The vast majority of writings comparing and contrasting the use of direct and indirect suggestions in hypnosis refer to the structure of language, and may sometimes reference the timing, tone and volume of the voice. But there is much beyond the way we word suggestions and how we use our voices that can have a major suggestive impact. These impacts are something we need to be keenly aware of in order to give maximum benefit to the influence of suggestions.
Body language, facial expressions, gestures, eye contact, physical contact such as a handshake, gender, age, bearing and appearance, including health, body type and clothing can all be major indirect suggestions that affect the meaning of our language. The meaning of language will also affect and be understood by each individual uniquely because of the various personal meanings and connotations each of us associates to words and phrases, and by the emotional state, mood and expectancies of your client.
Further indirect suggestions are given by the condition and style of the office, reception area, facilities and office building, including colors, artwork, cleanliness, temperature, scents, and by the function, form and quality of furniture. Various additional aspects of location include the size and prestige of the city or town, neighboring offices and adjacent buildings, section of city or town and immediate neighborhood, people one may encounter in the vicinity of your office, and noise levels.
Cultural and semantic factors also influence the meaning of suggestions, including the culture and language in which you and your client meet and converse, and each of your backgrounds and life experience. Time of day or night, current events and seasonal factors, including holiday periods, can be indirect suggestions that affect the way language influences people at a particular time.
There are many indirect influences in the written word as well as the spoken word. When seeing a suggestion or opinion in writing we are influenced by the source and our opinions about that source, be it a book, magazine, familiar website, mainstream news, advertisement, letter, email or billboard, and whether it be from a colleague, a friend, a relative, an organization we belong to, a government agency, or spam email. When reading a book the quality of writing, the book's quality and size, the cover, the background and additional writings of the author, etc., all add a context that affects the meaning and attention given to suggestions.
There is no such thing as a simple, independent direct suggestion. The context of a so-called "direct suggestion" always has a great many indirect surrounding influences. In fact the distinction of such influences becomes blurred, and some of the influences may be considered direct rather than indirect, depending on the situation and moment in time.
The Myth of the Inherent Superiority of Indirect Suggestions
As shown above, the degree of directness or indirectness of suggestion is far more complex and individualized than generally considered. Setting aside the important contexts which add to and transform the meanings of "direct suggestions," I will now focus on the language structure which refers to this term, in order to address the topic of direct and indirect suggestions in the framework commonly used. I feel this is important because of the tremendous extent to which significant misconceptions about direct suggestion have been disseminated over the past 35 years by many influential people in the field of hypnotherapy, including teachers, therapists and major authors.
The misconception that direct suggestions are inferior throughout all phases of a hypnotherapy session comes mainly through some of the individuals who identify themselves as Ericksonian hypnotherapists. For example, Stephen and Carol Langton claim, "Direct suggestion will only bring temporary relief, will intensify the transference relationship toward authority, and will increase repression of the conflict which led to the symptomatology." They add, "An Ericksonian hypnotist strives to be artfully indirect in all suggestions and interventions."
Working only indirectly makes no sense in certain forms of hypnotherapy, such as when working with Gestalt or ideomotor methods. For example, there are times when a Gestalt dialogue will go back and forth, progressing quickly and effectively, with each side making a few important comments. Following the Langtons' admonition, instead of the therapist saying, "Switch," each time the side appears to be done, with every completion the therapist would be obligated to say anything and everything indirectly, which could become awkward, inefficient, distracting and plain silly. "I wonder if you might feel drawn to expressing another side. Perhaps the one you were just talking to?" Or, "Perhaps you may be ready to say something. You might be pleased to notice yourself communicating from the other perspective. Or you might prefer first saying something further?" Or, "I wonder if you'll be surprised at how easy it may be to imagine a response. Maybe or maybe not, it doesn't really matter."
Erickson, Hershman and Sector claimed that directive hypnotherapy will be successful in only a small minority of cases because direct methods do not address the natural defenses of the client. It is interesting that Milton Erickson would make such an extreme statement. He used both highly directive and even authoritarian suggestions with some patients. Jay Haley has been particularly fascinated in Uncommon Therapy, and in some of his other books and articles, about Erickson's use of extraordinarily authoritarian methods.
According to Erickson, Rossi and Rossi, direct methods ensure that any response to a suggestion may be due to the demands of the situation or to the prestige of the hypnotist, rather than in response to the suggestion. It allegedly follows that since an indirect suggestion cannot be mediated by conscious awareness because of its covert nature, that, as Robert Meyer stated, "any response to an indirect suggestion will be due to the intervention and not to situational or prestige factors." Taking into consideration the documentation of the tremendous power of suggestion in placebo studies as described in Chapter 15, as well as many broader aspects of suggestion discussed in the beginning of this chapter, I find it hard to comprehend how an expert in hypnosis could even entertain the thought that prestige is not a factor in response to suggestion if you structure your wording indirectly.
