American Journal of Clinical Hypnosis
Volume 56, Issue 4, 2014
Special Issue: The Treatment of Anxiety: A Sampling of Varied
Approaches (please do not reproduce without permission)
By Carolyn Daitch, Ph.D.
Hypnotherapeutic Treatment for Anxiety-Related Relational
Discord: A Short-term Hypnotherapeutic Protocol
Anxiety disorders comprise one of the most common categories of
psychiatric disorders present in the population today (Kessler et al.,
2005; Kessler, Chiu, Demler, & Walters, 2005). In addition,
research indicates a link between anxiety and martial distress, with
anxious individuals reporting greater martial conflict and lower
levels of marital satisfaction (McLeod, 1994; Whisman, 2007;
Whisman, Sheldon, & Goering, 2000). In particular, people with
generalized anxiety disorder (GAD) are more likely to divorce
(Hunt, Issakidis & Andrews, 2002) and report low relationship
quality with their partners compared to those with other psychiatric
diagnoses (Whittchen, Zhao, Kessler, & Eaton 1994). This
suggests the need for couples’ therapy interventions which address
the impact of one partner’s anxiety on the overall relational
dynamic. It also underscores the importance of assessing for the
presence of clinical levels of anxiety when providing couples’
therapy. Likewise, when providing individual treatment for clinical
levels of anxiety, it is prudent to assess for the presence of
relational discord should the patient currently be in a romantic
partnership.
This article presents a hypnotherapeutic protocol for short-term
couples’ therapy which addresses the aforementioned subset of
couples’ experiencing anxiety-based relational discord. The
protocol is designed to complement individual treatment for
anxiety disorders. In addition, implications for further treatment
and empirical research are discussed. While the treatment protocol
introduced has not undergone clinical trials to empirically evaluate
its efficacy, it has been applied in practice with positive outcome.
As such it is being introduced in the hope of furthering
professional discourse on the innovative use of hypnotherapeutic
interventions and further awareness of the treatment needs of this
particular patient population.
Hypnosis in the Treatment of Clinical Levels of Anxiety
Currently, cognitive behavioral therapy (CBT) is considered the
gold standard in the treatment of anxiety (van Boeijin et al., 2005).
However, a variety of research has demonstrated larger effect size
when supplementing CBT with hypnosis (Bryant, Moulds, Guthrie,
& Nixon, 2005; Kirsch, Montgomery, & Sapirstein, 1995;
Schoenberger, 2008). In addition, a variety of studies provide
significant evidence of hypnosis as successful in the treatment of
anxiety and anxiety-related disorders (Alladin, 2008; Benson &
Frankel, 1978; Bongartz, Flammer & Schwonke, 2002; Flammer &
Bongartz, 2003; Galovski & Blanchard, 1999; Hammond, 2010;
Lynn, Kirsch, Barabasz, Cardena & Patterson, 2000; Lynn, Kirsch,
Irving, & Rhue, 1996; Melis, et al, 1991; Mende, 2009; Olmstead,
Zeltzer, & LeBaron, 1982; Palsson, & Moss, 2007; Revenstorf,
2003; Van Dyck, 1991; Van Dyck & Spinhoven, 1997; Whorwell,
1984). Considering the already widespread use of hypnosis as a
treatment approach for anxiety, it follows that hypnosis may
promote improvements when examining specific issues of anxiety
within the context of partnerships.
Hypnosis in the Treatment of Couples
Despite empirical evidence of hypnosis as an efficacious treatment
for anxiety, there is little specifically addressing hypnotherapeutic
interventions for the treatment of anxiety-related relational discord.
There is, however, a rich history of hypnotherapeutic protocols for
the treatment of family systems and couples’ therapy. Milton
Erickson’s approach to hypnosis has been actively incorporated
into strategic therapy for family counseling for decades (Gordon &
Meyers-Anderson, 1981; O’Hanlon, 1987; Zeig, 1985). Erickson’s
approach facilitates desired therapeutic outcomes via hypnotic
suggestions to re-direct and utilize patients’ pre-existing
cognitions, attitudes, and behaviors towards healthier patterns of
relational interaction (Erikson & Rossi, 1981). In addition,
Ritterman (1983) has integrated Ericksonian approaches into
family therapy by using hypnosis to directly address dysfunctional
patterns that negatively impact the family dynamic.
Hypnosis attempts to alter unhealthy perceptions and cognitions in
order to elicit reactions that patients may be able to transfer into
their relationship (Lankton, 2004; Kahn, 2009), fostering improved
communication, empathetic skills, active listening, and intimacy. A
number of clinicians have found success using hypnosis techniques
to shift dysfunctional relational patterns towards more positive
ones in ways that will facilitate healthy relationships (Gordon &
Meyers-Anderson, 1981; Lankton, 1983, 2008; Daitch &
Lorberbaum, 2013; Parsons-Fein, 2004; O’Hanlon, 1987; Zeig,
1985). As hypnosis has been shown to be an efficacious tool for
both the reduction of anxiety-induced distress and the enhancement
of couples’ therapy, it logically follows that hypnosis could be an
important tool for the treatment of anxiety-fuelled relational
discord.
Preliminary Considerations
The protocol presented in this article is primarily intended to be
applied as an adjunct to the individual treatment of an anxiety
disorder. Within the first one to two individual sessions, inquiry
into the status of the patient’s romantic partnership, if present, is
made. If determined that the protocol is indicated, the first couples’
session is scheduled within 4-6 weeks. However, I have found it
helpful to have one individual session with the partner prior to the
conjoint session. This individual meeting serves to establish
rapport by providing the partner with the experience
of being heard by the clinician as well as giving the therapist
further insight into the relational dynamic from the partner’s
perspective.
When an initial assessment specifies that brief couples’ treatment
is indicated, the short- term protocol consists of 4-7sessions.
However, the frequency in which the sessions will be delivered is
dictated by the anxious partner’s treatment progress in individual
sessions. The initial conjoint session need occur early in the
anxious partner’s individual treatment process for
psychoeducational purposes. However, the scheduling of the
remaining couples’ sessions need be timed to correlate with the
anxious partner’s mastery of individual treatment objectives
concerning the ability to regulate affective flooding. Additionally,
implications for longer-term treatment are discussed at the close of
this article.
