fifth the patient, and then, maybe, comes science. We first do everything for the patient; science can wait, research can wait.—Bela Schick185
The astute practitioner, confronted with a condition that is not readily identifiable, recognizes that he needs to do something both challenging and rewarding. He needs to enter the patient’s world.
This is a reversal of the conventional relationship in which the patient is expected to submit to the superior knowledge and expertise of the practitioner. That dynamic has been shown by studies to be counter-productive. Where the patient feels intimidated by the ‘authority’ of the medical encounter, he will often not disclose the information necessary to arrive at accurate diagnosis and appropriate treatment. In fact, he may even prefer to reveal sensitive information to a computer, or by filling in a questionnaire—even in the knowledge that his confidentiality may be compromised.186
Within the patient’s world, the problem-behavior will have a logic that extends beyond the symptoms and their cause. The landscape in which he has lost his way needs to be explored and understood before the problem-behavior can be changed.
This approach is, to borrow George Engel’s terminology, ‘biopsychosocial’. As the word suggests, it recognizes that the patient’s biology is intimately related to, or may even be affected adversely by, his relationships and emotions.187
We derive the metaphor of ‘entering’ the patient’s world from the martial arts. Many styles historically evolved out of social and religious conditions that forbade meeting violence with violence. Instead, the nature and direction of the attacker’s own energy was captured and redirected in a direction other than its original target. Later, more ‘spiritual’ forms, such as Aikido, re-cast the attacker as a ‘partner’, and developed elegant, almost balletic, strategies to avoid injury, either to the attacker or to the defender.
In the Medical NLP model, the practitioner is required to ‘enter’ the patient’s map of the world, without necessarily colluding with its distortions, with the intention of re-orientating him in a more useful and appropriate direction. Just as the skillful martial artist needs knowledge, flexibility, and practice to resolve conflict in a spirit unfamiliar to the rest of society, so the Medical NLP practitioner benefits from three skill-sets not normally encountered in a medical context: normalization; dissociation; and utilization.
In essence, normalization means we accept whatever the patient presents to us as ‘making sense’ within a certain context. Ultimately, the practitioner’s job is to understand what that context is.
Normalizing the patient’s experience can be deeply transformational, not least by removing feelings of shame, blame or being ‘beyond help’. Only then can the patient relax his efforts enough to entertain the possibility of change.
As an example, we cite the many patients we see whose tension visibly begins to dissolve when we explain their ‘anxiety disorder’, or ‘post-traumatic stress disorder’, as simply a name given to a natural, evolutionary survival mechanism that needs to be modulated or updated.
Thus far, the patient has been striving unsuccessfully to dissociate from the symptom in the belief that this will solve the problem itself. In doing this, he inadvertently establishes a bonded disconnection. Medicating his feelings, or suggesting that he will get better if only he challenges and reforms his ‘negative thinking patterns’, collude with this belief by failing to recognize and validate the purpose and reality of his pain.
By providing only symptomatic relief, both these approaches leave the structure of the core problem intact, and may even risk weakening the patient by removing the ‘challenge’ to his system, without facilitating his biological and psychological capacity to adapt and grow.
Change, however, cannot take place from within the problem-state, so the patient needs temporarily to be able to step back from his current response or behavior to view it from a more detached perspective. This can be done overtly, by suggesting he see the response or behavior literally on a screen (with himself in the picture) or, indirectly, using language patterns presupposing temporary detachment—‘If we could look at this a different way, a bit like a fly on the wall…’, etc. This serves to reduce the patient’s anxiety when reviewing the problem, as well as opening opportunities for you both to generate new meanings and responses.
Utilization recognizes everything the patient brings to a consultation as raw materials of change. The most obvious of these is, of course, the symptom itself.
Many Medical NLP techniques are created by symptom-solution linkage—that is, by connecting the ‘trigger’ of the problem-state to a new and more appropriate response. This is highly effective in many conditions otherwise considered intractable—and even more so when the new response more effectively meets an underlying need.
