An Ericksonian Template for Smoking Cessation

The Four Session Model

An Outline

SESSION 1

The history of the habit/assessment session relies upon solution-focused/strategic questions which seed pattern interruption, intersperse therapeutic suggestions (Erickson,) and also seed the elicitation of hypnotic phenomena in forthcoming sessions.  Seeding can be defined as activating an intended target by presenting an earlier hint.  Subsequent response behaviour is primed by alluding to a goal well in advance.  Seeding establishes a constructive set from which a future goal can be elicited. (Zeig, 2006)

The goals of this model target pattern interruption and hypnotic responsiveness, with each working together to facilitate habit extinction.  This article illustrates how solution-focused/strategic questions serve to seed future interventions while also creating the first movement of a changing (rapidly changing) pattern.  Dr. Erickson once wrote, “I would like to suggest to you that in the reading of my works you pay attention to… the snowballing effect of a change in behavior.” (Zeig, 1985)

Examples of Solution-Focused/Strategic Questions with Corresponding Interventions/Techniques

1. Which hand do you smoke with?

• Seeding of Pattern Interruption (O’Hanlon, 1987)
• Seeding of Symptom Prescription (O’Hanlon, 1987)

2. Which direction do you blow the smoke?

• Seeding of Pattern Interruption (O’Hanlon, 1987)
• Seeding of Symptom Prescription (O’Hanlon, 1987)

3. Exactly how do you PUT OUT your cigarette?

• Interspersal Suggestion (Erickson, 1966)

4. Do you crush, stomp, stamp, or flick IT OUT?

• Interspersal Suggestion (Erickson, 1966)

5. Have you ever seen yourself smoke?

• Seeding the elicitation of the hypnotic
• Phenomenon of dissociation (Edgette & Edgette, 1996)

6. How long does it take to FINISH SMOKING?

• Interspersal-Suggestion (Erickson 1966)

7. From the moment you wake up what do you do prior to your cigarette?

• Seeding of Pattern Interruption (O’Hanlon. 1987)
• Seeding of Symptom Prescription (O’Hanlon, 1987)

8. What were the circumstances surrounding the first cigarette you ever Smoked?

• Seeding the elicitation of the hypnotic Phenomenon of Age Regression (Edgette & Edgette, 1996)

9. What will it be like when you are smoke free?

• Seeding the elicitation of Future Progression (Edgette & Edgette, 1996)

10.  How will girlfriend/partner feel?

• Seeding the elicitation of Future Progression (Edgette & Edgette, 1996)

The client will next be given strategic task assignments, prescriptions to prepare him/her to stop smoking that they will perform between sessions one and two.  Tasks are individualized based upon the unique history the client has provided.  A case study from the work of Milton H Erickson, MD illustrates his usage of strategic task assignments, symptom prescriptions and in particular, utilization of the individuals strengths, in this instance motivation to follow direction. (O’Hanlon and Hudson, 1990) The following case study will demonstrate.

“A retired policeman explained to Dr. Erickson that he was suffering from obesity, problem drinking, and habitual smoking.  Upon learning the man purchased two packs of cigarettes per trip to the local corner store, (he also bought his groceries there, while buying this liquor at the next store over), Erickson stated, “Now, your problem is very simple.  You want to jog but you can’t.  But you can walk.  All right, buy your cigarettes one pack at a time.  Walk across town to buy your pack.  That will start to get you in shape. ….Go to a grocery a half mile or a mile away and buy just enough for each meal.  That means three nice walks a day. …you can drink all you want to.  Take your first drink at a bar at least a mile away.  If you want a third, find another bar a mile away.”

The man glared at Erickson, swearing at him as he stormed out of the office.  Approximately a month later a new patient came to see Erickson, he stated, “A retired policeman referred me to you. He said you are the one psychiatrist who knows what he is doing.” Erickson explains, “The policeman couldn’t buy a carton of cigarettes after that! And he knew that walking to the grocery store was a conscious act.  He had control of it.  Now, I didn’t take food away from him.  I didn’t take tobacco away, I didn’t take liquor away.  I gave him the opportunity to WALK.” (Rosen, 1982) Pgs 149-150 from My Voice will go with you.

