The Pretend Technique: Asking Clients to Fake Their Symptom

We define a symptom as a behavior that the client claims is beyond their voluntary control. We see this when a person describes a panic attack as something that happens to them rather than something they do. We see it when a child claims they cannot stop wetting the bed or when a husband insists he cannot stop his temper from flaring. In our tradition, we view these symptoms as strategies within a social system. They are communications that have become rigid. When you encounter a client who is stuck in this pattern, you must change the nature of the symptom from an involuntary event to a voluntary act. Jay Haley developed a method for this that we call the pretend technique. This intervention is more subtle than the direct symptom prescription. We do not tell the client to have the symptom. We tell the client to pretend to have the symptom.

I once worked with a young man who suffered from frequent, sudden bouts of chest pain. Medical doctors had cleared him of any heart condition, yet he remained convinced that his chest would tighten at any moment. He lived in constant fear of these episodes. During our third session, I told him that I needed to see exactly how these pains started so that I could understand his physiology better. I instructed him to sit in the hard wooden chair in the corner of my office. I told him that for the next five minutes, he was to pretend as hard as he could that he was having a chest pain episode. I told him to mimic the breathing, the facial contorted look, and the way he clutched his shirt. He was hesitant at first. He told me that he did not want to trigger a real attack. I insisted. I told him that if he could not show me a fake one, I could not help him with the real one. He began to pretend. He tightened his jaw and started to pant. He gripped his chest. After three minutes, he stopped and laughed. He realized that while he was pretending to have the pain, the fear was absent.

We use this technique because it creates a paradox that the client cannot easily solve. If the client pretends to have the symptom and the symptom occurs, the client is doing it on purpose. If the client pretends to have the symptom and the symptom does not occur, then the client has shown that the symptom is under their control. Either way, the involuntary nature of the problem is compromised. You are not asking for a miracle. You are asking for a performance. This performance changes the power structure of the problem. When you give this directive, you must maintain a professional and serious demeanor. You cannot let the client think this is a joke or a game of make believe. You must frame it as a necessary clinical observation.

You should use the pretend technique when the client is highly resistant or when a direct prescription might be too heavy for the relationship. I remember a case involving a ten year old boy who had a habit of yelling at his mother whenever she asked him to do his homework. The mother was exhausted. I saw them together in my office. I told the boy that I wanted him to practice his yelling so that his mother could get used to the sound of it. I told him that every afternoon at four o’clock, he must go into the living room and pretend to be angry at his mother for ten minutes. I told the mother that she must sit on the sofa and pretend to be upset by his yelling. They were required to do this even if they were having a good day. The boy found it difficult to stay angry on command. By the fourth day, he told his mother that he was too tired to do the pretend yelling. When the time for the actual homework came, the boy did not yell. He had already exhausted the behavior during the pretend session.

We recognize that symptoms often serve a function in a relationship. A child who has a symptom often brings the parents together to focus on the child rather than on their own marital struggles. If you ask the child to pretend to have the symptom, the parents must also pretend to help. This faking of the entire sequence exposes the repetitive nature of the family interaction. It makes the secret purpose of the symptom visible to everyone in the room without you having to explain it with theory. You do not need to tell the family that the child is helping the parents. You only need to have them pretend the sequence.

You must be precise in your instructions. When you give a pretend directive, specify the time, the place, and the duration. Tell the client to pretend to have a headache every Tuesday and Thursday at seven o’clock in the evening. Tell them to do it for exactly fifteen minutes. Instruct them to tell their spouse that they are now going to pretend to have a headache. The spouse must then pretend to offer comfort. I once gave this instruction to a woman who used her migraines to avoid social gatherings that made her anxious. I told her that she must pretend to have a migraine before a dinner party that she actually wanted to attend. She had to lie down in a dark room and have her husband bring her a cool cloth while she pretended to be in pain. After ten minutes of this, she found the charade so ridiculous that she got up, dressed herself, and went to the party. The symptom had lost its utility because it was no longer a mysterious force. It was a chore.

We often use the pretend technique to handle problems that seem stuck in a cycle of pity. When a client receives a lot of sympathy for their symptom, they have a strong incentive to keep it. By making the symptom a pretend act, you remove the payoff of genuine sympathy. The people around the client are now pretending to be sympathetic. This creates a strange atmosphere in the home. It is very hard to maintain a symptom when everyone knows that the behavior might just be a practice session. You are essentially teaching the client and their family that they have a choice in how they respond to one another.