Later chapters expand on this theme, but for immediate application, we offer here several ‘indirect’ interventions based on utilization.
How often does it happen that you absolutely know that if only someone did what you suggested, he would get the result he wants? In real life, of course, people often don’t, or won’t, follow what you might regard as excellent advice. This is not necessarily because they are being obstructive, but because the change somehow doesn’t seem to ‘fit’.
Paradoxical binds are linguistic devices that recursively link action X to the outcome Y by making not doing Y the motivation to do X. Confused? Well, the more confused you become, the more determined you’ll be to understand.
Try this with a friend:
Have him clasp his hands tightly, palm to palm, and extend both forefingers so they are parallel to each other. Deliver the following instruction exactly and with conviction:
Now, notice how your forefingers will automatically come together until they touch. I want you to try your best to resist, but the more you resist, the more you exhaust your ability to resist, until those fingers move together and touch…
…and simply sit back and watch. After a while, you will notice signs of effort. Your friend will pull the fingers apart, but each time the tendency to move together becomes stronger until he surrenders. Whatever explanation he chooses to give, the result is the same. By binding the response directly to the amount of effort he expends resisting it, the outcome becomes inevitable.
Here are some examples:
The more you allow the fever and runny nose to run their course, the more quickly your body will destroy the germs causing your cold.
You say it’s difficult to relax, so, instead of trying to relax, become as tense as you can be before you allow yourself to relax.
You don’t have to stop worrying. In fact, you may be the kind of person who needs to worry—so, I’d like you to set aside exactly 30 minutes at the same time every day so you can concentrate only on worrying as much as you can until you don’t need to worry any more.
(This latter approach—setting a special time during which the symptom must be indulged—has proved useful as an adjunctive treatment to Obsessive Compulsive Disorder.)
‘Framing’, ‘preframing’, and ‘reframing’—setting up or changing the context in which a particular situation or problem is experienced—is an important skill of Medical NLP.
There is no doubt that our attitudes to certain events alter according to the context in which we experience them. There is also considerable evidence to suggest that the meaning and degree of emotion we attach to our experiences directly affects the performance of our immune system through the mediation of the complex orchestration of our hormone, peptide, and cytokine flow.
The sound of a creaking stair during the day may not even be noticed; in the middle of the night, it can trigger feelings of fear and anxiety. Sustained anxiety may eventually result in a deterioration of both performance and the function of cells and organs. Adrenalin-fuelled experiences create different qualitative experiences according to the context in which they occur—‘exciting’, where the subject is involved in activity he enjoys, ‘stressful’ when it is activity he fears or dislikes. Since the biochemical impact of ‘excitement’ differs from that of ‘anxiety’, reframing proves a useful tool: ‘So, when you notice that you’re beginning to become stressed at all the things you have to do, you can start to become excited at the prospect of finding ways to manage your time and energy.’
Three of the most useful applications of framing follow.
Since the ‘expectations’ of patient and physician have been identified as a significant component of successful treatment outcomes, preframing is designed to set up both patient and practitioner for improvement and change.188,189 In general, preframes involve suggestions and assumptions rather than direct statements. Preframes are therefore also classed as presuppositions.
Avoiding the negative preframe. Clinicians often deliver negative preframes while seeking informed consent. This can increase the patient’s anxiety and elicit a ‘nocebo’ response. For example, an overemphasis on side-effects of medications is known by most practitioners to increase patients’ experience of some of those effects. Negative preframes often prompt the patient actively to search for these events; they may even cause the adverse response by the same mechanisms that underlie the placebo response.
Examples of commonly used negative preframes in everyday clinical practice include:
‘After the surgery, you may experience some swelling, pain, or tenderness and notice some bruising over the scar site. It will be uncomfortable for some weeks afterwards.’
‘The glyceryl trinitrate spray you use under the tongue when you get angina will probably give you a headache.’
‘The pain may actually get worse following the injection in your knee.’