Indeed, Ericksonian therapy is the art of changing patterns.

Examples of Strategic Task Assignments-Symptom Prescriptions

• Smoke every third cigarette with opposite (non-dominant hand).

• Time five cigarettes in order to determine how long each cigarette lasts.

• Pay attention with extreme focus, to the direction the smoke is exhaled.  Do this with three cigarettes per day.

• Perform morning pattern (individualized to client) differently prior to having first cigarette of the day. (ie: smoke prior to walking the dog; have two cigarettes instead of one with coffee; smoke on back porch while reading paper instead of in the basement).

• Smoke one cigarette in front of mirror before next session.

• Take a DEEP Breath in between each drag (do this with 3 cigarettes per day).

The first session serves simultaneously as an individualized solution focused/strategic assessment as well as an effective intervention.  Throughout session one it is of critical importance to emphasize that this is a four session model.  It is a process that is reliant upon the individuals unique experience of a changing, shifting pattern.  I frequently use the example of an academic course that begins in September and runs through December…asking a client, “would you ever request to take the final exam in mid October? Many clients return to the office after session two (the first formal hypnosis session) and express disappointment that they are still smoking.  Ineveitably, upon further inquiry, their smoking pattern has been meaningfully disrupted.

A client fo mine, a bright professional woman in her mid-50′s, presented as a three and a half pack per day smoker.  She was most engaing as well as enthusiastic about the prospect of terminating her smoking habit.  Upon leaving the office after session one, armed with her strategic task assignments, she was the picture of motivation….Upon returning for session two, she had the look of a deflated, disappointed soul.  Her first words were, “I’m such a failure!”  I immediately believed that somehting in her personal world, far more significant than her desire to quit smoking, had greatly impacted her mood.  Her second statement was, “I’m still smoking ten cigarettes a day, I AM a failure!”  In a most quizzical manner, I then inquired, “OK, let me get this straight, if your son, your beloved son, were to report to you that while working on an extraordinarily important project, one that was perceived to be most difficult, he had improved 600%, would label him a failure?’  (3 1/2 packs=70 cigarettes minus 60 cigarettes, 600% pattern reduction = 10 cigarettes per day).

Less dramatic examples are commonplace throughout the course of treatment.  Clients report changes in their smoking pattern that they have not experienced in decades.  These shifts in the experience of smoking (the amount, frequency, desire, taste, smell) are all examples of the expanding pattern interruption that ultimately results in the cessation of the habit.  However, an expected obstacle attempts to sabotage the measurable progress that is unfolding.  The conscious mind becomes stuck on the fact that smoking, regardless of the significant changes, is still occuring.

At this juncture I will often converse hypnotically, magnifying the progress, the pattern interruption, as akin to coming atractions at the movies, sneak previews provided by the subconscious mind of what it will be like to live a smoke free life, to be healthy, to have achieved such a meaningful goal.  It is of critical importance to reinforce that this therapy is a process that flows and grows to a successful outcome.

SESSION 2 – 4

The client will return for session two within three to five days.  Sesions two, three, and four consist of formal hypnosis and ongoing solution/strategic therapy.  The beginning of the second session affords the client the opportunity to report on her experiences in relation to the prescribed tasks.  Upon learning about the impact of the tasks/symptom prescriptions, coupled with the data received in session one, the clinician can now tailor the hypnotic interventions to the uniqueness of the client.  The therapist, as tour guide, may now lead the client into trance, eliciting the hypnotic phenomena that best positions him/her for success.

The hypnotic phenomena of future progression (Edgette & Edgette, 1995) was selected with a client of mine who was “read the riot act by my physician” for his five decade smoking habit.  Learninbg that this 70 year old man was completely enamoured with his 10 year old granddaughter, I believed that eliciting a future memory would prove to be most therapeutic.  An excerpt from the hypnosis will illustrate:

“You can move pleasantly, or perhaps curiously forward into hypnosis….I really don’t know how you can explore a healthy space, a time and a space, forward to the next best time…and you can enjoy losing track of time, flowing forward, like a bodiless mind…. experiencing yourself as having achieved a most meaningful goal.  What is there to see?  Can you smell the healing air?  Is that the sound of Allie’s voice?  And what a time it is now, that sweet voice, ‘I’m so proud of you Grandpa, I’m so happy you stopped….’  And on the inside you can FEEL THE PEACE…that heavenly voice serenading you for now and later, all the time, anytime, you can be free….letting go, going with your healing flow, and that’s  so nice to know….”

