ATTACHMENT-FOCUSED HYPNOSIS IN PSYCHOTHERAPY FOR …nvvh.com/wp-content/uploads/2015/12/IJCEH-64-1-03.pdf · trauma. In this article, attunement, representation, and mentalization

Intl. Journal of Clinical and Experimental Hypnosis, 64(1): 45–74, 2016Copyright © International Journal of Clinical and Experimental HypnosisISSN: 0020-7144 print / 1744-5183 onlineDOI: 10.1080/00207144.2015.1099402

ATTACHMENT-FOCUSED HYPNOSIS INPSYCHOTHERAPY FOR COMPLEX TRAUMA:Attunement, Representation, and Mentalization

Eric B. Spiegel

Private Practice, Philadelphia, Pennsylvania, USA

Abstract: The relational and psychological functions of attunement,representation, and mentalization are essential components of a secureattachment experience. Psychotherapeutic approaches informed byattachment theory have gained significant empirical and clini-cal support, particularly in the area of complex trauma. Despitethese advances, attachment-informed trauma treatment could benefitgreatly from the experiential wealth that clinical hypnosis has to offer.In its utilization of shared attention, tone of voice, pacing, represen-tational imagery, and hypnotic language, clinical hypnosis as a state,relationship, and technique offers psychotherapists a way of intro-ducing a healthy attachment experience and renewing appropriatedevelopmental functioning in patients who are survivors of complextrauma. In this article, attunement, representation, and mentalizationare reviewed from a hypnotherapeutic perspective.

Clinical hypnosis, the clinical utilization of hypnosis in treatment byhealth care professionals (Sugarman, 2013), has a great deal to offerpractitioners interested in attachment and development (Baker, 1981;Brown, 2009a, 2009b; Zelinka, Cojan, & Desseilles, 2014). Aspects ofhypnosis, including the state itself and the procedure through whichit is elicited, closely resemble features of attachment and will be fur-ther explicated in this article. Moreover, the therapeutic relationship isa central factor as the therapist and patient are in a delicate balance ofresponsiveness to one another as the hypnotic process unfolds (Baker,1981, 2000; Banyai, 1998; Diamond, 1984, 1987; Spiegel & Greenleaf,2005; Yapko, 2005). Factors such as alliance, trust, and reciprocity inthe therapeutic relationship all play a role in the hypnotic experience.Further, hypnotherapeutic techniques embedded in the relationshipand its process, such as tone of voice, pacing, and utilization emulate

Manuscript submitted May 11, 2014; final revision accepted November 6, 2014.Address correspondence to Eric B. Spiegel, Spiegel Psychological Services, PC, Attn:

Eric Spiegel, PhD, 132 S. 17th Street, FL 3, Philadelphia, PA 19103, USA. E-mail:[email protected]

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qualities of the healthy primary attachment relationship (Brown, 2009a,2009b; Zelinka et al., 2014).

This article proposes hypnotherapeutic applications from an attach-ment perspective within the treatment area of complex trauma.There is strong empirical evidence linking early complex trauma(abuse/neglect), the development of insecure attachment schemas (par-ticularly disorganized), and the subsequent development of border-line personality disorder (BPD) (Bateman & Fonagy, 2012; Brown,2009b; Carlson, 1998; Carlson, Egeland, & Sroufe, 2009; Choi-Kain,Fitzmaurice, Zanarini, Laverdiere, & Gunderson, 2009; Widom, Czaja,& Paris, 2009). A relational psychotherapeutic approach to treatingtrauma is understood to be a critical means for experientially rewiringunhealthy attachment schemas and re-engaging stalled developmentalprocesses connected to the original traumatic attachment relationship(Courtois, 2004; Courtois & Ford, 2013; Pearlman & Courtois, 2005;Peebles, 2008; Peebles-Kleiger, 2002). As this article will illustrate,attachment-focused hypnosis integrated into such a treatment has thepotential to significantly enhance and expedite this psychotherapeutichealing process. I propose and describe a hypnotherapeutic approachbased on the attachment principles of attunement, representation, andmentalization.

Attachment Theory: The Relationshipas a Mirror in the Development

of the Self

Attachment theory is the theoretical and empirical study of inti-mate relationships and their impact on the development of the self.According to Bowlby (1979), our lives center around intimate attach-ment relationships “from the cradle to the grave” (p. 129). Bowlby(1973) also postulated that secure attachment develops in the period ofinfant development occurring after object permanence. He emphasizedthat secure attachment provides two essential qualities to infants: (a) asafe haven, or place where infants can go to for emotional safety andsecurity, and (b) a secure base for exploration, or a launching pad foroutreach into the world with the knowledge that the attachment figureis located near enough to provide a safe haven if necessary.

Winnicott writes (1971) “the precursor of the mirror is the mother’sface. . .” (p. 1) ”. . . [the mother is] giving back to the baby thebaby’s own self” (p. 5). Appropriate mirroring contains two essentialattachment-related functions, contingency and marking, and serves tofacilitate secure attachment (Allen, Fonagy, & Bateman, 2008; Bateman& Fonagy, 2012; Fonagy, Gergely, Jurist, & Target, 2002; Wallin, 2007).

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With contingent mirroring, the attachment figure accurately matches thefacial or vocal expressions of the infant, serving to recognize and vali-date the infant’s preverbal emotional experience. Contingent mirroringis developmentally important because it allows the infant to discoverand explore his or her feelings as mental states, first seen through theother (attachment figure) but over time internalized into the self (e.g.,“If this is what my emotions look like in someone else, this is whatthey must be like inside of me”). On the other hand, marked mirroringinvolves the attachment figure inserting him- or herself into the attach-ment encounter in a way that contains the infant’s distress and providesboundary demarcation. A central component of marking is signifyingthrough the parental response that the infant feelings being contin-gently mirrored are not real. The parent is only pretending (and clearlyhas his or her own feelings that are different from the infant), soothing,and containing. For example, the parent might make a playful face afterinitially matching the infant’s distress. This serves to communicate tothe infant that his or her distress will not spill over into the world andcontaminate the parent (Bateman & Fonagy, 2012; Fonagy et al., 2002).Because preverbal experience is the predominant mode in the sensi-tive period of attachment, the caregiver’s facial expressions and tone ofvoice are more important than the actual words he or she is saying. As isthe case with contingent mirroring, when the parent consistently marksthe infant’s affect, then over time the infant is understood to internalizethis ability (Wallin, 2007).

