Posts Tagged ‘LICSW’
Selena is a precocious five-year old girl who could not stop sucking her fingers. Her teeth were beginning to protrude. Because she still believes in Santa Claus and the Tooth Fairy, I was positive that she would be very susceptible to hypnosis.
I asked Selena to “move to the magic chair where kids stop sucking their fingers .” Then , at my request, she named each finger. She responded with, “Bunny Rabbit,” “Robin” and other similar titles. I directed her to ask each finger if it liked being sucked. She said, “No.” Then , I asked her to find out what her fingers would rather do instead. After some conversation with her fingers, she told me they would rather play dolls, jump rope and do puzzles.
l suggested, “Let’s see how we can give those fingers more time to play.” With proper ceremony, I showed Selena my “magic wand.” I then asked her to “… think of a magic word that will keep you from sucking your fingers.” With delight, she squealed , “Poof!”
Next, I asked Selena to put each finger in her mouth. “But,” I cautioned her, “before you put your fingers in your mouth, say ‘Poof!’ And I will wave my magic wand.” We repeated this pleasant little ritual with each finger.
Then, I told her she could do that all by herself after she left my office.
The following week, Selena and her mother reported that Selena did not suck her fingers all week except for one short moment as Selena was leaving my office. The mother then mentioned, almost in passing, that she would ask me to help Selena overcome her bedwetting, but she knew Selena was not yet ready to stop that behavior. I began to talk to Selena, reinforcing the previous week’s process, but it seemed not to have any energy left in it. Then I told Selena, “I don’t want you to stop wetting the bed yet. But you will be ready very soon. So let’s do some things for when you are ready. OK? Can we do the same magic for the part of you that wets the bed?”
Selena agreed. I told her I would wave my magic wand and asked her what she would do. She replied that she “would dive, like this.” She stood and did a full body dive onto the couch. As she hit the couch she said, “POOF!”
Selena did several more dives on the couch and then progressed to crawling all over the floor saying she “was swimming like in the Olympics.” I gave her an “Olympic medal ” (a sticker) and told her that the medal was for “all the dry ‘Pull Ups’ you will have now.” A week later, I phoned the mother for a “follow-up.” She reported Selena had not sucked her fingers since the day of our first session and had not wet the bed since our second.Discussion by William Keydel, M.A.
Magical … and fun. This wonderful case illustrates three principles which are at the heart of Ericksonian psychotherapy. First and foremost is the acceptance and honoring of the client’s way of viewing the world. Dr. Williams begins by utilizing the preschooler’s belief in magic to set the stage for change. She deepens Selena’s natural imagery by asking her to name her fingers and creating the imaginary friends so common to children’s play. It is then these friends of Selena’s unconscious who provide motivation for change with reasons meaningful to the child and not even necessary for Williams to know. Williams also evokes Selena’s natural energy and excitement by allowing her to come up with the magical words and acts that would extinguish unwanted behaviors. In these ways, Williams has entered Selena’s world to stimulate change from within.
The second principle which stands out is the interruption of existing patterns through strategic interventions. The beauty of Erickson’s work stemmed from his ability to see the individual’s patterns and his creative responses to those patterns generating change with a minimal amount of effort. By having Selena say, “Poof!” as she put each finger up to her mouth , Williams introduced a change in the old pattern. Then this became a new pattern, reinforced by practice with each finger, and further reinforced by the excitement of creating magic on her own. In this case, it’s easy to imagine that Selena experienced no effort as the strategic intervention created its own reward. Similarly, Selena’s patterns for approaching bedtime were changed with her full-body dives which naturally utilized the playful energy of a child.
The third principle to be honored in William’s handling of the case, is the willingness to let go of theories and “treatment plans” and respond to the client. As Erickson is quoted by Gindhart, “Too many psychotherapists try to plan what they will do instead of waiting to see what the stimulus they receive is, and then letting their unconscious mind respond to that stimulus” (p. 120). While reinforcement is generally good work, Williams responded to her client’s “energy ” and appropriately moved on. Throughout her work with Selena, Williams demonstrates the elegance of responding to her client and thereby allowing Selena, in a general way, to structure therapy in accordance with her needs.
I could have focused on Williams’ effective use of permissive therapy and embedded commands; or my focus could have fallen on the value of using a naturalistic trance to avoid the awkwardness a formal trance induction is likely to have on a child. But, as Richard Dimond points out in “Trials and Tribulations of Becoming an Ericksonian Psychotherapist,” (Zeig, 1985), Ericksonian psychotherapy requires more than learning Erickson’s techniques. There are fundamental principles about entering in and trusting the unconscious system of the child across from us.
