Hypnosis in Psychotherapy

by Gérard V. Sunnen, M.D.
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The essence of psychotherapy is personal change. As a science dedicated to alleviate emotional distress and devoted to personality growth and individual development, modern psychotherapy brings together the findings of many disciplines. To psychoanalysis, which has been the guiding light of this interpersonal process for the first part of the 20th century, several new approaches have been developed in response to society's needs and inspired from contributions from related fields--from sociology to behavioral medicine.

The modern trend in psychotherapy, as in most fields, is increasing efficiency. How, in the best and most streamlined way, without compromising quality of care, can this individual's dilemmas and distresses be alleviated in the shortest possible time? This question is as important to the patient as it is to the therapist. Times have changed since the days when the only quality option was the couch, five times a week, in strict analytic style. Today, combination treatments are likely to be considered, with the idea that one treatment need not displace another. It is not uncommon, for example, to see a patient engaged in psychoanalytically oriented psychotherapy also be concomitantly treated, when indicated, by psychotropic medication or behavioral adjuncts.

It is in this context that hypnotherapy finds its most sophisticated applications. Hypnosis, in its therapeutic infancy, was used to remove symptoms by a direct head-on approach. Symptoms were ordered out, cajoled into disappearing, and threatened lest they came back--which they often did. In the early days of hypnosis, symptoms were seen as thorns and hypnosis as tweezers. In this model, the patient had the subjective sensation that a magical cure had been performed, that the resolution of symptoms had been done by forces beyond his control without participation of personal resources, and that ego strength had not been enhanced. Direct symptom removal is, however, not a useless technique. In the right patient, at the right time and for the right reasons, symptoms may be hypnotically banished without symptoms substitution--especially if new experiences or adaptive behaviors are learned concomitantly.

Today, with much greater, but undoubtedly still rudimentary, understanding of mental mechanisms, we see symptoms and resistances in the context of what has been called the ecology of the mind--as compromises in a dynamic structure of forces.

Hypnosis, responding to the increased sophistication of psychological concepts, is used as much to explore psychodynamics as it is to foster the experience of conflict resolution, all in the interest of increasing ego integrity.

Analytic hypnotherapy refers to a set of techniques which integrate hypnosis with analytically oriented psychotherapy. Using the patient's trance capacity and some of the phenomena inherent in hypnosis, from relaxation to dream formation, hypnotherapy holds the promise of making personal change more efficient and more rapid.

This is not to say that hypnotherapy seeks to compress in time all phases of psychotherapy. Indeed, certain phases, especially those dealing with the creation and solidification of human contact and rapport, need and must have ample time. Other phases, however, can be condensed or otherwise accelerated, without compromising clinical effectiveness. In fact, speedier discovery of conflicts and shortened resolution time, by the impact of the reality of positive change, often have a galvanizing effect, inspiring patients to the possibility of further change.

The practice of hypnotherapy has no set formula. Hypnosis may be used in the early (investigative), middle (working through), or final (termination) stages of psychotherapy. Some clinicians use it consistently, dividing each session into a hypnotic and nonhypnotic part; others apply it on an as-needed basis.

Regardless of theoretical perspectives, there are certain practical issues which must be attended to in any psychotherapeutic interchange. The patient presents with an awareness of emotional difficulties which may be stated explicitly or may remain couched in the most general terms. At times, the stated complaints are not the real ones--the conscious explanation being only a mirror of the unconscious distress, ie, the patient presenting with tension headaches who, despite initial denial, turns out to have a depressive condition.

The initial task of the therapist is to clarify issues at hand. Why is this individual seeking therapy at this time? Very often, the patient does not know. Anxiety, fears, feelings of guilt, depression, and aggressive ideation are final common pathways to conflicts which, resurfacing now, may have long roots in the patient's past. Clarification may happen during all phases of treatment, from exploration of current issues in the initial sessions, to the elucidation of more historical conflicts further on.