Mentalization: How Attachment Facilitates theRepresentational Development

of the Mind

Developmental researchers have focused on the impact of parentalmirroring and related attachment experiences in the maturation ofadaptive internal representation and reflective functioning in theinfant as he or she progresses into childhood and later adulthood.Mentalization is defined as “holding mind in mind” (Allen et al., 2008,p. 3). It is both a developmental milestone and an ongoing developmen-tal capacity by which we become aware that our mental states mediatethe way we experience the world (Fonagy et al., 2002). When we pos-sess high levels of mentalization, we demonstrate this through effectivereflective functioning. A person who mentalizes is aware of and attendsto his or her own and others’ mental states, as well as differentiatesthem from outwardly expressed behaviors (Allen et al., 2008; Bateman& Fonagy, 2006, 2012).

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The construct of mentalization is relevant in that it expands uponattachment theory. Rather than viewing attachment solely as a meansand end in and of itself (e.g., that the goal would be to developsecure attachment), mentalization researchers believe that the processof attachment also serves the purpose of creating a representationalsystem that is useful for survival and adaptation (Bateman & Fonagy,2006; Fonagy et al., 2002). Mentalization-based treatment (MBT) andother approaches informed by attachment theory emphasize improvingreflective functioning and affect regulation through a relational stanceand associated techniques that make patients more aware of and curi-ous about their and others’ mental states and processes (Allen et al.,2008; Bateman & Fonagy, 2006, 2012).

Complex Trauma: Conceptualizationand Treatment

The term complex trauma refers to a repetitive and escalating seriesof traumatic events occurring over a period of time, usually in a spe-cific context, such as in an attachment relationship (Courtois, 2004).Although there can be variance in the precipitating context, complextrauma often stems from pervasive developmental abuse or neglect andinvolves significant psychological harm to a survivor’s sense of person-hood and associated psychological functions (Courtois, 2004; Courtois& Ford, 2013; Herman, 1992; Pearlman & Courtois, 2005).

Three central domains tend to be present in the presentation ofadult survivors of complex trauma (Courtois & Ford, 2013). The first isemotional and/or somatic dysregulation. When the emotional and/orsomatic response is overreactive, the survivor will feel physiologi-cally flooded and have difficulty functioning. In the opposite “freeze”response, the survivor immobilizes and cannot martial appropriateinternal resources to resume normal functioning. Neuroception influ-ences the quality and intensity of physiological and psychologicalreactions to cues in the environment. Traumatic attachment promotesfaulty neuroception, leading to inaccurate “danger!” signals and a neu-robiopsychosocial fight/flight/freeze response. Thus, traumatic dys-regulation reduces the potential for further social engagement andinternalization of healthy relational experiences (Courtois & Ford, 2013;Porges, 2011).

The second domain is dissociation, or a disruption in the experi-ence of self-integrity. Potential expressions of dissociation could includeexperiences of loss of time, loss of consciousness, and loss of one’ssense of self (Courtois & Ford, 2013). As Van der Hart and colleagues(2006) describe in their structural theory of dissociation, any kind

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of dissociation involves a segregation of personal experience acrossaspects of personality and functioning. Expressions of traumatic experi-ence can become separated from other aspects of personality and dailyfunctioning. As a result, cues that trigger traumatic re-experiencing canoften result in a profound disruption and can shift to the survivor’squality of self-integrity and self-experience.

The last domain of complex trauma is compromised interpersonalrelationships. Because the traumatic harm is often inflicted by anattachment figure, complex trauma is strongly associated with insecureand disorganized attachment (Mikulincer & Shaver, 2007; Pearlman &Courtois, 2005). Significant attachment anxiety and avoidance matchHerman’s (1992) description of oscillating posttraumatic responses ofintrusion and numbing. In this case, we can conceptualize the intru-sion and numbing as being relationally based, in the form of attachmentanxiety and attachment avoidance, since the relationship itself (and any-thing that reminds the person of it) is associated with the traumain the survivor’s mind. One manifestation of the disruption to theattachment process caused by the complex trauma is the foreclosureof mentalization. Because reconciling the inherent contradiction of theattachment figure being the abuser and/or neglecter is too great of apsychological burden to bear, the child shuts down his or her inquis-itiveness about underlying mental states as a survival tactic. Curiosityabout internal mental states in oneself or others no longer feels safe, andthe result is a tendency to see things in black-and-white, world equalsmind, concrete terms. This tendency to think in such a nonmentalizingway is referred to as psychic equivalence (Allen et al., 2008; Bateman &Fonagy, 2006, 2012; Fonagy et al., 2002). For these reasons, a treatmentaddressing the developmental, relational, and representational aspectsof an insecure attachment is understood to be vital in ameliorating thedysfunctions in self-regulation that are associated with complex trauma(Courtois, 2004; Mikulincer & Shaver, 2007; Pearlman & Courtois, 2005).

Therapeutic treatment for complex trauma is usually divided intothree phases consisting of safety and stabilization, controlled repro-cessing, and working-through/integration (Courtois, 2004; Courtois &Ford, 2013; Herman, 1992; Peebles, 2008; Peebles-Kleiger, 2002). Thesafety and stabilization phase focuses on building therapeutic alliance,enhancing the patient’s sense of safety, and developing affect regula-tion, boundary management, and associated skills. Also emphasizedin this phase is the strengthening of patients’ capacities to restabilizeafter a disruption and self-soothe (Courtois, 2004; Courtois & Ford,2013; Peebles, 2008). Once a consistent, safe and stable frame has beenestablished, the treatment emphasis shifts to controlled reprocessing oftraumatic memories in the safe holding environment. In this phase, thefocus is on reprocessing traumatic material in such a way so as to facil-itate resolution of posttraumatic symptoms (Courtois, 2004; Peebles,

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2008). Finally, the working-through phase is an opportunity for collab-oratively restructuring patients’ understandings of themselves and theworld. Consistent experiences of safety with the therapist and othersengender the development of new neurobiological templates of howself, relationships, and the world work (Peebles, 2008). The therapeuticfeatures of establishing a stable relational alliance, creating safety andsecurity, and enhancing affect regulation are seen as core aspects of atrauma treatment (Courtois, 2004; Pearlman & Courtois, 2005; Peebles,2008).

Clinical hypnosis is best understood as a component of an existingphased psychotherapeutic trauma treatment, rather than as its own sep-arate treatment (Peebles, 2008; Phillips & Frederick, 1995). Hypnosis isparticularly valuable because hypnotic interventions occur in a statethat is comparable in many ways to that of a traumatized mind (Kluft,2012; Peebles, 2008; Peebles-Kleiger, 2002). As covered earlier in thisarticle (see Van der Hart et al., 2006), the traumatized mind can befocused on traumatic experience and dissociated from other aspects ofexperience or can be dissociated from traumatic experience and focusedon other aspects of experience. We can properly infer, then, that sucha person is already in a hypnotic state under such conditions. This isbecause hypnosis by definition is a state of narrowed, focused attention(absorption) that inevitably features dissociation (e.g., all phenomenaoutside of the cone of attention) (Brown & Fromm, 1986; Hammond,1990; Kluft, 2012; Peebles, 2008; Sugarman, 2013). As a result, we canconceptualize hypnosis as a way of adaptively utilizing the traumatizedmind in the service of positive therapeutic goals.