Contraindications
The treatment plan outlined below is contraindicated should an
initial assessment reveal the presence of any active inter-spousal
violence, at which point interventions in the anxious partner’s
individual treatment would shift to address physical safety
concerns. Should the non- anxious partner present with any
clinically significant impairment which would interfere with the
ability to engage in the couples’ treatment protocol, couples
treatment would likewise be halted and outside referrals be made.
Additionally, both partners need to possess the self-regulatory
skills sufficient to deescalate emotional flooding before entering
the second phase of the couples’ treatment.
Delivery of
Hypnotherapeutic Interventions
As the treatment outlined is hypnotherapeutic in nature, hypnotic
suggestions which simultaneously engage both partners are
incorporated in many of the interventions outlined in this article.
Preceding each hypnotic protocol outlined, patients are given a
standard hypnotic
induction. I frequently begin with the Ewin Rapid Eye- Roll ( Ewin
& Eimer, 2006), followed by diaphragmatic breathing (Daitch,
2007, 2011; Daitch & Lorberbaum, 2012) and safe place
visualization (Hammond, 1990; Daitch, 2011; Yapko, 2013) . As
there are a variety of effective hypnotic inductions and deepening
techniques, the particular induction and deepening techniques
chosen are likely to vary given the clinician’s training. As long as
induction leads the patient into a sufficient depth of hypnosis (see
Hammond, 1998), the difference in clinicians’ induction and
deepening methods are of no concern. It is also paramount that
clinicians take sufficient time to fully re-alert patients following
the hypnotic intervention (see Kluft, 2012).
Treatment Protocol Phase 1: Psychoeducation (1 session)
The initial inquiry into the status of the patient’s partnership
presents the opening through which the couples’ treatment can be
initiated. Once the relational disconnect has been identified and
assessed and the partner brought in for an initial joint session,
psychoeducation can begin. The following topics for
psychoeducation, along with accompanying hypnotherapeutic
interventions, are presented.
Anxiety: the basics.
The psychoeducation process begins with an explanation of
anxiety. First, it is crucial that patients understand that the
experience of some stress and anxiety is actually adaptive. The
capacity to experience fear, stress, and anxiety allows us to
mobilize to address and overcome any threats or challenges to our
wellbeing. Problems occur, however, when the degree of fear and
anxiety experienced does not “match” the environmental challenge
present. Thus patients are led to understand that the goal of
treatment is not to extinguish the anxious partner’s experience of
anxiety and stress altogether, but rather to alter stress reactions so
that they are appropriate to
the environmental challenge at hand. By reframing the symptom as
an internal resource that is essential to both surviving and thriving
if mobilized adaptively, the Ericksonian principle of utilization
(see Daitch, 2007; Havens, 1989; Rossi, 1980; Lankton, 1985;
Gilligan, 1986; O’Hanlon, 1987; and Erickson & Rossi, 1979;
Hammond, 1990) is at work. The reframe of anxiety as a resource
also supports another goal of treatment: teaching patients to
tolerate discomfort of anxiety when it does arise.
As the anxious partner has a diagnosed anxiety disorder,
psychoeducation regarding the specific features of that disorder,
which would be a routine component of psychoeducation for
individual treatment, is also appropriate to provide at this juncture.
During or following the process of delivering psychoeducation
pertaining to any specific symptom constellations, additional
content regarding affective flooding is crucial (see below). This
information is presented conversationally and then reinforced
hypnotically.
Affective flooding.
The metaphor inherent in the term “affective flooding” aptly
captures the nature of the psychological state it describes: floods
arise quickly, strike with overpowering force, are overwhelming to
experience, and leave destruction in their wake. Further
illuminating the experience of affective flooding is the knowledge
that the brain is wired in such a way that it is far easier to become
flooded with emotion than to self-regulate and manage this
emotion with reason (LeDoux, 1996). It is crucial that patients
conceptualize heightened anxiety as an experience of emotional
flooding in which intense emotion overwhelms the patient’s efforts
to self-regulate and otherwise cope. This understanding can
transform both partners’ conceptualization of the anxiety that is
impacting their relationship.
The tripartite brain.
It is helpful to communicate a rudimentary understanding of how
the brain functions when a person is experiencing heightened
anxiety. This understanding serves to diminish shame in the patient
as well as soften judgment from the partner. This process begins
with a verbal explanation of the neurobiology associated with the
affective flooding that occurs during the experience of heightened
anxiety. To do this a theoretical model of the brain first articulated
by MacLean (1990) is used. In MacLean’s model, the structures in
the brain can be grouped into three sections based on the order in
which the human brain is thought to have evolved. First is the
reptilian brain, or hindbrain, which is associated with more basic
survival functions such as breathing, balance, etc. Next came the
midbrain, or mammalian brain, which is associated with the
expression and experience of emotion, and finally the forebrain,
associated with higher-level processes such as language, logic, and
impulse control.
The midbrain gone rogue.
When affective flooding occurs due to, for example, heightened
anxiety, the midbrain becomes hyperactive and the optimal balance
between the midbrain and the forebrain activity becomes disrupted.
As metaphor is a tool which allows patients to deftly grasp new or
previously learned concepts, the midbrain during periods of
affective flooding can be characterized as a midbrain gone rogue.
An auditorily-based metaphor follows: it is as if the emotion-based
midbrain is speaking through a bull horn while the logic-based
forebrain delivers its message with a whisper. Emotions are
amplified and the ability to successfully engage logic-based selftalk, as well as impulse control, is impeded.
Affective flooding: understanding the midbrain gone rogue.
The following hypnotic intervention reinforces the
psychoeducational content regarding affective flooding using
hypnotic imagery to further illuminate information conveyed.
And as you relax... everything else can fade into the background of
awareness...as you focus your attention on my voice and your own
internal experience...and I suggest that you take a moment to really
acknowledge yourself... honor yourself... and honor your partner...
recognizing that you both showed up today... and perhaps you are
open to learning something new that can help you understand
yourselves and each other better... that will help you both
understand the anxious brain.... And you, (insert anxious partner’s
name) can look forward to discovering that your symptoms make
sense as you get your head around your own brain, with some
increased education about how it works...and you, (insert nonanxious partner’s name), can look forward to understanding in
much greater depth how to make sense of your
partner’s/wife’s/husband’s reactions that are so different than
yours.
