked even the mention of the word hypnosis. The patient was unable to speak and could only communicate through writing. We will now pick up on Erickson's account.

Despite the author's unfavorable view of possibilities there was one thing of which he could be confident. He could keep his doubts to himself and he could let Joe know by manner, tone of voice, by everything said that the author was genuinely interested in him, was genuinely desirous of helping him. . . . The author began:

Joe, I would like to talk to you. I know you are a florist, that you grow flowers, and I grew up on a farm in Wisconsin and I liked growing flowers. I still do. So I would like to have you take a seat in that easy chair as I talk to you. I'm going to say a lot of things to you, but it won't be about flowers because you know more than I do about flowers. That isn't what you want. [The reader will note that italics will be used to denote interspersed hypnotic suggestions which may be syllables, words, phrases, or sentences uttered with a slightly different intonation.] Now as I talk, and I can do so comfortably, I wish that you will listen to me comfortably as I talk about a tomato plant. That is an odd thing to talk about. It makes one curious. Why talk about a tomato plant? One puts a tomato seed in the ground. One can feel hope that it will grow into a tomato plant that will bring satisfaction by the fruit it has. The seed soaks up water, not very much difficulty in doing that because of the rains that bring peace and comfort and the joy of growing to flowers and tomatoes. That little seed, Joe, slowly swells, sends out a little rootlet with cilia on it. Now you may not know what cilia are, but cilia are things that work to help the tomato seek grow, to push up above the ground as a sprouting plant, and you can listen to me, Joe, so I will keep on talking and you can keep on listening, wondering, just wondering what you can really learn, and here is your pencil and your pad, but speaking of the tomato plant, it grows so slowly. You cannot see it grow, you cannot hear it grow [suggestions for negative hallucinations], but grow it does —the first little leaflike things on the stalk, the fine little hairs on the stem, those hairs are on the leaves, too, like the cilia on the roots, they must make the tomato plant feel very good, very comfortable if you can think of a plant as feeling, and then you can't see it growing, you can't feel it growing, but another leaf appears on that little tomato stalk and then another. Maybe, and this is talking like a child, maybe the tomato plant does feel comfortable and peaceful as it grows. Each day it grows and grows and grows, it's so comfortable, Joe, to watch a plant grow and not see its growth, not feel it, but just know that all is getting better for that little tomato plant that is adding yet another leaf and still another and a branch, and it is growing comfortably in all directions. [Much of the above by this time had been repeated many times, sometimes just phrases, sometimes sentences. Care was taken to vary the wording and also to repeat the hypnotic suggestions. Quite some time after the author had begun, Joe's wife came tiptoeing into the room carrying a sheet of paper on which was written the question, "When are you going to start the hypnosis?" The author failed to cooperate with her by looking at the paper and it was necessary for her to thrust the sheet of paper in front of the author and therefore in front of Joe. The author was continuing his description of the tomato plant uninterruptedly, and Joe's wife, as she looked at Joe, saw that he was not seeing her, did not know that she was there, that he was in a somnambulistic trance. She withdrew at once]. And soon the tomato plant will have a bud form somewhere, on one branch or another, but it makes no difference because all the branches, the whole tomato plant will soon have those nice little buds —I wonder if the tomato plant can, Joe, feel really feel a kind of comfort. You know, Joe, a plant is a wonderful thing, and it is so nice, so pleasing just to be able to think about a plant as if it were a man. Would such a plant have nice feelings, a sense of comfort as the tiny little tomatoes begin to form, so tiny, yet so full of promise to give you the desire to eat a luscious tomato, sun-ripened, it's so nice to have food in one's stomach, that wonderful feeling a child, a thirsty child, has and can want a drink, Joe, is that the way the tomato plant feels when the rain falls and washes everything so that all feels well. [Pause.] You know, Joe, a tomato plant just flourishes each day just a day at a time. I like to think the tomato plant c&nknow the fullness of comfort each day. You know, Joe, just one day at a time for the tomato plant. That's the way for all tomato plants. [Joe suddenly came out of the trance, appeared disoriented, hopped upon the bed, and waved his arms; his behavior was highly suggestive of the sudden surges of toxicity one sees in patients who have reacted unfavorably to barbiturates. Joe did not seem to hear or see the author until he hopped off the bed and walked toward the author. A firm grip was taken on Joe's arm and then immediately loosened. The nurse was summoned. She mopped perspiration from his forehead, changed his surgical dressings, and gave him, by tube, some ice water. Joe then let the author lead him back to his chair. After a pretense by the author of being curious about Joe's forearm, Joe seized his pencil and paper and wrote, "Talk, talk."] Oh, yes, Joe, I grew up on a farm, I think a tomato seed is a wonderful thing; think, Joe, think in that little seed there does sleep so restfully, so comfortably a beautiful plant yet to be grown that will bear such interesting leaves and branches. The leaves, the branches look so beautiful, that beautiful rich color, you can really feel happy looking at a tomato seed, thinking about the wonderful plant it contains asleep, resting, comfortable, Joe. I'm soon going to leave for lunch and I'll be back and I will talk some more. (pp. 205-206)

Erickson (1966) indicated that despite his "absurdly amateurish rhapsody" about a tomato plant that Joe had an intense desire for comfort and to be free from pain. This meant that Joe "would have a compelling need to try to find something of value to him in the author's babbling" (p. 207) which could be received without his realizing it. "Nor was the reinduction of the trance difficult, achieved by two brief phrases, 'think, Joe, think' and 'sleep so restfully, so comfortably' imbedded in a rather meaningless sequence of ideas" (p. 207). Joe was impatient and anxious to resume the talk after lunch. "When it was suggested that he cease walking around and sit in the chair used earlier, he did so readily and looked expectantly at the author.

You know, Joe, I could talk to you some more about the tomato plant and if I did you would probably go to sleep, in fact, a good sound sleep. [This opening statement has every earmark of being no more than a casual commonplace utterance. If the patient responds hypnotically, as Joe promptly did, all is well. If the patient does not respond, all you have said was just a commonplace remark, not at all noteworthy. Had Joe not gone into a trance immediately, there could have been a variation such as: "But instead, let's talk about the tomato flower. You have seen movies of flowers slowly, slowly opening, giving one a sense ofpeace, a sense of comfort as you watch the unfolding. So beautiful, so restful to watch. One can feel such infinite comfort watching such a movie."] (p. 207)

Joe's response was excellent and during the following month he gained weight and strength. Only rarely did he experience enough pain to need aspirin or demerol. A month later, Erickson visited again and after much casual conversation, "Finally the measure was employed of reminiscing about 'our visit last October.' Joe did not realize how easily this visit could be pleasantly vivified for him by such a simple statement as, 'I talked about a tomato plant then, and it almost seems as if I could be talking about a tomato plant right now. It is so enjoyable to talk about a seed, a plant'" (p. 208). As a result of these two extended sessions, Joe lived comfortably until his death over three months after the first contact.

One would be incorrect to assume that Erickson's primary therapeutic method was the use of interspersed suggestions within metaphors. Close long-term colleagues have estimated that not more than 20% of Erickson's work consisted of the use of metaphors (Hammond, 1984, 1988b). Erickson flexibly used both very direct and very indirect suggestions, depending on the clinical situation. However, the clinician should be aware that the patient's unconscious mind has the capacity to perceive meaningful suggestions offered in seemingly casual conversation or metaphoric stories. Metaphoric communication offers us one more avenue for therapeutic intervention.

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