The therapist trance as a generator of associative techniques in therapy
The therapist trance as a generator of associative techniques in therapy
J. Shaul Livnay (Weisbrot) PhD
As I examine my writings and presentations over the last several years, I find that they all concern themselves with refining my main tool in therapy: my sensitivity, resonance and ability to express most effectively my understanding and experience with the patient in a way that most benefits the latter. One of the facets in this process is fostering my personal integration as a person and therapist. Basescu (1990) has remarked upon his own tendency to writing "self-centered papers upon his work as an analyst". As therapy outcome research has shown that eight times as much outcome variance is accounted for by therapist differences as by treatment differences (Luborsky, 1987), this preoccupation of mine seems to be in a necessary direction, as most of the research has usually concentrated upon the latter (Luborsky, 1987).
I previously (Livnay, 1992a, 1992b) described techniques of sharing and self-disclosure during therapy, involving provocative and sometimes interesting while bizarre statements designed to spurt the therapeutic process. I moved on to non-verbal variations through work with the Gong (Livnay, in press). This paper presents an approach (rather than a set of special techniques) which has become an integral part of how I work, whether it is with patients, students, or supervisees.
Two themes and their interrellation will be elaborated: the use and refinement of the Therapist Trance, in respect to associations which focus upon my relation to, and experiencing of the patient, and how the latter becomes material for the therapeutic process.
The therapist's trance
An increasing number of clinicians have been relating to the trance aspects of their experience in therapy, and to the necessity of it for progress and efficiency in therapy. I must note that I find the term therapist trance a bit constricting, as it indicates a certain intent or effort, while I find myself to enter the latter automatically when I enter a treatment situation. It is for me the natural state for my work .How is this state characterized (The following italics are mine)?
Erickson and Rossi (1977) related to Erickson's use of the externally oriented interpersonal trance state, which entails setting aside conscious processes so that all attention is absorbed in the client, without going inside to think or to analyze, nor to be distracted by extraneous external cues .
Deikman (1969) emphasized the value of de-automatized experience, in casting aside the shell of automatic perception, of automatic affective and cognitive controls in order toperceive more deeply into reality. .
Gilligan (1987) detailed seven steps which enable the therapist to develop this trance. He contended that thereby, one effects the alteration of phenomenal experience: tunnel vision, motoric inhibition, body tingling, and other trance characteristics. One thereby achieves the paradoxical experience of feeling totally connected to the patient,while at the same time feeling detached and impersonally involved (which sounds like another way of describing intense empathy).
Erickson explained that he would enter such a state whenever he had doubts as to his ability to see the really important things.(Erickson and Rossi, 1977). Likewise, Rogers (1985) described similar experiences of allowing unconscious processes direct therapy:
I have come to value highly these intuitive responses. They occur infrequently ... but they are almost always helpful in advancing therapy. In these moments I am perhaps in a slightly altered state of consciousness, indwelling in the client's world, completely in tune with that world. My non conscious intellect takes over. I know much more than my conscious mind is aware of. I do not form my responses consciously, they simply arise in me, from my nonconscious sensing of the world of the other (p. 565)
Scagnelli (1980) contends that the use of trance by the therapist enhances and assists therapeutic interaction, raises consciousness, reduces anxiety., allows freer access to unconscious material. The therapist can concentrate energy, and be in touch with his own as well as the patient's current feeling state. The therapist works with here and now rather than impose an intellectual set. It heightens empathic contact. Body/mind and feeling state are used as a bio-feedback instrument.
The foremost figure involved in the research and delineation of the therapist trance and the interactional aspects of the hypnotic situation for the last decade has been Diamond (1980, 1983, 1984, 1987, 1988). He (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. Orne (1962) suggested that it was necessary for the therapist to enter a folie a deux while still maintaining sufficient objectivity. Diamond's work with a model of the client as therapist (1980, 1983), to be described below, was a creative way to connect with the therapeutic potential inherent in the therapist working while being in trance.
Likewise, Vas (1993) has described his using a counter-trance technique in working with psychotic patients, by entering a trance state in order to mirror and lead the patient into a more integrated position.
Loriedo (1992) in relating to the role of minimal cues in hypnosis emphasized that hypnotic rapport consisted of the mutual sensitivity of both hypnotist and subject to each other's minimal cues. The therapist's intense attending (through trance) is essential to hypnotic therapy.