Milton Erickson often used these types of indirect tasks to bypass the conscious resistance of a person. He knew that if you fight a symptom head on, the symptom usually wins. If you join the symptom or ask the client to mimic it, you are moving with the energy of the problem rather than against it. You should watch the client’s body language closely when you suggest the pretend task. If the client smiles or looks confused, you are on the right track. If they become angry, you must double down on the clinical necessity of the task. Tell them that you cannot treat a symptom that you have not seen in action. The client who can fake a panic attack for ten minutes has already lost the ability to claim the attack is a spontaneous disaster.

When you move the pretend technique into the context of a couple or a family, you change the power balance of the entire household. We know that a symptom often functions as a stabilizer for a relationship that cannot otherwise handle direct conflict. If a wife suffers from frequent bouts of weeping and helplessness, the husband must step into the role of the protector. This arrangement defines their hierarchy. He is the capable one and she is the one in need of rescue. You disrupt this rigid structure by instructing the wife to pretend to have a weeping spell at a specific time, such as six o’clock every Tuesday evening. When the symptom becomes a scheduled performance, the husband’s response must also become a performance. You tell the husband that when his wife begins her scheduled weeping, he is to sit with her, hold her hand, and offer the exact words of comfort he usually provides. Because both parties know the distress is a pretense, the husband is no longer a spontaneous rescuer and the wife is no longer a spontaneous victim. They are both actors in a play. This makes the helpful behavior as artificial as the symptom.

I once worked with a couple where the husband claimed he was unable to drive on highways because of sudden, overwhelming sensations of dizziness. This limitation forced his wife to drive him to every business meeting and social event. The wife complained about the burden, yet she never refused to drive him. To break this cycle, I instructed the husband to pretend to feel dizzy for fifteen minutes before they left the house for any appointment. He was to sit on the sofa and describe his pretend dizziness in great detail while his wife practiced her supportive listening. I told the wife she must listen with a concerned expression even though she knew he was faking the sensation. After three days, the husband reported that the pretense was more exhausting than the dizziness itself. He found it difficult to maintain the performance while his wife watched him with a knowing smile. By making the dizziness a chore, we removed its utility as a method of control. You will find that clients often give up a symptom when the social cost of pretending it outweighs the benefits of having it.

You must be precise when you deliver the instructions for the pretend performance. If you are vague, the client will find ways to avoid the task. You specify the location, the duration, and the required audience. We use the pretend technique to make the symptom a burdensome obligation. For a child who refuses to go to sleep because of pretend fears of the dark, you instruct the parents to have the child pretend to be afraid for twenty minutes every afternoon at four o’clock. The child must sit in a darkened room and call out for the parents. The parents must go to the child and offer comfort just as they do at midnight. When the child has to work at being afraid during a time when they would rather be playing, the midnight fears lose their appeal. You are shifting the symptom from the category of an uncontrollable event to the category of a dull assignment.

When we work with families, we observe how the symptom keeps the members engaged with one another in a repetitive loop. A child who develops a persistent cough with no medical basis may be drawing the attention of two parents who are on the verge of a separation. The cough forces the parents to stop arguing and focus on the child. In this situation, you instruct the child to pretend to cough for ten minutes every time the parents begin to discuss a difficult topic. You tell the parents that they must stop their conversation and attend to the child’s pretend cough by offering a glass of water and checking the child’s temperature. This directive makes the underlying function of the symptom explicit. The parents quickly realize that the child is monitoring their tension levels. Once the function of the cough is brought into the realm of a scheduled performance, the child often stops the behavior because it no longer serves to protect the parents. The parents are then forced to deal with their own conflict without the distraction of a sick child.

I worked with a woman who suffered from what she called a paralyzed will which prevented her from cleaning her house or completing her work assignments. She lived with a roommate who constantly nagged her to be more productive. I instructed the woman to spend thirty minutes every morning pretending to be paralyzed by indecision. She was to sit in a chair in the middle of the kitchen and stare at a pile of unwashed dishes. I told the roommate that she must stand next to the chair and provide five minutes of encouragement, followed by five minutes of criticism. They were to follow this script exactly. This intervention changed the nagging from a spontaneous reaction into a formal requirement. The woman found that she could not stand the scheduled nagging. By the third day, she began cleaning the dishes before the scheduled time just to avoid the performance. You are looking for the moment when the client decides that being functional is easier than being a performer.

