UTILIZATION AND INDIRECT SUGGESTION IN

ALCOHOLICS MULTIPLE-FAMILY GROUP THERAPY WITH

John D. Lovern Veterans Administration Hospital

Loma Linda, CA

Joseph Zohn ALCENAS Hospital

Kirkland, WA

The great versatility and utility of Ericksonian approaches to psychotherapy are demonstrated by the application of these techniques to large, multiple-family group therapy of alcoholic families. Using such techniques as unconscious conditioning, therapeutic binds, indirect suggestion, and the utilization ap- proach, a therapist can manage an unwieldy group of 70 or 80 resistant patients and lead them in apositiue, therapeutic direction. This paper describes how a set of specific goals are achieved using these techniques.

The development of indirect forms of hypnotic suggestion demonstrated that hyp- notherapy need not be limited to traditional, formal induction techniques (Erickson, 1967; Erickson & Rossi, 1979; Erickson, Rossi & Rossi, 1976; Haley, 1973). Recently, it was pointed out that indirect forms of hypnotic communication can be extended to a group setting and used to influence behavior of entire groups as well as that of individuals (Lovern, 1980). The present paper demonstrates a further extension of this approach by describing its use in large, multiple-family groups.

The techniques described are employed in the family component of an inpatient alcoholism treatment program of a Veterans Administration Hospital, in which hyp- notic forms of communication are used to deal with alcoholics’ denial of their problems and resistance to therapy. This approach has proved useful in neutralizing, circumvent- ing, and utilizing alcoholics’ resistance so that they are led to recognize and admit the gravity of their problems and consequently pursue recovery earnestly.

Our choice of therapeutic approach is based on an understanding of alcoholism similar to Johnson’s (1980). We define alcoholism as a comprehensive life-style problem which adversely affects its victims in the physical, psychological, social, interpersonal, and vocational areas and ultimately leads to death. One of its cardinal characteristics is its effect on the judgment of those who are afflicted, which leads them to deny the fact that they are alcoholics and resist efforts to help them. We view abstinence from alcohol and other sedative-hypnotic drugs as a condition which must be met before recovery can proceed.

We regard family members and close associates of alcoholics as active participants in the interpersonal system which supports and perpetuates the disease. “heir in- volvement leads them to suffer great emotional pain and eventually to become obsessed

John D. Lovern, PhD, is a n Assistant Professor of Psychiatry, Lorna Linda University School of Medicine and a Staff Psychologist, Veterans Administration Hospital, 11202 Benton St., Lorna Linda, CA 92357.

Joseph Zohn, PhD, is a Staff Psychologist, ALCENAS Hospital, Kirkland, WA.

July 1982 JOURNAL OF MARITAL AND FAMILY THERAPY 325

with the alcoholic. They unwittingly sustain the disease process, even though they desperately wish it to end (Fewell & Bissell, 1978: Jackson, 1954). In short, family members must recognize the existence of their own problems and become involved in a program of recovery for themselves. This viewpoint has been recently supported by Gorman and Rooney (1979) who found that alcoholics’ wives who were active in Al- Anon were able to modify their behavior in adaptive directions regardless of whether or not their spouses quit drinking. These findings concurred with Maxwell’s (1976) conten- tion that family members can learn to cope with the pressures associated with al- coholism if they are offered appropriate therapy.

GOALS OF FAMILY THERAPY

We pursue two interacting sets of goals in family therapy: Outcome goals-desired behavioral outcomes for the patients (both alcoholics and family members), and process goals-objectives whose attainment helps the therapist to manage the therapy situa- tion.

Outcome Goals Alcoholics and their families have several important needs which therapy should

address, The families need to discover that they have problems in addition to those caused by the alcoholic, and that there is help available for them. In addition, alcoholics and their families need to feel mutually understood and to begin to cooperate. Finally, since alcoholics and their families previously have failed in all their attempts to stop the progression of alcoholism, neither is likely to expect the therapy to help them. Therapy must face this fact by providing an experience which is so convincingly powerful that those who are involved in i t can dare to believe that it will prove helpful. Based on these needs, the outcome goals are: (1) cessation of denial by family members and acceptance of and participation in a recovery program (we prescribe Al-Anon or Alateen); (2) mutual understanding and cooperation in their respective recovery efforts on the parts of both family members and alcoholics; and (3) a powerful emotional experience to build the expectancy that the therapy is potent enough to help the patients change their lives.