Dimond, R. (1985). “Trials and Tribulations of Becoming an Ericksonian Psychotherapist.” In Zeig (Ed.), Ericksonian Psychotherapy, Vol. 1: Structures. NY: Brunner/Mazel
Gindhart, L. (1985). “Hypnotic Psychotherapy.” In J. Zeig (Ed.), Ericksonian Psychotherapy, Vol. 1: Structures. NY: Brunner/ Mazel
People who are hit with panic attacks have a common response. They feel compelled to fight the symptoms with all their available resources. They brace for the fight as they approach any feared situation. And if they predict this on-guard approach will fail, they avoid entering the scene as the only way they can guarantee their safety. But this resistance and avoidance comes with a price: a restricted lifestyle, anxious hypervigilance and often depression.
Over the past three decades, specialists in the treatment of panic disorder have helped their clients move from a commitment to resist their symptoms to one of acceptance. By allowing the racing heart and spinning head and wobbly legs to continue in a permissive mental environment, clients discover that they don’t actually have a heart attack, go crazy or faint. As they adopt this new permissive attitude – “It’s OK to be anxious here.” “I can handle these symptoms.” “I’m willing for people to notice my nervousness.” – then each panic attack runs a more limited course with far less intensity.
While this permissive approach has been standard, there also has been a secondary approach to treatment: to voluntarily, purposely seek to increase the uncomfortable physical symptoms. This paradoxical approach, dating back at least to Dr. Victor Frankl’s logotherapy, is now set to take center stage. The chief reason is a pragmatic one: the more provocative treatment is the briefest of treatments.
This winter, the Anxiety Disorders Association of America will release Facing Panic: Self-help for People with Panic Attacks. This guide is a synthesis of the work of this field’s foremost clinician-researchers. Here is the central therapeutic strategy, expressed as five instructions to the reader:
Get anxious on purpose. Once you are anxious, encourage the symptoms to continue for a long time. During this time, stop worrying and start supporting yourself. Let go of your safety crutches. Do this over and over again, in all your fearful situations.
Let’s look at each of the five directives:
Get anxious on purpose. The key here is not just to become anxious, but to purposely choose to get anxious. It is the seeking of the anxiety state that distinguishes this step from the more common approach of tolerating or putting up with the symptoms. It is a shift in one’s relationship toward anxiety, and it is a critical distinction. “Having” anxiety is insufficient; “wanting” anxiety is the central goal.
Once you are anxious, encourage the symptoms to continue for a long time. Here is an extension of the first step: invite your distress to stay around as long as possible. Try to keep it. If it subsides, feel disappointed, and look for ways to bring it back. We know from our studies of flooding that prolonged exposure leads to habituation. But this only occurs if the person drops his guard and allows the anxiety to exist during that time. I am proposing that we challenge the foundation of this flooding protocol. We can greatly shorten the required length of exposure if we emphasize the person’s therapeutic stance: first, to seek out the uncomfortable symptoms, and then, to consciously desire for them to remain for as long as possible.
During this time, stop worrying and start supporting yourself. While we encourage clients to feel scared and to feel the uncomfortable physical sensation of panic, we discourage worried thoughts (there is an appropriate therapeutic time to encourage worried thoughts, too, but I won’t cover that in this brief article.). We are battling two fronts here. First, panic sufferers will worry about just how uncomfortable the symptoms will feel. But, more importantly, they will worry about the catastrophic outcomes: fainting, having a heart attack, making a fool of themselves. We want them to learn, through specific exercises, that the panic attack will be uncomfortable but not horrible. Once they can downgrade their interpretation of the symptoms, then they can accept their symptoms instead of fear them. This stance is reflected in such supportive statements as, “I’m scared, and I’m safe.”
Let go of your safety crutches. Safety crutches are actions that help prevent or mute the symptoms of panic. We have identified over seventy behaviors, such as carrying an anti-anxiety medication in their pocket, practicing breathing skills, monitoring their pulse rate, sitting close to an exit, leaning against a wall, staying somewhere only briefly, turning the radio up, never passing a car, and always avoiding crowds. While these are understandable, protective strategies, they all are based on the fundamental misperception that panic symptoms result in catastrophe. We help clients identify their safety crutches and gradually reduce their reliance on them. As they realize that they can manage the sensations of panic without these restrictions, they are willing to take more risks in the provoking situations.