Sometimes, presenting conflicts are directly related to experiences repressed for years. Clarification in such cases entails not only an exploration of current symptoms but necessarily demands the bringing to light of these important experiences which directly feed them. The following case illustrates clarification by the use of a technique called the affect bridge (Watkins, 1971), whereby the current emotion is linked to its epigenetic center. In psychotherapy, the same technique is used when we ask: When did you first experience this emotion? Hypnotherapy can make for shorter transit time from current emotion to its antecedent repressed counterpart. A bomber copilot sought help for inner turmoil, tension, and generalized anxiety which had built up appreciably in the past 24 hours. He had just flown a mission and was very apprehensive about leaving on another one soon. Very distressed, he admitted having had frightening, destructive fantasies while last flying the airplane: an impulse to punch out the control panels had left him shaken and doubtful of himself.

This high level of anxiety prevented him from being insightful about his situation. Searching for clues to these recent feelings, he mentioned a personality conflict with the pilot, but could not make it account for the degree of turmoil he experienced. His apprehension about the next mission was all the more fueled by his need to save face--he had to fly; he could not accept the idea of being taken off flying status and possibly being looked down upon.

He accepted the suggestion of using hypnosis for relaxation and, perhaps, clarification of his feelings. His anxiety level dropped off considerably during the latter part of the induction, and deepening of the trance left him sitting without any sign of the tremulous anxiety he manifested when first stepping through the door. In searching for the emotions accompanying, and hidden by, his anxiety, he was asked to go back, in mental image, to his seat in the cockpit of the airplane. Invited to talk, he described an insidiously escalating conflict between himself and the pilot. He was angry, sullen, and felt violent. In hypnosis, he showed mildly strained, reddened facies. 'When was it, back in time, that you felt similar feelings?" After fleeting moments, he started talking slowly. He was back with his older brother 15 years previously, playing around his family home. He was taunted by him and a group of his friends, belittled, infantilized. Overwrought with rage, he had gone back home, where, in privacy, he had kicked his brother's belongings. This incident stood out as one among several similar ones.

"It is clear to you and to me, as you sit here, that the pilot, although he reminded you of your brother by some of his actions toward you, is not your brother. This will be very clear to you from now on, and you will, as a consequence, act toward your colleague only as the present situation warrants; you will not bring anything into it back from your past."

He was also given ego-strengthening suggestions, ie, enhancement of the ability to handle emotions, development of his ability to relax and master situations, etc. Future missions were completely uneventful and three follow-up sessions centering on his relationship with his brother served to free up old angers and liberate some self-esteem.

In this example, several processes were called into play during the hypnotic intervention. The patient was led to the elucidation of current affects. Then, through a bridging technique, he was able to age regress and to reexperience the pictorial and emotional imagery which tied into his conflicts. He was provided with cognitive restructuring, ie, "the pilot is not your brother," and finally, in the context of ego-supportive measures, was able to integrate previously unconscious material into his field of consciousness.

Clarification of conflicts basically entails the discovery of all the feelings that enter into them. The following case example illustrates this process, used hypnotically, in a conflict involving the superego in its relationship to a constellation of sexual feelings, guilt, anxiety, and anger.

An attractive young woman was brought to the emergency room by the police. She had been wandering around the street, early in the morning, with few clothes, no papers, and no money. She was alert, suffered no trauma, and was clear medically. Her eyes were lucid and her demeanor appropriate; she was tense, polite, and concerned about her situation. Especially disturbing to her was the fact that the very last memory she had about herself dated back an entire week when she was attending to her job as a secretary in a neighboring city. She could talk about her life, her family in Europe, her strict religious schooling, her immigration to the United States, in detail, but she could not, however hard she tried, recall any of the events for an entire week that culminated in her dramatic admission to a major city hospital.

