The majority of the experimental research studies and clinical reports to date supports the conclusion that psychotic and personality disorder patients have hypnotic capacity and can utilize that capacity productively and safely. As with all patient populations, there will be some individual patients who will decline to work with hypnosis. Aside from these self-selected exceptions, the usefulness and safety of hypnosis with the severely disturbed patient depends primarily on the skills and sensitivity of the therapist for creating a positive relationship with this population. Accessing the hypnotic capacity and potential usefulness of hypnosis for the severely disturbed patient requires the development and maintenance of trust and a positive patient-therapist transference relationship. In addition, just as traditional psychotherapy with the severely disturbed patient requires special skills to provide firm limits within a supportive environment and special sensitivity to the pacing of therapy, so also does hypnotherapy with these patients require similar skill and sensitivity. Therefore a primary requirement for working with the severely disturbed population with hypnosis would be that the therapist already possesses knowledge and skills for working with this population in traditional therapy.
Although we might assume that clinical hypnosis could be potentially utilized by any personality disorder or psychotic patient within the framework of a positive, supportive therapy relationship, the real therapy world is much more complex. As every therapist is aware who has worked with psychotic and personality disorder patients, the development and maintenance of a positive and constructive transference relationship can be extremely difficult and sometimes impossible. Therefore, the development of a therapeutic hypnotic process with these patients (dependent as it is on transference) can be equally difficult and sometimes impossible.
With the goal of developing and maintaining a positive and constructive transference relationship with the severely disturbed patient, hypnotic work with these patients will generally emphasize acceptance and support. However, within this framework of support the therapist must be able to set limits. These limits will most likely be viewed by the patient as non-supportive and may disrupt the positive transference. It is the therapist's job, then, to maintain reasonable and stable limits while trying to maintain as stable a positive transference relationship as possible. This is a difficult task to say the least. But it is the crucial task of any therapy with the severely disturbed patient. In addition, the therapist must also be able to monitor the dependency relationship and the support to ensure movement toward growth rather than promoting pathological dependency or helplessness.
In order to develop a positive relationship/transference with a severely disturbed patient sufficient to support the utilization of hypnosis, the particular issue of the patient's concerns and fears over control and trust in the relationship must generally be addressed. In all intimate relationships (and perhaps more so in the hypnotic relationship) there is potential for loss of control and for anxiety regarding such loss. In the case of the severely disturbed patient, these anxieties tend to express themselves as a fear of abandonment or an opposite fear of incorporation/engulf-ment (due in part to the significance of these fears in the pathology and history of these patients). In working with the severely disturbed patient, we have learned to mitigate these dual fears of abandonment and engulfment by utilizing autohypno-sis, stressing patient autonomy and mastery in hypnosis, permitting eye-opening to check out physical separateness and control, maintaining limits that protect against merging, utilizing hypnotic imagery to create needed distance, and the therapist modeling the safety of the hypnotic trance.
In general, current hypnotherapy work with personality disorder and psychotic patients is based on a conceptual framework that is rooted in the psychoanalytic and developmental approaches to the treatment of severe disturbance. The symptoms of severe disturbance are considered to be best understood as manifestations of the patient's failure to progress along normal stages of human development (Baker, 1981; Baker & McColley, 1982; Bowers, 1961, 1964; Brown, 1985; Brown & Fromm, 1986; Kernberg, 1968; Kohut, 1977; Murray-Jobsis, 1984, 1990, 1991b, 1992, 1993, 1996; Scagnelli, 1976, 1980; Winnicott, 1965).
Within the context of a developmental model, the symptoms of severe disturbance can be seen as being related to problems and conflicts around initial awareness of self and issues of separation-individuation. Thus, the symptoms of personality and psychotic disorders can be understood to be manifestations of a failure to progress along normal stages of human development. Within this developmental framework, the task of therapy in general and of hypnotherapy in particular is to correct the developmental failures. The support and acceptance, along with the setting of reasonable and stable limits, are designed to provide the 'good enough' environment (relationship). This good enough relationship is designed to allow positive bonding and a positive self-concept; facilitate acceptance of separateness; promote a working through and acceptance of unresolved feelings of despair, anger, and anxiety; and promote growth into positive autonomy. Thus the current use of hypnosis in therapy with the severely disturbed patient is designed to correct and redo experiences, and to fill-in the missing life experiences in order to allow the severely disturbed patient to reclaim his potential for healthy growth and development.
Current use of hypnosis with psychotic and personality disorder patients also stresses pacing the therapy work according to the patient's capacity for insight and growth. The therapist follows the patient's lead empathically, promoting growth but not pushing for it. Allowing the patient to pace the therapy protects the patient from being overwhelmed by traumatic material from the past or by premature attempts at insight. This empathic contact between therapist and patient is perhaps essential to successful therapy with the severely disturbed patient whether working in traditional psychotherapy or hypnotherapy. However, such sensitive empathic pacing is perhaps more important in hypnotherapy where the patient is somewhat more vulnerable to therapist suggestion or pressure.
Concerning specific hypnotic techniques, virtually all traditional psychotherapy techniques can be adapted for use with hypnosis. Behavior modification techniques such as progressive relaxation, reciprocal inhibition and desensitization, and role rehearsal for competence and mastery can be utilized in hypnosis with rapid and effective results. Psychodynamic techniques can also be utilized in hypnosis with the personality disorder or the psychotic patient. Free association, dream production and analysis, and projective techniques are all dynamic techniques that blend naturally and easily with the imagery of hypnosis. In addition, some specialized hypnotic techniques such as age progression and age regression can be used with the severely disturbed patient. In working with age regression to access repressed or highly traumatic material, it is essential to follow the patient empathically pacing. It is also important, in utilizing techniques aimed at reaccessing traumatic experiences, that the therapist be prepared to handle intense affect, to contain affect to avoid retraumatizing the patient, to reframe or redo past traumatic experience as appropriate, and to create imagery shifts if imagery becomes too threatening.
In addition, current hypnotic techniques for utilizing hypnosis with the severely disturbed patient include specific techniques designed to deal with their specific developmental deficits. The technique of renurturing with hypnotic imagery is designed to create the capacity for initial bonding/relatedness and self-love, utilizing images of the adult patient and the therapist as a composite 'mother'.
Hypnotic imagery and scripts for developing the 'infant/child' through separation experiences with a sense of mastery rather than abandonment have been developed and are currently utilized. Finally, a generic technique of creating 'healing scripts' to redo or resolve old trauma has been developed and is utilized.
In summary, we now have an understanding of how to reach and help the severely disturbed patient, and we currently have a powerful arsenal of techniques to utilize within the scope of hypnotherapy.
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