Atunement , Representation, and Mentalization inHypnosis: Hypnotically Utilizing Qualities of

Attachment to Re-Engage Healthy DevelopmentalFunctioning in Trauma Patients

I believe that an attachment-focused hypnotherapeutic approach (a)introduces the mutative components of attachment into the traumatreatment in a more explicit and intentional manner than a tra-ditional hypnotherapeutic treatment might and (b) provides theattachment-oriented psychotherapist with a focused and experien-tial means (hypnosis) for the patient to internalize and integratethe language, phenomenological experiences, and imagery of healthyattachment experiences. By first directing attention to the sensoryand relational anchors inherent within the patient, therapeutic set-ting and therapeutic relationship (“attunement”) and then subse-quently developing the patient’s capacity to mentally represent them

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(“representation”), the hypnotherapist facilitates and strengthens theemergence of mentalization and the adaptive use of language for thepurpose of reflective functioning.

When considering the use of hypnosis to facilitate the developmentof mentalization in this type of work, it can be helpful to think ofmentalizing in an expanded sense. As described earlier in this article,mentalizing is typically operationalized in a lexical manner, requir-ing language, cognition, and secondary process functioning in order to“hold mind in mind.” Mentalizing has to do with thinking, and think-ing requires symbolic processing. However, it is also possible to hold animagery-based pictorial representational awareness that precedes but isrelated to reflective awareness of mental states. Images are both prever-bal and linguistically evocative connectors to the sensory experience,and the sensory experience is derived from the immediate here-and-now moment (E. L. Baker, personal communication, March 27, 2013).Thus, when a hypnotherapist attunes to the patient and notices aloudan indisputable observable phenomenological process occurring exter-nally (a form of utilization known as a “truism”; e.g., “your feet are onthe floor . . . your hands are in your lap . . . you’re breathing in andout”; Patterson, 2012), they are constructing an internal mental repre-sentation for the patient of the immediate sensory experience at hand(Baker, 1981).

As a result, in working in a forward, developmentally sequencedmanner, we utilize hypnotic attunement in the here-and-now to permis-sively guide the patient towards sensorimotor and phenomenologicalanchors in her1 body. This is a method for developing positive body-based awareness of somatic anchors that can become the initial buildingblocks for developing subsequent internal resources. Through thistherapeutic attunement, the patient begins to enhance her own capac-ity to be present with her body in a contained and grounding way.As the patient becomes more skilled in this type of self-directed sen-sory attunement in the space of the therapeutic relationship, attentionturns to internal representation through hypnotic imagery. At first, theimagery begins with immediate sensorimotor phenomenological expe-riences (e.g., representing the immediate moment in the patient’s mind)and then later shifts to more fantasy-based representational imagery.The latter imagery takes advantage of the patient’s developing imagina-tion to picture scenes emphasizing salient aspects of healthy attachmentand affect expression, self-regulation, and identity development. Thus,we use pictures to enhance the patient’s capacity for describing herexperiences with language. Pictures become the building blocks for

1For purposes of simplicity and differentiation, in this article I use the male gender inreferring to the therapist and the female gender in referring to the patient.

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words. As the patient’s ability to describe her experiences with wordsimproves, her self-reflective language becomes more sophisticated,which in turn informs her use of symbolic representational imagery.In the subsections below, each phase is described in greater detail.

AttunementAttunement is a term that is derived from the literature on the psy-

chotherapy relationship. While there are variations in terminology (e.g.,empathic attunement) and the focus of attunement (e.g., to affect, tocontent, etc.) by theoretical orientation, it generally refers to the abil-ity of the therapist to accurately track, to understand, and to relateto the patient’s experience as if he were that person (Kohut, 1977;Rogers, 1957). This simultaneously joined yet differentiated empathicattunement is a critical part of the bond, or attachment, betweenpatient and therapist that constitutes a healthy “working alliance” inpsychotherapy (Gelso & Hayes, 1998).

The particular power of hypnosis as a treatment tool is rooted in itsfacilitation of attunement and the joining together in trance of patientand therapist in ways that are not as easily achieved in waking ther-apy (Baker, 2000; Diamond, 1987). The bond that comes with a strongworking alliance between therapist and patient in waking state ther-apy has been shown to yield therapeutic benefits for the patient (Gelso& Hayes, 1998). Conceptually related to the working alliance, yet alsomore extensive in its depth and intensity, the hypnotherapy term “sym-biotic alliance” refers to an internalized, mental sense of togetherness inhypnosis that occurs as a result of hypnotic attunement and hypnoticphenomena. In this hypnotic joining, time becomes distorted, the hyp-notic language of the therapist becomes co-mingled with the patient’sassociated sensory experience, and the external regulatory functionsof the therapist are experienced by the patient as if they are comingfrom inside the patient (Baker, 2000; Diamond, 1987; Zelinka et al.,2014). Diamond posits that this symbiotic alliance meets Mahler’s (1968)description of a “corrective symbiotic experience” in that the patientabsorbs and experiences feelings of soothing, safety, and security byhypnotically fusing with the therapist. Like Mahler, Diamond comparesthis process to the infant’s preverbal attachment experience with itsmother. Longitudinal experimental research on the social psychobio-logical synchronization of patient and therapist in trance suggests (a)a measurable and significant attunement and synchronization betweentherapist and patient during hypnosis and (b) that hypnosis allows forthe accumulation of more proprioceptive anchors in the patient, such asthe capacity for being attached in a safe, secure, and tolerable way thatfeels good (Banyai, 1998; Varga, Jozsa, Banyai, & Gosi-Greguss, 2006).

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Because boundary establishment, repair, and maintenance are essen-tial and defining components of psychotherapeutic and hypnother-apeutic trauma treatments (Peebles, 2008; Phillips, 2013; Phillips &Frederick, 1995), it is important to always ratify the patient’s senseof awareness, control, and mastery over these boundaries during theattunement process. Indeed, the hypnotic experience of attunementmay feel terrifying to trauma patients who experience discomfort withcloseness (Scagnelli, 1976), as is the case with high avoidant attach-ment (e.g., the avoidant dimension in fearful-avoidant/disorganizedattachment styles). However, rather than attempting to create a state ofmerger or fusion in hypnosis, we are utilizing the natural attunementthat is inherent in the hypnotic process to facilitate a number of devel-opmentally appropriate goals for the patient. One of these goals isoften utilizing the unfolding attunement to reaffirm her control overher boundaries. For example:

As you focus on the sound of my voice with each breath in and out . . .

good, that’s right . . . your unconscious mind can automatically noticeand recognize whether it would like to imagine my voice as being closebeside you like a soft lullaby or at a safe distance like an echo from faraway . . . or perhaps somewhere in between that feels just right for you.