An amobarbitol sodium (Amytal) interview could have been done at this point. The amnesic hiatus--a week of this woman's life subtracted from the reach of her conscious mind--could be retrieved; but as the drug leaves the body, the amnesia returns. Using hypnosis, if feasible, is preferable because not only can memories and their emotional connections be brought out of the unconscious, but they can be worked with to encourage resolution.

She spoke and related well. The fact that she was in a helping environment was clear to her. She consented to hypnosis, with assurances that utmost care would be taken to make the experience as gentle as possible. Her somewhat agitated state gave way to a certain torpor, as a counting method was underway: "10, 11, 12, as we get to 20 we are more and more able to communicate with your subconscious mind. As you may know, your subconscious is a powerful part of your mind that contains dreams and all memories, from childhood on. And if your subconscious mind is willing, maybe it can let us in on some things it knows, at its own pace, for the purpose of making you feel better, more complete and whole ... 13, 14 . . ." Hand levitation followed. "As you sit here in deep hypnosis, and we are here with you, maybe you can begin to think back to the time, some weeks ago, when you were working as a secretary ..."

She began to speak. During her narrative, she was questioned, open endedly, about the sequence of events in her recent past. At times she became anxious and had to be guided back into relaxation before returning to her story. She described how, in the last few weeks, she had felt alone and with few friends. She had received an invitation to spend a day with a "family friend," a man she had known peripherally for a number of years. To her surprise, when she came to his home, he had prepared dinner, and to quell her feelings of shyness and social anxiety, she readily accepted the many drinks he offered her.

In the first hypnotic session, she could not recall the events that transpired from dinner time to the next few hours when, in the very early light of the morning, she found herself, half dressed, stumbling out of the apartment into the street. An amnesic core stayed on, which, in subsequent sessions, was clarified and eventually integrated. The forces of her superego, fueled by her intensive education and family tradition had pushed this first sexual experience beyond the doors of awareness, and at the same time, for the sake of ensuring completeness, had taken a whole week of her life along with it.

Hypnotherapy was mixed with short-term psychotherapy to modify some of the strong superego forces (by tempering their severity), to help with the ventilation and attenuation of affect, and to restore and even enhance self-esteem. She left the hospital two days later with all memories at her conscious disposal.

Psychogenic amnesia is a defense and a resistance protecting the equilibrium of the psyche from sudden overwhelming affect. Resistance, the sum of forces resisting therapeutic change, is a hallmark of any psychotherapeutic process, hypnotic or not, and although only few affects are involved--anxiety being the main one-its manifestation has many faces, from coming late or missing sessions to avoiding certain topics, from developing other symptoms to acting out. Hypnotherapy must treat defenses as forces with a purpose and not as static barriers in need of being broken.

In most hypnoanalytic interventions, supportive as well as insight methods are used. Supportive measures, in this context, do not imply blanket reassurances for the patient. Rather, they convey, first, an understanding of dynamic forces, then a strategy of encouraging or reinforcing healthy constructive ones and repressing or weakening those which are not. In the above example, punitive superego forces are dampened, with a view toward expanding the self-concept to accept the healthiness of having sexual desires.

Another facet of the therapy involves the ventilation and catharsis of repressed affect, which although not integrative in itself, provides for attenuation of emotion and for subsequent easier handling. Several techniques exist for hypnotic catharsis including open, expressive catharsis; implosive desensitization; or silent abreaction, ie, the use of projective imagery to "see oneself" emote.

Hypnotherapy may similarly be used to treat phobic disorders, when the phobia has a focal beginning in the patient's life. In such cases, "depth hypnotherapy"--hypnosis to retrieve painful experiences and historical conflicts--may be combined with more "surface hypnotherapy"--hypnosis to teach relaxation and to control the manifestations of anxiety.

