» Treating the “Contra-indicated”. Reflections in treating difficult clients
J. Shaul Livnay (Weisbrot) PhD
Those very patients, who we usually purport to fit the categories of contra-indications to the use of hypnosis, are those who often are the most demanding the use of hypnosis when they turn to me for treatment. During the past few years, the latter have been referred to me at an augmented pace. As I begin the process of intake with these patients, I am often struck with a contradiction: their level of organization bespeaks of alarm signals for standard hypnotic approaches. Yet, the medium of hypnotic communication is what speaks most to them. The paper will deal with this basic dilemma, delineating the courses of action that I have developed, as well as the modifications in approach required.
During the past few years, I have discerned a certain trend in referrals: More and more individuals turn to me for help, whom I would have usually classified as belonging within the categories of contra-indication for the use of hypnosis. Yet these very same individuals seem to strike a chord which eventually leads me to attempt to integrate hypnosis in their treatment. This presentation will deal with the process we undergo in assessment and treatment modification in order to adapt a hypnotic approach in the treatment process.
It usually begins with a certain note of desperation in the first contact on the phone. Choosing hypnosis entails the last hope for these clients, and is mixed with pressure to comply, to deliver the goods. I usually feel an instinctual wince and withdrawal, mixed with fear of contributing to a sense of further deterioration by utilizing “my powerful tools”. I have been brought up to recognize the latter to be “contra-indicated” in cases of poor organization, depression, paranoia and proclivity to decompensation into psychosis.
It continues during the first meeting, when I begin to take in the person in his or her entirety, & become impressed with his or her genuine needs and striving for betterment.
Again & again, I find myself “seduced” by such a patient: Upon hearing their background & needs, I find myself hesitantly and warily agreeing to use hypnosis.
It is clear to me that some very powerful counter-transferential themes are very quickly being elicited in me, around the different relational dimensions which Diamond (1987) delineated, characterize the hypnotic experience:
1.Transference, 2. Therapeutic alliance (rational, as well as irrational), 3. Fusional – symbiotic, & 4. Real relationship.
Smith (1984) emphasized the importance of the therapist initially allowing him or herself to get “sucked in” in order to obtain formulations which further the fuller understanding of the patient. He describes the use of the curative fantasy, which the patient introduces through the content and means of relating his request, as well as by the affects aroused in the therapist.
Diamond (1984) notes with admiration how the hypnotherapist has to gather up the courage to both tolerate and to experience unconscious affects and images of the patient within himself, to tolerate the pain and the uncertainty, while remaining strong, stable, and good enough to support and direct the healing journey.
Watkins & Watkins (2000) emphasize the therapist’s readiness to enter the alliance with the patient embarking on abreaction. They emphasize the power of the therapist’s self, the willingness to resonate and actively enter the situation which creates the possibility of a corrective experience. Co-experiencing.
Baker (2000) expands upon the intricate dynamics at play in the hypnotic relationship in delineating the transitional space in which the therapy envelops. He emphasizes the relational dynamics of containment, attunement and projective identification at play in the transitional space.
Carolusson (1999) suggests a more individual assessment of the patient going beyond DSM IV nomenclature, to include obstacles to health, motivation, behavior & feelings in the interview, attitude to having problems, & history of relationships, inner drama of early relations, self image, & resources.
A perusal of the different cases which I have treated highlights several identifying characteristics which typify these patients:
They have been in therapy for many years, upon several different occasions, though each time emerging with a sense of lack of satisfaction or fulfillment.
All tend to be suspicious of, as well as fed up with verbal therapies. Often they tout verbal prowess and admit to being able to fool, suck in the therapist to continue to do more of the same, without progressing.
Each is longing for powerful intervention, which will overcome the usual ploys, as well as empower them to overcome their inadequacies and insufficiencies.
They all long to be filled and refueled. The themes of emptiness, depression and abandonment are quite prevalent. There is a kind of addictive equivalent in the air.
Each present serious difficulties in being in contact, whether it is with others, or with themselves. They come with a plea: Connect me to myself & others
What modifications are necessary?
During the past ten years, I have developed several approaches and focal themes in my work with these clients. Though the former may seem applicable to most clients, they are most salient and vital with the latter.