Many scientific studies have been done to compare the efficacy of direct and indirect suggestions. In some cases the studies clearly surprised the researchers, who had set out to prove the superiority of indirect suggestions. The preponderance of evidence of scientific research to date clearly documents that direct suggestions are as good as or better than indirect suggestions. While a few studies have concluded the superiority of indirect suggestion, some of those have been seriously flawed. For example, Joseph Barber's claim of superior results with indirect suggestion have repeatedly failed in attempts to replicate, and the indirect condition used by Matthews, Bennett, Bean and Gallagher was substantially longer than the direct condition. Hammond states, "The furor of the past decade over the belief that 'indirect is always better' is rather reminiscent of the extensive research literature that has now failed to replicate the creative, but nonetheless unfounded tenets of NLP. As mental health professionals we may stand too ready to adopt unproven theories as truth."
A Wider Perspective of Direct Suggestions
Many who use indirect suggestions describe a wonderful multitude of forms of varying complexity regarding all stages of hypnotherapy sessions, including preinduction communication, inductions and hypnotic suggestions. However, the vast array of possible uses of direct suggestions are sometimes summarized in a simplistic sweeping generalization, such as the statement by Meyer, "Direct techniques are those that directly attack a problem or symptom by suppressing them with orders (suggestions)...." To the contrary, direct suggestions are commonly used in the context of comprehensive therapy in many ways, including while taking into account underlying issues. It is rare to find a hypnotherapist trained through a licensed school who does not strive to work holistically with clients.
If I'm helping someone with smoking cessation, for example, whether or not regression modalities are also used in the course of a brief series of sessions, some of our work will be in direct (and indirect) suggestion. Addressing various motivations, lifestyle issues and potential challenges, I can give individualized direct suggestions that include increased confidence, tapping into motivation, constructive activities for the hands and mouth, healthy eating habits, good habits of attention, self-expression, breathing techniques and awareness, exercise, hobbies, self-acceptance and appreciation, good relationships, clear focus at work, encouraging emotional stability and healthy channeling of energy. All this is tied in as part of the overall process of tapping into one's full potential to reach a stated objective. Initial cravings for tobacco and associations of habit patterns can be transformed and redirected in a myriad of constructive ways, that for many clients helps them succeed far beyond their presenting goals.
To give further examples, if I am inducing hypnosis with directive techniques, that doesn't mean I'm attacking a problem by suppression. If I am developing ideomotor responses I might say, "Keep thinking of the word, 'yes,' until a finger begins to rise." This is a direct suggestion. Even if I gave the direct suggestion, "Imagine the middle finger is your yes finger, and imagine it lifting and rising," that is certainly not attacking a problem by suppressing it with orders. During a Gestalt process in hypnosis I may give a direct suggestion such as, "Now become four-year-old Mary," or "Focus on your breathing," or "Become aware of your hands." These are just samples of the countless possibilities of using direct suggestions in positive, effective ways.
There are many circumstances in which I feel indirect suggestions may be the most appropriate choice. For example, when far along in therapy and a client is doing well, I may move mostly indirectly for one or more sessions. It also tends to be my preferred method when working with various forms of pain relief. I usually prefer being indirect on the occasions when I give amnesia suggestions. At various points in many types of sessions, I may use indirect language. However, I will often stick primarily with a particular style throughout a session, from the pre-hypnotic interview to the posthypnotic discussion, whether the style is very directive, moderately directive, permissive or indirect.
In my experience in helping most individuals break an addiction, the session in which the person is to cease the substance abuse is usually best done in a firmly directive motivational style, and typically directive in the next session a few days later as well. If there are exploratory sessions regarding underlying issues based on regression, Gestalt or ideomotor modalities, a more direct style will often be particularly effective. The style of those sessions that are primarily suggestion-oriented will tend to gradually shift, and by the time we're moving on to suggestions for long-term results, a session with an indirect style may be particularly appealing.
Some therapists claim as a broadly generalized truism that the way to overcome resistance, or potential resistance, is to use indirect suggestions. There are numerous causes and forms of resistance, but I do many things over the series of sessions to help lessen the possibility or transform it. As part of a first session, I will do my best to build rapport and positive yet realistic mental expectancy. I check for significant motivation, get details of reasons for the goal, history of successes and failures including important situational factors in the presenting issue and other related issues in a person's life, begin checking for possible secondary gains, find out about various past experiences with hypnosis or lack of experience, discuss the importance of the client's commitment and cooperation, and, if necessary, give a detailed explanation of hypnosis and hypnotherapy including the removal of misconceptions. I endeavor to work comprehensively, taking account of underlying issues, personality factors, fears, strengths, other issues that may be beneath the conscious awareness, and so forth.