The following case demonstrates how the capacity to create dream imagery in hypnosis may be tapped to arrive at traumatic memories. Dream induction is often preferable to other techniques for phobia exploration because the subject is able to protect himself from intense anxiety through a number of different mechanisms including dissociation (the dreamer as observer witnesses the scene) and symbolization. At the same time, dreams provide dues which, like guideposts in a forest, weave through the barriers of defense to lead to better understanding.

A church organist came for consultation because of increasing anxiety, sometimes bordering on panic, during his performances. At 38, he was an accomplished musician whose services were very much sought after. Two months before, during a well-attended service, he remembers looking up at the high vaults and the rose windows and feeling twinges of apprehension; his fingers developed mild numbness, and he began to sweat. He was puzzled, and even more so when the same feelings, more pronounced, returned during his next performance a few days later. By now, he was clearly apprehensive. He could not understand this novel and distressing reaction which only occurred in this setting. His syndrome worsened and, when his anticipatory anxiety began consistently to darken his daily activities, he sought help.

He brought up the possibility of using hypnosis himself. Clinical experience shows that when patients do so, they are more likely to respond and benefit from the treatment.

The induction led to deep relaxation and to a good working trance level. Some time was spent making him aware of how deep relaxation felt within his body. "As you sit here deeply relaxed in a soothing hypnotic trance, I am going to ask the part of your mind that creates dreams to help us today. We have talked about the distressing feelings you have had recently, and it would be very helpful to know more about how they came to be. Your subconscious mind knows about that, I am almost certain. So I'll ask that part of your mind, if it would be kind enough to, to put together a dream that will tell us about your feelings, using any images it wants, for whatever length of time. Please let it do so after I count to three, and I will remain quiet until you signal me with your right index finger (ideomotor response) that you have stopped."

Four minutes later he raised his index finger. He was guided out of the trance and recounted the following dream. "I was real small, maybe 7 or 8 years old and I visited our neighbor, an older woman who used to give me candies. She gave me some, and then started singing a song, a religious song. I found it strange because I had never heard her sing. It was getting very noisy; I looked up and I saw the chandelier shaking, then the ceiling. I got scared, so I cupped my hands over my ears and hid under the table."

Using this dream and free association to elucidate symbolism, we arrived in time at the following memory: as a child of five, his mother (the neighbor in the dream) took him to church. It was a special occasion; maybe, he thinks, a mass for someone's death. The church was packed with people standing all around him. He held his mother's hand as the coats, dresses, and knees of people pressed against him. The music was loud, sonorous. It was a hot day (loud in the dream) and even hotter inside. He felt pushed, pressed, constricted--and frightened. He wanted to leave, to get some fresh air, some light. He looked up to see his mother but could not, because of obstructing faces, and instead fixed his eyes on a rose window high above. The church felt like it was spinning; then he fainted.

Subsequent exploration revealed that he had had his first anxiety episode, two months before, on the first anniversary of his mother's death. When all these memories and connections fell into place, he experienced a sense of release and relief. Given, in addition, posthypnotic suggestions for relaxation and self-mastery, he continued in his work symptom-free and with unhampered creativity.

The dream techniques carry a prominent position in hypnotherapy because they can be applied to a wide range of clinical problems--from exploration of complaints and resolution of symptoms to the task of finding creative solutions. The hypnotized subject may be asked to create a dream during the trance or, more open endedly, may be given a posthypnotic suggestion to have and remember any number of dreams until the next session. Depending on the patient, and current therapeutic demands, instructions for the elaboration of dreams may center on the distant past, on present reality-based problems, or on the future, ie, "as you see yourself in this future situation, how do you imagine yourself feeling? How would you like to see yourself experiencing and handling this event? What do you envision would be best for you?"

Symbolism, condensation, displacement, and other primary process mechanisms in hypnotic dreams are the same as those found in sleep dreams. In hypnotic dreams, however, some degree of volitional control and guidance may be applied in the context of hypnotic rapport so that, if need be, the patient may be asked to redream about the same conflict, to use different, perhaps more understandable symbols, to remember the dream clearly, and to be insightful about its meanings.

