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Utilizing Ericksonian Hypnosis in Psychiatric-Mental Health Nursing Practice

Zahourek, Rothlyn P., Perspectives in Psychiatric Care TOPIC. Ericksonian hypnosis conceptual framework. PURPOSE. To acquaint psychiatric-mental health nurses with hypnotic principles and how these can be integrated into their practice. SOURCES. Published literature and author's clinical experience. CONCLUSIONS. Ericksonian hypnosis offers an array of potential interventions for psychiatric-mental health nurses to integrate into their practices in a framework familiar to nurses: holism, honoring and respecting individuality, and capitalizing on an individual's strengths. Search terms: Communication, Ericksonian hypnosis, indirect suggestion, psychiatric-mental health nursing practice, suggestion ********** Clinical hypnosis is a therapeutic tool and not a therapy in itself. Thus, it can be incorporated into nearly any form of therapeutic communication or psychotherapy modality. Clinical hypnosis is a process of observing and co-creating states of consciousness with another person and participating in a relationship in which the purpose is some sort of change for that client. Contrary to how Hollywood might present it in a sci-fi movie, hypnosis is not done to another and is not a manipulative power play. If hypnosis were so powerful, we would have a foolproof method to help people change unwanted behaviors and perceptions. Hypnosis differs from relaxation, imagery, and biofeedback modalities in focusing on how and when suggestions are incorporated into the intervention. Hypnosis' long legacy in psychiatry really began with Freud in his development of psychoanalytic theory (Zahourek, 2001). Freud's contemporaries used hypnosis successfully to provide surgical anesthesia before the development of chemical anesthesia. Hypnosis was later used in World Wars I and II to "cure" soldiers experiencing "battle fatigue" (post-traumatic stress disorder) so they could return to the front. To date we still do not know exactly what hypnosis is and why it is successful with some and not others. Theories abound, and well-controlled research continues to yield contradictory and confusing results regarding one form of hypnosis being more effective than another (Mathews, 2000). Most clinical practice continues to rely on theory that has been derived from the many published anecdotal case reports rather than on double-blind controlled studies. Researching hypnosis with its many individualistic and uncontrollable variables is similar to researching psychotherapy itself. Ericksonian hypnosis, developed by psychiatrist Milton Erickson (1901-1980), offers psychiatric nurses a unique opportunity to expand their repertoire of practice. Ericksonian hypnosis is both simple in being an intentional form of communication, and complex in its capacity to help individuals learn self-soothing techniques and to restructure ego defenses and strengths in psychotherapy. The framework is useful for both long-term psychodynamic therapy and for shorter-term, solution-oriented treatment. Ericksonian psychotherapy can be employed with clients who have various diagnoses including anxiety, phobias, habit disorders, depression, and post-traumatic stress. This article explores some of the basic approaches of Ericksonian therapy and offers examples for integrating these into psychotherapy. The focus is on integrating these techniques without formal induction techniques. I hope psychiatric nurses will respond with "aha," stating to themselves, "I already do some of that naturally." A goal subsequently is for nurses to use these tools more intentionally, skillfully, and purposefully in their practice. Further, this approach to psychotherapy and hypnosis draws on a basic psychiatric nursing tenet I was taught in a foundations of nursing class: "All behavior is meaningful, purposeful, and can be understood."