I believe that when we attune to our patients in hypnotherapy, we doso in ways that have contingent and marked qualities to the mirroring.We share in and affirm their experience (contingent mirroring; see ear-lier examples of truisms). At the same time, we pace slightly ahead ofthem in the hypnotic process and offer suggestions from our own van-tage point about what they might expect to happen next that wouldserve to contain that experience in which we are sharing (marked mir-roring). For example, a therapist incorporating contingent and markedmirroring into his hypnotic attunement might state:

And as you continue to listen to my voice, I wonder what you willnotice first. Perhaps you will notice that your hands are becoming moreand more comfortably warm, maybe first in the fingertips and then thepalm, to just the right amount of warmth for you . . . or maybe youwill notice that with each effortless, automatic, and natural breath out,your breathing becomes more rhythmic and relaxed . . . and it reallydoesn’t matter what you notice first . . . whether it’s your hands, or yourbreath, or some other pleasant, natural process unfolding in your body. . . because you can begin to have an experience . . . perhaps slowly orperhaps more quickly . . . of feeling more and more [relaxed, comfortable,secure, anchored, grounded, present, alert; word choice would describethe attachment and trauma treatment goal that we wanted to address inthe moment].

In reviewing the above example, it is my view that a powerfullycurative process begins to unfold when accurate and positive somatic

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tracking (e.g., observing aloud a natural, automatic, and beneficialunfolding physiological process in the patient) is paired with the devel-opmentally rich qualities of vocal prosody in the hypnotherapist’s tone,pacing, and rhythm of voice. This synchronistic experience of having arelationship figure tune into the patient’s phenomenological experienceand do so in such a soothing and affirming manner is deeply satisfyingand evokes the developmental rhythms of secure attachment.

In describing the affective neuroscience of attunement, Schore (2012)writes that right hemisphere communication is analogous to primaryprocess functioning or day dreaming, which is how a hypnotic statecan be described (Brown & Fromm, 1986; Hammond, 1990; Sugarman,2013). In an attuned therapeutic encounter, Schore explains, right brainto right brain communication between therapist and patient is occur-ring. He summarizes this right brain interpersonal communication as“the music behind our words” (Schore, 2012, p. 38). As we know,musical instruments can convey great meaning in the way that theyarticulate a song. Notes of music can carry deep emotional and phys-iological resonance without a single word being uttered, as in the caseof classical or electronic dance music. In this regard, then, the hyp-notic “music”—the rhythmic manner in which the hypnotic languageis delivered—can become even more significant than the hypnoticlanguage itself in promoting healthy attachment.

Additional neurophysiological pathways of attunement exist in thehypnotic process. Mirror neurons, which are present in the prefrontalcortex, serve to help the patient and therapist emulate the motoricmovements of one another. The gestures, expressions, and posture ofthe therapist stimulate mirror neurons in the patient, much in the samedevelopmental vein as between a parent and infant. This motoric infor-mation encoded through observation of the interpersonal encounterallows the patient to imitate the therapist. It is through this imitationthat internal emotional associations begin to develop in the patient(Cozolino, 2010). Milton Erickson referred to hypnotic ideomotor induc-tion techniques and suggestions as “pantomime techniques,” becausethey accentuate the automaticity, involuntary, and unconscious motoricprocessing that exists and can be activated in the patient (Erikson, 1964,as cited in Rossi & Rossi, 2006, p. 271). Rossi and Rossi utilize the termrapport zone to refer to the empathy about others’ minds that develops inthe patient. They hypothesize that this type of mental empathy beginswith mirroring observations and repetition of movements and thentransitions into mirroring of and curiosity about internal mental pro-cesses. Through its presentation of psychosocial cues in the therapeuticencounter, hypnosis thus stimulates patient rapport zones and gener-ates brain neuroplasticity in the sensory-motor cortex and associatedareas (Rossi & Rossi, 2006).

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From the perspective of attachment researchers, it is the repetitionof experiences of joint attention inherent in the attunement that leadsto the development of self-directed attention, which in turn fostersinternal mental representation and mentalization (Allen et al., 2008;Fonagy et al., 2002). Allen and colleagues (2008) define joint attentionas a shared attentional space between caregiver and child that facili-tates the development of self-directed attention. Relatedly, they describementalization as requiring “effortful control of attention” (Allen et al.,2008, p. 36). In an effortful way, we are harnessing the executive func-tions of our mind to focus in on mental states, whether our own or thoseof others.

Comparably, hypnosis by definition is focused attention (Brown &Fromm, 1986; Hammond, 1990) that happens in a joint therapeuticspace. In a hypnotic induction, the therapist directs the patient’s atten-tion to a particular object, sensation, or experience (Brown & Fromm,1986; Hammond, 1990). As the patient focuses her attention on this ref-erence point, the therapist focuses on the patient’s responses (nonverbaland verbal) to assess for hypnotic phenomena (e.g., depth of breath-ing, muscle tone, facial cues) and the patient’s subjective reactions tobeing hypnotized. The therapist will regulate his pacing, language,tone of voice, and actual content to appropriately mirror and guide theresponses of the patient (Brown & Fromm, 1986). Furthermore, the ther-apist can utilize the joint attention present in the hypnotic therapeuticrelationship to facilitate greater patient awareness of internal experi-ences. For example, the therapist might state, “You are fascinated by thethoughts and feelings that just seem to come up in your mind” (Brown& Fromm, 1986, p. 59). Hypnotic language is utilized to enhance patientcuriosity about her inner world.

As an interesting parallel to the developmental transition from jointattention to self-directed attention, hetero-hypnosis is often a devel-opmental antecedent to self-hypnosis because the patient is learningfrom the therapist how to apply her own innate hypnotic capabilities(Levitan, 1998). Ultimately, it is the transition from joint attention to self-directed attention that paves the way for the patient’s internal represen-tation of here-and-now phenomenological experiences. This transitionwill be discussed in greater detail in the section “Representation.”

The process of attunement to positive somatosensory experiencescan serve as a metaphor for boundary management and affect con-tainment. As an example, eye closure and fractionation can functionas methods for utilizing the body (in this case the eyelids) to regulateboundaries. In the initial induction, permissive motoric suggestions canbe given to the patient with regard to controlling the degree to whichshe would like to have her eyes open or closed. Additional contin-gent suggestions can be given regarding the patient’s mastery of beingable to regulate these somatic boundaries. Assuming it is appropriate, a

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fractionation suggestion can then be given asking the patient to (briefly)open and then reclose her eyes. The suggestion to reclose her eyesis paired with another deepening suggestion emphasizing a clinicallyappropriate goal (e.g., safety, mastery, affect regulation, boundary man-agement). Thus, the fractionation not only serves to deepen the trancebut also demonstrates to the patient her burgeoning positive masteryover her body. Thus, in this regard, muscle control, boundary man-agement and trance ratification become paired together in a way thatis pleasing to the patient. An example of this and other attunementhypnosis interventions are provided in Table 1.