‘We need to do an exercise ECG, chest X-ray, and blood tests to check whether you have heart disease, or whether you might get a heart attack.’
It is relatively simple to deliver relevant information while at the same time actively seeking to reassure the patient, encourage him to tolerate unavoidable discomfort, and orientate him towards improvement and recovery:
‘After the surgery, some people experience tenderness and bruising over the operation site. This is quite natural, and, if it does happen, as you begin to recover the swelling goes down and the bruising and pain usually clear up over the next few days.’
‘The glyceryl trinitrate spray used under the tongue can give some people’ [presupposing ‘but not you’] ‘a headache as the angina pain clears and your breathing gets better.’
‘You may notice the pain gets worse after the joint injection before it begins to get better and your knee becomes more comfortable.’
‘We need to do an exercise ECG, chest X-ray, and blood tests to make sure your heart is okay. If anything shows up on the tests we’ll be able to give you the best possible treatment to make sure your condition improves.’
An audit by Medical NLP Master Practitioner Dr. Khalid Hasan, consultant anesthesiologist at Britain’s Queen Elizabeth Hospital, Birmingham, reveals that preframing patients to recover easily and comfortably significantly reduces bed time, and the need for perioperative medication, including pain-killers and anxiolytics.190
The content reframe specifically seeks to change the meaning the patient has attributed to his experience without directly challenging it. A content reframe is specifically called for when the subject has used one or other of the Meta Model violations known as ‘complex equivalence’ (X is the same as, or means, Y) or ‘cause-and-effect’ (X causes Y).
Note: The Meta Model as presented in Bandler and Grinder’s The Structure of Magic is a revolutionary tool for extracting Deep Structure (the actual meaning of a statement) from the Surface Structure (what is said). We urge practitioners to become fully conversant with all the patterns to clarify their own thinking and reasoning and to increase their effectiveness when working with patients.
Meaning and appropriate action are further constricted where nominalizations (processes represented as events, also known as ‘reification’) are used. For example:
Statement: ‘My anxiety’ (nominalization) ‘gets really bad as soon as I get behind the wheel.’
Content reframe: ‘Being anxious’ (process returned to the nominalization) ‘whenever you get behind the wheel could also remind you to stay alert and drive carefully’ (the ‘meaning’ of anxiety is changed).
Reframes should never be delivered without adequate pacing and rapport to avoid seeming dismissive or platitudinous. To give another example:
‘Being over-anxious can be worrying’ (pace). ‘But’ (turning word) ‘being anxious to just the right degree’ (presupposes ‘degree’ of anxiety can be adjusted) ‘can remind you to stay alert and drive carefully… so let’s take a look at how we can be sure that the level is just right’ (preframe).
The following are examples of practitioner-generated statements patients brought into our consultations, followed by the reframes that reassured them during subsequent, probably unnecessary, appointments:
Statement: ‘Your lifestyle and lack of exercise are causing these symptoms and increasing your risk of getting heart disease. You have to change all this.’
Reframe: ‘Your symptoms are messages from your body telling you that now is a good time to start eating more healthily and getting some regular exercise.’
Statement: ‘Colds are caused by a virus. We don’t give antibiotics for that.’
Reframe: ‘The mild fever and the stuffy nose are signs that your immune system is fighting off the virus really well. We wouldn’t want to do anything that might interfere with your body’s natural responses.’
Statement: ‘The growth was cancerous and if left it could have spread and become terminal.’
Reframe: ‘The growth was cancerous, but luckily we’ve found it early enough to remove it and do everything we can to make sure you remain well in the future.’
As its name suggests, ‘context reframing’ seeks to normalize or validate responses or behaviors by transferring them to a wider or different context.
One of the earliest presuppositions out of which NLP developed was that all behavior has value, although sometimes that behavior is better suited to a different situation. For example, ‘anxiety’ may be perceived as a ‘problem’. ‘Being anxious’, though, is a natural and protective response to a real or potential threat, and can serve to help us avoid the perceived danger or create contingency plans to deal with it when it comes.