Ericksonian Hypnosis Milton Erickson, considered the father of American hypnosis, developed his unique brand of hypnosis based on approaches he called naturalistic, utilization, and indirect (Erickson & Rossi, 1979). These approaches incorporated the waking trance and the appreciation of such seemingly negative characteristics in psychotherapy as resistance (Yapko, 1995). Naturalistic approach. Erickson had polio as a child and spent time in an iron lung, from which he watched his baby sister learn to walk. He developed acute observational skills that he later used in his theory and clinical practice development. For example, he used his observations of how his sister learned basic skills in his later trance-induction techniques. According to Erickson (Erickson & Rossi, 1979), we learn skills such as walking, bike riding, and swimming one muscle and one step at a time. When we learn these skills, the steps are indelibly imprinted in our nervous systems and become automatic and unconscious behaviors. To become mentally aware of such minute steps takes concentrated work and effort, employing both visual and kinesthetic recall of when and how we learned them. The early learning was so concentrated that it occurred in an altered state of consciousness. As a result, it can be more readily remembered in a trance state. Incorporating such universal and natural experiences into what Erickson believes is a naturally occurring process of altered states of consciousness or trances is called the naturalistic approach (Yapko, 1995). Utilization approach. Erickson believed that everyone's level of awareness--consciousness--varied throughout the normal passage of time. These variations, or circadian and diurnal rhythms, provide a continuum or consciousness from alert waking, to semialert but usually focused trance, to sleep (Rossi, 1991). Stress or crisis alters the level of awareness, catapulting the individual into a trance state in which he or she is more susceptible to new ideas or suggestions. In Ericksonian theory, a formal induction of a trance state that characterizes more traditional forms of hypnosis is not necessary for the individual to become more susceptible and suggestible. In a waking trance, the individual may be as receptive to suggestion as in a deep trance. The utilization approach, basic to Ericksonian hypnotherapy, reflects the theory's tenet, which is to accept the client as a unique individual and appreciate where he or she is. This statement summarizes an important Erickson principle that values individual characteristics, including such phenomenon as resistance and how resistance can be used in psychotherapy. Indirect approach. Another hallmark of Ericksonian hypnosis is the indirect approach, which is distinguished from directive and authoritarian approaches in traditional hypnosis. In such traditional forms, specific suggestions for a behavior change or an outcome usually are given in an authoritative manner. Suggestions such as "relax and soften your muscles; become aware of your breathing; stop smoking now; let the blood flow more easily to your feet; remember a time when you felt in control" are examples of direct approaches. Suggestions constructed indirectly may be unusual in nature. Erickson is known for such indirect interventions as paradoxical intent (Haley, 1973), therapeutic metaphors (Kopp, 1995), and story telling (Lankton & Lankton, 1988; Larkin & Zahourek, 1988), and the creation of a positive atmosphere through "yes sets." The core ideas of Ericksonian hypnotic psychotherapy--utilization, naturalistic approach, the waking trance, appreciating resistance, and indirect suggestion--differentiate it from traditional hypnosis and are also familiar concepts in nursing. Hildegard Peplau (1957/1982), in her classic paper "Therapeutic Concepts," states that psychiatric nurses must have "an understanding of the concepts of awareness and unawareness, attention and inattentions, especially with regard to relations between feelings, thoughts and actions.., to grasp the hidden meaning of symptoms and other forms of communication used by patients ..." (p. 102). Basic Concepts of Traditional and Ericksonian Hypnosis Consciousness. Consciousness is viewed as a highly variable subjective mental state of awareness, and as fundamental neurological processes of perception, sensation, movements, and cognitions (Erickson, 1980). Consciousness varies according to one's interpretation of experience, which in turn depends on one's previous experiences and sociocultural background. Consciousness may be altered purposefully though one's will, or change spontaneously as a result of environmental stimuli. Emotionally charged events and boredom both are associated with such alterations. Alterations occur naturally and are part of everyone's normal experience.

Trance. Trance is a changed state of awareness or consciousness. It varies naturally and continuously. Most people have experienced at least a light trance, such as becoming completely absorbed in a good book and losing track of time and orientation to place. According to Erickson (1967/1989), the degree of trance in a therapeutic situation depends on rapport in the hypnotic relationship, and on the client's need and the circumstances of the interventions. In the trance state, the therapeutic work is done but a deep level is rarely necessary for the success of that work. In Ericksonian hypnosis, change is less dependent on depth than on desire, motivation, and the receptivity to accept the suggestions from another on either a conscious or an unconscious level. A trance is characterized by catalepsy, suggestibility, dissociation, time distortion, and amnesia or hyperamnesia. * Catalepsy is a state of balanced muscle tonicity that allows individuals to remain in one position for long periods of time. A waking trance occurs naturally and appears as an open-eyed glassy stare. The person is able to carry on normal activities. People driving long distances often experience a sense of losing time and wondering how they got from point A to point B; this is a classic example of the waking trance. * Dissociation, while considered to be a characteristic of trance, may also occur naturally without trance induction. It is a natural "ability to break a global experience into its component parts, amplifying awareness for one part while diminishing awareness for others" (Yapko, 1995, p. 115). O'Hanlon (1987) described dissociation as a separation of psychological states: consciousness from unconsciousness, emotions from thoughts, feelings, and behaviors. Erickson (1967/1989) viewed dissociation as a detachment. Therapeutically, dissociation enables an individual to experience past, present, or future painful (physical or emotional) experiences from a