Attunement in hypnosis can also serve to realert or refocus thepatient on her immediate anchors during a dissociated state (e.g., blink-ing her eyes and reopening them; feeling the crisp air in her lungs asshe takes a deep, refocusing breath in, feeling the ground beneath herby pressing the soles of her feet against the floor). It can also be incor-porated as a cue in conjunction with a hypnotic suggestion for positiveaffect or cognition. For example:

When the word refocus pops up in your mind, it will be a signal to you totake a deep breath, count to three, blink and reopen your eyes slowly andclearly, and feel fully alert, present, and in control of your body.

Utilizing these types of sensorimotor anchoring and grounding inter-ventions in the attunement phase allows the patient to establish, tomaintain, and to appreciate a sense of “this is what it feels like to bein my body in a way that feels good.” She is developing a frameworkfor being with herself in a positive way that she can reference andreturn to as she needs to. This foundation in turn allows her to bet-ter tolerate traumatic cues that would have previously triggered rapidhyperarousal or dissociation.

RepresentationWhen a patient can direct her own attention in a sustained way, she is

better prepared to create a detailed representational picture in her mindof the phenomenon to which she is attending. Moving the patient fromtactile sensory attention of her somatic experiences (e.g., “this is whatmy foot feels like [in a sock, shoe, barefoot, etc.]” to visual mental rep-resentation of those experiences [e.g., “this is what my foot looks likein a mirror as it feels __”) strengthens representational capacities andobject constancy (Baker, 1981). It also naturally follows that, as theseinternal working models of self-experience and self-constancy developin hypnotherapy, the patient can begin to move from representing partsof her body and parts of herself to representing her whole body andwhole being; from representing “it” to representing “I”; and from repre-senting “me” to representing “we” (whomever the “we” may be; moreon this in the subsections that follow). This movement facilitates a senseof self-integration.

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] at

00:

08 0

3 D

ecem

ber

2015


Tabl

e1

Hyp

noti

cA

ttun

emen

t:Sk

ills,

App

licat

ions

,and

Exa

mpl

es

Skill

App

licat

ion

Exa

mpl

e

Ideo

mot

orin

duc

tion

tech

niqu

es(e

.g.,

arm

levi

tati

on,

reve

rse

arm

levi

tati

on,

Chi

asso

nte

chni

que)

Sinc

eat

tune

men

tis

bid

irec

tion

al(t

hepa

tien

tis

also

attu

ning

toth

eth

erap

ist)

and

not

rest

rict

edto

verb

alin

tera

ctio

ns,t

his

type

ofno

nver

balm

odel

ing

ispa

rtic

ular

lyhe

lpfu

lfor

pati

ents

who

are

resp

onsi

veto

mot

oric

mov

emen

t.In

mod

elin

gth

ebe

ginn

ing

ofth

eid

eom

otor

tech

niqu

e,th

eth

erap

ista

ctiv

ates

mir

ror

neur

ons

inth

epa

tien

t.

“Now

havi

ngfu

llyre

view

edho

why

pnos

isw

orks

,I’m

und

erst

and

ing

that

you

feel

read

yto

proc

eed

.Is

that

corr

ect?

Goo

d.W

elly

oum

ight

becu

riou

sto

lear

nth

atth

ere

are

man

yw

ays

ofen

teri

nga

hypn

otic

stat

e.A

ndif

it’s

alri

ghtw

ith

you,

I’d

like

tosh

owyo

uan

inte

rest

ing

way

ofbe

ginn

ing.

Why

don

’tyo

u(a

llow

your

arm

tod

rift

,lif

tup

your

arm

and

bend

itat

the

elbo

w,e

tc.)

just

like

Iam

doin

gri

ghtn

ow.A

ndal

thou

ghhy

pnos

ism

aybe

gin

sim

ilarl

yfo

rm

any

peop

le,e

ach

pers

onex

peri

ence

shy

pnos

isun

ique

ly,i

nth

eir

own

spec

iala

ndhe

lpfu

lway

.So

ina

mom

ent,

I’m

goin

gto

[put

my

arm

dow

n,et

c.]a

ndyo

uca

nfo

cus

your

atte

ntio

non

your

[arm

,fing

ers]

as[i

t/th

ey]b

egin

to...

”(O

neca

nth

enus

ein

duc

tion

lang

uage

such

asth

atfr

omH

amm

ond

[199

0].)

Uti

lizat

ion

Thi

sis

the

mos

tim

port

anta

ndun

iver

sals

kill

ofat

tune

men

t.O

neof

the

over

arch

ing

aim

sof

attu

nem

enti

sto

incr

ease

pati

ents

’abi

litie

sto

mor

eco

nsis

tent

lyan

dsa

fely

obse

rve

and

utili

zeth

eir

mom

ent-

to-m

omen

tex

peri

ence

.The

ther

apis

tin

itia

llym

odel

sit

for

them

wit

hth

ego

alof

incr

easi

ngth

eir

abili

tyto

do

itfo

rth

emse

lves

.

“And

asyo

uco

ntin

ueto

liste

nto

my

voic

e,Iw

ond

erw

haty

ouw

illno

tice

firs

t.Pe

rhap

syo

uw

illno

tice

that

your

hand

sar

ebe

com

ing

mor

ean

dm

ore

com

fort

ably

war

m,m

aybe

firs

tin

the

fing

erti

psan

dth

enth

epa

lm,

toju

stth

eri

ghta

mou

ntof

war

mth

for

you

...

orm

aybe

you

will

noti

ceth

atw

ith

each

effo

rtle

ss,a

utom

atic

,and

natu

ralb

reat

hou

t,yo

urbr

eath

ing

beco

mes

mor

erh

ythm

ican

dre

laxe

d...

and

itre

ally

doe

sn’t

mat

ter

wha

tyou

noti

cefir

st...

whe

ther

it’s

your

hand

s,or

your

brea

th,

orso

me

othe

rpl

easa

nt,n

atur

alpr

oces

sun

fold

ing

inyo

urbo

dy

...

beca

use

you

can

begi

nto

have

anex

peri

ence

...

perh

aps

slow

lyor

perh

aps

mor

equ

ickl

y...

offe

elin

gm

ore

and

mor

e[r

elax

ed,

com

fort

able

,sec

ure,

anch

ored

,gro

und

ed,p

rese

nt,a

lert

;wor

dch

oice

wou

ldd

escr

ibe

the

atta

chm

enta

ndtr

aum

atr

eatm

entg

oalt

hatw

ew

ante

dto

add

ress

inth

em

omen

t].”