Process Goals A family therapist in our program is confronted with a unique and challenging

treatment situation. Our 30 alcoholic inpatients are represented by up to 40 or 50 family members a t our weekly sessions, resulting in as many as 70 or 80 participants (with the average being between 50 and 60).

With so many patients, it is difficult for a therapist to ensure that everyone pays attention and feels involved in the therapeutic process. Most meetings contain a few participants who defiantly refuse to listen or participate. In addition, the situation is often complicated by the fact that some patients try to challenge the therapist or undermine the therapy by diverting it in a nontherapeutic direction. For example, family members occasionally attend meetings drunk and create disturbances. Others try to start debates or other long-winded digressions, reducing the therapy to useless interactions ranging from intellectual discussions to shouting matches. There is an ever-present potential for such groups to degenerate into unruly crowds.

A therapist could easily be overwhelmed by this kind of situation, lose control of the group and allow the therapy session to become a useless or even destructive event. lb avoid this outcome, the therapist must never allow the group to take the lead. Instead, the therapist should stay a step or more ahead, nurture attentiveness and cooperation, and lead the group in a direction which will be most therapeutic. The

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process goals are for the therapist to: (1) lead the group and avoid being led by it; (2) create open-minded responsiveness in as many patients as possible; and (3) utilize the characteristics and productions of the individuals comprising the group to orches- trate an experience for them which will be therapeutic.

USE AND APPLICATION OF INDIRECT SUGGESTION

The following are examples of how we use techniques of indirect hypnotic com- munication to achieve both process and outcome goals in multiple-family group therapy. The illustrations consist of descriptions of events drawn from typical family meetings, supplemented by explanatory and interpretive commentary.

Opening the Meeting with Unconscious Conditioning What the therapist does a t the very beginning of a family meeting sets the

emotional tone and establishes implicit rules of conduct for the participants. When the therapist expects that a group is likely to be unruly, he often uses the technique of waiting for silence, in order to subtly bring the group process under control.

Without explaining his purpose, the therapist expectantly waits for the group to become silent. As the group’s conversation increases or decreases in volume, the therapist pairs certain nonverbal communications with these occurrences. For example, when the volume rises, the therapist fidgets impatiently by tapping his pen, crossing and uncrossing his legs and scowling. As the volume subsides, the therapist stops fidgeting and sits erect. He stops scowling and assumes a purposeful expression, leans forward as if to address the group and visually scans the participants as if expecting some, as yet undefined, response. After several repetitions of these pairings, the entire group eventually becomes eerily silent. When the silence is well established, the therapist allows it to persist just long enough so that he is fairly certain that there is a widespread feeling of discomfort waiting to be relieved by direction from him. Finally, the silence is broken by the therapist asking innocently, “Is everyone ready?“

This maneuver of waiting for silence is actually a process of unconscious condition- ing (Erickson & Rossi, 1979), in which the patients are being conditioned to do a good deal more than simply to be silent. What they learn, without realizing it, is actually quite complex: They learn to pay close attention to the therapist a t a nonverbal as well as a verbal level, they learn to wait for direction from the therapist, and they learn to do what the therapist wants them to do without having to be told. This technique is also an example of the utilization approach (Erickson, 1967). It takes into account the need of the participants for guidance on how to behave in an unfamiliar and uncomfortable situation and utilizes this fact by forcing them to become attuned to subtle variations in the therapist’s behavior as the only means of satisfying their need.