distance. It is characterized by a sense of distance, disconnection, numbness, and disbelief. * Time distortion, experienced as time expanded or shrunk, is also a hypnotic trance phenomenon. In hypnosis, the value placed on a past, present, or future experience also can be altered. * Amnesia or hyperamnesia is loss, or intensification, of feeling states and recall. These, too, may be altered in one's present or past experience when using hypnosis. All these trance phenomena may be used therapeutically to anticipate new experiences or to relive old ones in a revised manner. Suggestion. Suggestibility is a central phenomenon of hypnosis. It is an enhanced receptivity to new ideas and an altered responsiveness to stimuli. In order for a person to act on the content of the suggestion, it must be acceptable to the individual. When suggestions are accepted, the person may experience profound changes such as temporary hallucinations and dissociations, deafness, blindness, amnesia, or numbness. Again, these phenomena may be used therapeutically to help people realize the numerous capacities that are available to them in their own consciousness. Giving suggestions is the means of hypnotic communication, which occurs in numerous forms. Direct or indirect suggestions are the most basic forms. A direct suggestion provides specific information or directions that usually includes an outcome (e.g., "You can go to that party tomorrow without feeling anxious"). An indirect suggestion is less authoritative and allows room for interpretation (e.g., "When you attend the next party, you may find you are increasingly comfortable"). In the last example, time (when) and degree of comfort (may, increasingly) are both left vague. The previous suggestion might be made even more indirect by stating, "When you decide to go to a party, you may find it interesting how your feelings have changed." The decision of going to a party, the timing, and the responses anticipated to the whole process are framed positively but the specifics are left nonspecific, allowing the client to fill in the gaps. Because indirect suggestions are believed to bypass resistance, theorists contend that the frequency of using these suggestions should be proportional to the degree of the client's resistance (Zeig, 1980). Indirect suggestions may be integrated or interspersed in conversations and may be based on obvious truths that the

client will find agreeable. These are described in Ericksonian theory as interspersed, truisms, and yes set suggestions. In practice, Erickson and most clinicians use a blend of direct and indirect suggestions. In normal interactions, people use suggestions all the time. Suggestions are more powerful when the individual's level of awareness has shifted (a trance state). Observing for these subtle changes provides opportunity for clinicians to make therapeutic comments (suggestions) that have greater potential for realization than those given in usual conversation. The therapist's tone, movements, change of cadence and rhythm of speech, and demeanor can "anchor" or reinforce the suggestion (Bandler & Grinder, 1979). Anchoring provides an additional nonverbal form of suggestion that evolves naturally out of the process of the interaction and is used intentionally by the therapist. Basic Ericksonian Concepts of Hypnotherapy The heart of Ericksonian hypnotherapy is the utilizationy concept, or "accept and utilize" (Yapko, 1986, 1990). In practice this is an expanded version of accept the client where he/she is and plan and execute every intervention based on that knowledge. The utilization approach depends on a knowledge and understanding of the patient as a total psychosocial-spiritual-sociocultural being who has values and behaviors in concert with that wholeness. Utilization is also a holistic process of "incorporating aspects of the client's existing behavior and perceptions, current and past relationships, life experiences, innate and learned skills, and abilities into the therapeutic change process" (Dolan, 1985, p. 6). The utilization approach is truly "walking in another's shoes." It is a way of both viewing and interacting with the client, and requires the therapist's respect of the person as well as an understanding and acceptance of him- or herself. In this framework of respect, the therapist accepts the meaning and value of the client's resistance and appreciates the unconscious need to keep symptoms even when the client consciously wishes to be rid of them. The utilization approach helps the client transpose symptoms into something more friendly, familiar, and manageable so that the individual feels more in control. Yapko (1986) summarizes the characteristics of the utilization approach as follows: (a) each person is valued as unique, (b) the client's experience is valid for him or her, (c) each person assigns meaning to his or her experiences based on the person's unique frame of reference, and (d) a way to "accept and utilize" is to join the person at his or her flame of reference. One manifestation of this is to use the client's form of language. Reframing. As an Ericksonian approach, reframing reflects the principle of accept, utilize, and modify. A common example of reframing is viewing one's situation in a different context (e.g., a crisis as both a dangerous event and an opportunity for growth). Ericksonian psychotherapy is inherently optimistic. It contends that change is possible and, in fact, inevitable. "Ericksonian utilization, with its inherent perspective of optimism and non-judgmental posture, offers as antidote for the demoralization that handicaps therapists working with clients labeled chronic and resistant" (Dolan, 1985, p. 2). Ericksonian naturalistic approaches focus on the here and now and everyday experiences. These common experiences are used as precursors to trance. The client's "naturally occurring behavior in the here and now.., is used to absorb attention, redirect it inward, and induce trance" (Edgette & Edgette, 1995, p. 9). The therapist's incorporating natural internal experiences such as memories, images, and kinesthetic sensations to induce trance facilitates that process. Using an Ericksonian approach, the therapist creates an optimistic futuresolutions orientation that is based on the recognition of the client's resources rather than on liabilities or past problems (Edgette & Edgette, p. 9). The Process of Ericksonian Hypnosis The process of Ericksonian psychotherapy is similar to psychotherapy but emphasizes both client and therapist awareness and subtle behaviors. * The therapist learns about the client's background, culture, processes of learning, areas of stuckness and resistance, desires and goals, strengths, and talents. This is essential for the process to begin.

