It is difficult to separate diagnosis from therapy, as the latter begins the moment the patient enters the office, if not before. This chapter will offer a practical, “how-to-do-it” approach for eliciting the emotional needs and intentions that many emotionally disturbed persons have for maintaining the chronicity of their symptoms. Naturally, the following suggestions for understanding most behavior disorders do not have to be followed literally. Rather, the therapeutic procedure needs to be varied from patient to patient and may even have to be changed as therapy progresses.
Highly complex hypnoanalytic procedures should be attempted only by the well-trained hypnotherapist. However, the mature physician, who has already proven his competence by successfully handling psychoneurotics in his practice, can use hypnotherapy as outlined below. The applications depend on the extent of his training and his ability to understand adequately the needs and values of symptoms.
Brief hypnotherapy for symptom removal, as distinguished from hypnoanalysis, can achieve relatively permanent results in psychosomatic disorders. Throughout this book it has been demonstrated that hypnosis is more than mere suggestion; it is a powerful vehicle for the communication of new ideas and understandings. Whenever a person relaxes, he can more effectively concentrate upon another's communications, and, as a result, he becomes more receptive, self-objective and, therefore, more capable of examining his needs. This leads to a better understanding of his difficulties and also establishes greater cooperation.
The following maxims should be reemphasized: that a patient is not treated by hypnosis, but in hypnosis; that hypnosis merely intensifies the rapport between therapist and patient; and, therefore, it merely extracts the patient's potentialities.
Hypnotic technics can be incorporated into any school of psychotherapy. The choice depends upon the nature and duration of the therapy and the experience of the therapist. Raginsky wisely states: “There is little scientific justification and limited value for a concept of hypnosis which remains isolated from the mainstream of psychological thinking and research.”3
Assuming that the therapist finds out how and under what extenuating factors the symptoms occurred, and how they operate, he should then ask himself if he thinks he can modify and control these factors by hypnosis. There are no absolute rules for conducting hypnotherapy. What is necessary is common sense, clinical judgment and intuition, and a good knowledge of human behavior. All physicians, whatever their specialties, should be able to carry out hypnotherapy as skillfully as any other medical maneuver. Since psychosomatic problems constitute a large percentage of medical practice, it is inexcusable for any physician not to be able to use hypnotherapy, within the usual restrictions, as an adjunct to psychotherapy.
To be a successful hypnotherapist, one does not have to have a powerful personality. He does not have to sit behind the patient, or look for “complexes,” or necessarily have to probe the “unconscious” in order to give “insight” into “causative” factors. Most patients accept logical and meaningful communications, especially if these help allay their tensions. The most successful communications include anything and everything that is part of a person—his hopes, his fears, his motivations, his attitudes toward right and wrong, and even his religious concepts and beliefs.
Modern-day hypnotherapy emphasizes the value of the present—the here and the now. Explaining human relatedness in terms of instinctual energies or libidinous drives, though helpful for understanding how a particular symptom developed, is not always necessary for attacking and removing symptoms. It is necessary, however, that emotional needs, satisfactions, and goals be understood rather than irrelevant minutiae of the entire life span. Hypnosis is more effective if the total life situation is viewed more in terms of current opportunities, successes, and reasons for past failures. It should never be forced on the patient.
The goal of hypnotherapy is to establish a willingness to accept those ideas that can enhance the patient's understandings. By such measures, the subject can recognize the need for symptoms used for secondary gain purposes. Through positive and constructive suggestions, he can neutralize harmful symptoms produced by destructive thoughts, feelings, and memories.
Under autohypnosis, one often can more readily explore the needs for a symptom. At least, the “how” and the “why” of a symptom are ordinarily more readily understood in a contemplative state of self-absorption. The unique receptivity or self-reflection which characterizes the autohypnotic state usually is conducive to greater understanding.
Many times a symptom which is maintaining a neurosis can be “kept on leash” by posthypnotic amnesia. By such measures, the therapist can be on the alert for possible symptom substitution. When trading down is successful, the patient can describe how he feels now that he no longer has to contend with the symptom.
Most disturbed patients suffer more from their inability to deal with their current problems than they do from hidden traumas. Therefore, they should be encouraged to express their feelings as to how they react to these and what they propose doing about them. This is of the utmost importance and is more valuable than merely telling a patient that he should “give love and affection” to replace hostility and aggression. These are, at best, ineffective intel-lectualizations. It is much better to teach him how to recognize and adjust to the everyday situations that affect his functioning.
