» Issues involved in hypnotic work with adolescents
J. Shaul Livnay (Weisbrot) PhD
A treatment approach with adolescents is described which entails the careful utilization of hypnotic techniques to deal with and articulate many of the developmental issues which the adolescent brings into the treatment process: control, autonomy, dependence-independence, motivation, activity-passivity, identity among others.
Psychological work with adolescents usually present the practitioner with special challenges, as it seems that we are working with a collection of different people at the same time: a child, an adult, a rebel, a wanderer among the above. The introduction of hypnotic techniques into the therapy process provides a combination of flexibility and structure, giving the therapist a repertoire of tools as well as a framework to remain in contact with the adolescent throughout the therapeutic journey, as the adolescent shifts between the different positions. The problems, challenges and sensitivities of the age period are usually reproduced in the therapeutic relationship with the adolescent. It is a challenge of delicate balances between opposites over several dimensions:
1. Control: To be in control, to lose control, to be under magical control.
2. Independence vs. dependence.
3. Responsibility vs. irresponsibility.
4. Activity vs. passivity.
5. Playfulness, curiosity and risk-taking vs. seriousness and over-caution.
6. Resistance vs. over compliance
8. Identity, individuality, sense of self
As the adolescent introduces the different dimensions, hypnotic techniques can be essential in their identification, elaboration and working through. The aim of this paper is to raise the issues, challenges and modifications as well as dangers involved in the application of hypnotic techniques in work with adolescents.
The literature on the applications of hypnosis with children is rich and abundant. If one seeks to extend the search to applications with adolescents, the list narrows. Most articles relate to adolescents as an afterthought or extension of childhood. Very few relate specifically to adolescent populations, and fewer still go beyond a case presentation of the application of a specific technique, or concentration upon a specific problem (drugs, etc.).
Haber et al (1979) found adverse effects of depersonalization, dissociation, fears, and anxieties when hypnotherapy was attempted with obese adolescents. They urged the need for caution and experience, and stressed the sensitivity of the adolescents being placed in a passive-dependent position, while sensitized to the attraction/threat to closeness to adults. They found the hypnosis to heighten the threat to their tentative independence and identity.
Rigler (1985) set out to collect fellow hypnotherapist's experiences and approaches with adolescents, subsequent to a frustrating treatment experience with an adolescent patient. He often found in his practice that the suggestion to employ hypnosis led to an early break in the therapeutic relationship. He found his colleagues to disregard developmental issues in approaching their clients, and to regard the issues of trust and fear of loss of control as important, while depth of trance, hypnotizeability, capacity for imagery and motivation did not seem related to developmental level. Permissive approaches were favored over directive approaches, and ideo-motor and confusion techniques were seldom used (for fear of insinuating manipulation). Holz (1990, 1993), on the other hand has found adolescents over 12 to be able to respond to interventions with images, paradoxes, and word games which connect to the inner net of associations. Rigler saw the departure from conformity and the need for autonomy to be the crucial factors coming into play, wherein the magical hue around hypnosis to exacerbate the perception of giving up control to the therapist. He emphasized the transferential reactions involved, which could be both positive (over dependency and passivity), or negative (mistrust, suspicion, hostility about another controlling parental figure entering the picture). He emphasized the need to take these tendencies and reactions into account in relating and refining techniques and approaches to the adolescent.
This highlights the very point being stressed here: The very pitfalls and dangers involved in suggesting or introducing hypnotherapy into treatment situations with adolescents also provide the experienced, perceptive and sensitive hypnotherapist with opportunities to deal very experientially with the very issues of control, autonomy, dependency and individuality, with which the adolescent is so preoccupied. This requires first and foremost awareness and expectation on the part of the therapist, to seek out those various crossroads in the therapy, and thereby to provide the adolescent with a genuine growth experience. It is clear that the approaches and techniques must be carefully fitted for each adolescent.