Do this over and over, in all your fearful situations. To overcome panic, people need to practice their skills again and again, in as many different locations and circumstance as possible. Primary in this effort is to want to feel anxious and to desire to remain uncomfortable for as long as possible. As they change their attitude in this manner, they discover that going face-to-face with panic eventually reduces their symptoms and gives them back their freedom.
When asked about James Braid, Ernest Rossi said, “Braid is the true father of hypnosis (personal communication, Dec. 7, 2001). His work forms the basis of what I’m doing today.” This praise becomes understandable after a quick look at Braid’s contributions. He not only popularized the terms hypnosis and hypnotist; he first explained trance states as the interplay of physiology and psychology.
Historians credit Braid (1795-1860) as both the first researcher of psychosomatic medicine and the father of modern theories of hypnotherapy.
Braid’s work marked the end of Mesmerism, which held that a hypnotist emanated magnetic fluids to invoke trance. Mesmer believed he could ‘mesmerize’ trees in order to hypnotize passersby, reasoning that the magnetic fluid would pass from the trees to the subjects.
Braid debunked Mesmer’s theory by utilizing a simple ocular fix as an induction technique. He had subjects stare at common, household objects and within minutes, they entered a trance state. His studies proved that hypnosis occurs naturalistically within the subject and wasn’t dependent on the showmanship of the hypnotist. He wrote, “The whole (of the induction) depended on the physical and psychical condition of the patient… and not at all on the volition, or passes of the operator” (Braid, as cited in Tinterow, 1970, p. 283).
Erickson often echoed this theme, “Once you really know…that you don’t do it, your subject does it, you can have unlimited confidence…that your patient is going to go into a trance” (Argast, Landis & Ruelas, 2000, p. 55).
Braid asserted that everyone can be hypnotized, assuring his contemporaries that, “success is almost certain.” (Braid, as cited in Tinterow, 1970, p. 287). Braid described trance as a “universal phenomenon” and “a law of our species” (p.288). Erickson was later to concur, stating, “As long as your subject is alive, you can expect some developed trance state” (Argast et al., 2000, p. 55).
In 1843, Braid conceptualized trance as a, “shift of the nervous system into a new condition,” (Braid, as cited in Tinterow, 1970, p. 271) marked by excitement and the mind’s fascination with a single idea. “It is this very principle, of over-exciting the attention, by keeping it riveted to one subject or idea which is not of itself of an exciting nature… and (a) general repose which excites in the brain and whole nervous system that peculiar state which I call Hypnotism” (p. 301).
Similarly, Braid characterized psychopathology as a mind fascinated with a single, negative idea.
“Abnormal phenomenon are due entirely to this influence of dominant ideas over physical action, and point to the importance of combining the study of psychology with that of physiology, and vice versa” (p. 369). He added that, “all the natural functions may be either excited or depressed… according to the dominant idea existing in the mind of man… whether that has arisen spontaneously, had been the result of previous associations, or the suggestion of others” (p. 369).
Braid regarded hypnotism as a “valuable addition to our curative means,” describing it as “a powerful and extraordinary agent in the healing art,” while cautioning that it wasn’t a “universal remedy” (p. 272). About hypnotherapy, he believed that “the imagination has never been so much under our control or capable of being made to act in the same beneficial and uniform manner by any other mode of management hitherto known” (p. 272).
Braid also detailed the first list of naturally occurring, hypnotic phenomenon: eye movements, pulse and respiratory changes, and catalepsy. He stated that, “All the (hypnotic) phenomena are consecutive” (p. 307). He reported an “extreme acuteness of hearing during the first stage of hypnotism” and advised “allow(ing) the hearing to disappear, by which time all of the other senses will have gone to rest…I allow all of the senses to become dormant and then rouse only the one I wish to exhibit in the state of exalted function, when operating carefully” (p. 312).Braid wrote poetically about how subjects find a somatic balance so they do not topple over. “They acquire (a) center of gravity, as if by instinct, in the most natural and therefore in the most graceful manner ” (p. 305). He added that because of this “faculty of retaining any position with so much ease, I have hazarded the opinion that the Greeks may have been indebted to hypnotism for the perfection of the sculpture” (p. 305)References:
Argast, T., Landis, R. & Ruelas, G. (2000) Now You Wanted A Trance Demonstrated Today. Laguna Nigel, CA: SCSEPH
Tinterow, Maurice M. (1970) Foundations of Hypnosis: From Mesmer to Freud. Springfield, IL: Charles C. Thomas