165. Gazzaniga M (1998) The Mind’s Past. Berkley, CA: University of California Press.

  166. Evans P, Hucklebridge F, Clow A (2000) Cerebral Laterisation and the Immune System, in Mind, Immunity and Health. London: Free Association Books.

  167. Platt FW, McMath JC (1979) Clinical hypocompetence: the interview. Annals of Internal Medicine 91(6): 898-902.

  168. Desmond J, Copeland L (2000) Communicating with Today’s Patient. San Francisco: Jossey-Bass.

  169. Realni T, Kalet A, Sparling J (1995) Interruptions in the medical interaction. Archives of Family Medicine 4: 1028-33.

  170. Marcinowicz L, Chlabicz S, Grebowski R (2007) Open-ended questions in surveys of patients’ satisfaction with family doctors. J Health Serv Res Policy Apr; 12(2): 86-9.

  171. Burack R, Carpenter R (1983) The predictive value of the presenting complaint. Journal of Family Practice 16(4): 749-54.

  172. Miller S, Hubble M, Duncan B (1996) Handbook of Solution Focused Brief Therapy. San Francisco: Jossey-Bass.

  Phase 3: Reorientation

  11

  Accessing Patient Resources: the potential for change

  The world as we have created it is a process of our thinking. It cannot be changed without changing our thinking.—Albert Einstein

  One of the presuppositions of NLP, and a guiding principle of the work of Milton Erickson, is that all patients have the resources needed to produce change.

  To some, this may seem overly optimistic, especially where both patient and practitioner feel baffled and helpless when confronted with a particularly complex and chronic condition. To those patients and physicians who genuinely feel they have ‘tried everything’, the statement may even seem platitudinous or blaming.

  In Medical NLP, we modify the statement slightly. We suggest that both patient and practitioner have resources that have not yet been investigated or applied, and of which they may not yet be aware.

  Problem-based medicine tends to regard illness as the result of a deficit. A patient regarded as deficient in some way or other requires ‘fixing’. The role of practitioner and patient then becomes one of the active and informed acting on the passive and uninformed.

  The patient’s resources

  Among the resources that patients bring into treatment may be included:

  the desire to achieve a healed state (or else they would not have sought help);

  the evolutionary drive of all living entities to strive for allostasis at every point in their lives until the moment of death;

  successful changes and healings they have accomplished in the past; and

  the ability, under guidance, to envisage an existence in which allostasis is restored.

  Several factors may, however, initially stand in the way of identifying resources. It may be (and often is) that the patient has not yet fully engaged with one or all of the resources mentioned above. Secondary gain (psychology’s assertion that people sometimes stay sick to achieve some hidden benefit) may often be used to explain a patient’s ‘resistance’ to treatment, thereby aborting further investigation.

  Many patients (and, we would say, many practitioners) have not even considered the presenting condition as a symptom of the body-mind system’s attempt to regulate itself, albeit unsuccessfully. Also, the patient’s problem-state of mind may preclude recollecting ‘successful’ or ‘happy’ times in the past, or imagining improvements in the future, simply because, at this stage, it seems too risky.

  Some ‘patient-centered’ approaches suggest that only a ‘non-directive’ approach is ethically acceptable, and that interventions that take place outside the patient’s conscious knowledge are unacceptable. We disagree. We have no problem in regarding the patient’s request for help as a mandate to proceed in his interests. The fact that he might be better served when some parts of the intervention take place covertly is, in our opinion, unavoidable.

  The outcome (and this part of the treatment must be negotiated with the patient’s full consent) informs everything else we do.

  Identifying, accessing and stabilizing resources

  Resourcing, then, is accomplished by three processes: behavioral shaping (or response shaping); informative feedback; and the NLP core skill of anchoring. Since effective anchoring is a technique critical to all successful NLP interventions, and one that is particularly important to resourcing, we recommend that some time is spent in mastering it.

  Successful resourcing requires a creative balance between an overt uncovering of patient strengths and more oblique methods bringing together as yet unacknowledged positive experiences, abilities, and behaviors. It is important to pace the patient’s experience appropriately. Focusing too soon or too directly on what is not wrong will damage rapport and engagement and be perceived simply as a dismissive things-are-not-as-bad-as-you-think attitude.

  The power of anchoring

  Anchors are often explained in terms of classical conditioning as a stimulus that elicits a particular response.

  Russian psychologist Ivan Pavlov’s experiments at the turn of the last century demonstrated how a specific tone, sounded when a group of dogs were given food, could eventually trigger salivation, even when food was not present. The experiment, together with a series conducted later by B. F. Skinner, much of it with pigeons, excited some psychologists. They envisaged being able to correct human behavioral ‘errors’ with little effort, and even less concern for how the ‘black box’ of the human brain functioned.

  It was a belief that led to many spurious and inhumane ‘treatments’ and child-rearing models. The fact that we are deeply patterned—and patternable—organisms is undeniable. We respond automatically to many stimuli (think of hearing a song that automatically recalls emotions belonging to the distant past). But we are also much more than that. Unlike a dog or a pigeon, we have the capacity to reflect on our behavior; to act (when we know how) on our patterning; and even to use it for our own self-regulation and personal evolution.