Following is a description of my approach with adolescents, in an attempt to match the hypnotic tools in light of some of the aforementioned developmental issues. It should be noted that in each case, the methods take more than one issue into account. In fact, the more dimensions touched by each approach, the better fit for each adolescent.
Most often, adolescents have very mixed feelings about coming to psychological treatment. It is essential for treatment to be successful, to be able to establish an agreed upon basis for treatment. When the contract is based upon the parent's or school's presentation of the difficulties, the adolescent proves to be very resistant. The use of hypnosis provides an opportunity for specifying focuses which are both tangible, attractive, as well as non-threatening. Very often, some form of relaxation training and or use of imagery provides interest to enhance the motivation. Once the primary and more focused goals are reached, motivation and trust are achieved, so that there is a willingness to touch more general and profound issues.
During the course of therapy with a highly resistant and withdrawn 16 year old youth who was musically gifted and usually equipped with a walkman and earphones, I casually asked him about the battery wear of his set, and if he was interested in learning to use a model that precluded batteries or earphones (which get sweaty during the many heat waves in Israel!). I succeeded in arousing his curiosity and attention. I proceeded to teach him to imagine his favorite group playing one of their songs. As he was creative and imaginative, he was able, very quickly to begin to experience a positive "auditory hallucination", by clearly hearing several pieces played by the "grateful Dead". As his interest and confidence increased, he thereupon asked me if we could work on a severe flight phobia that he had. This was the first sign of active involvement on his part in the therapy, and a clear turning point. We succeeded in helping him get over his fear of flying, enabling him to visit his father overseas, and when he returned, we began to work on some of the issues troubling him. The use of an imaginal technique which gave him a sense of control clearly led to the beginning of motivation for treatment, as he for the first time began to define some of his own goals in the treatment.
Baumann (1970) sought to treat Berkeley adolescents suffering from drug abuse, using trance approximation of the drug experience. He thought to provide them with an alternative which would help them give up the drugs. Despite initial results, he became disappointed, as widespread practice produced no significant reduction in the abuse. On the other hand, he showed that his subjects were able to "hallucinate" the effects which they had achieved using drugs, through hypnosis. This just points out the possible powerful effects that the trance experience can have for the adolescent, when he is invited to reaccess to a strong and meaningful experience in his life. as the past experience is easier to access than anything which we might want to suggest, this proves to be an excellent "opener" for hypnotic experience.
Another aspect of motivation is the common complaint of adolescents or of their parents, that they don't feel like doing their homework, to study for tests, or to undertake certain tasks or chores. They feel or are called lazy. In some cases, the problem is just around getting started with such chores, in others it is in continuing or finishing. These difficulties relate as well to activity vs. passivity, as well as to passive aggressive manifestations of protest to a feeling of being forced to please someone else, instead of feeling free and autonomous to act for themselves.
Some modification of anchoring to situations of energy, will, interest with flow and enthusiasm, and then subsequently linking those feelings to the situation which turns off the motivation often leads to a transfer of interest. I suggest at times a "secret-private script" in situations of boredom, wherein the adolescent is attending to the task which arouses avoidance, yet imagines it to be something more exciting, a kind of stimulating background music! In cases of problems attending during school lectures, I tell the story of Prof. Grande, who taught us about the history of Western Europe through the bedrooms of the Royalty. Somehow, he found the key to catch our attention, and enable the historical ramifications to penetrate our consciousness!
An alternate approach is to focus upon the resistance at the opening gate, by visualizing the conflict, attempting to reach a resolution between the opposing forces through more dramatic means (see the section on identity for some elaboration).
Many of the adolescents which I see express many signs of rebellion and anger towards parental interference and control, which is often also transferred onto their teachers, while exhibiting significant signs of lack of self-confidence and independence manifested in poor study skills and test-anxiety. As long as they are studying with someone (friend or tutor), they can express and reflect their knowledge. As soon as they are left on their own, especially in a tension-provoking experience such as an exam, they freeze up and blank out, not being able to start out on their own.