I work with exploratory ideomotor methods and various regression strategies as applicable, as part of the strive for long-term success. In utilizing the strengths of the client and the vast resources of the subconscious, potential areas of resistance can be turned into strengths. For example, the rebel part of the client can be encouraged to rebel against the old patterns of negative behavior and thought processes. And in many ways, including during interactive hypnosis, what might appear to be resistance can often be reframed into opportunities and cooperation. For that matter, within a Gestalt process, very little needs to be considered resistance; almost anything that comes up for the client is a valuable part of the process that can be utilized. In the context of all of this, if something I would consider to be resistance arises, how I work with it will depend upon the form and context of the resistance. If some aspects of the resistance seem best to approach via a form of suggestion, depending on the circumstances either a very directive or indirect style will be best, as opposed to mildly directive or somewhat permissive.
Powerful modalities that I frequently use in regression work, such as the affect bridge, Gestalt and ideomotor methods, call for a primarily directive manner, so that is the principal style in this series and in my forthcoming book, Ideomotor Magic in Exploratory Hypnosis. Also, Become the Dream, in integrating Gestalt dreamwork with hypnotherapy, demonstrates the primarily directive style that is appropriate for that form of therapy.
Toward An Accurate Representation of Erickson and the Field of Hypnotherapy
The wild distortions communicated regarding direct vs indirect suggestion are part of a bigger picture. I have great respect for Erickson's genius, and he has contributed enormously to the profession. But history is being dramatically altered by a significant number of Ericksonian therapists, including many prominent leaders, who have had an alarming level of ignorance about vitally important realms of hypnosis history, theory and application. Many talk about Erickson as "The Father of Hypnotherapy." The brochure of a hypnosis school brushed off great ranges of long-established modalities of non-Ericksonian hypnosis with a single sentence about how grateful we can be to Erickson for lifting the field of hypnosis out of the domain of stage hypnosis.
In his contribution to Hypnosis: Questions and Answers, and again in Trancework: An Introduction to the Practice of Clinical Hypnosis, Michael Yapko says there are three major models of hypnosis: Traditional, Standardized and Ericksonian. According to Yapko, the Traditional hypnotherapist has an authoritarian demeanor, demands a high degree of compliance, knows only direct styles of suggestion, does not have an individualized approach to different clients, reacts to resistance through confrontation or interpretation, gives low value to insights, does not recognize the possibility of secondary gains, and has a negative characterization of the subconscious. Yapko's portrayal of the Standardized category is the same kind of caricature given above, except that the demeanor may be permissive.
A writer in Recovering magazine contrasted Ericksonian hypnosis with "standard clinical hypnosis" in which the therapist allegedly merely repeats a series of commands. This "authori-tarian hypnotherapist," who "often uses a technical aide," is assumed to have the answers, and in hypnosis "communication is a one-way street."
Such caricatures did not fit the profession decades ago, and do not fit now. I have taught thousands of hypnotherapists and have discussed hypnotic procedures with hundreds of other hypnotherapists from around the world over several decades. I don't know if I've ever met this "standard clinical hypnotist." Hypnotherapists I've talked with are consistently holistic, doing their best to work comprehensively, including underlying issues. They are familiar with various interactive processes, and the majority use a variety of directive, permissive and indirect styles. However, considering the current proliferation of superficial brief hypnosis trainings (including some Ericksonian-style) that do not conform to the law, surely there are some incompetent non-Ericksonians in practice, just as there are some incompetent Ericksonians.
I have often heard absurd generalizations made by some zealous promoters of technique packages, including claims about the limits of "traditional" hypnotherapy. First, whatever was done decades ago by some stage hypnotists and amateurs is not relevant to the history or traditions of the field of clinical hypnotherapy, a field which had plenty of scientific documentation and many intelligent and creative clinical practitioners before Erickson began to be called The Father of Hypnotherapy. Secondly, there will always be inept or irresponsible practitioners of any form of therapy, and we need to be careful what generalities and conclusions we draw from what we hear. Also, we need to be aware of potential limits and pitfalls of the techniques we do use, recognizing that any system of therapy has its place and its limitations, and needs to be balanced by our sensitivity, creativity, intuition, life experience and knowledge of other forms of therapy.