We often use the pretend technique to address issues of inadequacy in professional settings. You might work with a manager who feels like an impostor and fears speaking up in meetings. You instruct this manager to go into the next meeting and pretend to be a person who is confused by the topic of discussion. They must ask three questions that they already know the answers to, acting as if they are struggling to grasp the concept. This forces the manager to take the lead in a social interaction under the guise of being incompetent. By pretending to be less capable than they are, they gain control over the social environment. They observe how others react to their questions and they realize that they can influence the flow of the meeting. The fear of being seen as inadequate vanishes because they are now choosing when and how to display that inadequacy.

You must remain serious when you give these directives. If you treat the pretend technique as a joke, the client will not follow through. You present the task as a necessary clinical observation. You tell the client that you need to see exactly how they produce the symptom so that you can understand its mechanics. This frame makes the client an assistant in the clinical process. I once had a client who suffered from a facial tic that happened whenever he felt judged. I asked him to produce the tic on command for five minutes while I watched him through a magnifying glass. I told him I needed to see which specific muscles were involved. He found it nearly impossible to replicate the tic voluntarily with that level of scrutiny. When he could not do it, I asked him to keep trying until he was exhausted. This changed his relationship to the tic. It was no longer something that happened to him. It was something he failed to do well under pressure.

We apply the pretend technique to depression by asking the client to schedule their sadness. You instruct the client to spend one hour every morning from eight to nine pretending to be at their lowest point. They must stay in bed, pull the covers over their head, and think only of their failures. If they live with a partner, the partner must come in every fifteen minutes and ask if there is anything they can do to help. The client must respond that there is no hope. By the time the hour is over, the client has usually had enough of being sad. They have fulfilled their quota for the day. You are using the principle of satiation to reduce the frequency of the symptom. When the client is forced to be sad on a schedule, they often find themselves wanting to be productive during the rest of the day.

The timing of the follow up session is vital. You do not ask the client how they felt about the task. You ask them for a detailed report on how the performance went. You ask how many times they succeeded in pretending and how many times they forgot to pretend. If the client reports that they forgot to have the symptom, you congratulate them on their progress in gaining control over their schedule. If they report that they performed the task perfectly, you increase the duration of the performance for the next week. You continue to expand the requirement until the client finds the pretense so intrusive that they would rather be well. The power of the pretend technique lies in its ability to make the symptom a chore that the client no longer wishes to perform. We are not interested in the client’s insight into why they have the symptom. We are interested in the client’s decision to stop having it.

You can use the pretend technique to manage anger in a household. I worked with a father who had frequent outbursts of temper that frightened his children. I instructed him that every Wednesday at dinner, he was to pretend to be angry about the way the table was set. He had to raise his voice and gesture wildly for three minutes. I told the children that their father was practicing his acting skills and that they were to watch him and give him a grade on his performance from one to ten. The father found that he could not maintain a threatening presence while his children were evaluating his technique. The anger lost its power because it was no longer a genuine threat. It was an awkward performance. This intervention stripped the anger of its ability to intimidate. The father became more aware of his behavior and the children became less afraid of his outbursts.

When you use this technique with a client who has a history of trauma, you focus on the present behavior rather than the past event. You do not ask the client to pretend to be traumatized. You ask them to pretend to have the specific modern symptom that bothers them today, such as a jumpy reaction to loud noises. You instruct them to spend ten minutes a day pretending to be startled by every sound in their house. They must exaggerate their physical reaction. This allows the client to practice the physical movements of the symptom in a safe, controlled way. By performing the startle response on purpose, the client begins to feel that the response is a physical act they can modulate. We are moving the client from being a victim of a reflex to being a master of a movement.

We observe that the pretend technique is most effective when the practitioner remains detached and focused on the data. You do not offer sympathy when the client describes how difficult the task was. You treat the difficulty as a technical problem to be solved in the next session. If the client says they felt silly, you tell them that feeling silly is a common side effect of the initial stages of this particular clinical protocol. This keeps the focus on the strategy and away from the client’s resistance. You are not arguing with the client about their symptoms. You are giving them a new way to use them. The client’s struggle to follow the instruction is more important than the symptom itself because it signifies that the old patterns are being disrupted. You are looking for the moment when the client realizes that they are the one deciding when to weep, when to be afraid, or when to be angry. A symptom that is produced on demand is no longer a symptom. It is a choice. A man who can fake a heart palpitation on Tuesday at four o’clock is a man who knows he is not dying.