Now you don’t need to be a neuropsychologist to get this... and I
do know that most people as intelligent as you are have found it
helpful to possess a basic understanding of the anxious brain. And
you might enjoy learning that, as anxiety rises and rises, a tidal
wave of activity floods the midbrain... the emotional center of the
brain.... And as you know, floods arise quickly, strike with
overpowering force, are overwhelming to experience, and leave
destruction in their wake. And when that flooding occurs in the
midbrain it’s of course harder to hear the input of the logic-based
forebrain... the voice of reason and rational thought.
When you’re flooded with anxiety, it’s is as if the emotion-based
midbrain is speaking through a bull horn while the logic-based
forebrain delivers its message with a whisper... emotions shouting
and causing alarm... and that cool, calm, logical voice, that logical
part of yourself... can only whisper... has so little power to quiet
your emotion.
And the voices of others, too... even the voice of your partner,
whom you love, only comes across with the power of a whisper...
drowned out by the shouts of the emotion- based midbrain.
But you can look forward, now, with pleasant anticipation to the
rewards that will come to you as you increasingly understand the
anxious brain ....and this understanding can be for your
benefit...your growth.... It can influence your feelings, thoughts,
and behavior.... You may be pleased to discover that this
knowledge can actually be transformative... leading to a new depth
of understanding and compassion for yourself... and your partner.
[Re-alert.]
Neurological underpinnings of the relational disconnect.
When affective flooding occurs due to heightened anxiety, logicbased input from any source, whether it be the forebrain of the
affectively flooded patient or that patient’s partner, speaks with the
volume of a whisper. As such, the auditory metaphor used in the
previous hypnotic intervention frames the non-anxious partner’s
inability to quell the anxious partner’s anxiety with rationallybased appraisals of the triggering stimuli. As soon as the nonanxious partner enters the scenario and tries to engage the
affectively flooded partner with logic-based appraisals, a
disconnect occurs. The anxious partner often feels unheard,
shamed, and isolated as the partner’s logic-based input is not
sufficient to calm affective flooding.
The non-anxious partner can feel equally frustrated and
disconcerted in response to the anxiety-related relational
disconnect which occurs. Well-intentioned, logic-based attempts to
soothe the partner are ineffective as the anxious partner remains
rigidly adherent to irrationallybased appraisals of both internal and external stimuli despite the
non-anxious partner’s pleas to the contrary. Without intervention,
this dynamic often persists without resolution.
Colors of logic and emotion.
Following didactic psychoeducation, hypnosis is again used to
enhance the patients’ grasp of the information. After hypnotic
induction and deepening both partners are directed, in trance, to
elicit a memory of a specific time when the two of them were
experiencing relational conflict due to anxiety-related emotional
flooding. This passage has been adapted with permission from
New Harbinger Publications Inc, © 2012, Carolyn Daitch and
Lissah Lorberbaum.
Perhaps you can imagine a specific time when the two of you were
neither connected nor emotionally attuned—talking but not really
communicating... [if one such incident has been discussed in the
couples’ session already, the clinician might suggest the patients
choose this]...that’s right...and now, take your time to really get in
touch with the feelings... the emotions you felt during that
interaction.. [encourage the amplification of negative affect] ... and
as the feelings come up, just sit with them, noticing them without
judgment... that’s right....
Now, as you continue holding the feelings that arose for you, recall
the image of the three-part brain we’ve spoken of...with its three
distinct parts: the hindbrain toward the bottom, the midbrain in the
middle, and the forebrain at the top.... And imagine now that you
can see directly into your partner’s brain...seeing the midbrain...
the forebrain....
And now, [insert anxious partner’s name], imagine that your
partner is speaking from that logical, rational place. Maybe your
partner is giving you the typical first
response of suggestions—solutions—trying to respond to your
anxiety with logic. And as you see your partner speaking to you,
remember that [insert non-anxious partner’s name] is speaking the
language of reason—the language of the forebrain. And now,
[insert non- anxious partner’s name], imagine that your partner is
speaking from that emotion-based, anxious place. And as you see
your partner speaking to you, remember that [insert anxious
partner’s name] is speaking the language of emotion—the
language of the midbrain.
And now, [insert anxious partner’s name], as you see your partner
speaking to you with the language of reason, the language of the
forebrain, allow yourself to see this active part of the brain—the
forebrain—light up in a cool, calm blue, while the other two parts
of the brain remain dark and silent. And now, [insert non-anxious
partner’s name], as you see your partner speaking to you with the
language of emotion, the language of the midbrain, perhaps you
can imagine seeing this active part of the brain—the midbrain—
light up in a bright red of alarm, a vivid, intense color...while the
other two parts of the brain remain dark and silent. [Pause.]
Now each of you can take a moment to see the words, too, that are
being spoken by your partner... see the words drift from your
partner’s mouth to you... And as you see these words, [insert
anxious partner’s name], allow yourself to think, There’s
’s blue words, representing the language of reason. And as you see
these words, [insert non-anxious partner’s name], allow yourself to
think, There’s ’s red words, representing the language of emotion.
And as you both sit here... next to one another... imagining in your
mind’s eye the blue words of logic and the red words of emotion
drifting towards one another...out
of your mouths... take a moment to inhale... and exhale
slowly...and as you exhale, perhaps a sigh of relief as you relax
into the knowledge that yes, you really are speaking two different
languages... so of course it feels like neither of you are hearing one
another... that your message isn’t really sinking in.... And know
that from this shared knowledge... this shared understanding that
the languages of logic and emotion are in play... you can work to
build connection and resolution...planting a seed of understanding
that will continue to grow... because now that you know that two
different languages are being spoken, neither of you need be lost in
translation any longer. [Re- alert.]