The intricacies of the hypnotic relationship have been analyzed by Diamond (1987) leading him to suggest four relational dimensions of hypnosis:
1. The transferential dimension
2. The dimension of therapeutic alliance, wherein he differentiates between the realistic and the magical elements.
3. The fusional-symbiotic alliance which is at the oral, pre-oedipal -narcissistic level, and finally
4. The real relationship.
Research by Banyai and her co-workers (Banyai et al,1985;Banyai et al, 1990; Banyai, 1991; Gosi-Gregus et al, 1992) has demonstrated the presence of each of these levels even upon a first meeting in a laboratory setting between total strangers (Varga et al, 1993). Banyai (1992) further identified two different working styles of hypnotists: one a physical-organic style characterized by proximity, warmth, being very personal with the subject, which she likened to Ferenczi's (1909) description of a maternal hypnotist, as opposed to a analytical-cognitive style, characterized by distance and reason, which she likened to Ferenczi's description of a paternal hypnotist. She found interesting interactions between hypnotist's style and interaction with subject and hypnotist hypnotizability.
A full inspection of the therapist's experience during therapy requires relating to the counter-transference dimension. Of direct relevance to the topic being raised here is the discussion in the literature around disclosure and sharing of counter transference with the patient. While it has been crucial to urge the importance of the therapist allowing himself to enter trance, and thereby become more aware of his counter transference as well as other feelings, there is as well a necessity to be aware as well of the complexities and dangers raised by sharing and disclosure.
During the past 15 years many writers have departed from Freud's (1910, 1915) narrow definition of counter transference as a more or less unconscious resistive reaction on the part of the therapist to the patient's transference Several writers have begun to propose careful use of disclosure and sharing of counter transferential feelings with the patient.(Epstein & Feiner, 1979; Gorkin, 1987; Wollstein, 1988). It is interesting to note that in the past, we again find Ferenczi as the only proponent of an open approach which included occasionally disclosing the therapist's feelings and attitudes to the patient, going as far as free associating to the unconscious motives when making a counter transferentially based error in therapy (Gorkin, 1987).
Gorkin (1987) elaborated the reasons for which disclosure was found beneficial::
1. The confirmation of the patient's sense of reality.
2. The need to establish the therapist's honesty or genuineness.
3. The need to establish the therapist's humanness.
4. The need to clarify both the fact as well as nature of the patient's impact upon the therapist, and on people in general.
5. The need to end an impasse or to break through a deeply entrenched resistance.
Gill (1988) emphasized the need to carefully elicit and discern what the patient's reaction is, how he or she experiences the therapist's disclosure, the personal meaning it has? Wollstein (1988) added that the entrance into the area of disclosure enables the patient to fully explore his or her contribution to a relationship, and to receive confirmation of the effect he or she has upon others.Fisher (1990) emphasized the intimacy required in the treatment situation in order that the sharing of the therapist's disclosure to be effective. He emphasized that the most profound opportunity for sharing was through the use of the therapist's countertransference.
Ehrenberg (1984) noted that the expression of affective reactions to the patient adds a new dimension.to therapy..The therapist's shared counter transference reactions help the patient to become aware of repetition compulsions and provide empathy, understanding as opposed to feelings of distance, estrangement and abandonment. Jourard (1971) added that the best way to foster self-disclosure is to model it:.intimate self-disclosure begets self-disclosure.
Basescu (1990) emphasized striving to analyze and understand deviations from neutrality, dealing with them openly in the context of the therapeutic relationship. Their impact needs to be explicitly clarified.A mutuality of relevant self-revelation.and the disclosing of the therapist's feeling reactions invites experiential exploration.
Josephs (1990) urged caution in the sense of the partial nature of verbal disclosures. The openness of the therapist may be used as an authoritarian ploy. The therapist needs to.be open to react.the patient's reaction to his openness and sharing. He needs to make the patient aware of nonverbal reactions to the therapist.
Menaker (1990) noted that a revelation at a time and in context that is appropriate relative to the patient's communication provides an echo or elaboration of the echo to the patient's own experience, which can cement a bond, inhibit projection, fostering identification..
Gruenewald (1971) related specifically to the types of counter transferential reactions which arise during hypnotherapy. She isolated problems with aggression, power drives and unresolved dependency needs of the therapist as the most common themes which emerge and interfere during the course of hypnotherapy:
1. Aggression may be expressed through unduly forceful and long attempts at induction which raise resistance, which in turn cause a projection of a sense of failure onto the patient, causing punitiveness and rejection. At times, a patient may be pushed too early or unnecessarily into traumatic material without due regard for his defenses. One aspect of the misuse of power has been linked to a "sibling countertransference" (Fromm 1968)
2. Dependency may be expressed by identification, through taking over a parental role and reinforcing dependency rather than helping the patient deal with it. On the other hand, the therapist defending against his needs may keep the patient at too great a distance, denying him the warmth and support he needs.