(Con

tinu

ed)

Dow

nloa

ded

by [

Joan

nes

Mer

tens

] at

00:

08 0

3 D

ecem

ber

2015

58 ERIC B. SPIEGEL

Tabl

e1

(Con

tinu

ed)

Skill

App

licat

ion

Exa

mpl

e

Trui

smA

type

ofut

iliza

tion

.Her

e,w

eut

ilize

acu

eth

atw

eob

serv

ein

the

pati

entw

hose

trut

hhe

orsh

eca

nnot

den

yfo

rth

epu

rpos

eof

ascr

ibin

gth

erap

euti

cally

sign

ifica

ntm

eani

ngin

ahy

pnot

icsu

gges

tion

that

we

link

toth

etr

uism

(con

ting

ent

sugg

esti

on).

“As

you

noti

ceyo

urse

lfsi

ttin

gon

the

beig

eco

uch,

you

can

real

lyfe

elyo

urtw

ofe

eton

the

floo

r.Tw

ofe

et...

just

asth

ere

are

two

ofus

here

inth

isro

omto

geth

er...

atju

stth

eri

ghta

mou

ntof

spac

efo

ryo

u...

ascl

ose

orfa

ras

you

need

usto

be.A

ndyo

urtw

ofe

etar

eon

the

floo

r...

whe

ther

you

are

sitt

ing

orst

and

ing

...

stan

din

gst

illor

wal

king

.And

itis

righ

t,is

itno

t,th

atyo

urtw

ofe

et...

left

and

righ

t...

wal

ked

you

into

this

offi

ceso

that

you

coul

dbe

righ

ther

ean

dri

ghtn

owin

just

the

way

that

you

need

?A

ndit

isal

soco

rrec

t,is

itno

t,th

atyo

uha

vebe

enw

alki

ng...

free

ly,e

asily

,and

effo

rtle

ssly

...

onyo

urow

ntw

ofe

et...

sinc

eyo

ufir

stle

arne

dho

wto

wal

k,is

n’tt

hatr

ight

?A

ndha

veyo

uev

erim

agin

edho

wyo

ufi

rstl

earn

edto

wal

k?It

doe

sn’t

real

lym

atte

rif

itco

mes

tom

ind

inth

ism

omen

tor

not.

..

beca

use

ona

dee

ple

velt

haty

our

unco

nsci

ous

min

dca

ntr

uly

und

erst

and

and

appr

ecia

te...

inw

hate

ver

way

and

wha

teve

rti

me

isri

ght.

..

you

mus

tkno

wth

atyo

upr

ogre

ssed

from

bein

gim

mob

ile...

tobe

ing

able

toro

llup

...

roll

dow

n...

and

roll

all

arou

nd...

then

tocr

awlin

g...

atfi

rsts

low

lyor

unsu

rely

...

and

then

perh

aps

late

rm

ore

quic

kly

and

mor

eco

nfid

entl

y...

toth

enta

king

your

first

step

s...

may

beat

first

tent

ativ

ely,

then

late

rm

ore

asse

rtiv

ely

...

and

wit

hev

ery

step

that

you

took

...

you

bega

nto

real

ize

that

you

coul

dta

kean

othe

r...

one

step

coul

dtu

rnin

totw

ost

eps

...

two

step

sin

tofo

urst

eps

...

four

coul

dtu

rnin

tom

ore

...

But

now

I’d

like

tote

llyo

uso

met

hing

real

lyin

tere

stin

g...

wou

ldyo

ulik

eto

know

wha

ttha

tis?

Bef

ore

...

ther

ew

astw

o...

and

one

...

and

alth

ough

you

may

have

prev

ious

lyth

ough

ttha

titw

asap

pare

ntth

ata

pare

ntta

ught

you

how

tow

alk

...

you

real

lyto

okyo

urfi

rsts

teps

the

mom

entt

hey

letg

o,is

n’tt

hat

Dow

nloa

ded

by [

Joan

nes

Mer

tens

] at

00:

08 0

3 D

ecem

ber

2015


righ

t?A

ndal

thou

ghit

can

feel

good

toha

veso

meo

neho

ldyo

urha

ndan

dw

alk

byyo

ursi

de

...

that

can

happ

enw

hene

ver

and

how

ever

you

are

read

y...

you

will

alw

ays

beab

leto

wal

kon

your

own

two

feet

...

just

asyo

uw

illal

way

sbe

able

tohe

arw

haty

oune

edto

hear

wit

hyo

urow

ntw

oea

rs..

orse

ew

haty

oune

edto

see

wit

hyo

urow

ntw

oey

es...

orsm

ellw

haty

ouw

antt

osm

ellw

ith

your

own

two

nost

rils

.And

each

ofth

ese

two

belo

ngs

toth

eon

eth

atis

you

...

and

hold

ing,

wal

king

,he

arin

g,se

eing

,sm

ellin

g...

are

just

the

begi

nnin

gof

allt

hew

ond

erfu

lth

ings

that

you

can

do

...

and

that

do

isal

soa

be...

And

isn’

tnic

eto

know

that

you

can

bew

ith

your

self

inal

lthe

sew

ays

that

feel

good

?A

ndyo

uca

nfe

elm

ore

and

mor

eco

mfo

rtab

lebe

ing

wit

hyo

urse

lf...

whe

ther

itis

byyo

urse

lfor

wit

hso

meo

neel

se.”

Pros

ody

&Sy

nchr

ony:

Paci

ng,r

hyth

man

dto

neof

voic

e

Mea

ntto

repl

icat

eea

rly

heal

thy,

dev

elop

men

talr

hyth

ms

ofat

tach

men

t.T

heke

yis

tost

ayin

step

wit

hth

epa

tien

t’sm

omen

t-to

-mom

ent

expe

rien

cew

hile

slig

htly

lead

ing

ind

irec

ting

wha

tone

obse

rves

next

and

the

mea

ning

one

give

sto

the

obse

rvat

ion.

The

ther

apis

t’svo

ice

isin

anin

stru

men

td

esig

ned

toev

oke

rhyt

hm,

tone

,and

effe

ct.

Imag

ine

spea

king

the

abov

eex

ampl

ew

ith

part

icul

arat

tent

ion

toal

tern

atio

nsof

volu

me,

pace

,and

enun

ciat

ion

ofsy

llabl

es.

(Con

tinu

ed)

Dow

nloa

ded

by [

Joan

nes

Mer

tens

] at

00:

08 0

3 D

ecem

ber

2015

60 ERIC B. SPIEGELTa

ble

1(C

onti

nued

)

Skill

App

licat

ion

Exa

mpl

e

Eye

clos

ure

/

Frac

tion

atio

n1.