Amplification/attenuation of affect
. As these clients have difficulties modulating and regulating their emotions and affects, I often deem it necessary to aid them to “get a handle” on affects, intrusive thoughts, stress: One direction which I have developed I have called the “Control Panel” (Livnay, 1996). The latter provides a metaphor which is hands on, to feel that you can begin to control the uncontrollable, through imagining a panel of dials, each of which has an imaginary effect a specific dimension of how the client experiences a situation (visual, auditory, kinesthetic etc.). By providing an open-ended format, which invites personal “translation”, each patient can ponder his uniqueness, approach, style in “tuning in/out” and thereby reduce avoidance of problematic areas or interactions and or relationships.
Razi had a tendency to externalize his ruminative thoughts to the form of “devils” in his right hemisphere. This was in line with his religious mysticism. I decided to invite him to get control over what he partially feared to be an auditory hallucination, through “installing” the control panel. As he was quite suggestible, the format rapidly gave him some control over his ruminations, and led to a much-needed calming effect, which enabled him to begin to face some of the unfinished issues with his father. Most significantly, the format enabled him to internalize some separation, as he for the first time in treatment took in something which I offered him, and really chewed and elaborated upon it. He worked on the dials at home, changing and elaborating them till they began to suit him.
Strengthening of the observing ego, empowering protecting the experiencing ego. It could be said that one of the general characteristics of trance-work is to “play” with the relationship between the observing and experiencing ego. I have found these clients to need precise assistance in giving them the ability to modulate the relationship. Two of the specific methods which I frequently employ are:
The Hot Air Balloon Imaginal Technique (H.A.B.I.T.) (Livnay, 1996), As you slowly rise and leave your take-off point, you can begin to notice how, what seemed so impinging, looming large & threatening begins to shrink in size. As you continue, you begin to take in the larger picture. The instructions invite an alteration or modification in the client’s perspective. Continuing the journey, special emphasis is placed upon a relaxing, light feeling which will further enable the client to experience different hypnotic phenomena in direction of the aims of the therapy.
The Theater technique (Wolberg, 1948) is very conducive to enhancing the observing ego position, as the client is invited to be a spectator at the theater. During the first act, he is invited to see some aspect of his problem on stage. During the second act, he is invited to see it from a different perspective. “You might find yourself looking at the stage from the side, or from above, all the way on top, or even from behind… the stage, or from below, from the orchestra pit. It’s interesting how all of a sudden, you begin to notice other aspects from these angles!. Only during the third act, do we offer the possibility of joining the action, by seeing yourself on stage, participating in the scene. It’s really fascinating, how you can be sitting in your seat, and be watching yourself there on stage!”
These approaches provide us with examples of a hypnotic, suggestive mode for strengthening the Observer role, in order to gradually be exposed to an alteration in experiencing (visit from another cloud in HABIT, resolution in the 4th act in the Theater).
Centering, I have found it further useful to somewhat modify the tried and true safe place technique to the direction of a basic way to begin to augment sense of self. I invite the client to create his own niche: ““Find your place in the armchair…in the middle.. finding the north gives you all the other positions. A sense of being oriented, being in that spot or place in time where you can really be YOU. Without any pretensions or poses. That area or place deep within your center where you feel safe and comfortable, to be simply yourself, to be most yourself: unadulterated you.” Even these seemingly comforting words can at times be threatening, when that sense of self is not grounded.
Dor, a young man appearing only two weeks before his wedding, became very threatened by the invitation, as he came to the realization that he had always fled from defining himself, by always pleasing others. Facing his shaky sense of self during the trance led to a depressive reaction as well as a yearning to finally be real.
Flowing downstream, Etti found herself a tree for shade, comfort, to work upon some basic rooting and anchoring. I had used the imagery of flowing downstream to increase her balance and calm. She had come out of balance, and uprooted, as she had fled her home in another country to seek “refuge” to be able to reconstruct her sense of self. Again, the trance work aroused deep emotions of sadness, emptiness and distraught as she came in touch with her poorly formed sense of self.
Flexibility & Improvisation: These clients test our ability to be ever open and flexible to adjust and adapt our methods and techniques to respect their needs and realities.