In order to create a context reframe, ask, ‘Where else might this response or behavior be useful?’ Context reframes are appropriate when the speaker reasons or explains an experience using a Meta Model violation that involves judgment while deleting information that could justify the judgment. Listen especially for the word ‘too’, although this might be implicit in the statement. Examples are ‘I’m too busy’; ‘I’m too anxious’; ‘He’s demanding’; ‘I’m stressed’.
Asking where else this behavior or response might be useful or relevant, we replace the problem frame with one that suggests relevance and change. ‘Being busy’, for example, may be reframed as useful ‘when there are specific tasks to be done’ (implying, or stating overtly, that there is also a benefit to relaxing, where appropriate).
Obsessive behavior may often be brought under control where treatment includes providing a context frame in which the behavior would be appropriate (we know of a woman who had a cleaning obsession that she re-directed into setting up a popular and highly profitable celebrity housekeeping service). Patients may even be comforted by context reframes applied to certain organic disorders—the sickle cell anemia trait, for example, may be regarded as ‘useful’ in an area with a high incidence of malaria, since it confers added resistance to the malarial parasite.
Reframes of all kinds will not ‘take’ if they are not matched to the situation at hand. Richard Bandler advises the practitioner to use all sensory modalities to replicate the subject’s complaint, and then asking himself the questions, ‘What else could this response/behavior mean?’ and ‘In what other situation could this be useful?’191
The following is a transcript of part of a consultation with a young professional woman referred after being diagnosed as having ‘psychotic episodes’.
Case history: The patient reported problems with a former boyfriend who was making her life a misery. According to her version of events, it was a classic case of ‘stalking’: wherever she went, there he was; silent calls and hang-ups several times a night; suddenly appearing when she least expected it. She would often look out of her bedroom window in the middle of the night and see him standing in the shadows of the trees on the other side of the road. Sometimes he would ride past her, motorcycle helmet covering his face, ‘just to let me know he knows where I am at any time and can reach me whenever he wants’.
There was just one problem: the ex-lover was in Canada, and she lived on the other side of the world. Moreover, she knew he now lived abroad. But her explanation was ‘simple’: he had profound psychic powers that allowed him to appear wherever, and in whatever form, he desired.
Many practitioners we speak to report similar cases: spell-casting, the evil eye, psychic control, ‘spirit’ manifestation. Some of these are examples of different cultural beliefs and interpretations, others of ‘psychiatric’ disorder.
Problems of this class occur when the subject fails effectively to resolve conflicts caused by a collision between internal and external ‘realities’. Whether we regard these experiences as ‘real’ or not is irrelevant—and frankly we don’t presume to know. However, responsibility for helping sufferers of such conditions, broadly diagnosed in the Western paradigm as ‘psychiatric’, increasingly falls on primary care physicians.
This pressure, coupled with the widespread, but ill-founded, belief that ‘mental illness’ is the result of chemical imbalance in the brain, is confusing, and we sympathize with those who resort to psychotropic medications in the hope that the symptoms will come under control. Not only are these problems perceived as complex and deep-seated, but, to the unskilled practitioner, complaints as apparently bizarre as ‘remote stalking’ can be unnerving.
Our assertion is: they need not be. By focusing on structure and process, we can supplement our existing helping skills without colluding with the patient or directly attacking his beliefs.
This is especially important when consulting with people from cultures in which such beliefs are not exceptional. Many cases of ‘disordered thinking’, when viewed in the context of the culture in which they occur, turn out to have reasonable explanations. Only relatively recently, for example, has it been recognized that many patients of Caribbean backgrounds diagnosed by British psychiatrists as schizophrenic were in fact suffering from a particularly acute form of stress triggered by racism.192
Our approach, then, seeks not to challenge and replace the patient’s ‘reality’ with our own, but to help the patient discover new choices and coping strategies. To accomplish this, we need to look at the symptomatic behavior and ask ourselves two questions: how can this be acting to protect the patient, and how, in his model, could it be explicable or ‘true’?