  Anchors, then, are a means to an end. As stimuli that predictably evoke specific psychophysiological states, they may be incorporated as tools to facilitate the integration and effective functioning of a wide range of other psychophysiological capabilities.

  An anchor may be set up accidentally or deliberately. It may result from several repetitions or a single, traumatizing incident (as with some phobias). Heightened emotion, such fear or grief, makes us more susceptible. Anchors can occur singly or in sequences. Triggers may occur in any of the senses: sight, sound, touch, smell, or taste. The more senses involved in creating both stimulus and response, the more intense the ‘internal’ experience is likely to be.

  Most importantly, anchors are irrelevant until they are triggered, or ‘fired’.

  Anchors, not pathology

  Until we are aware of how they are established and how they function, most anchors are set up and triggered outside our conscious awareness. Many responses, otherwise thought of as pathological, may, in fact, be seen as caused by negative anchoring.

  Take, for example, the following:

  Case history: The patient complained of developing a ‘social phobia’ when meeting new people. The practitioner noted that the condition had surfaced some weeks after the sudden and tragic death of the patient’s mother, and had progressively worsened since then.

  Interestingly, he described the symptoms of his ‘phobia’, not as ‘anxiety’, as might be expected, but as ‘sadness’ and ‘despair’. During the consultation, the practitioner anchored the ‘sad’ feeling and asked him to ‘follow the feeling back’ to when he had first experienced it. The patient recalled with considerable emotion the funeral of his mother at which he was battling to contain his grief, while meeting and shaking hands with scores of mourners.

  When the patient had recovered his composure, the practitioner asked permission to ‘test something’. He reached out, shook hands with the patient, and the patient instantly collapsed back into the sad and despairing state he had felt at the funeral. Immediately, he recognized that his ‘phobic’ response was not caused by meeting new people, but was triggered by the physical act of shaking hands: an anchor that had been set up at a time of heightened emotion.

  Anchors, as we will demonstrate later, not only explain aspects of many chronic conditions, but can be effectively ‘installed’ to therapeutic effect. Anchors may be intrapersonal (self-anchoring) as well as interpersonal (operating between people). The triggers may be real and external (a handshake, the sound of fingernails raking down a blackboard), or entirely imaginal—that is, the response may be triggered simply by thinking of a particular event (pause and think for a moment of sucking a segment of lemon). Anxiety disorders often involve a physical response to the memory, or future imagining, of a sensitizing event that is long past.

  Setting anchors

  The most commonly applied therapeutic anchor is kinesthetic. But although it is significantly easier to link a physical touch with an emotional or physical response, it may not always be appropriate to touch a patient.

  However, when touch is permissible, such as in taking a pulse or palpating, we suggest that you tense the muscles of your hand and fingers as you touch the patient, then relax them. This subliminally cues the patient himself to relax (see behavioral shaping, below), as well as anchoring relaxation to your touch.

  Auditory anchors might include a specific word or phrase, a sound or a tone. We advise practitioners to set up a specific phrase (such as the Ericksonian favorite, ‘That’s right…’) as early as possible in the consultation each time he notices a positive response from the patient.

  Visual anchors could be set by nodding, smiling, or making a specific gesture. Olfactory and gustatory anchors are less likely to be deliberately used in consultation. However, we need to be aware that the smells associated with hospitals and clinics may set up negative anchors in some patients.

  We have found that we can help some patients minimize nausea while undergoing chemotherapy by addressing the issue of smell and sensation as anchoring.

  Conditions of anchoring

  In order for anchors to be effective, the following conditions must be met. Anchors link a specific trigger to a specific response. Therefore:

  Remember, or create, a desired state. Heighten the state by marking the sensory detail as rich as possible. Make it big, bright, and appealing. If anchoring overtly, agree on a name to avoid confusing it with any other states.

  The anchor needs to be precisely timed, set just as the state begins to ‘peak’. Make sure that it is released a moment before the state begins to subside. The intention is to stabilize the most intense stage of the experience, not to capture its dissipation.

  The trigger must be unique. An anchor that can be accidentally ‘fired’, by a casual touch or ambient sound, will rapidly lose effectiveness. Use more than one sense to create the trigger, if possible (for example—a tense-to-relaxed touch, together with the words, ‘That’s right…’).

  The process must be tested for effectiveness. Don’t trust to chance.

  The process must be repeatable. If it is to be used therapeutically at a later date, an anchor needs to be durable enough to be fired when needed.

  Later, we will discuss the setting and application of anchors more specifically, but, at this point, we would like to explain why we have spent so much time on the engagement phase of the consultation.

  The practitioner as ‘meta-anchor’

  Clinical outcomes may be demonstrably enhanced by positive expectation and belief (including that of the practitioner).173,174,175 Some studies even suggest that strong belief and positive attitude can measurably affect the patient’s cellular function.176 While this research is regarded with skepticism in more orthodox circles, there is no doubt in many patients’ mind that certain practitioners have the ability, somehow, to make them ‘just feel better’.