Phase 2:Time-out (1 session)
Once the couple has a thorough understanding of affective
flooding and its impact upon communication and connection, the
time-out intervention provides the framework to engage in
behavioral shift. It is in this phase that couples gain explicit tools
to discontinue the problematic interactions surrounding one
partner’s experience of excessive anxiety. Prior to the conjoint
couples session, the anxious partner will have already been taught
to identify his or her indicators that affective flooding is about to
occur and initiate an immediate cease in activity, a time-out (see
Daitch, 2007; Daitch & Lorberbaum, 2012). During this brief
interlude the patient accesses a space which facilitates privacy. The
patient would use a separate room in the house, a private office or
cubicle, an outdoor area, or even a public restroom if no other area
avails itself. In this planned interlude, the patient engages in a host
of self-regulating techniques such as a the Ewin Rapid Eye-Roll
(Ewin & Eimer, 2006), deep breathing, positive self-talk, and selfhypnosis using kinesthetic cues to access a safe place that has been
previously established in-session while the patient was in trance
(see Daitch, 2007; Daitch, 2011; Daitch & Lorberbaum, 2012). As
mentioned earlier, this phase of the couples work is not to be
entered into until the anxious partner has demonstrated ability to
successfully engage in affect regulation which either circumvents
or calms anxiety-related affective flooding.
Once the anxious patient’s progress in individual sessions is
sufficient, the conjoint couples session provides the opportunity to
shift communication patterns by integrating the time- out into the
couples’ interactions. Given that conflict often arises surrounding
the non-anxious partner’s well-meaning but unsuccessful attempts
to help the anxious partner engage in affect regulation, it is
necessary to change this interaction Recalling the neurologicallybased futility of logic-based attempts to deescalate affective
flooding, this is more than understandable. It is the anxious partner
who has the agency necessary to de-escalate his or her own
affective flooding. Time-outs acknowledge this, provide the
anxious partner with the opportunity to engage in self- regulation,
and stop the non-anxious partner from engaging in a way that
would assume responsibility for this role.
In the session the anxious partner has the opportunity, with the
help and support of the clinician, to explain the time-out to the
partner. Then both partners and the clinician set a protocol for the
enactment of the anxious partner’s time-out so that interaction can
resume once the anxious partner has regained a greater degree of
affect regulation.
Phase 3: Enhance positive affect (1-3 sessions)
Once the couple is actively engaging the time-out procedure to
alter previously ingrained interactional patterns, the focus of the
couples’ sessions shifts to enhancing positive affect. Hypnotic
interventions utilizing age regression, age progression, and the
juxtaposition of two feelings are employed to accomplish this
treatment objective.
Age regression.
With age regression interventions, couples are guided to retrieve
previously accessed affective states that were present during times
in the past in which attuned connection and positive regard were
more optimal. It is not uncommon that couples experiencing the
relational difficulties that have brought them into treatment will
demonstrate a sense of amnesia regarding the positive regard and
attuned connection that were more frequently experienced and
easily accessed at earlier stages of the relationship. Age regression
(Daitch, 2007; Edgette & Edgette, 1995; Gebhard, 2013) helps
elicit the positive sentiment that Gottman (2000) notes is crucial in
couples’ ability to successfully negotiate conflict and disconnect.
Once both partners are in trance, the therapist directs each partner
to simultaneously scan their memory banks for a time in the past
that signified a more positive period in the relationship (Yapko,
1988). They are then directed to access a particular event which
occurred during this time period in which feelings of connection
with and warmth toward the partner was experienced. Next the
therapist provides direction to help both partners vivify and
intensify the affective experience of attunement and positive regard
(D. Brown, personal communication, May 5, 2002).
Age progression.
Just as accessing positive past experiences can amplify positive
affect in the present, so too can envisioning positive experience to
come. With age progression interventions (see Daitch, 2007),
couples are guided in trance to construct and then vivify a time in
the future when the desired treatment outcome has been achieved
in its entirety (Yapko, 1988, 2001, 2011). As Hammond (1990)
notes, age progression interventions can be used to facilitate
patients’ identification of hopes for the future. Likewise, age
progression facilitates positive expectancy for desired treatment
outcome (Edgette & Edgette, 1995; Hammond, 1990; Yapko, 1997,
2012),
and thus bolsters the likelihood of a successful treatment outcome
(Lankton, 2008; Rosen , 1982).
Juxtaposition of Two Feelings
Juxtaposition of Two Feelings is a hypnotherapeutic intervention
which facilitates the elicitation of dual perspective to enhance
positive affect. Utilizing ego state constructs, the therapist guides
both partners to identify multiple parts of self that coexist. Watkins
(1992) appropriately termed these distinct parts of self part-persons.
In discussing Ego State Therapy, Hammond writes that one can
“selectively amplify or diminish parts of his or her experience in
order to achieve a higher purpose” (1990, p. 322). Frederick and
McNeal (1993) also reference this higher, stronger, more
developed part of the self. When a patient is in trance, Ego State
Therapy can be utilized to access the part of self that possesses
sufficient wisdom and maturity (Frederick, 2005, 2013).
In the hypnotherapeutic intervention the therapist simultaneously
guides both partners into trance, and then guides both to access a
part of self that is more mature, temperate, tolerant, and
understanding. It is this part of self that can be called upon as an
internal resource when partners are in conflict, mitigating the part
of self that identifies more strongly with ego states that are more
easily triggered. Using the resources of the more mature ego state,
the therapist guides the patients to amplify positive affect and then
elicits the feelings present during relational conflict. The majority
of the intervention then focuses on guiding both partners to
enhance their ability to maintain these two conflicting feelings
simultaneously. The following excerpt has been adapted with
permission from New Harbinger Publications, Inc., © 2012,
Carolyn Daitch and Lissah Lorberbaum.
Let’s start with the negative thoughts and feelings.... I suggest that
you think about a particular time when you and your partner were
in conflict... and now, as you think about this time... allow yourself
to let any feelings of hurt, aloneness, and disappointment come up...
yes... that’s right.... I’d like you to also notice whatever thoughts
accompany these feelings [use example phrases that the patients
have mentioned previously, e.g. How could he not understand me
after living with me for so long? Why does she always make
mountains out of molehills? ].
And now that you’ve connected to these upsetting feelings and
thoughts... really let them come up for you in all their intensity....
And as you do this, focus your attention on your left hand... that’s
right... imagining that you are placing all of that negativity into
your left hand.... And envision all this negativity flowing from
your mind into your left palm. [Pause.] Now, still holding these
feelings in your left palm, close your fingers to make a fist...
encapsulating all these negative feelings in your fist.