With the patient referred to above, the practitioner’s reasoning went in the following way. When people experience the loss of a loved one, they often refuse to accept that the relationship has ended.193 Even though the loved one has died or left, they seem to see or hear them unexpectedly. Thoughts about the loved one occur frequently and unbidden, and attempts to exclude these thoughts seem to increase their frequency and intensity. They try to cope with their feelings of loss and grief by attempting to separate from them—but, at the same time, they might feel guilty about ‘forgetting’ the loved one in those moments in which they succeed in thinking about something else.
All these responses are commonly experienced and generally regarded as ‘normal’. Now, supposing the subject succeeds to some degree in separating out from the unwanted experiences (that is, she successfully denies responsibility for generating the thoughts and feelings), but the experiences themselves persist. Her left-brain ‘spin doctor’ then has to come up with a ‘rational’ explanation for why it is happening.
Note: The client’s comments are in bold typeface. The practitioner’s comments are italicized; explanations of his language and therapeutic patterns are bracketed.
Client: ‘He was always trying to change me—make me into something else.’
(The client demonstrates resistance to being changed by an outside element or person. The practitioner notes this; change needs to be within the patient’s control.)
‘In what way?’
Client: ‘To make me a better person. More assertive, he said. To stand up for myself.’
(The practitioner notes the phrases ‘a better person’ and ‘to stand up for myself’.)
‘Is that something you’d want for yourself?’ (The practitioner tests whether the patient really does want to be in control)
Client: ‘Well, yes, but not when someone is putting so much pressure on you all the time.’
(Change needs to be self-directed.)
‘So, if you could find a way that you could do that for yourself?’
(The practitioner tests for concordance.)
Client: ‘Yes, of course.’
(The practitioner anchors the agreement by nodding and smiling, then seeks gently to prompt into rejecting her own earlier presupposition that the ex-boyfriend was too powerful to resist.)
‘That’s right. So, when you have this experience of his “powers”…’ (said in a slightly disbelieving and contemptuous tone).
Client: (Grimaces) ‘He thinks he’s great, but I think he’s actually very weak. That’s why he has to use psychic stuff to get at people.’
‘That’s right and he’s not the strongest wizard in the world? That may be what he thinks he sees reflected in the mirror but thinking he’s great is a kind of shield, a protective barrier, deflecting anything he directs at you, wouldn’t you say?’
Client: ‘Oh, yes.’
(The practitioner anchors her response, and then begins to employ primes directed at the client protecting herself by ‘reflecting’ and ‘deflecting’, rather than by counter-attack. This is an ecological consideration. We seek to provide peaceful resolution to both internal and external conflicts wherever possible.)
‘And, if you find you have real powers of your own—they don’t even have to be psychic—to deflect his powers, would you use them?’
(The practitioner analog-marks the embedded command, ‘you have real powers of your own…to deflect his powers…use them’.)
Client: (Uncertainly) ‘Uh…Well, I wouldn’t want to hurt him, even now. That’s not the kind of person I am…’
‘Oh, I’m not suggesting that for a moment. But if there were a way for you to set things up so that he or anyone else couldn’t do anything that wasn’t in your best interests, you wouldn’t be responsible for what happened to them, would you? I mean, if I throw a ball too hard against the wall and it bounces back and hits me in the ribs, is that the wall’s fault?’
(The practitioner paces the patient’s concern, and then reframes it to return the responsibility for any actions to the ‘originator’. This is reinforced by the ball metaphor. Note, too, the faintly confusing ‘hypnotic’ language.)
Client: (Laughs) ‘That’s an idea. Like a shield. It’d need to be really tough.’
(The patient begins to assemble and solidify information suggested subliminally (at no point do we say, ‘do this’ or ‘do that’; this way, we avoid symmetrical argument and the ‘yes-but’ response). By processing unconsciously and then formulating a solution, the patient is ‘taking ownership’ of her own response.)
‘It would.’