Shock, Confusion-Restructuring, Implied Suggestion, and Therapeutic Binds Having established an element of control through the technique of waiting for

silence, the therapist next moves to reduce the participants’ resistance and to structure their experience to maximize their cooperation with outcome goals. lb do so, the therapist first uses psychological shock (Erickson et al., 1976) to depotentiate resistant mental sets, and then uses indirect suggestion and a therapeutic bind (Erickson & Rossi, 1979) to create and solidify a new ordering of the participants’ expectancies and com- mitments. Throughout this process, the therapist uses vivid visual imagery to heighten shock and capture the Participants’ imagination, and again makes maximum use of the utilization approach. The therapist’s communications stir predictable reactions in the participants, which are then capitalized upon to build additional reactions, with this process continuing in a stepwise, strategic manner until a firm commitment is obtained

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from the participants to behave in a way selected in advance by the therapist. The therapist speaks in a solemn and earnest tone, taking care to ensure that the

quality of his voice, his facial expression, and his body language all agree with the content of his speech. These factors combine to convey an impressive and compelling message to his listeners. The content of the talk is as follows: First, the therapist asks the participants to estimate the number of deaths associated with Legionnaires’ Dis- ease (they usually guess in the neighborhood of 50 deaths), while asking them to recall the state of crisis and media attention which existed when this disease was first discovered. Then, they are asked to guess the death rate associated with alcohol use. After several guesses, the therapist quotes the most recent government estimate (NIAAA, 1978) of 205,000 alcohol-related deaths in the United States annually. This number is translated to the more meaningful figure of none alcohol-related death every two and a half minutes.” The therapist quickly points out that approximately the same number of Americans will die alcohol-related deaths during the therapy meeting alone (two hours) as were held hostage in Iran in 1980-81.

Even more vivid and shocking images are summoned, with long pauses between the presentation of each image to allow the participants to visualize each one fully in their minds. For example, details of the tragic mass suicide of the religious cult in the Guyana jungle are described. The therapist discusses the difficulty the authorities had in disposing of the 900 rapidly decomposing bodies, then wonders aloud about the kinds of difficulties experienced by those responsible for the 205,000 bodies (the alcohol- related deaths). Participants are asked to imagine how large a pile one could make with that number of corpses, and to mentally experience other details of such a scene. The horrifying nature of the images and the order and pacing with which they are pre- sented, with each image progressively more terrible than the last, combine cumula- tively to shock the participants, disorient their resistant sets, and unsettle whatever expectancies they may have brought with them to the therapy situation.

The next step is to take advantage of the fact that participants are temporarily without a sound way to structure their experience and guide their participation, and are therefore likely to accept a new structure if one is offered. This is essentially the same as the confusion-restructuring approach described by Erickson et al. (1967). The new structure introduced at this time is designed to lead the participants to behave in accordance with the outcome goals. The structure consists of a set of suggestions, coupled with a bind, which ultimately leads the participants to make the following commitment: (a) a sincere resolve to do whatever is necessary to fight alcoholism; (b) absolute honesty about any relevant subject, even if personal or embarrassing; and (c) recognition of the fact that all participants are in the role of patients during the meeting, no matter what their preconceptions might have been (e.g., they “came to help” an alcoholic but not become involved themselves). Great care is taken to further impress the participants with the serious, life-death nature of the problem of al- coholism, to underscore the necessity of these commitments.

The therapist knows that the participants will resist making these commitments, so he utilizes this tendency by giving them something to resist: He demands that they make the commitments, but states the demands in extreme terms. The participants can resist the extreme portion of the demands, but they are likely to accept the actual suggestion. This is facilitated by the fact that the extreme version of the commitments makes the actual commitments seem moderate, even though they would ordinarily appear quite drastic. This approach, called “providing a worse alternative” by Haley (1973), is form of indirect suggestion, because it accomplishes a desired result without suggesting that precise result directly.

Finally, the therapist introduces a bind to secure acceptance of the suggestion.

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Using the most solemn, deliberate, and impressive tone thus far employed, the therapist announces: “This is what is expected of you, and nothing less. (Pause) If you don’t want to go along with these conditions, Z want you to GET OUT NOW!” This message places the participants in a difficult bind: Should they stay and endure the trials outlined by the therapist, or should they leave and by doing so admit publicly their insincerity and lack of commitment to do something about the life-death problem of alcoholism? Naturally, the participants will find it easier to do nothing, that is, stay in the meeting, and thereby avoid the embarrassing alternative of leaving. The therapist has linked this expected behavior with the previously unrelated commit- ments, so that now the participants make the commitments simply by doing nothing.