Em

phas

ize

cont

rolo

fbo

und

arie

s(e

yelid

sop

en/cl

osed

/d

egre

es)

2.Fo

ster

curi

osit

yin

sim

ilari

ties

/d

iffe

renc

ebe

twee

nin

tern

alan

dex

tern

alst

ates

and

expe

rien

ces

3.M

anag

ed

isso

ciat

ion

orab

reac

tion

thro

ugh

eith

erre

-ale

rtin

gfr

omor

dee

peni

ngtr

ance

[Ati

niti

aley

ecl

osur

e]“a

ndis

n’ti

tnic

eto

know

that

your

eyel

ids

can

rem

ain

open

orbe

gin

tocl

ose

byth

emse

lves

...

soon

eror

late

r...

just

inti

me

...

wat

chas

itha

ppen

s...

easi

ly...

auto

mat

ical

ly...

inw

ays

you

coul

dn’

thav

epo

ssib

lykn

own

you

wou

ldkn

ow.A

ndm

aybe

your

eyel

ids

wou

ldlik

eto

rem

ain

open

...

orm

aybe

they

’dlik

eto

clos

e...

orpe

rhap

sth

ey’d

like

tocl

ose

alit

tle

...

asth

eyre

mai

nm

ostl

yop

en...

or,

onth

eot

her

hand

,the

yco

uld

rem

ain

open

alit

tle

...

asth

eycl

ose

alo

t...

oryo

uco

uld

keep

one

eye

open

and

clos

eth

eot

her...

Idon

’tkn

ow,

and

itre

ally

doe

sn’t

mat

ter...

butt

he‘I

’tha

tis

you

know

sju

stw

haty

oune

edri

ghtn

ow,i

sn’t

that

righ

t?Ju

stas

you

can

expe

rien

ceex

actl

yth

eri

ghtd

egre

eof

com

fort

that

you’

dlik

eto

feel

inyo

urbo

dy

inth

ism

omen

t...

wha

teve

ris

righ

tfor

you

...

you’

llbe

able

tofe

elit

clea

rly

...

asea

syas

A-B

-see

ing

clea

rly

insi

de

...

even

wit

hyo

urey

elid

sse

cure

lycl

osed

...

.and

now

you

can

see

inyo

urm

ind

,can

you

not,

that

your

eyel

ids

are

like

your

own

pers

onal

doo

r...

and

you

can

open

and

shut

this

doo

rto

goou

tsid

eor

insi

de

exac

tly

asyo

une

ed.A

ndju

stas

you

can

use

this

doo

rto

lety

ours

elfg

oou

tand

then

in...

orin

and

then

out.

..

you

can

keep

othe

rsou

twhi

leyo

ure

mai

nse

cure

lyon

the

insi

de

...

oryo

uca

nle

toth

ers

join

you

and

bew

ith

you

asyo

une

ed...

and

som

etim

esit

isen

joya

ble

tobe

wit

hju

styo

urse

lfan

dot

her

tim

esyo

um

ight

enjo

yth

eco

mpa

nyof

som

eone

who

myo

uca

ntr

ust.

..

and

your

unco

nsci

ous

min

dkn

ows

just

wha

tis

righ

tfor

you

inea

chm

omen

t.A

ndw

ould

itbe

alri

ghtt

obr

iefl

yop

enyo

urey

esfo

rju

sta

mom

ent?

”[A

tpo

inti

ntr

ance

offr

acti

onat

ion.

]“T

hat’s

righ

t...

good

.Tak

ea

mom

entt

ore

orie

ntyo

urse

lf.A

ndno

w,w

hene

ver

you

are

read

y...

your

eyes

can

clos

eal

lby

them

selv

esag

ain

...

mor

eea

sily

than

they

did

befo

re...

and

you

can

feel

even

mor

e[c

omfo

rtab

le,s

ecur

e,an

chor

ed,e

tc.]

than

you

wer

ea

mom

enta

go.”

Dow

nloa

ded

by [

Joan

nes

Mer

tens

] at

00:

08 0

3 D

ecem

ber

2015


Arm

cata

leps

yIn

add

itio

nto

rati

fyin

gth

etr

ance

expe

rien

ce,t

his

hypn

osis

tech

niqu

ebe

com

esan

imm

edia

te,s

enso

ry-b

ased

sym

bolo

faff

ectc

onta

inm

ent.

“Let

’sob

serv

eso

met

hing

toge

ther

that

you

may

find

help

ful.

..

wou

ldth

atbe

alri

ght?

I’m

goin

gto

tell

you

som

ethi

ngab

outo

neof

your

arm

s...

pick

one

...

good

...

that

mig

htsu

rpri

seyo

u.B

utyo

um

ight

find

that

you

are

plea

sed

tod

isco

ver

how

surp

rise

dyo

uar

e...

orsu

rpri

sed

tod

isco

ver

how

plea

sed

you

are

...

asyo

ube

com

eaw

are

ofth

is.”

[Not

e:th

erap

istg

ives

sugg

esti

onfo

rpo

siti

vean

tici

pati

onin

the

even

ttha

tca

tale

psy

orim

mob

iliza

tion

has

nega

tive

trau

mat

icim

plic

atio

ns.]

“As

you

focu

syo

urat

tent

ion

onth

isar

m,y

ouca

nim

agin

eit

beco

min

gve

ryst

rong

...

sove

ryst

rong

and

thic

kan

dso

lid...

and

ofco

urse

we

can

mov

eso

lidob

ject

sw

hen

and

asw

ene

edto

...

butf

orno

wIw

ond

erw

heth

eryo

um

ight

imag

ine

the

arm

asbe

ing

stif

fand

rigi

din

its

stre

ngth

...

that

’sri

ght,

stif

fand

rigi

dan

dhe

avy

...

asst

iffa

ndri

gid

and

heav

yas

anir

onba

r...

beca

use

anir

onba

ris

stif

fand

rigi

dan

dhe

avy

and

iner

tand

unbr

eaka

ble

...

good

...

and

your

arm

isso

stif

f...

and

rigi

d...

and

heav

y...

just

like

anir

onba

r...

that

you

wou

ldn’

teve

nbe

able

tom

ove

itif

you

trie

d.G

oah

ead

and

try.

”[U

pon

rati

fica

tion

]“A

ndis

n’t

itam

azin

gto

beco

me

awar

eof

how

stro

ngth

atir

onba

ris

?Iw

ond

erw

hati

twou

ldbe

like

toim

agin

ea

who

leco

ntai

ner

mad

eou

toft

hats

ame

iron

.Str

ong

and

solid

and

unbr

eaka

ble

...

and

able

toho

ldju

stab

out

anyt

hing

secu

rely

insi

de

...

You

can

nod

your

head

asit

com

esto

min

d.