Now... still holding those feelings in your left fist... take a few deep
breaths... letting yourself become so nicely relaxed... allowing
yourself to become just a little calmer with each exhalation. [Pause
for a minute of clock time.] Now deliberately shift your attention
to positive feelings and thoughts about your partner....and as you
do you might experience a feeling of satisfaction, of contentment,
as you connect to what is most endearing about [say partners’
names] ...can you hold this feeling of appreciation, perhaps with
tenderness... ... experiencing the appreciation fully and deeply.
[Pause.]
And continue to let those warm, tender feelings and the
accompanying thoughts come up... in all their intensity.... And now,
imagine all of these good feelings flowing directly from your heart
into the palm of your open right hand.... Really feel them
gathering in the palm of your hand... and hold them there, cupping
this hand into a fist. And now that you are clasping all of these
good feelings in your right fist, and all
the negative feelings in your left, slowly bring your hands
together... interlocking your fingers so that your palms touch...
allowing the positive, warm feelings to exist alongside the painful
feelings... sensing the two sets of feelings coexisting in the same
small space. Notice how one set of feelings doesn’t cancel out the
other.... Perhaps you can now be receptive to the difficult parts as
well as the good parts that are inevitable in any relationship...
receptive to the difficult feelings as well as the positive... and
acknowledge that at any given time, no matter how allencompassing your negative feelings toward your partner may
seem, you actually have more than that one feeling, and more than
one thought, available to you.... And now, take a moment to slowly
bring both your hands to your heart... resting your open palms, left
palm over right on your chest, just over the place where your heart
beats underneath...This can be your cue to easily call to mind the
inevitable truth the positive and the negative can coexist... and isn’t
it nice to know that you can access positive feelings towards one
another... that these feelings are always available... that you
actually have the positive feelings available right alongside the
negative.... And when you feel ready to bring this exercise to a
close, I will count slowly from one to twenty, and you can take all
the time you need to open your eyes. [Re-alert slowly with
counting.]
The Juxtaposition intervention challenges the assumption
sometimes present for partners that relational success, as well as
successful treatment outcome, is dependent upon the absence of
anger, frustration, and hurt in response to one’s partner. Patients
often carry the misconception that eliminating negative regard
towards the partner altogether is necessary for success in
treatment. The Juxtaposition intervention helps patients
acknowledge that relational rifts and the frustrations that
accompany them are a component of relationships; success comes
not from their absence, but in each partner’s ability to regulate
negative affect when these rifts inevitably do arise.
Phase 4: Differentiate (1-2 sessions)
The experience of attunement is fundamental to the success of any
intimate relationship. Siegel (2007, p. 290) comments “[S]uch
resonant states feel good as we feel ‘felt’ by another, no longer
alone but in connection. This is the heart of empathic relationship,
as we sense a clear image of our mind in the mind of another.” Yet
when one partner has an anxiety disorder, each partner’s appraisal
of environmental stimuli and interoceptive stimuli can differ
sharply. As discussed earlier, highly valenced anxiety inducing
stimuli are often neutral or mildly valenced for the non-anxious
partner. When this occurs, the ability to sense a compassionately
held representation of the self in the mind of one’s partner can be
challenged.
To address this relational impediment it is crucial to help couples
differentiate between the concept of shared connection and shared
perspective. When individuals sustain the belief that their partner
need share their perspective in order to feel supported and aligned,
differences in perspective run the risk of perpetuating seemingly
irreparable ruptures in attunement. Teaching couples to embrace a
template of relationship in which differing perspectives are not
only expected but validated provides a basis to repair anxietybased ruptures in attuned connection, and sometimes can
circumvent such ruptures altogether.
Following psychoeducation regarding accepting and even valuing
differing perspectives, couples are taught basic skills to validate
one another’s differing perspectives and emotions in
response to shared environmental stimuli. In teaching validation
the following tenets are conveyed:
1.
Partners can validate one another even in the absence of an
understanding of the reasoning behind the other partner’s
perspective.
2.
Partners can validate one another even when they strongly
disagree with the other partner’s perspective or appraisal of a
situation.
3.
Engaging in validation is crucial when a lack of
understanding, strong disagreement, or both arise.
4.
The act of validation does not require or imply agreement
with the partner’s perspective.
5.
The act of validation acknowledges the innate value of the
other’s perspective, as well as the validity of the other
partner’s emotions.
The following hypnotherapeutic intervention further facilitates this
learning.
Now that you are relaxed...you can discover how easily
you can move into a more flexible and open state of mind... and we
know that in hypnosis you can enjoy a kind of cognitive flexibility
that sometimes is difficult when you are stressed or anxious. And
as you look forward to achieving that flexibility of thinking,
perhaps you can take in some new ideas...
Of course, it’s only human to wish that your partner always agreed
with you, saw the world just as you see it, and shared your
opinions, feelings, and convictions.... But you know and I know
that this just doesn’t always happen. Inevitably the two of you and
will sometimes disagree...or have trouble even understanding your
differences... and this
is especially likely when one of you views the world with anxious
eyes and the other does not... because when this is the case... you
each have a fundamentally different experience of life.... And this
capacity to have such different perspectives, such different
experiences... such a different take on the same situation... can
create a chasm between the two of you... a chasm that widens with
each instance the two of you fail to really “get” the other’s side.
It’s as if you each were standing on two different sides of a
canyon...a deep, dark gulf separating each side... and no matter
how much you longed to reach one another... longed for the
support and comfort that shared perspective brings... the canyon is
just too wide...the sides too far apart... the gulf between, too deep....
Would you be willing to imagine this canyon? One side formed
with rocks that are deep reds ...or perhaps any color that represents
to you the language of emotion...and the other side formed with
rocks of a cool blue-gray hue...or the colors of that seem to you to
be fitting for the language of logic...And now see yourselves on
your respective sides... gazing at one another across the
precipice...wishing and longing to connect, but not knowing how....