Clarification of the presenting dilemma sometimes is the only treatment needed as is exemplified in the following case.

A highly successful 50-year-old marketing specialist came to be treated for an ill-defined sense of unhappiness. Although happily married with two children doing exceedingly well, productive and financially rewarded in his work, he had had, for several months, a sense of following a path in life "that is not quite right." He made the following analogy "I feel I am on a fast moving train but that maybe I should be on another." Sifting the details of his life failed to bring up solid reasons for his sense of disquietude; in addition, he showed no evidence of any psychiatric or medical disorder. He mentioned that recently he had published his third article in a fiction magazine, and he had remarked, with some wonderment, on finding himself more interested in European history than at any time in his life.

A man with a flair for new experiences, he readily accepted a trial of hypnosis for purposes of clarification of these vague feelings of unhappiness. "I would ask you, as you sit here in hypnosis, to bring up some of the feelings we have been talking about, and for you to approach them and experience them even more than you have so far (affect enhancement), so that you, can describe them better. Maybe this feeling of unhappiness contains other feelings. If it does, look at them with an eye on identifying them more and more clearly. If at any time you want to say something, please do; otherwise, I'll just stay here quietly while you search . . .

He said nothing. Minutes later, a smile came across his face, which some seconds later left an imperceptible glow of contentment. After exiting from hypnosis, he was asked about the meaning of his smile. He described that moment of smiling as one of discovery; his dilemma was understood--not resolved, but understood. He clearly saw how he was trapped by success. He was living his life much too much as he "should be," "should" referring to the expectations of all those around him, reinforced by the tangible evidence of his proficiencies. He always had strong leanings to devote energies to writing, only to be stifled (well meaningly so he admitted) by his parents who pushed his business career. He was afraid to rearrange his priorities. Would he lose the interest, respect, and support of those around him if he tried to be even a part time writer? Could he possibly make a transition to what was closer to his heart, writing, yet be equally successful?

He had had, as is not uncommon, an "ah ha" experience during hypnosis. Although he may have had this realization by himself in his own time at some point in the future, in psychotherapy or not, hypnosis provided the context for several discongruent dimensions of his life to be suddenly perceived as a "whole." In this case, one hypnotic session provided him with what he wanted. He eventually reached a solution of compromise, cutting down his job responsibilities progressively, and at the same time, writing and getting published.

This case illustrates the growing attention to what may be called problems of personal meaning or existential worth. It is increasingly realized clinically that a wide range of human problems are generated by frustrations to the creative expression of the drive for individual meta-significance.

Hypnotherapy may be called upon to deal with more complex patterns of mentation and behavior which, unlike delineated symptoms, have diffuse ramifications for the personality, permeating, often destructively, the patient's life pattern.

Ego state therapy (Watkins, 1979), based on the contributions of Federn (1952), sees patterns of behavior and experience as manifestations of ego subsystems which have a certain autonomy and internal consistency. Unlike multiple personality disorders, which have relatively rigid boundaries, ego states are more loosely integrated into the total personality. Yet, as structures of drives, fears, wishes, cognitions, and experiences rooted in their own developmental stages, they have the power to influence the final common pathways to behavior.

When a patient is to be treated with ego state therapy, it is helpful to begin with an exploration of these concepts in the waking state, with mention that the hypnotherapist, during hypnosis, may ask to communicate with some subparts of the personality. Often, concerns about having multiple personalities are raised by the patient; but differences should then be brought out, including the fact that many of the expressions of ego states are already known to the patient.

A computer-science student sought therapy for reasons that she could not clearly define in the first sessions. Especially bothersome to her, yet somehow comforting, was her lifestyle. At 28, she found herself alone most of the time, experiencing intense feelings of separateness. She worked out her schedule so that she was up most of the night and attended some classes in the late afternoon. The idea that she was sabotaging relationships was not new to her. At times, she would have a series of several dates; but when a male relationship became important to her, she started "behaving erratically," leading predictably, to its dissolution.