The point being raised here is that as the therapist allows himself to connect with his counter transference and become aware of such themes as just described, the process of coming to terms and sharing provides an intimacy which may have a profound impact and serve as a kind of repair of the usual pattern of interaction of the patient (a corrective emotional experience as proposed by Alexander & French, 1946). Often, the therapist's counter transference reflects a kind of a "pacing" and matching of previous relations, while the disclosure provides the first "lead" or break from the old pattern.
A severely constricted and depressed yound woman who had been sexually abused for years as an adolescent by her step-father, was very reluctant to depart from the normal talking mode. . Having been trained in hypnosis, I thought from the outset to try to work-through the repeated traumas by doing age regression work. As I enthusiastically began to try to implement my therapeutic plan , I found the patient extremely resistant, and gradually becoming more constricted and withdrawn. I came to realize that I was recreating the abuse, by trying "to force her to take in" my hypnotic intervention. As I became aware of the re-enactment within the therapy, I chose to disclose and share with the patient my discovery which brought about a relaxing of her defensiveness. She had never confronted her step-father, and he had never said a word. For the first time, she was able to ward off "the attack" in the context of a male who was acknowledging how he was relating to her. The experience was extremely significant and had an impact on her, in the direction of beginning to heal the wound and open her to a different mode of experience with a man. Eisen (1989) has noted a similar pattern of excessive therapeutic zeal with amnesiac patients.
The approach proposed here expresses itself on four levels:
1. Natural/automatic self trance induction: The cues of sitting, facing, and focussing upon my client's (patient, student or supervisee) face and eyes bring about a narrowing as well as a sharpening of concentration upon the "myself with the client" dyad. Thereupon, all sensations, thoughts, images, and feelings are linked to the situation (I will filter out any prevalent personal issues which might be preoccupying me temporarily, but my it is my experience that such thoughts tend to be set aside when I enter trance). I share the latter when I feel the internal productions are relevant. Whereas earlier, I thrived upon provocative, bizarre, dramatic productions, today I am comfortable with the mundane.
The categories which emerge in my trance include perceptions of the patient, personal memories as well as memories of previous therapeutic relationships, stories, feelings, observations which are brought up for the patient's inspection, in a tentative while open manner. In supervision, the main reservoir consists of associations to situations wherein I am the therapist.
2. During "formal" trancework: Most of my trance work entails the use of a free worded, flow of association kind of induction. While I may have consciously planned to touch upon specific, salient points according to the treatment aims, I usually find myself drifting to further areas which just "seem to come to mind". I usually verbalize freely the words and images which come to mind. Whenever I look back and reflect upon my verbiage, interesting emphases emerge and become clear, as to my grasp of what Scagnelli (1980) emphasized was the present feeling state of the patient. I must add that I find my productions to reflect past, present as well as future dimensions.
A student in a hypnosis course asked to work on a severe flying phobia (she had take a 500 km. flight home that afternoon). As I began to work with her in trance, I found myself talking about buffers, cushioning, safety and insulation. Then I heard myself uttering "luftgeshaeft", talking about psychologists and the necessity of using hot air (see Diamond's fascinating analysis of archaic involvement in Erickson's work, with the Wizard of Oz metaphor (Diamond, 1988)). At that point, I made the click with her inner world, and she sighed, smiled , acknowledging the connection and entered deeper into trance. She called later that night thanking me for the pleasant flight!
3. Working with the Gong. When I play the Gong for a patient (see Livnay in press for a description) I draw upon a combination of my feeling state, my understanding of the patient's needs, and my treatment aims.These are translated into the tones I elicit, the intensity and rhythm which I use. While I start out my playing with certain aims, my playing brings me into a similar trance so that I find myself drawn into a specific pattern which both reflects the patient's reaction to my playing (pacing), as well as elements which at times reveal to be counter transferential on my part. As the playing is non-verbal, it is especially susceptible to be a medium for unconscious themes which are prevalent in the interaction at the time of the playing. The structure and pattern of my playing, as well as the patient's reactions, experience and associations to it then become the matter for subsequent discussion and analytical inspection.
4. Client-as-hypnotist. A special variation of the therapist trance is the situation where the therapist invites the patient to take on the role of the hypnotist, and to hypnotize him. Plapp (1976) described working with a highly disturbed adolescent who, though he requested hypnosis, did not succeed in entering trance. When he asked to "turn the tables" with Plapp's consent, he succeeded for the first time in accessing his imagination, and in attending to the interpersonal relations. Diamond (1980, 1983) has described an elaborate technique and very specific indications and contra-indications. I use two variations. With patients who are uncomfortable with closing their eyes and express feelings of vulnerability and discomfort, I suggest that they keep their eyes open, and that I close my eyes while I continue with the induction and hypnotic work. This has proved to ease their concerns and hesitations, provided that I have been sensitive to their feelings and questions about the change in balance between us, fears about "taking over" and so forth. In other cases, I let the patient actually do an induction, while I enter trance along the lines described by Diamond.