And isn’t it nice to know that connection is possible... it is possible
to leap across this chasm... you have the ability to do so right
now...by simply being curious about your partner’s perspective...
and this curiosity has the power to transport you... to lift you from
your moorings and gently carry you across the chasm...as if carried
by a gondola or a magic carpet... placing you down gently on your
partner’s side of the cliff.... And now imagine yourself standing on
that other side of the cliff... seeing the world through that
differently-colored hue...feeling the relief that comes as you takein
the sights that before you simply couldn’t even fathom.... And now
take a moment to say to yourself “of course it makes sense to see
the world differently when I’m standing on this side....”[At this
point you might take some time to elaborate the different
perspectives, drawing on specific knowledge about the couple.]
And now... in your mind’s eye... see yourself gently soaring back
to your side of the chasm...taking the knowledge of your partner’s
perspective back with you.... and now with your feet firmly planted
on the ground... knowing that you have stood at both vantage
points... taken in both views...you can take a moment to
acknowledge that both vantage points are equally real... equally
valid... just different. [Pause.]
And it’s so understandable, when we’re in conflict, to dig our heels
in firmly to the ground of “our side,” to stay fixed and rigid on our
side of the rock...but true connection requires
generosity...compassion... and flexibility... which you can embrace
as you awaken the curiosity that allows you to traverse the
chasm...freeing yourself from your moorings... allowing you to
welcome the views from both sides...and in doing so the space
between no longer has the power to divide you... to keep you
apart... it is simply a space that is acknowledged... and surpassed.
[Re-alert.]
Facilitating Rehearsal and Transfer (used in all sessions)
The final key to success involves facilitating the occurrence of the
behavior change and psychotherapeutic growth that the in-session
interventions seed. While treatment interventions outlined here are
all delivered within the clinician’s office, much of the success of
treatment is determined by the patients’ ability to apply skills
learned in the therapist’s office to interaction outside the therapy
room. It is well documented that patients’ willingness to engage in
therapeutic homework has been correlated to successful treatment
outcome (Burns & Spangler, 2000; Coon & Thompson, 2003;
Kazantzis & Lampropoulos, 2002). Likewise, a key component of
treatment involves in-session interventions which directly facilitate
the transfer of new skill sets into the interaction that the couples
will engage in once outside the therapist’s office. The three core
components of interventions used to promote rehearsal and transfer
are outlined immediately below.
1.
The homework contract: upon entering the therapeutic
relationship, homework is outlined as a condition of
treatment and the rationale behind this delineated.
2.
Explicit homework assignments: each week, homework
assignments are given to supplement the hypnotherapeutic
interventions presented in-session. This may consist of the
direction to engage in self-hypnosis while listening to tapes
of the in-session hypnotic interventions, or may be to practice
taking time-outs or regularly engage in the therapeutic
exercises presented to facilitate differentiation.
3.
Hypnotherapeutically facilitated visualization of engagement
in homework activities: at the close of each session, the
couple is once again guided into trance and led through a
visualization of engaging in the given homework activities in
the coming week.
By delivering hypnotherapeutic interventions which directly
facilitate therapeutic homework, couples are not only provided
with therapeutic homework, but hypnosis is utilized as a tool to
seed positive expectancy, increase compliance, and facilitate
greater treatment success. In addition, patients have the
opportunity to develop an increased sense of agency as they are
explicitly taking an active part in their recovery. Rather than
feeling the passive recipient of a therapeutic intervention or, on a
larger level, a course of treatment, the homework contract and its
implementation can allow for patients’ success on multiple levels.
Discussion
The presentation of any treatment protocol I apply would be
incomplete without discussion of the importance of individualizing
treatment. Just as hypnotic interventions can be enhanced by the
utilization of a patient’s preferred sensory modalities and life
experiences, so too can therapeutic protocols be enhanced by the
clinician’s sensitivity to the patients’ feedback with respect to the
applicability of a particular intervention. I am a proponent of
adapting interventions or even applying different interventions that
might be better suited to a patient’s individual needs based on
patient feedback.
This is especially the case when patients demonstrate resistance.
Erickson not only respected the patient’s right to be resistant, he
welcomed the resistance and used it in the therapeutic process:“If
they bring in resistance, be grateful for that resistance.... Whatever
the patient brings to you in the office, you really ought to use”
(Erickson & Rossi, 1981, p.16). For this reason I recommend that
clinicians have a plethora of therapeutic tools in their repertoire
should a patient’s response to a particular intervention not be
yielding the desired therapeutic outcome. A wide variety of
hypnotherapeutic interventions that can additionally be
incorporated into this treatment protocol have been put forth to
achieve this purpose (see Daitch 2007; Daitch & Lorberbaum,
2012). Likewise, in my own application of the protocol above I
leave ample room for the individualization of treatment.
Unfortunately, individualization of treatment hinders the
standardization of protocols, making it more challenging to
empirically test the efficacy of such treatments. As such, the
treatment protocol put forth in this article has not undergone
clinical trials to empirically evaluate the protocol’s efficacy. The
protocol does, however, provide implications for further research.
The completion of the current protocol also presents the possibility
of longer-term couples’ treatment. Once explicit interventions are
put into practice giving the couple the opportunity to engage in
behavioral shifts and enhance attuned connection, the nature of the
couple’s bond and the systemic relational aspects of symptom
development and maintenance can be addressed. This can be a
longer-term treatment objective that I encourage couples to pursue.
In relationships which are negatively impacted by one partner’s
anxiety disorder, emotional support tends to be more unidirectional
and an over-dependent bond can result. In a relational
configuration I see frequently when anxiety is present, the nonanxious partner is the principal provider of emotional support and
takes on an excessive amount of responsibility. This role remains
largely rigid.
The counterpart in the anxiety-based over-dependent configuration
is the anxious partner, whose role of being cared for and
emotionally supported remains equally rigid. Given that the
experience of clinical levels of untreated, chronic anxiety can
undermine the anxiety sufferer’s sense of agency, the self-concept
that maintains this role rigidity is understandable. However,
individual psychotherapeutic treatment that runs parallel with the
couples sessions has provided the anxiety sufferer with
interventions that facilitate affect regulation and increased agency.
Thus in the final stages of the couples treatment a window of
opportunity exists in which therapeutic interventions can facilitate
a shift in the relational dynamic that capitalizes on the anxiety
sufferer’s newly gained sense of agency. Suggested therapeutic
interventions for this stage of treatment, then, facilitate the
development of bi-directional emotional support and,
concomitantly, the development of the role flexibility necessary for
this to occur.