Backward Communication, Response Attentiveness, Common Everyday Dance, and Spontaneous Regression

Backward communication is a method for defusing resistance in a person or a group to whom a therapist wishes to communicate an idea. It consists of engineering situa- tions in which the patient is led to communicate the same idea “backward” to the therapist which the therapist intends to communicate to the patient (Lovern, 1980). This process often takes the form of questioning guided by a strategy which leads those answering the questions, bit by bit, to a conclusion which the therapist had in mind all along. This process shapes the general outline of the remainder of the family therapy session. Supplementing this approach are utilization of common everyday trance, re- sponse attentiveness (Erickson & Rossi, 1979), and spontaneous regression, which cumulatively lead participants to a potent therapeutic experience.

Common everyday trances are “those momentary pauses when the . . . person is quietly looking off into the distance or staring at something, as he or she apparently reflects inward” (Erickson & Rossi, 1979, p. 16). Response attentiveness is a “state of extreme attentiveness in responding to the nuances of communication presented by the therapist” (Erickson & Rossi, 1979, p. 2). Both of these phenomena are occasions when a patient is more open to therapeutic suggestions. A therapist who is aware of these phenomena can judge by their occurrence how well helshe is reaching patients, and can utilize these cues as aids to timing the delivery of therapeutic suggestions.

These phenomena occur as by-products of the therapeutic approach. As one partici- pant after another relates compelling and emotionally stirring personal experiences related to alcoholism, the rest of the participants react sympathetically. For example, participants are commonly observed to be staring fixedly, nodding slowly, or even becoming cataleptic for periods of time as they enter common everyday trances or increase their response attentiveness. During these altered states of consciousness, the patients often vividly relive (or regress to) experiences from their pasts which are similar to life experiences being described by others in the meeting. At such times, spontaneous emotional outbursts (herein referred to as spontaneous regression) may occur. For example, it is not unusual for one patient to cry, followed by others, until crying has spread contagiously throughout the group.

Examples. Strategies for our family therapy meetings are often constructed around a theme. For example, an entire meeting may be devoted to exploring the remarkable correspondence between the psychological symptoms of the alcoholics and those of the family members, with the goal of having the participants discover that they are suffering from the same disease (regardless of whether or not they drink). lb implement this strategy, the therapist carefully orchestrates the conversation with guided ques- tioning (backward communication), eliciting vivid and compelling personal stories from participants about their psychological symptoms. These stories each comprise a prog- ressive step in the direction of the startling discovery toward which the therapist leads the group (i.e., that they are all suffering from the same disease). The stories also serve

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as elements which the therapist weaves together to create images designed to strike unconscious emotional chords in the participants. The following is a specific example of how this strategy is carried out.

The therapist notes the composition of the group, so that the approach chosen will be relevant to those in attendance. In this example, there is a preponderance of married couples, consisting of male alcoholic patients and their wives.

The therapist begins by addressing the wives. He states: ‘<I think we need to discuss what it is like to be married to an alcoholic.” Then, drawing a name from list of those present, he calls upon one wife: “Mrs. X, what is it like for you?” The therapist accepts her original, tentative response and builds on it, asking more questions and involving other wives in the discussion, until she or one of the other wives tells a personally revealing and painful story. The therapist attaches a label to this experience which is acceptable to the participants and dramatically writes it down, making clear that he is compiling a list and that additional stories are expected.

The questioning resumes, and during the ensuing interaction, in which as many wives as possible are involved, a delicate process takes place: As the wives respond to questions, the therapist accepts and utilizes some responses, encourages and em- phasizes or discourages and de-emphasizes others, and subtly shapes their responses until another painful and emotionally stirring life experience is described. This one too is labeled and listed.

This process continues until the therapist has compiled the list he originally set out to elicit from the wives. %ically, the list contains the following items: (1) A feeling of not being able to live with, and not being able to live without the alcoholic; (2 ) guilt; (3) anger and resentment; (4) fear, worry, dread, and helplessness; (5) low self-esteem, depression, and self-pity; (6) dishonesty and denial.