During the course of a demonstration of hypnoanalytical techniques, I invited the students to use Chevreuil's Pendulum technique (LeCron, 1963) on me. As I entered a deep trance, I shifted between different levels of dissociation (hypnotized subject, the observer, the teacher) to use my experience to model and express, while doing some significant inner work.
During each of these levels, I find my experience to certainly be characterized by the different aspects of trance described above in italics. Allowing myself to access as well as express my experience has several consequences.
1. A model is being provided for openness to both inner processes and interaction, for letting go and flowing, and foremost expressing trust in my unconscious . As Jourard (1971) remarked above, trust begets trust. When such interactions are repeated throughout the course of the process, they have a cumulative effect upon the client.
2. The atmosphere becomes looser, lighter, more flowing as well as intimate. A playfulness is introduced which can be likened to Shapiro's (1988) hypno-play therapy.
3. There is an enhancing and strengthening of the rapport and the working alliance, on both the conscious and manifest level, as well as on the unconscious, pre-verbal level (see Diamond , 1987). The sharing of the therapist's inner life and processes with the patient, especially insofar as these are connected to the patient's dynamics, has a very strong impact upon the "magical" expectations and primitive strivings of the latter in the therapeutic relationship.
4. I come in contact with material which both increases my empathy and grasp of the client. I often use the materials as a kind of symbolic anchor long thereafter, returning to the image, thought or sensation henceforth during the working through of the material. It provides me with a focal point, as well as with a channel and direction for organizing the associative material.
During the course of therapy with a severely debilitated young borderline woman, I kept imagining a symbolic crossroads between a Rock Concert and a tribunal with a judge sitting high above. I used my "visions" to connect to an inner world of conflict and strife which she had been splitting off, but expressing through hysterical conversion symptoms. The disclosure led to an active dramatization of the different parts, and a complex dialogue on different levels (real dimension vs the fusional). As a result, there was a subtle strengthening of the working alliance, and significant progress.
Issues of sharing, disclosure and appropriateness
Many questions have been raised about appropriateness by the authors above.
1.Personality organization While disclosure of counter transference has often been described first and foremost with the most disturbed cases (Racker, 1953; Searles, 1979; Scagnelli, 1980), Diamond (1983) has cautioned against using his technique with patients with a poor level of organization. I find such poorly organized patients thirsty for role reversals, thriving whenever there is real, intimate sharing. Though extreme caution and elaborate preparation and structuring is necessary, I have found that first of all, patients with severe personality disorders are those who most elicit in me entering into trance states. These states very often bring me into contact with a more "mothering style", according to Banyai's descriptions (1992). Secondly, these very patients are most in need to feel that the therapist is departing a standard position and coming at least half-way to meet them. Lastly, these patients especially need to feel that they reach us emotionally, that we really empathize and feel their way of experiencing the world. Sharing with them makes us real and genuine, and enhances the basic trust of which they are so lacking.
2. Whose need? Whenever the therapist considers sharing or disclosing , sharing must always be weighed with respect to the benefit or needs of the patient. Many authors have cautioned about therapists' irreverent use of sharing or disclosure for narcissistic, aggressive or dependency needs (Gruenewald, 1971; Josephs, 1990). The caution must be weighed against over-intellectualization and loss of the benefits of spontaneity. The approach described here assumes a high level of maturity and self awareness on the part of the therapist, including the ever present tendency to check and assess the basis of the motivation for verbalizations and actions. Diamond (1983) has stressed the need for the therapist to have reached a high level of integration. The critical discrimination to be made is when is the urge to share expressing a personal issue which is not connected to the client, and when is the urge counter transferential in the sense of a manifestation of enactment which when subsequently analyzed along with the patient, will express openness and a meaningful inspection of the interactional patterns which the patient elicits.
3. "Right or left" brain interventions. Must the material be understood first before being shared? A measure of trust and modeling for the client is achieved in trusting the unconscious by sharing spontaneous productions, as long as the therapist is willing to integrate and process the intervention subsequently. I sometimes "chew" on associations for months, and return repeatedly, as therapeutic anchors or milestones, as mentioned previously.
4.Acting-out/dramatic dimension. The approach emphasizes a willingness to introduce a dramatic mode into therapy which is under the therapist's control, rather than to be merely limited to the analytic, observer position. Spotnitz (1963, 1976) has referred to the use of the therapist's "acting out" both the unconscious conflict, as well as the suggested solution to the conflict within the therapy session.