In conclusion, brief couples’ treatment both complements the
anxious partner’s individual treatment and provides an opportunity
to shift the relational dynamic of the partnership to lessen discord
and enhance positive affect, empathy, and attunement. It also sets
the stage for longer term treatment to facilitate even greater shift in
the relational dynamic. Through the couples’ hypnotic treatment,
significant individual gains for each respective partner can be
achieved as well. The non- overtly anxious partner not only gains
an understanding of the etiology and treatment of anxiety but gains
an enhanced understanding of the suffering of the anxious patient,
which facilitates increasing awareness and empathy. Likewise, the
anxious partner shifts from self-absorption to awareness of the
partner with compassion and learns to engage in perspective taking
which increases both awareness and empathy. For both partners,
the relationship can become a source of support rather than
contention.
The use of hypnotic interventions for the treatment of anxietyrelated relational discord offers coupes a powerful vehicle for
change. Hypnosis increases cognitive flexibility and can bypass
ego defenses and conscious resistance. As such, it effects changes
in attitude, understanding, and generates new responses and
communication patterns that are beneficial to both the anxious and
non-anxious partners. This article highlights the value of
embracing creativity to develop and employ hypnotherapeutic
interventions for specialized target populations. Hypnoticallybased couples’ treatment is an important adjunct to individualized
treatment addressing clinical levels of anxiety.
References
Alladin, A. (2008). Cognitive hypnotherapy: An
integrated approach to the treatment of
emotional disorders. Chichester, UK: John Wiley & Sons
Ltd.
Bryant, R. A., Moulds, M. L., Guthrie, R. M., & Nixon, R. D.
V. (2005). The additive benefit of
hypnosis and cognitive-behavioral therapy in treating acute stress
disorder. Journal of
Consulting and Clinical Psychology, 73 (2), 334-340.
Burns, D.
D., & Spangler, D. L. (2000). Does psychotherapy homework lead
to improvements
in depression in cognitive-behavioral therapy or does improvement
lead to increased
homework compliance? Journal of Consulting and Clinical
Psychology, 68 (1), 46-56. Coon, D. W., & Thompson, L. W.
(2003). The relationship between homework compliance and
treatment outcomes among older adult outpatients with mild-tomoderate depression.
American Journal of Geriatric Psychiatry, 11, 53-61.
Daitch, C.
(2007). Affect regulation toolbox: Practical and effective hypnotic
interventions for
the over-reactive client. New York, NY: WW Norton &
Company.
Daitch, C. (2011). Anxiety disorders: The go-to guide
for clients and therapists. New York, NY: WW
Norton & Company.
Daitch, C., & Lorberbaum, L., (2012)
Anxious in love: How to manage your anxiety, reduce conflict,
and reconnect with your partner. Oakland, CA: New Harbinger.
Edgette, J. H., & Edgette, J. S. (1995). The handbook of hypnotic
phenomena in psychotherapy. New York, NY: Brunner/Mazel.
Erickson, M. H., & Rossi, E. (1979). Hypnotherapy: An
exploratory casebook. New York, NY: Irvington.
Erickson, M. H., & Rossi, E. L. (1981). Experiencing hypnosis.
New York, NY: Irvington Publishers.
Frederick, C. (2005). Selected topics in ego state therapy. The
International Journal of Clinical and Experimental Hypnosis, 53
(4), 339-429.
Frederick, C., & McNeal, S. (1993). Inner strength and other
techniques for ego strengthening. American Journal of Clinical
Hypnosis, 35 (3), 170-178.
Galovski T. E., & Blanchard E. B. (1999). The treatment of
irritable bowel syndrome with hypnotherapy. Applied
Psychophysiology and Biofeedback, 23 (4), 219-232.
Gilligan, S. G. (1986). Therapeutic trances: The cooperation
principle in Ericksonian hypnotherapy. New York, NY:
Brunner/Mazel.
Gordon, D., & Meyers-Anderson, M. (1981). Phoenix: Therapeutic
patterns of Milton H. Erikson. Cupertino, CA: Meta.
Gottman, J. (2000). Marital Therapy: A Research-Based Approach
Training Seminar. Training manual for participants of seminar,
Couples Therapy: A Research-Based Approach— Level I Training,
May. Novi, MI: The Gottman Institute.
Hunt, C., Issakidis, C., & Andrews, G. (2002). DSM-IV
generalized anxiety disorder in the Australian National Survey of
Mental Health and Well-Being. Psychological Medicine, 32, 649–
659.
Hammond, D. C. (Ed.). (1990). Handbook of hypnotic suggestions
and metaphors. New York, NY: WW Norton.
Hammond, D. C.
(1998). Unconscious exploration with ideomotor signaling. In D. C.
Hammond
(Ed.), Hypnotic Induction and Suggestion (2nd ed.) (pp. 93-100).
Chicago, IL: American Society of Clinical Hypnosis.
Hammond, D. C. (2010). Hypnosis in the treatment of anxiety- and
stress-related disorders. Expert Review of Neurotherapeutics, 10
(2), 263-273.
Havens, R. A. (Ed.). (1989). The wisdom of Milton H. Erickson:
Hypnosis & hypnotherapy. New York, NY: Irvington Publishers.
Kahn, S. (2010). When two is better than one: Hypnosis with
couples. In S. J. Lynn, J. W. Rhue, & I. Kirsch (Eds.), Handbook
nd
of clinical hypnosis (2 ed.)(493-518). Washington, DC: American
Psychological Association.
Kazantzis N., & Lampropoulos,G. K. (2002). Reflecting on
homework in psychotherapy: What can we conclude from research
and experience. Journal of Clinical Psychology, 58 (5), 577-85.
Kershaw, C. J. (1992). The couple's hypnotic dance: Creating
Ericksonian strategies in marital therapy. New York, NY:
Brunner/Mazel.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K.R.,
Walters, E. E. (2005). Lifetime prevalence and age-of-onset
distributions of DSM-IV disorders in the National Comorbidity
Survey Replication. Archives of General Psychiatry, 62 (6), 593602. doi:10.1001/archpsyc.62.6.593.