I have found the use of anchoring (Bandler & Grinder, 1979) the youth to the positive feelings associated with their functioning in the presence of the necessary object, using a finger anchor in the dominant hand, to provide confidence and changes in the anxiety-fraught functioning in the frightening situation. The use of the hands has much symbolic significance, in the sense of "taking matters into your own hands", "getting a handle on the situation", and so forth. It especially is very portable, and affords an easy transfer. Working on a simple technique which the patient has to practice and elaborate at home, after having it taught in the presence of the supportive figure (the therapist), provides in-vivo working through of the issue of dependence and independence, while touching on the issue of control and activity-passivity. I usually invite the patient to practice using variations, attempting to elicit creativity and individuality. Whenever difficulties or problems in the "homework" arise, it provides concrete material for working on the ambivalence towards dependence. Once the positive feelings of calmness, confidence, competency are linked to the anchor, then the patient imagines himself in the test situation, this time with the new tools, and is reinforced again in the session for the possible new functioning, with the emphasis placed upon succeeding on his own, while he knows that he has the supportive figure "at hand".
A highly dependent 17 year old high schooler would totally blank out in every test situation, while showing impressive knowledge in presence of her tutor. She consistently "failed" at every attempt at hypnosis, expressing much passive-aggressive resistance. She exuded "confidence" and certainty about her fate of failing every test. Upon further inquiry, she revealed that the figure whom she found most supportive was Phil Collins. She always played his tapes when she was depressed and down. She was surprised at how easily she was able to imagine listening to him during our session, and was willing to practice strengthening the anchor during the week. During the next session, she was able to imagine him "accompanying" her into the test, and subsequently dramatically changing her mood and performance. Once she began to experience the change in an actual test, she became ready to work on the larger issues of dependence and aggression towards her divorced parents.
The issue of control usually emerges immediately upon raising the idea of introducing hypnosis into the treatment situation. While as with all patients, the illusions and fears about hypnosis must be fully discussed, often the initial attempts at integrating hypnosis should include the emphasis around enhancing the adolescent's sense of control very actively. I have previously mentioned the use of the hands and their significance in giving a concrete feeling of "taking matters into hand" which signifies the increase of control. This can be achieved through teaching self-hypnosis through the use of hand anchors, using the clenched fist technique (Stein, 1968) especially to reduce anxiety, as well as the initial use of teaching de-hypnotization before teaching hypnosis (Kleinhauz, 1986): The adolescent is told that whenever he feels the need or urge to exit the trance state, he need only to simultaneously clench both fists. This is practiced several times, as the signal is anchored and connected to the experience of coming out voluntarily.
One of the more innovative techniques involves turning the tables and giving the adolescent the chance to take over and hypnotize the therapist. Plapp (1976) showed great courage by consenting to be hypnotized by an extremely disturbed adolescent who exhibited considerable resistance at every attempt at hypnosis (though he had requested its use). Once the patient stepped into the hypnotist's role, he began to manifest the first signs of identification and internalization, as he in fact emulated Plapp's methods and use of imagery. While this method requires great caution and sensitivity (see Diamond 1980, 1983 for an elaborate discussion of methodology, conditions and contra-indications), it speaks to adolescents on several levels. It directly places them in a position of control over both the techniques, as well as the therapist. The fact of turning the tables strikes a deep chord. The therapist can thereby provide a model for openness and genuiness by sharing his trance experiences, while helping the adolescent to try out for himself what the therapist had previously demonstrated. Furthermore, the therapist shows flexibility and a willingness towards taking a risk, and most importantly, showing trust in the patient, by putting himself in "his hands" temporarily. The switch can be appropriate after some prior experience and demonstration of hypnosis by the therapist, after the establishment of some basic rapport It is especially indicated when it comes in response to the adolescent's request for both control and some need for mutuality, experimentation and give and take. The mutual experience must be fully explored, and any reservations during the process must be respected. Sensitivity to these signs provides the opportunity to work on both sides of the issue of control, dominance, equality and taking chances vs. caution.