Successful hypnotherapy, too, is in reality a collaborative and reciprocal effort between therapist and patient—each learning from the other. Thus it is not the type of therapy but the strength of the interpersonal relationship that is responsible for recovery.2
In some instances, an understanding of the role that the symptom complex plays in the patient's emotional economy is important. It is for such patients that hypnotherapy must be modified into an uncovering technic and adapted to a specific patient's needs. In this way, access to those aspects of the personality not accessible to psychotherapeutic technics at a nonhypnotic level can be gained. For such therapy to be effective, the therapist must give the patient an opportunity to gratify certain basic needs which are present in varying degrees in all psychosomatic processes.3
THE EMOTIONAL NEEDS*
The Need to Talk
Talking is the best method for alleviation of tensions. The patient discharges pent-up feelings. A permissive attitude provides him with a sympathetic listener. Since the patient depends on the physician for understanding and guidance, therapy begins with the initial interview. Listening to what the patient states is really an art. The good clinician must pay particular attention to everything that is being heard. To the trained listener, the body “language” is as clear as a symphonic arrangement. There are no fixed rules which can be used for this phase of hypnotherapy. The following general principles, however, will be of assistance:
1. It is wise to let the patient talk, especially during deep hypnosis since it is here that important facts are often revealed.
2. Listen patiently to what the patient is saying. Then he will feel that you are really interested in him and his problems.
3. Never interrupt when inconsequential material is being discussed. Keep in mind the old adage: “If one opens his mouth enough times, he will stick his foot into it.” In a patient-physician interview, the patient is expressing his feelings as well as talking about what he thinks are the facts.
4. Always put yourself in the patient's position. Understand not only what he is saying, but how he is saying it, and why he says what he does at this particular moment. Does he need sympathy? Is he misinformed? Does he feel guilty and is he therefore seeking reassurance? Is he angry, afraid, or evasive as he talks about highly charged topics?
5. Show empathy and personal warmth. Ask for richer details, more complete examples, or amplifications of what he has stated. Ask, “Then what happened?” “So?” “And then?” Or, more pointedly, “Why?”
6. Avoid criticism, argumentation, and condemnation. Remember that emotionally disturbed individuals can accept only a part of what they know to be the whole truth. Psychoneurotics deceive themselves over a long period of time; seldom are they able to see themselves as objectively as others see them. Therefore, never tell the patient that he is “seeking sympathy.”
Always encourage the patient to talk about himself and his attitudes toward work, marriage, recreation, and politics. Religious views should be brought into the conversation. Many deeply religious individuals misinterpret religious tenets and feel guilty.
A certain amount of time (30 to 50 minutes) should be allotted to each interview. The time interval can be in keeping with the needs of the individual patient. At times, 2 to 4 hours may be necessary for psychiatric emergency patients. Some patients need to talk of their childhood, their handling by parents, their attitudes toward school and work, and sexual experiences. The discussion should permit ventilation of the patient's true feelings, and this will indicate how faulty attitudes and sentiments have developed. Such questions as, “How did you feel when that happened?” or “What did you feel like doing when your father (or your husband or your mother-in-law) did or said that?” help to spur the patient to relate other significant experiences.
A detailed account of pertinent life situations which decreased or increased the patient's selfesteem, as well as those in which he experienced a sense of frustration and failure, is meaningful. Specific incidents at home, at work, and at play throw light on the pattern of the personality, with particular attention to faulty behavior or attitudes. These attitudes are brought to the fore by asking, “Why did you act in this particular way.” “What purpose did it serve?” These questions may bring out that the patient needs to be independent and successful at all costs, that he feels resentful toward those whom he tries to please, or that he has a need for perfectionism to avoid criticism. Here hypnosis can be used in a supportive role, as it more readily permits the release of ideas and feelings which in themselves exaggerate conflictual situations associated with the presenting symptoms.