Explorative psychotherapy led to discussion about her family life. Having lived alone for over 10 years, she recalled with anxious sadness the turmoil between her parents. Her much older sister had already left the household. She brought back images of her parents fighting constantly, her father and her mother threatening to leave each other, and her comforting her mother who, often crying in her room by herself, would tell her what a crucifixion marriage was. She also tried to placate her father so that he would calm down enough to stay in the family.

In her daily routine, she felt alone and painfully awake in the early hours of the morning, dealing with gnawing sensations of internal void and of bitterness mixed, all too rarely, with fleeting hope. There was maybe, she would tell herself, a reason for all this, a way out, and a promise of a more normal life. This is how she sought therapy.

Agreement was made for exploration with hypnotherapy. She reached medium to deep hypnotic trance levels. 'Could you let us know [notice the use of "us" to reinforce the idea of a therapeutic alliance] if some of the feelings we have talked about in your daily life have connections with the experiences you had in your family as you were growing up?" It didn't take much time for her to nod yes. "I know it may be a little uncomfortable for you to do so, but let us, if you would, go back to that time, so we can retrieve some experiences, some feelings that can help our understanding of you, some memories that will help you eventually to feel better and happier."

Within a few moments she started talking. She placed herself in the middle of a heated argument between her parents. Each threatened the other with instantaneous departure. Frantically, yet unable to do much, she tried to ease their threats. What if my mother left, or father, or both? I would be all alone (like I am now, living out what I dreaded most).

She was asked to give this part of her, the one caught in this triangular family scenario, a name. First she said "the mediator." Later, she changed it to "the savior" (of the family), and later, in subsequent sessions, she called it "the frightened little girl."

The "frightened little girl" carried with her a vision of relationships wrought with tragedy. In hypnosis, she was able to answer questions, almost as a separate entity, about her own likes, dislikes, fears, and fantasies. In adult life, when a relationship became intimate, the "frightened little girl," through subconscious mechanisms, was able to alter total behavior, making the patient erratic"--emotionally labile, irritable and angry, suddenly sullen. In hypnosis she said "If it goes any farther, I will be faced with the same situation like with mom and dad."

In ego state therapy, these subparts of the patient are not told to go away or to stop their bothersome activities. From their perspective, these semiautonomous ego states are looking out for their welfare and existence, presumably in the interest of the whole person. Instead, efforts are made for their fears and wishes to be expressed and understood, and in turn, for them to understand, albeit in their own primitive ways, how certain changes could benefit all parties involved.

The cases and the commentaries above give the reader an idea of the tremendous range of applicability hypnosis has in the psychotherapeutic context. One should not remain, however, with the impression that hypnotherapy is a magical royal road to mental health. Like any other therapeutic intervention, it has to deal with the fabric of the patient's character structure and the various defensive forces along the way. There are also failures of hypnotherapy, stemming from misperceptions or misconceptions of patients' problems. Even Erickson writes of a seemingly innocuous hypnotic suggestion which set back therapeutic progress for three weeks. He asked a young woman "to see the loveliest thing you ever saw in your life," and she recreated her mother's lovely face in the aftermath of a fatal automobile accident.

Hypnotic phenomena, however, much like snow tires on an icy road, can be applied to therapeutic traction, helping many phases of psychotherapeutic work, from the exploration of the past and resolution of the present to the shaping of one's future directions.

ERICKSONIAN APPROACHES TO HYPNOTHERAPY

There are many ways to integrate hypnosis into psychotherapy, and many more are undoubtedly awaiting discovery. One integrative approach which has received a lot of attention derives from the work of Milton Erickson whose teachings of clinical hypnosis have been noted for their creativity and their attention to complex human psychological dynamics.