  Whether or not the connection between practitioner attitude and patient response is ever widely accepted, we believe a practitioner who exhibits strong congruence, optimism, and engagement may function, at least in part, as a ‘meta-anchor’. His state, if strong and coherent enough, may, in fact, collapse the patient’s state in whole or in part—that is, he becomes the doctor-drug to which Michael Balint refers.177

  Pitfalls to avoid

  Given our susceptibility to anchoring, the practitioner should avoid accidentally setting up negative anchors or reinforcing unwanted behavior. Practitioners are often encouraged to practice ‘active listening’ by regularly acknowledging the patient’s disclosures by nodding, sounds such as ‘uh-huh’, and encouraging statements like, ‘Okay’ and ‘I see’.

  These should be used with caution, and carefully timed. Nodding, smiling, and other gestures of acknowledgement made at the precise point where the patient is expressing his pain or distress may well anchor in the response we are striving to modify. (As we discuss elsewhere (see page 367), active listening tends to encourage the patient to speak more than he intends, simply because the practitioner’s non-specific verbal responses are frequently interpreted as a prompt for more information). Difficult as it might be in the beginning, it is important to remain fully engaged, but neutral, at these times, reserving comments and other acknowledgements to be used in ways we will discuss later in this chapter.

  Case history: One of the authors was commissioned by a large London hospital to help chaplains of all denominations who were reported to be suffering from burnout. When interviewed, they all agreed they felt exhausted and debilitated by their perceived inability to help the many patients they encountered who were suffering from chronic, painful, and often terminal illnesses.

  As is our usual procedure, the job began with a period of observation—and the following was noted. Patients often appeared to be fairly relaxed and in good spirits, chatting, reading, or watching television. When the chaplain appeared, he would sit down with a concerned and serious expression on his face, lean in towards the patient and inquire along the lines of, ‘So, how are you feeling today?’ The sonorous words and body language of the chaplain clearly signalled that he expected the patient to report negatively—which is exactly what happened. The patient visibly slumped, his expression becoming inwardly turned and reflective, then he would reply in some variation of, ‘Not so good today…’. Patient and chaplain each appeared to be ‘performing’ the way the other expected them to.

  To the observer, it seemed clear that the chaplains had become anchored to the perceived suffering of the patients, who in turn responded to the chaplains’ over-serious and concerned demeanor.

  The chaplains were taken aside, and the principle of anchoring explained to them and rehearsed (somewhat reluctantly at first) in adopting a more upbeat and positively expectant manner. After a couple of days, the tone of the meetings changed noticeably. The chaplains became more ‘human’, teasing and joking with their charges, and the patients responded with visible pleasure at the chaplains’ visits. Later, the chaplains reported feeling more relaxed, energized, and optimistic about their work.

  Anchors and strategies

  When you experimented with the third part of the exercise at the end of the previous chapter (and, if you haven’t, we suggest you return and do so now), you might have noticed that each part of a subject’s strategy depended on the part that immediately preceded it.

  Without that part (or any other), the strategy cannot run as a sequence. In terms of the conditioning process, a specific stimulus leads to a predictable response (S > R). The important thing to note here is that the response, in turn, functions as a stimulus to the next S-R unit, and so on, until the strategy has run its course. This is known as a ‘chain’. Anchoring, as we will now see, becomes the building block of the principles and techniques designed to identify, access, and stabilize the patient’s resources. (For more on strategies, see Appendix D, pages 367 to 369.)

  Behavioral shaping

  All conditions have limits or boundary conditions. There are times, or places in the body, where they are not experienced. The patient has a repertoire (as yet unrecognized) of behaviors that divert him from his suffering. No experience—however much the subject may protest to the contrary—can be maintained at the same level all the time. The human nervous system is not structured in a way that permits this to occur.

  However, since the patient may feel overwhelmed by a problem and be incapable of finding his way past it, the purpose of shaping is gently and respectfully to guide him towards a greater awareness and activation of his capabilities, and to help him develop a more proactive and self-efficacious attitude.

  To this end, we are interested in: exceptions to the problem state (times when the problem does not occur); the ability to shift and maintain attention to experiences outside the problem state; past successes and achievements; reducing the problem’s size and impact by attending to its components, rather than the whole (splitting); and accessing and developing solutions and solution-states (also referred to as desired states).

  The patient will already have some, if not all, of these resources. But it is almost certain that he will not be aware of them. As long as he is associated into the problem, his (unsuccessful) struggle will be to dissociate—and ‘dissociation’, in his terms, will be to engage in the frustrating attempt to not-have the symptom.

  By trying not to have the problem, he has inadvertently placed himself in the paradoxical bind we call a ‘bonded disconnection’. The more he struggles to disconnect, the more closely bonded he becomes.

  Shaping is not in itself a therapeutic technique. As with elements of the earlier stages of the consultation (including engagement; lowering systemic overload; priming; respecting and listening to the patient’s story; and applying the Clinical Questioning Matrix), the purpose is to orientate the patient in the direction of improvement, healing, and health.

 

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