At this point, the therapist summarizes what the wives have said by reading the list back to them. He asks them if this list of emotional symptoms of living with an alcoholic accurately depicts what they have experienced. Since the list was carefully built upon the responses of the wives, they naturally agree that it is accurate. When they answer this question (about the list’s accuracy), they fail to examine critically the label “emotional symptoms” which the therapist inserted, and they thereby unwittingly accept it as a definition of their experiences. In so doing, they also accept the logical implication that, since they suffer from emotional symptoms, they must therefore be emotionally ill.

Next, the therapist shifts attention away from the wives to the alcoholics. He asks: “And what is it like to be an alcoholic?” Their competitiveness and desire for an equal share of the limelight have been frustrated and therefore growing while the wives were talking, and the therapist utilizes these motivating foxes to generate a spirited discus- sion. The alcoholics cooperate willingly, under the therapist’s subtle guiding influence, to produce a list of their own emotional symptoms. The startling discovery which the participants make a t this time is that the lists are identical (save for the fact that the alcoholics cannot live with or without alcohol, whereas the wives feel this way about the alcoholics).

lb drive home the point that alcoholics and their family members are all suffering from the same disease, the therapist draws several more parallels. First, he points out (or if there is time he questions participants in a guided manner until they point out) that many physical symptoms are similar. For example, alcoholics and spouses of alcoholics both frequently develop ulcers or other gastrointestinal disorders. In addi- tion, the pattern of symptoms associated with withdrawal from alcohol is quite similar to those experienced during withdrawal from a person, as during a divorce or separa- tion. Finally, the therapist reveals that i t is possible, in fact not a t all unusual, for a family member of an alcoholic to die of alcoholism, even though he or she may never

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have had a drink of alcohol. For example, a family member could be beaten to death or shot by an out-of-control drunk. A family member may be driven by hopelessness and despair to committing suicide. Highway accidents and deaths in fires or other mishaps created by intoxicated alcoholics may also be classified as deaths due to alcoholism.

Family members who previously believed that they had no serious problems usu- ally discover by this point in the therapy session that they actually do have problems. Often the discovery takes place, not during the therapy session, but sometime later, after the new information has had time to be processed unconsciously. Family members frequently tell of spending sleepless nights during which their minds are flooded with unexpected revelations. Since we have become aware of these occurrences, we have enhanced them by adding both direct and indirect suggestions that participants will have similar experiences. These suggestions are reinforced by older participants (those who have attended several meetings). They describe their experiences of this type to newer members, who are often impressed by the reports and then follow suit.

When family members finally accept the fact that they have serious problems, they are ready to accept a referral for help. When they appear ready, they are told (or preferably they are led by the therapist to ask) where to go for the kind of help they need. Usually, the other family members make the referral to Al-Anon or Alateen, coupling the referrals with personal endorsements and stories of the effectiveness of these resources.

Comments. While contemplating the preceding description, the reader can imagine what the result might have been if the therapist had simply told the family members that they were sick and needed to go to Al-Anon. Doubtless, most of them would have thought: “Well, that’s your opinion,” and then dismissed the matter from their minds. What occurred was a much more desirable result: The family members told the therapist that they were sick and needed to go to Al-Anon. There was no resistance by the participants, because no one was trying to force them to do or to think anything. Instead, they were communicating ideas to the therapist, and he chose not to resist hearing the ideas. Their discovery of these ideas, coupled with the emotional arousal they experienced on the way to their discovery caused them to feel a profound impact. This impact is usually sufficient to convince the participants that the therapy is powerful enough to help them, even though other attempts failed previously.

Attendance and Participation by Significant Others I n Family Meetings and Al-Anon Although it is generally acknowledged that alcoholics’ family members and sig-

nificant others ought to be involved in the recovery effort, many programs fail to do so. Too often, treatment personnel state that they “would like to” involve families, but they cannot because of factors such as lack of adequate staff, distance of family members from the clinic, or resistance on the part of family members. This lack of success in involving the families seems particularly disturbing in light of a conclusion reached separately by Gerard and Saenger (1966) and Janzen (1977), that even one contact by program staff with a member of the family makes a difference in the length of time the alcoholic remains in treatment. Gerard and Saenger (1966) also found a positive rela- tionship between family contacts and improvement in their alcoholic patients. In addition, Catanzaro, Pisani, Fox and Kennedy (1973) and Corder, Corder and Laidlaw (1972) have noted that treating the family reduces treatment costs, and, if offered on an inpatient basis, also increases the likelihood that patients whose families are involved will continue as outpatients.