Milton Erickson is described in the Recovering article as having single-handedly "revived serious scholarly and pragmatic interest in hypnosis in the 1940's." I've repeatedly heard similar kinds of dramatic claims, which consist of two fallacies. First, serious scholarly and pragmatic interest had been continuing prior to that. Second, Erickson was no more influential than some other important hypnotherapists of his time were, until after Jay Haley's Uncommon Therapy was published in 1973. (For example, the word "Ericksonian" did not exist prior to 1974.) During the middle third of the 20th century, hypnotherapists were influenced by a very broad array of hypnotic procedures, including major insights and discoveries of LeCron, Watkins, Kroger, Elman, Weitzenhoffer, Cheek, Boyne, Crasilneck, Wolpe, Wolberg and Hilgard.
Contrary to the article and many other claims I've heard and read, many options of established clinical hypnosis procedures are far more complex than merely giving commands, and various forms are interactive. Here are a few influential examples, which developed from foundations set by interactive processes of the late 19th and early 20th centuries: Elman's pioneering breakthroughs in hypnoanalysis in the 1940's; various uses of ideomotor methods, first developed by LeCron in the 1950's; Wolpe's systematic desensitization techniques, developed in the 1950's; comprehensive emotional clearing strategies, including the integration of Gestalt and other modalities with hypnosis, developed first by Boyne in the 1960's. Traditional texts such as Kroger's Clinical and Experimental Hypnosis (1963) and Cheek and LeCron's Clinical Hypnotherapy (1968), each emphasizing working with underlying and associated issues to presenting problems via a wealth of interactive exploratory, regression and insight oriented interventions, were classic training texts for years before Haley's own classic began the explosion of interest that would soon make Erickson a demigod in some circles.
Many practitioners of named hypnotic styles greatly exaggerate their uniqueness. For example, many "Ericksonian" techniques were used prior to Erickson, and independently by his contemporaries, including various forms of indirect suggestions, metaphors, truisms, encouraging resistance, seeding ideas, double binds, use of space and position, implying a deviation, amnesia, emphasizing the positive, and uncommon homework assignments. The masterful Erickson developed some of his methods in his own way or with greater complexity than they had been used before. But regarding the huge gray area of defining Ericksonian hypnosis, I accept the assertions of those who use such techniques but insist that they are not doing "Ericksonian" hypnosis. Those methods and styles Erickson used that were also used independently by contemporaries or earlier practitioners do not have to be considered "Ericksonian."
I am not criticizing Ericksonian-oriented practitioners as a whole. They have fine tools at their disposal, and there are many who have a broad appreciation of non-Ericksonian modalities. I teach a wide variety of techniques in my classes that could be associated with Erickson, and I have tremendous respect for the man and his brilliant work and great range of accomplishments. It's fine for therapists to emphasize a particular set of methods, but I would like to encourage all hypnotherapists to not limit their training to one or more packages of techniques or styles. For example, most Ericksonian teachers and texts are limited in regression modalities, and unfamiliar with some powerful emotional clearing methods and most of the treasures of ideomotor methods.
There are times when predominantly indirect suggestions may be more effective, and times when predominantly direct suggestions tend to be preferable. As D. Corydon Hammond states, "Hypnosis - like so much of psychotherapy - is still more art than science." Some individuals tend to respond better to one type of suggestion than another, but the majority of people tend to respond well to the skillful use of a range of styles. Often the more important determinant of style is what a person is working on as well as related issues, the stage of therapy, and the primary emphasis of hypnotic work being done in that session (e.g., suggestion, metaphor, regression, exploratory ideomotor, dreamwork, systematic desensitization, and/or the integration of other therapeutic interventions).
My concern lies with hypnotherapists who claim the superiority of their package of techniques, often creating a whipping boy out of the mythical "standard clinical hypnotist." This is not limited to some Ericksonians. For example, such chauvinism has been communicated by some NLP Practitioners. Contrary to the claim that therapists who use a particular brand of hypnosis have a wider range of techniques than others, the opposite is true. If you want to have a truly broad range of options at your disposal, don't limit yourself to one or a few hypnotic orientations. Include tools that are associated with Erickson and others, whether or not your source is directly from such a named system, and integrate therapeutic modalities not generally associated with hypnosis. There is plenty of evidence that relying on a limited range of methods and one approach is usually associated with inexperience as a therapist. In fact, research has found that the most highly experienced therapists ascribe to an eclectic approach, refusing to be limited by adherence to only one orientation.
I have refrained from giving a sampling of disturbing stories from some films I have seen and information told to me by some former clients of Ericksonian therapists. The purpose of such a sampling would have been to emphasize my point about not making generalizations from stories of incompetent or insensitive therapists. But rather than be provocative, I am striving to end inappropriate provocations and encourage peace. My intention is to educate, to help lessen the dissemination of demeaning misinformation, and to encourage hypnotherapists from a wide range of backgrounds and interests to unite in appreciation of the magnificent diversity, range, capabilities and complexities of our great profession.