Identity, self, and individuation
During adolescence, establishment of a firm sense of identity is one of the prime challenges (Erikson, 968). While one of the common fears about hypnosis is the very giving up of identity and individuality (Chertok, 1982), we can use both the enhancement of focal attention, as well as the widening of the flow of the associative process during trance, to increase the sensitization to the adolescent's sense of uniqueness, and to work on the integration of the different facets of his developing sense of self. In a way, we could say that we can use hypnosis to take the adolescent through the different phases of development according to Werner's (1948) orthogenetic principle, wherein all development in organisms pass through three stages: Global-undifferentiated, to the differentiation of discrete parts, to the reintegration of the differentiated parts into a complex, differentiated whole. At the outset, the adolescent presents a picture which emphasizes some symptomatic dysfunctioning which covers a global sense of self which is either: 1. defensively positive (I'm O.K., but they are causing me...) where "they" are either symptoms experienced as ego-alien, or objects in the present life space, or 2. in most cases negative (I am a failure, I can't...). Through the use of hypnosis, we begin to differentiate the different aspects of the self in conflict, which are causing the symptoms. Through various imaginal and ideo-motor techniques, we elicit, elaborate and articulate the various parts, creating temporary dissociations. Finally, we strive to begin to organize the inner dialogues into a coherent sense of self, by resolving the conflictual interactions, reaching a new integrated whole.
Imaginal techniques used to identify different parts of the problem, include the Theatre Technique as modified by Brown & Fromm (1986), and a Hot Air Balloon guided imagery technique which I have refined (from Walch's Red Balloon, 1976) enabling to work on reframing of the problem by looking at it from high above, holding meetings with birds, projecting onto clouds etc. I attempt during the interaction with the adolescent to encourage to project and dissociate the different parts or sides, approximating the "parts parties" created in Ego State Therapy.
I also used a modified procedure of the Chevreuil Pendulum (LeCron, 1965) to elicit a dialogue with cut-off parts which are involved in the symptomatology. This technique is especially successful with adolescents, as it arouse alot of fascination and curiosity about the unconscious. It provides them with the drama which they thrive on, and touches upon some of the magical qualities which they expect from hypnosis. Again, such techniques provide the kind of intersection where careful and sensitive handling enables the working through of many of the ambivalences.
Another variation which I have found useful is to introduce a Gong into the therapy process (Livnay, 1992; Livnay, in press). Listening to my playing elicits a deep trance with both powerful relaxation as well as emotional arousal. On the other hand, as I invite the adolescent to play the Gong, their develops a situation wherein different dialogues are elaborated through the "interaction with the Gong (see Livnay, 1992 for elaboration).
I use each of the three methods to continue to the integrative phase, as we work on achieving cooperation among the different sides, assessing priorities, weights and balances, gradually moving to a more coherent, unified sense of self, individuality, and uniqueness. Throughout, there is a delicate balance provided as I fluctuate from active participation in the drama to a sideline, coaching position. During this process, many issues of transference and counter-transference are likely to emerge (see Diamond's (1987) excellent analysis of the relational dimensions during hypnotherapy), and require attention and consideration, as Rigler pointed out above.
I have attempted to give some examples of how I use hypnotic techniques to relate to some of the developmental dimensions which emerge during the treatment of adolescents. I find the bottom line in work with adolescents to be genuineness in the light of contradictions. I find hypnosis useful in negotiating the way between the opposites, in that it tends to engage the adolescent in a more active and dramatic way. The use of hypnosis affects the therapist no less so, through increasing empathic contact as well as awareness of his own internal processes through what has been called the therapist trance (see for instance Scagnelli's (1980) excellent article on the topic). Thereby, the opportunity for frank and genuine communication is made more possible, providing the atmosphere necessary to enhance the developmental process.
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