* The therapist secures and maintains the client's attention by talking with the client about what brought him or her to treatment, "telling absorbing stories that parallel the client's experience," or by doing "something unexpected" (Yapko, 1995, p. 100). * The therapist notices the increased signs of the client's focused attention (e.g., changed breathing, glassy-eyed stare, catalepsy). * The therapist can deepen the state using direct and indirect suggestions such as saying, "That's right; I can see you are really contemplating this matter. Can you allow yourself to find a new way to view this situation-maybe something you did in the past or maybe from the ideal, or from the perspective of how you would like to see the resolution, or maybe through the view of someone else that you care about? How would that person interpret the situation?" * The client engages in a mental internal search, using past experiences and the vision of a future resolution. This internal search encourages the person to conduct a review of resources from within as well as from others who are both idealized and valued or from those who may hold opposing views and values. * The therapist paces with the client. He or she may breathe in the same rhythm or sit in the same posture. The goal of pacing is to sense as much as possible how the client is feeling. * The therapist leads the client into deepening the experience and considering new possibilities (e.g., "Allow yourself to more deeply appreciate your experience. Can you enhance it even more?"). * The client experiences an unconscious search, and his or her perspective begins to expand. * The client's imagery may be engaged, through which experiential, problem-solving, and behavioral rehearsal is possible. * The therapist reinforces the experience (e.g., "You have accessed a new part of yourself that has infinite possibilities ..."). * The therapist provides posthypnotic suggestions (e.g., "You have accessed a new part of yourself that has infinite possibilities ... to help you solve past, current, and future problems.... You may find newer solutions as time goes on and you will find this experience accessible to you in your memory bank of problem-solving tools that you can use any time you so desire."). According to Yapko (1995), posthypnotic suggestions form a necessary bridge for the client to convert the internal, hypnotic-state, specific suggestions into external future perceptions, cognitions, feeling states, and behaviors (p. 77). * The therapist helps the client associate this experience with future problem-solving capacities. Ericksonian Techniques Within the above process, Ericksonian techniques of therapy are evident. Many have been described in the literature. The following are illustrative clinical vignettes. Utilization. Ms. Paul is relating how much she did not want to take a midwinter trip to visit her parents in a Florida retirement community. She states, "I should be grateful. Everyone wants to leave the ice and snow and go to Florida. But I'm dreading it. I feel guilty. Lots of people would love this opportunity." She sat quietly staring off into space, her breathing more shallow as she appeared to be visualizing some aspect of the trip. The therapist responded, "Well, maybe some people would be grateful to get away from the cold [agreeing with the client and not countering her experience; joining the resistance], but how many people do you know find it fun when they're in their 30s to visit a retirement community even if it is warmer [adding an element of doubt; creating a yes set]?" She thought about that and stated, "Gee, I don't know anybody who would want to do that! Maybe I'm not so different." This is a very brief example of not confronting the resistance, "I need to feel guilty