Our program is very successful in involving the significant others of our patients in the recovery process due to the fact that we use a variety of maneuvers to encourage or coerce family members to attend, such as making eligibility for passes contingent upon significant others’ attendance a t the family meeting and Al-Anon or Alateen. The

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results of a recent survey of 100 consecutive admissions to the inpatient section of our alcohol dependence treatment program revealed that THO of these patients were repre- sented a t the weekly family therapy meeting by at least one significant other (generally a spouse, lover, child or other family member) during their inpatient stay. An additional 23% were represented by friends or acquaintances from Alcoholics Anonymous. These figures are especially impressive in view of the fact that 72 of the 85 patients (84.7%) who actually had family members in the general vicinity of the hospital (liberally defined as living within a 100-mile radius) had significant others involved in the family component of the program.

Data were also collected regarding Al-Anon and Alateen participation of the same family members. Our results reveal that significant others of 67% of our patients were involved with Al-Anon or Alateen during our patients’ inpatient stay. It bears noting that this was 75.3% of the families who were still in contact with their alcoholic or who had plans to associate with him.

PRELIMINARY DATA ON PROGRAM EFFECTIVENESS

Characteristics of Our Patients The following demographic information was obtained from 100 consecutive admis-

sions to our inpatient program between August, 1979 and March, 1980. Admission to our program is open to veterans eligible for care in a VA Hospital who seek, and are judged by screening personnel to need, inpatient alcoholism treatment. In addition, they must be ambulatory and able to participate meaningfully in a group interaction. Our patients, all males, ranged in age from 20 to 65, with a mean age of 45.99 years. They had completed from 3 to 18 years of education, with a mean of 12.07 years. Just prior to admission, 36% of these patients were employed full-time, 5% were employed part-time, 36% were unemployed, 11% were retired, and 12% were disabled. With regard to marital status, WO were single (never married), 33% married, 18% separated, 36% divorced and 4% widowed. Forty-seven percent of these patients had been married two or more times. The ethnickultural background of these patients was 85% White, 6% Black, 6% American Indian and 3% Mexican-American. Before entering our program, a significant proportion of our patients (57%) had been treated unsuccessfully in other alcoholism treatment programs. A large proportion (34%) had also been treated for mental or emotional difficulties.

Preliminary Findings The present report contains preliminary figures regarding whether a sample of our

patients have remained completely abstinent from alcohol since leaving the inpatient program 12 to 14 months ago. More complete findings await the activation of the program evaluation component of our program.

We demand complete life-style change on the part of our patients as the basis of their recovery. Many patients find this expectation more than they bargained for, and they therefore leave treatment early. In a sample of 75 consecutive admissions (over a period of 14 to 16 months prior to the survey) 38 of 75 (50.7%) failed to complete the inpatient phase of the program, while 37 (49.3%) did successfully complete that phase of treatment. Despite this relatively elevated dropout rate, 32 of the entire 75 (42.7%) had still remained totally abstinent from alcohol a t the time of the follow-up evaluation. However, if one were to merely consider the abstinence figures for those patients who successfully completed the inpatient phase of the program, 27 of 37 (73%) were able to maintain their sobriety for the entire 12 to 14 month follow-up period. Although incomplete a t the time of this writing, the preliminary outcome figures for those individuals who remain actively involved in the outpatient phase of the program (a 12

332 JOURNAL OF MARITAL AND FAMILY THERAPY July 1982

to 18 month follow-up program) are higher than the abstinence rates for those individu- als who completed the inpatient program and refused follow-up care.

CONCLUSION

This paper described a unique application of the Ericksonian techniques of utiliza- tion and indirect suggestion in multiple-family group therapy as a component of an alcoholism treatment program. This specific approach is presented in hopes that it will stimulate therapists in other settings who deal with other clinical populations, to devise creative approaches which take advantage of the considerable potential inherent in Ericksonian approaches to therapy.

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