While working with Abe, a 64 year-old public servant suffering from insomnia, I developed a mounting-stairs-to-the-gate-of-sleep induction, incorporating his negative emotions on the odd numbered stairs, and positive emotions (antidotes) on the even-numbered stairs. We recorded the trance work, him commenting and “editing” my words, till we came up with a polished collaborative version, which was to his satisfaction, enabling him to fall asleep.
Miki became quite tense and disconcerted during trance, reporting sexual-discomfort at having to close her eyes, while I, a man was looking at her. I suggested we reverse the positions, in a variation of diamond’s client-as-hypnotist, by her keeping her eyes open and listening to my voice, as I then closed my eyes, and proceeded to lead her through the induction. She was so taken in by my willingness to respect her sensitivity so dramatically, that next time, she requested to go into trance the usual way.
Simplicity: As the years go by, I find myself simplifying my view of things.
I find the essence of a hypnotic view to be connected to the reality that the earth is round. Though Pythagoras discovered the formula ages ago, we often do not accept this fact emotionally. Panic reactions, disaster scripts are tied to a view that if so and so occurs, it will be the end of the world. The emotionality is predicated upon the sense that there is no continuation. Verbalizing these thoughts with these clients provides a pre-hypnotic suggestion that they can persevere if they stay with the affect.
Supplementing the roundness of the earth is the realization that we speak very often in a digital/dichotomous mode with the either/or mentality. I have discovered that in foregoing the use of the word or, (which demands forced choice), we reach a more holistic view of things when we supplant it with and.. We thereby raise the possibility that several factors are simultaneously effecting our reality & causing our behavior. This enables connecting to unconscious factors, and to get in touch with primary process thinking.
As these clients are characterized by an extreme distrust of verbal intervention, it is necessary to achieve a gradual return to increased verbalization, by developing a desensitization towards the antipathy of words.
Rani presented himself as an expert at verbal manipulation. He bragged during the initial interview about his adeptness in neutralizing all of his former therapists through his use of words. He was coming to me to find another means, which he wouldn’t be able to control and deflect. His responses to hypnosis were quite volatile and dramatic, including jerky repetitive movements. During the Theater technique, he reported a young youth kneeling before a knight with a sword raised about the youth’s head. This image was repeated from yet a different angle. His reaction was the threat of decapitation, while I experienced a crowning ceremony .Did he need to “lose his head” in order to reach a breakthrough? Discussing the transferential aspects of the image (my being experienced as a castrating decapitator as was the father/ hope of enabling to empower him) were a beginning to enable connecting his fears of closeness and relationship to his hopes for solution. We continued to link his images during hypnotic work to words, gradually creating a safer web.
Filling up at the inner source. Hypnotic work with these clients is often experienced as refueling, taking in my words to fill up the emptiness. What is beneath the emptiness? Often, I find a fear of success, commitment? Loss of the special, familiar position of the victim. Letting go of the warmth derived from self-pity is very often too risky for these clients.
Individuation, mutual respect & acknowledgment of differences is especially crucial in these cases. In the staircase induction with Abe (see above), I worked laboriously to emphasize the collaboration, as Abe became in charge of “quality control”. He was charged with refining the procedure to reflect his individual needs. Through he initially expressed reluctance to engage in self-hypnosis, becoming an active participant in the refinement of the procedure provided him with the tacit respect that he so sorely lacked, having been severely traumatized as a child by overly critical and rejecting parents.
If we return to the questions raised at the outset, as to the dilemmas that these clients raise, it is possible to delineate a trend in the approach. These clients are drawn by the expectations raised by hypnosis, and by their disappointment with conventional approaches. A cautious and adapted use of hypnosis enables them to enter therapy, to begin to get in touch with the salient issues. At the same time, hypnosis often intensifies confronting their difficulties. I use hypnosis in these cases as a transitory method, entering with them into transitional space (Baker, 2000), and gradually introduce more verbal discussion and understanding. Hypnosis is then used intermittently as a resource, source of support as well as clarification towards integration.
The intention here has been to raise questions and to point to some directions in dealing with difficult clients.
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