Erickson's style and methods of dealing with the hypnotic situation were unique and innovative enough so that the title "Ericksonian approaches to hypnotherapy" is clearly warranted. His beliefs were opposed to all strictly formulated theories for psychotherapy, with or without hypnosis (Moore, 1982). For him, theoretical constructs of human mentation and behavior were unduly restrictive and inhibited the therapist's awareness of the unique individual to individual interactions between himself and his patient. No one psychotherapeutic encounter is identical to the next; indeed, each moment of psychotherapy is unique in its own right.

Erickson did not have a personality theory into which the patient could fit. Rather, it was the other way around; he developed a personality theory for each patient, taking account of the patient's private way of processing life. Even his use of the terms "conscious" and "unconscious" were personalized to the patient. Rather than adhering to a Freudian topographic model, he preferred to think of the conscious in the dynamic context of the unconscious, with both dimensions being accessible to the many levels of interpersonal communication.

In view of the fact that these techniques require integration into the personal style of the therapist, a high degree of skill and intuitive understanding, they are not for the beginner. They are, first and foremost, strategies of psychotherapy to which hypnosis may be judiciously applied, and for this reason, a "how-to" explanation could not do them justice. Although the art of his craft poses challenges to the observer, in view of the complexities of the hypnotic interaction, the lack of controls, and the uniqueness of each individual patient treated, certain concepts may nevertheless be extracted from his work which, when integrated, become the essence of his therapeutic illuminations.

Erickson used formal induction in less than 10% of his cases. Instead, he infused the important elements of induction into the stream of interpersonal communication. In the trance, the individual's locus of self moves from external to internal realities.

The therapist observes and experiences the patient's mode of communication on as many different levels as possible--verbal, nonverbal, emotional, styles of imagery, cognitive functioning, and "enters" the patient's frame of reference, ie, his interpretation of reality, internal, and external. The therapist gradually modifies the patient's cognitions and behaviors so that the resulting change will be experienced by the patient as self-benefiting and ego syntonic.

To move with and around the critical observing and defensive ego, various techniques may be used, usually unobtrusively, and integrated into the casual conversation. Confusing the logical mind, much in the same way as the "koan"--the insoluble riddles of Zen--opens the way for new perceptions outside the patient's ordinary frame of reference. Surprise statements, paradoxes, and double binds jolt ordinary perspectives and call for novel ways to consider solutions. Indirect approaches sidestep ego vigilance, and focusing awareness on different sense modalities opens doors to the use of other mental areas (the right hemisphere for example).

Symptoms and their connected defensive forces are approached with respect and with the understanding that they represent purposeful, albeit maladaptive, compromises. The aim of hypnotherapy, or of all psychotherapy for that matter, is for the patient to incorporate symptoms into his field of control, in ways that will benefit growth, maturation, and happiness. Symptoms are then "mastered" and may be recreated or let go at will. To this end, different techniques may be called upon. Symptom prescription allows the patient to approach dreaded or distasteful symptoms with less fear or repulsion and to establish some jurisdiction over when, where, and how strongly or weakly they appear. The patient may then be asked to practice experiencing a mood, a feeling, or performing certain behaviors that already exist, or even to encourage the continuation of a symptom that appears to be waning. Prescribing the symptom to its worst extreme or to the absurd carries the process even further.

Defenses and resistances, as parts of the symptom complex, are similarly handled, sometimes encouraging them, sometimes challenging them, always in a style that is nonrigid, fluid, and adaptive. One is reminded of the Japanese method of psychological and physical training, Aikido, where force is not met with counterforce but is allowed to spend itself or to be diverted to new directions.

Many of Erickson's therapeutic results have yet to be adequately explained, their mechanisms comprehensively systematized, and their outcomes replicated. This is an example of how the clinical practice of hypnosis differs from laboratory analysis, how techniques relate to their craft, and how theory has yet to account for the uncharted areas of the human mind.

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Gérard V. Sunnen M.D.
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