and ungrateful. And I am surely different form everyone else," with "Maybe I am not so different; is that possible? Maybe I don't need to feel so guilty." Reframing and utilization. A client in a dual-diagnosis program for substance abuse and mental illness had been encouraged to take Antabuse to curb his relapsing course with drinking alcohol. He was resistant and stated he was too anxious. The therapist stated, "You know, this medication does not only react badly with alcohol; it is also an antianxiolytic." The client looked at the therapist as if she were crazy, knowing full well that the medication was not classified as antianxiety. The therapist had his full attention and stated, "You know that if you don't have to worry so much about drinking that you will be less anxious; antabuse is an antianxiety med in that sense." The client laughed and still resisted. Two weeks later he stated, "I want to take that antianxiety medication you talked about." This is an example of reframing and utilization of the client's resistance and using humorous metaphor. Metaphors. A metaphor is a term that stands for something other than its usual meaning. Metaphors can be powerful psychotherapeutic tools. Often, metaphors help clients circumvent resistance and help them see things in a different light. They may be used as a tool to enable a reframing process. When perceptions change, feeling states are likely to change as well. Clients then are more able to think about new approaches and behaviors. Common metaphors act as lenses and filters for viewing reality. Seeing the glass `full' or `empty' is a common metaphor for optimism and pessimism. Learning basic skills and progressing normal processes such as the seasons or growth and development are common metaphors for change. Metaphors of machinery and maintenance of machinery may be metaphors for self-care and survival under adverse circumstances (Larkin & Zahourek, 1988). For example, Sally had suffered a brain injury in an accident and had been trying to adjust several years to her inability to withstand stimuli. She described feeling flooded and overwhelmed, and that her filter no longer worked. The therapist felt the filter metaphor would be useful to help her develop increased capability to withstand stimuli. The therapist asked the client to describe the filter as she experienced it in the present. Sally concentrated on the image and exhibited a glassy-eyed stare as she described the filter as "It's like an old wire mesh kitchen sieve; it has holes in it and it's rusty and dilapidated." The therapist asked, "What would a brand new one look like that you just bought at the hardware store?" Sally responded, "It's shiny stainless steel, very strong, and all the holes are uniform and even; it's easy to work with because it has a nice sturdy wooden handle." The added metaphor of a sturdy handle indicated a potential for her having control over "her new mental metal filter." She enjoyed the image and the metaphor of being able to screen out stimuli when she needed. She used this successfully in many situations when she felt potentially overwhelmed. Integrating suggestions into conversation. During the course of a therapy session in which John was struggling with trying to decide what to do with his problematic marriage, the therapist asked him to stop for a moment and sit quietly. She changed the tone of her voice, setting the stage for a change in the level of their awareness and stated, "You have many options, and several are painful to consider. Have you in the past ever been plagued with a decision and decided to just `sleep on it'? Isn't it amazing how the next morning, or maybe even the next afternoon, you get a `mental flash' and you know exactly what to do? The decision is made and it just `feels right.' I wonder if some night before you go to sleep you might consider trying that and see what happens." This is a set of indirect suggestions that include establishing a "yes set" with a "truism" (you have many options and if you "sleep on something" the answer comes). The process is permissive in asking the client "if" he wants to try "some" night. It is left up to John to decide when, and if, he will try. The realization of the suggestion is more probable since the suggestion is based on an already familiar experience. Paradoxical suggestions. A paradoxical suggestion joins with the client's resistance and encourages the client to accentuate what he/she has been trying to change. This often demonstrates to clients that they, in fact, do have more power and control than they thought. Paradoxical suggestions have to be used carefully. A therapist would not want to increase a behavior that is potentially life-threatening, such as drinking alcohol or taking illicit drugs. Paradoxical suggestions might be used with an obsessive compulsive who is having trouble with repetitive thoughts or behaviors. Initially the therapist can say, "You have struggled for years not to count every book on my bookshelf. Why don't you take time now to count them twice and let me know when you are finished."