We often find that the most difficult stage of the pretend technique is the moment the client realizes the symptom has lost its power to alarm the social circle. You must prepare the client for this void. When a daughter stops faking a headache, her mother may find she has nothing to do with her evenings. You must then give the mother a task to fill that space, or she will inadvertently encourage the daughter to return to the symptom. We use the follow-up sessions to observe how the family rearranges itself without the crisis. You might instruct the mother to spend those evenings reading a book in the same room as the daughter, but without speaking.

I once worked with a family where the father used his chronic back pain to avoid household chores and to keep his wife from going out with her friends. I told the father to fake a back spasm every Saturday at ten. I told the wife that when he did this, she was to assist him to the recliner and then proceed to leave the house for two hours to run errands. Because the spasm was a scheduled pretend, the wife did not feel guilty for leaving, and the husband could not feel resentful because he was merely following my instructions. Within three weeks, the father reported his back felt much better and he no longer needed the task. He had lost the utility of the pain. We see this often: when the symptom no longer produces the desired social effect, it vanishes.

You must be careful to frame the pretend technique as a diagnostic tool. You tell the client you need to see the symptom in a controlled environment. This prevents the client from feeling that you are making light of their suffering. If a man suffers from social anxiety, you ask him to go to a coffee shop and pretend to be nervous. You tell him to specifically shake his hands while holding his cup and to look at the floor when the cashier speaks. When he returns, you ask him for a detailed report on which muscles he had to tense to look authentically nervous. We find that this level of detail forces the client into a meta-position. He is no longer the anxious man. He is the observer of an anxious performance.

I worked with a woman who had a phobia of elevators. I told her to go to a local department store and stand near the elevator. She was to pretend she was about to have a panic attack every time the doors opened. She had to breathe rapidly and clutch her purse. I told her to do this for thirty minutes. She came back to the next session and told me she could only do it for ten minutes because she felt silly. I told her that her inability to finish the task was a serious setback and that she must try again, this time for forty-five minutes. She realized that she could not sustain the panic when it was a requirement.

We use the pretend technique to highlight the hierarchy of the family. In many cases, a child uses a symptom to take charge of the parents. A child who refuses to eat is often the person with the most power in the kitchen. You change this by telling the parents to tell the child to pretend to refuse to eat. The parents are giving the orders, even if the order is to be difficult. This restores the proper hierarchy. The child is now being obedient by being difficult. When you prescribe the behavior you want to change, you take control of it.

I recall a case involving a teenage boy who was constantly lying to his parents about his grades. I told the boy that he must tell one lie every day at dinner, and he must tell his parents it is a lie after he says it. The parents were to thank him for the lie and then discuss something else. This removed the drama of the discovery. The boy found that lying was no longer an exciting way to rebel. It was just a boring part of the dinner conversation.

You must watch for the moment when the client tries to reclaim the symptom as a real event. They might say, “I know you told me to fake the headache, but yesterday I had a real one.” We respond by treating the real headache as an excellent performance of the fake one. We say, “You did such a good job faking it that you even fooled yourself.” This keeps the behavior within the category of the voluntary. You do not allow the client to slip back into the role of the helpless victim. You are the director, and they are the lead actor. Everything that happens in their life is part of the play you are producing together.

The final stage of the intervention is the disappearance of the symptom. You do not announce a cure. You simply observe that the client has stopped performing the tasks. You might say, “I noticed you didn’t have time to fake your anxiety this week. I hope we haven’t lost our focus on the study.” The client will usually shrug and say they just didn’t feel like doing it anymore. This is the goal. The symptom has become a choice, and the client has chosen to stop. We do not need to talk about why they had the symptom in the first place. We only care that the symptom is no longer necessary for the family system to function.

We observe that the practitioner who masters this technique becomes a master of the social sequence. You are not a person who listens to problems. You are a person who designs solutions by rearranging the pieces of the client’s life. When a client fakes a symptom, they are engaging in a creative act. They are taking the raw material of their suffering and turning it into a deliberate performance. This is the highest form of control. A woman who can fake a panic attack on a crowded bus is a woman who no longer fears the bus. She has turned her terror into a technical exercise that she can start and stop at will.

I have seen a man with a fear of germs find that by faking his hand washing for us, the urge to wash lost its force and became a redundant task he no longer enjoyed at all.