Kessler R. C., Chiu, W., Demler, O., & Walters, E. E. (2005).
Prevalence, severity, and comorbidity of 12-month DSM-IV
disorders in the National Comorbidity Survey Replication.
Archives of General Psychiatry, 62 (6), 617-627.
doi:10.1001/archpsyc.62.6.617
Kirsch I., Montgomery, G., & Sapirstein, G. (1995). Hypnosis as
an adjunct to cognitive- behavioral psychotherapy: A metaanalysis. Journal of Consulting and Clinical Psychology, 63 (2),
214-220.
Kluft, R. P. (2012). Enhancing workshop safety: Learning from
colleagues' adverse experiences (Part II—Structure/Policy).
American Journal of Clinical Hypnosis, 55 (1), 104-122.
Lankton, S. (Ed.) (1985). Ericksonian monographs: Number 1.
Elements and dimensions of an Ericksonian approach. New York,
NY: Brunner/Mazel.
Lankton, S. (2004). Assembling Ericksonian therapy: The
collected papers of Stephen Lankton. Phoenix, AZ: Zeig-Tucker.
Lankton, S. (2008). Tools of intention: Strategies that inspire
change. Williston, VT: Crown House Publications.
Lankton, S., & Lankton, C. (1983). The answer within: A clinical
framework of Ericksonian hypnotherapy. New York, NY:
Brunner/Mazel.
LeDoux, J. (1996). The emotional brain: The mysterious
underpinnings of emotional life. New York, NY: Simon and
Schuster.
Lynn, S. J., Kirsch, I., Barabasz, A., Cardena, E., Patterson, D.
(2000). Hypnosis as an empirically supported clinical intervention:
The state of the evidence and a look to the future. International
Journal of Clinical and Experimental Hypnosis, 48 (2), 239-59.
Lynn, S. J., Kirsch, I., & Rhue, J. W. (Eds.). (1996). Casebook of
clinical hypnosis. Washington, DC: American Psychological
Association. doi: 10.1037/11090-002
McLeod, J. D. (1994). Anxiety disorders and marital quality.
Journal of Abnormal Psychology, 103, 767–776.
Melis, P. M., Rooimans, W., Spierings, E. L., Hoogduin, C. A.
(1991). Treatment of chronic tension-type headache with
hypnotherapy: a single-blind controlled study. Headache, 31, 686689.
Mende, M. (2009). Hypnosis: State of the art and perspectives for
the twenty-first century. Contemporary Hypnosis, 26 (3), 179-184.
O’Hanlon, W. H. (1987). Taproots: Underlying principles of
Milton Erikson’s therapy and hypothesis. New York, NY: WW
Norton.
Parsons-Fein, J. (2004). Loving in the here & now. Los Angeles,
CA: J.P. Tarcher. Palsson, O. S., & Moss, D. (2007). Irritable
Bowel Syndrome (IBS) Concurrent with
Fibromyalgia. In S. Ostalecky (Ed.), Fibromyalgia: The complete
guide from medical
experts and patients (119-127). Sudbury, MA: Jones &
Bartlett.
Ritterman, M. (1983). Using hypnosis in family therapy.
San Francisco, CA: Jossey-Bass
Publishers.
Rossi, E. L. (Ed.) (1980). Collected papers of Milton
H. Erickson (Vols. 1-4). New York, NY:
Irvington.
Schoenberger, N. E. (2000). Research on hypnosis as
an adjunct to cognitive-behavioral
psychotherapy. International Journal of Clinical and Experimental
Hypnosis, 48 (2),
154-169. doi: 10.1080/00207140008410046
Siegel, D. J. (2007).
The mindful brain: Reflection and attunement in the cultivation of
wellbeing. New York, NY: WW Norton.
van Boejin, C. A., van
Oppen, P., van Balkon, A. J. L. M., Visser, S., Kempe, P.T.,
Blakenstein, N., & van Dtck, R. (2005). Treatment of anxiety
disorders in primary
care practice: A randomized clinical trial.
British Journal of General Practice, 55, 763- 769.
Van Dyck, R., & Spinhoven, P. (1997). Does preference for type
of treatment matter? A study of exposure in vivo with or without
hypnosis in the treatment of panic disorder with agoraphobia.
Behavior Modification, 21,172-186.
van Dyck, R., Zitman, F. G., Linssen, A., Corry, G., Spinhoven, P.
(1991). Autogenic training and future oriented hypnotic imagery in
the treatment of tension headache: outcome and process.
International Journal of Clinical and Experimental Hypnosis, 39, 623.
Watkins, J. G. (1992). Hypnoanalytic techniques: Clinical
hypnosis (Vol. 2). New York, NY: Irvington.
Whisman, M. A. (2007). Marital distress and DSM-IV psychiatric
disorders in a population-based national survey. Journal of Family
Psychology, 116, 638–643.
Whisman, M. A., Sheldon, C. T., & Goering, P. (2000). Psychiatric
disorder and dis- satisfaction with social relationships: Does type
of relationship matter? Journal of Abnormal Psychology,109, 803–
808.
Whittchen, H. U., Zhao, S., Kessler, R. C., & Eaton, W. W. (1994).
DSM-III-R generalized anxiety disorder in the National
Comorbidity Survey. Archives of General Psychiatry, 51, 319–328
Whorwell, P. J., Prior, A., Faragher, E. B. (1984). Controlled trial
of hypnotherapy in the treatment of service refractory irritablebowel syndrome. Lancet, 2, 1232-1233.
Yapko, M. D. (1988). When living hurts: Directives for treating
depression. New York, NY: Brunner/Mazel.
Yapko, M. D. (1997). Breaking the patterns of depression. New
York, NY: Doubleday. Yapko, M. D. (2001). Treating depression
with hypnosis: Integrating cognitive-behavioral and
strategic approaches. Philadelphia, PA: Brunner-Routledge.
Yapko, M. D. (2012). Trancework: An introduction into the
practice of clinical hypnosis. New York, NY: Routledge.
Zeig, J. K. (Ed.). (1985). Eriksonian approaches to hypnosis and
psychotherapy. New York, NY: Brunner/Mazel.