Precautions for Integrating Hypnotic Techniques While hypnosis is considered to be a safe intervention for most psychiatric disorders and for many medical conditions, nurses should be cautious about using formal trance inductions and suggestions without formal training in hypnosis and a background in psychiatric nursing. Novice clinicians should avoid clients who are psychotic, severely character disordered, exceptionally dependent, or have suffered severe trauma and abuse, and those who may develop an eroticized transference toward the therapist. These conditions are especially risky because of the potential for the emergence of primitive and overwhelming affective states and subsequent personality disorganization (Edgette & Edgette, 1995). Literature and research exist on hypnotic applications from both a clinical and a legal perspective (Scheflin & Shapiro, 1989). Training is available through numerous resources, including the American Society of Clinical Hypnosis and The Milton H. Erickson Foundation in Phoenix, AZ. Many universities and medical schools provide workshops, courses, and training. Few nursing programs at present offer specific content in clinical hypnosis, although many teach relaxation and guided imagery as well as techniques for communication. Conclusion Ericksonian hypnotic techniques offer an array of potential interventions for the psychiatric-mental health nurse to integrate into practice. Furthermore, the approaches are based in a theoretical framework that is familiar to nurses: holism, honoring and respecting individuality, and capitalizing on an individual's strengths rather than weaknesses. An appreciation for alterations in level of awareness and the therapeutic use of suggestion may enhance all caregivers' practices. Psychiatric nurses will find numerous opportunities to implement the concepts and interventions described in Ericksonian hypnosis. References Bandler, R., & Grinder, J. (1979). Frogs into princes: Neurolinguistic programming. Moab, IFF: Real People Press. Dolan, I.M. (1985). The path with a heart. New York: Brunner Mazel. Edgette, J.H., & Edgette, J.S. (1995). The handbook of hypnotic phenomena in psychotherapy. New York: Brunner Mazel. Erickson, M. (1980). A special inquiry with Aldous Huxley into the nature and character of various states of consciousness. In E. Rossi (Ed.), The collected papers of Milton H. Erickson on hypnosis: Vol 1. The nature of hypnosis and suggestion (pp. 83-107). New York: Irvington Press. Erickson, M. (1989). Hypnosis. In S. Lankton (Ed.), Ericksonian monographs #5: Ericksonian hypnosis application, preparation, and research. New York: Brunner Mazel. (Reprinted from Encyclopedia Britannica [14th ed., 1967]) Erickson, M.H., & Rossi, E.L. (1979). Hypnotherapy: An exploratory casebook. New York: Irvington Publishers. Haley, J. (1973). Uncommon therapy. New York: Norton. Kopp, R.R. (1995). Metaphor therapy: Using client centered metaphors in psychotherapy. New York: Brunner Mazel. Lankton, C., & Lankton, S. (1988). Tales of enchantment: Goal-oriented metaphors for adults and children in psychotherapy. New York: Brunner Mazel. Larkin, D.N., & Zahourek, R.P. (1988). Therapeutic storytelling and metaphors. Holistic Nursing Practice, 2(3), 45-53.

Mathews, W.J. (2000). Ericksonian approaches to hypnosis and therapy: Where are we now? International Journal of Clinical and Experimental Hypnosis, 48, 418-427. O'Hanlon, W.H. (1987). Taproots: Underlying principles of Milton Erickson's therapy and hypnosis. New York: Norton. Peplau, H. (1982). Therapeutic concepts [Aspects of Psychiatric Nursing, League Exchange: No. 26, section B]. In S. Smoyak & S. Rouslin (Eds.), A collection of classics in psychiatric nursing literature (pp. 91-108). Thorofare, NJ: Slack. (Original work published 1957) Rossi, E. (1991). The 20 minute break: Using the new science of ultradian rhythms. Los Angeles: Tarcher. Scheflin, A.W., & Shapiro, J.L. (1989). Trance on trial. New York: Guilford Press. Yapko, M. (1986). Ericksonian hypnosis. In B. Zibergeld, G. Edelstein, & D. Araoz (Eds.), Hypnosis: Questions and answers (pp. 223-231). New York: Norton. Yapko, M. (1990). Trancework: An introduction to the practice of clinical hypnosis. New York: Brunner Mazel. Yapko, M. (1995). Essentials of hypnosis. New York: Brunner Mazel. Zahourek, R.P. (2001). Trance and suggestion: Timeless interventions and implications for nurses in the new millennium. Holistic Nursing Practice, 15(3), 1-10. Zeig, J. (Ed.). (1980). Teaching seminar with Milton H. Erickson, M.D. New York: Brunner Mazel. Rothlyn P. Zahourek, PhD, RN, CS, HNC, is a Junior Research Associate, New York University, Division of Nursing, New York, and has a private psychotherapy consultative practice in Amherst, MA. Author contact: rorryz@aol.com, with a copy to the Editor: mary77@concentric.net