The Need to be Told What to Do
The patient comes to the doctor in need of support and guidance. He wants someone who can alleviate his sufferings. The value of an authoritarian approach may be attributed in part to being told what to do by a therapist who plays “God.” The immature and emotionally disturbed individual wants to be told what to do just as a child does. Patients who look upon the therapist as an omnipotent father-confessor, and who expect a relatively paternal authoritative attitude in him, respond best to hypnotherapists who use such an approach. On the other hand, those who anticipate the most effective help from a therapist who is permissive do better with those who assume this role. A therapist must be flexible and, if critical attitudes are mobilized by an authoritative approach, he should be able to adapt his technic to the patient.
The Need to be Accepted
The patient with psychosomatic complaints usually is tense, worried, and anxious. Often guilt is present because of hostile attitudes, depressed feelings, or the self-depreciation that makes him believe that he is “no good” or “a failure.” Such a patient needs reassurance. (However, many an emotionally disturbed person is looking for personal reassurance rather than a “clean bill of health,” that is, assurance that he is a worthwhile person.) The physician who makes a diagnosis of “no emotional disease,” often will not help the emotionally inadequate person; he will be chagrined when such patients are not “cheered up” or pleased. Not infrequently, they may even feel worse—to the dismay of the well-meaning doctor.
However, if the physician shows that he is pleased with a cooperative patient's progress, he has given the patient what he really needs. When patients are told that they are cooperative (“You have done your best to help me”) or are directly complimented (“That was an intelligent account of the development of your symptoms”), most of them begin to feel a sense of increased self-esteem. They generally respond with a desire to please the doctor who is so “understanding”! This is shown by an increased willingness to discuss personal topics and a readiness to accept the fact that they are immature, dependent, and inadequate; this is in contradistinction to previous patterns of blaming others for their troubles. With this approach, patients will feel complimented by your personal interest in their illnesses and encouraged to go on to discuss personal problems. I do not hesitate to prescribe medication that I deem is indicated.
The Need to be One's Real Self
Therapy which allows ventilation relieves pent-up feelings; this often leads to emotional security. Thus patients are able to accept the responsibility for their behavior. In most discussions, patients reveal their dependence on the opinions of others, and they relate how they have avoided every opportunity to get away from the domination of their parents, or what they believed to be the demands of an employer, a husband, or a wife. Patients will now be encouraged to do what they really want to do. When a patient reports an incident of behavior, he is asked, “What did you really want to do? Why didn't you do it?” The patient, who already has accepted the doctor as an equal and a collaborator, begins to practice what he has been taught. He brings in reports showing how he has asserted himself in a life situation and is complimented on his progress. Gradually, he learns to speak up for himself and to please himself as well as others. He literally learns to think of himself and for himself for the first time; heretofore he had been apprehensive about the possibility of offending everyone with whom he came into contact. The patient becomes his true self and, with this change in behavior, there comes a sense of freedom of action and a feeling of well-being which he has not experienced for many years.
The Need to Emancipate Oneself from the Influence of the Hypnotherapist
Finally, there is the need the patient has to break off his dependency on the doctor. Any type of suggestion in the form of advice fosters dependency. I usually eliminate dependency through utilization of autohypnosis. Likewise, dependency is eradicated if I tell the patient, “You hypnotized yourself. I didn't. You were the one who developed the symptom, were you not? The same mechanisms by which you became anxiety-ridden can be used for dissolution of your problems if you yourself do it through autohypnosis.” This takes hypnotherapy out of the realm of magic.
As hypnotherapy progresses, usually less regular interviews are necessary. Visits should be reduced and then discontinued as the reasons for the needs for the symptoms are clarified and recovery takes place. Patients who do not understand their problems should not be discharged, as not infrequently such patients will keep their neurotic symptoms. These will limit their activities and keep them semi-invalids, who become wholly dependent on the physician. This breaking up of the patient-physician relationship is of the utmost importance. It should be emphasized that the patient is not improved until he has completely dismissed his therapist, put aside his drugs and other routines, and progressed to the point where he feels free to act as a healthy, emotionally secure individual, in keeping with his own personal needs and interests.
REFERENCES
1. Conn, J.H.: Psychologic treatment of psychosomatic disorders (paper read before annual meeting of the Academy of Psychosomatic Medicine, October, 1957).
2. Kroger, W.S.: And psychotherapy is indicated. West. J. Surg., 68:138, 196, 1960.
3. Raginsky, B.B.: The use of hypnosis in internal medicine. Int. J. Clin. Exp. Hypn., 8:181, 1960.