The hypnosis continued with Allie as the anchor, the ongoing, never ending post hypnotic suggestion.  Sessions two-four allow the client to unleash the healing potential of her subconscious mind.

The Non-Smoker who Still Smokes (NS-SS)

The NS-SS defines a client who is unaware that she has succeded.  The NS-SS remains habituated to the belief that extinguishing a smoking addiction is usually impossible and normally excruciatingly difficult.  The NS-SS is unwittingly trapped in a stuck zone provided by the conscious mind, this limited thinking mind insists on ignoring how, for instance, a 1.5 pack per day smoker over a span of thirty years is now smoking 4-5 cigarettes per day which are no longer enjoyable and typically most unpleasant.

The NS-SS is the client who begins session three and/or four explaining that the program just isn’t working, stating, “I just can’t stop…I’m still smoking, I just can’t stop.”  At this juncture, the clinician needs to question the client in the following manner.  “From the moment you left the last session what changes, however subtle, have occurred in your experience of smoking?  What do you notice regarding the amount/frequency, taste, smell, feeling about smoking?  The NS-SS will respond in a most interesting, revealing manner:

“I just don’t like it.”

“I go long periods of time without smoking.”

“It tastes horrible.”

“I feel like I’m choking.”

“I just don’t want it”

“But I’m still smoking four cigarettes a day!”

The clinician can now enable the client to bypass the grip of the conscious/thinking mind by identifying, ratifying, and simplifying the real change, the transformation, the cure that has occurred.

The following will illustrate: A client of mine began the fourth session of her smoking cessation treatment describing herself as an “incurable smoking addict.”  Upon engaging her with the aforementioned questions, she stated that she “hated smoking,” emphasizing that she really doesn’t like anything about it anymore.  With intense certainty, I anointed her to the  status of NS-SS, a classification that guarantees an overwhelmingly positive prognosis.  In order to ratify and simplify her success, I inquired as to what food she totally detested, to which she replied, “lima beans.”  She then detailed her experience in eating lima beans in much the same fashion she had described her experience of smoking cigarettes, “I hate the smell, I feel like I’m gagging, etc.”  I then suggested that she could stop at a restaurant and eat a bowl of lima beans, then go to the market and buy 5 pounds of lima beans, then eat more lima beans before bed and have even more for breakfast.  She could eat lima beans four or five times a day indefinitely…. or she could, “Throw out your cigarettes and enjoy your success!”

The infinite, benevolent healing power of the subconscious mind can completely bypasss the understanding of the conscious mind.  The NS-SS is thus created, performing a brief, but most valuable role.  The NS-SS is always welcomed by the clinician who can now identify, ratify, and simplify the success of the client.

Four sessions are crucial to long term resolution in order to enable the client to acclimate to the positive change/identity shift that becoming a non-smoker entails.  This model begins as an experience of slight, subtle, pattern interruption, evolves into meaningful, often unconscious change, then rapidly cures.

References

Zeig, J.K. (1985). Experiencing Erickson an Introduction to the man and his work.  New York: Brunner/Mazel.

Zeig, J.K. (2002). Personal communication.

Zeig, J.K. (2006). Confluence: the selected papers of Jeffrey K. Zeig. Phoenix: Zeig, Tucker, & Theisen, Inc.

O’Hanlon, W. (1987). Taproots: Underlying principals of Milton Erickson’s therapy and hypnosis.New York: Norton.

Edgette, J.H., & Edgette, J.S. (1995). The handbook of hypnotic phenomena in psychotherapy.New York: Brunner/Mazel.

Erickson, M.H. (1966). The interspersal technique for symptom correction and pain control.American Journal of Clinical hypnosis, 8, 198-209

O’Hanlon, W. & Hexum, A.L. (1990). An uncommon casebook, Milton H. Erickson, M.D. New York & London: WW Norton & Co.

Rosen, S. (1982). My voice will go with you. New York:WW Norton & Co.