Client: ‘Like a really strong mirror…’
(A practical solution: armor that is strong, but portable.)
‘Made out of?’
Client: ‘Steel maybe, only light enough not to bother me as I move about…’
(The practitioner anchors the qualities and also presupposes that, by taking the proposed actions, the patient can then safely forget—note the embedded command—about consciously responding to a perceived threat.)
‘Steel, light. That’s right. So, if you could set that up and kind of forget about it, knowing it would continue protecting you, would that be something worth having? And then you can forget the whole thing?’
Client: ‘For sure!’
(Strong concordance.)
‘And then the problem you’ve been having isn’t your problem any more, so, when that happens, how would you be feeling and acting differently and better now?’
(Note the temporal shifts in the practitioner’s language. The problem is expressed in the past tense and the solution—acting differently and better—is presupposed as already existing in the present: ‘now’. The question also prompts the patient into a transderivational search to provide subjective meaning to the ‘artfully vague’ words ‘feel’, ‘differently’ and ‘better’. This is intended to increase the patient’s adherence.)
Client: ‘Great. I could just…live my life and enjoy it.’
‘And what’s interesting to me is that you would be a more assertive person. Stand up for yourself. In a strange kind of way, he might just have helped you to get something you wanted—except he was going about it the wrong way, and now you can do it for yourself…’
(Embedded commands, in bold type, reframing and ‘handing over’ responsibility for change to the patient.)
Client: ‘Yes.’ (Laughs, nods)
‘So, let’s just go through it and make sure it fits. Close your eyes and think about what your shield, your protective mirror, would be like…’
(Begins to coach the patient into adopting her new strategy.)
Creating explanations for irrational events is a characteristic of altered states, and often appears bizarre to the observer. The only explanation this patient had was ‘psychic control’. In all other areas of her life, she was, by any assessment, entirely reasonable, rational, and sane. On any other subject, in any other situation, she had a grounded, realistic, and reliable perspective. She was, quite literally, being ‘driven crazy’ by her inability to come to terms with the rejection.
Thus, in Medical NLP, we move, invited, through the patient’s territory, with respect for (but not necessarily collusion with) his world view. The changes we help him make accord with and expand his map of reality. Then, when the patient takes ownership of the change, we withdraw. There is no room for ‘therapist’s ego’. First the patient…always.
1. Select three symptoms a patient might bring to a consultation (e.g., ‘My mind races so much at night I can’t get to sleep’) and write out ways you can: normalize the experience within the context of the patient’s life; find a utilization for it and, reframe it—first by content, then by context.
2. Become alert to narratives and symptoms that suggest ‘disordered’ thinking. Each time you encounter an example, pretend you are the patient and seek out the possible (not necessarily the actual) logic that would need to make the details ‘hold water’. Write down your explanations. Regard everything the patient says as ‘true’, then ask yourself the questions:
How could this appear true?
What could this be true of?
185. Wolf IJ (ed.) (1965) Aphorisms and Facetiae of Bela Schick. Baltimore: Waverly Press/Knoll Pharmaceutical.
186. Robinson R, West R (1992) A comparison of computer and questionnaire methods of history-taking in a genito-urinary clinic. Psychology and Health 6: 77-84.
187. Engel G (1977) The need for a new medical model: a challenge for biomedicine. Science 196: 129-36.
188. Duncan BL, Miller SD, Sparks JA (2004) A Revolutionary Way to Improve Effectiveness Through Client-directed, Outcome Informed Therapy. San Francisco: Jossey-Bass.
189. Vase L et al (2003) The contribution of suggestion, desire and expectation to placebo effects in irritable bowel syndrome patients: an empirical investigation. Pain 105(1-2): 17-25.
190. In preparation.
191. Bandler R, Grinder J (1982) Reframing. Moab, UT: Real People Press.
192. Littlewood R, Lipsedge M (1989) Aliens and Alienists, 2nd ed. London: Unwin Hyman.
193. Kubler-Ross E (1969) On Death and Dying. New York: Macmillan.