Goo

d.N

ow...

allo

wan

unpl

easa

ntfe

elin

gor

sens

atio

nto

com

eto

min

d...

and

asit

doe

s,th

e‘y

es’fi

nger

can

rise

tole

tme

know

whe

nyo

uar

eaw

are

ofit

...

and

now

imag

ine

that

this

feel

ing

orse

nsat

ion

isfl

owin

gou

tofy

ou...

allt

hew

ayd

own

thro

ugh

the

arm

s...

and

hand

s...

and

outt

hefi

nger

tips

...

and

into

this

iron

cont

aine

r...

that

’sri

ght.

..

and

you

can

becu

riou

san

din

tere

sted

...

like

asc

ient

istc

ond

ucti

ngan

expe

rim

ent.

..

toim

agin

eho

wth

ese

feel

ings

and

sens

atio

nsap

pear

as

(Con

tinu

ed)

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62 ERIC B. SPIEGEL

Tabl

e1

(Con

tinu

ed)

Skill

App

licat

ion

Exa

mpl

e

they

leav

eyo

urbo

dy

...

may

beth

eylo

oklik

ea

colo

red

liqui

d...

orso

me

othe

run

ique

imag

eth

atco

mes

tom

ind

...

you

coul

dsh

are

wha

tyo

uar

eno

tici

ngal

oud

ifyo

uw

ante

dto

...

and

then

...

whe

neve

ryo

uar

ere

ady

...

you

coul

dcl

ose

the

top

ofth

eco

ntai

ner

and

secu

rely

lock

all

ofth

eco

nten

tsin

sid

eth

eco

ntai

ner...

know

ing

that

itis

stro

ngen

ough

toho

ldth

em.A

ndyo

uca

npa

yat

tent

ion

now

tow

haty

our

bod

yfe

els

like

afte

rit

has

rele

ased

thes

ese

nsat

ions

,thi

sen

ergy

...

Wha

tdo

you

noti

ce?”

[Aft

erhy

pnot

icex

plor

atio

n,co

nsid

erof

feri

nga

post

hypn

otic

sugg

esti

onfo

rth

eun

cons

ciou

sto

secu

reth

eco

ntai

ned

affe

ctin

the

way

that

itne

eds

toaf

ter

the

sess

ion

isov

er].

[Not

e:A

subg

roup

ofpa

tien

tsw

illm

ove

thei

rar

ms

atth

ehy

pnot

icsu

gges

tion

for

cata

leps

y.T

his

coul

dbe

anin

dic

atio

nof

poor

hypn

otic

resp

onse

.But

just

aslik

ely,

itco

uld

also

bea

sign

ofth

epa

tien

t’sd

efen

sive

/pr

otec

tive

func

tion

ing.

Shou

ldth

isoc

cur,

prov

ide

sugg

esti

ons

that

reaf

firm

the

pati

ent’s

sens

eof

cont

rol.

For

exam

ple,

“tha

t’sri

ght.

..

good

...

isn’

titn

ice

tokn

owth

atyo

uco

uld

mov

eyo

urar

mif

you

real

lyw

ante

dto

?!Yo

uar

ed

isco

veri

ngm

ore

and

mor

eal

loft

hew

ays

inw

hich

you

are

stro

ngon

the

outs

ide

...

and

insi

de.

And

Iwon

der

wha

tyou

run

cons

ciou

sm

ind

will

do

next

toal

low

you

tofe

elev

enm

ore

stro

ngan

dse

cure

and

prot

ecte

d.”

]

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Post

hypn

otic

sugg

esti

onPo

sthy

pnot

icsu

gges

tion

sar

eim

port

anti

naf

firm

ing

for

the

pati

entt

hati

tis

poss

ible

for

her

topo

siti

vely

attu

neto

and

bew

ith

hers

elfo

utsi

de

ofth

eth

erap

yse

ssio

n.T

hese

sugg

esti

ons

then

beco

me

cues

for

tran

sfer

ring

this

attu

nem

entt

oex

tern

alen

viro

nmen

ts.

Dai

tch’

s(2

007)

“OK

sign

al”

tech

niqu

eis

anex

celle

ntex

ampl

ein

that

itis

afo

rmof

sens

orim

otor

anch

orin

gan

dal

soa

cue

for

apo

sthy

pnot

icsu

gges

tion

.In

this

exam

ple,

the

ther

apis

task

sth

epa

tien

tin

hypn

osis

toal

low

thei

rth

umb

and

fore

fing

erto

com

eto

geth

eron

thei

row

nan

dto

uch.

The

ther

apis

tdir

ects

the

pati

entt

ono

tice

the

sens

ory

aspe

cts

ofth

etw

ofi

nger

sto

uchi

ngan

dth

engi

ves

aco

ntin

gent

sugg

esti

onfo

ra

posi

tive

affe

ctiv

eas

soci

atio

nw

ith

this

sens

ory

expe

rien

ce.T

heth

erap

ist

obse

rves

alou

dth

atth

epa

tien

tis

mak

ing

the

“OK

”si

gnw

ith

her

fing

ers.

Furt

her,

ever

yti

me

that

her

fing

ers

touc

h,it

can

rem

ind

her

ofth

epo

siti

vefe

elin

g(s)

,sen

sati

on(s

),an

dex

peri

ence

(s)t

hats

heha

dd

urin

gth

ehy

pnos

isse

ssio

n,as

wel

las

leth

erkn

owth

atev

eryt

hing

will

beal

righ

t.R

e-al

erti

ngT

his

can

bea

hypn

otic

met

hod

for

refo

cusi

ngth

epa

tien

ton

imm

edia

tese

nsor

yan

chor

sd

urin

ga

dis

soci

ated

stat

e.

“...

and

whe

nth

ew

ord

‘re-

focu

s’po

psup

inyo

urm

ind

,itw

illbe

asi

gnal

toyo

uto

take

ad

eep

brea

th,c

ount

toth

ree,

blin

kan

dre

open

your

eyes

slow

lyan

dcl

earl

y,an

dfe

elfu

llyal

ert,

pres

ent,

and

inco

ntro

lofy

our

bod

y.”

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Hypnotic representation also serves to further the previously incom-plete formation of self and object constancy, which is a necessarycomponent of boundary formation and self-integration (Baker, 1981;Phillips, 2013). This is particularly relevant and helpful for adult traumapatients who have Borderline spectrum personality organization (e.g.,features of BPD) and will be described in greater detail below. In expli-cating her concept of object constancy, Mahler (1968) theorizes thatin the third year of appropriate development, children achieve objectconstancy, in which they can internalize a positive, loving, and sooth-ing image of their mother and integrate it into moments of distress inwhich they experience their mother as “bad,” due to misattunementto their needs. Thus, with this milestone, they are able to experiencetheir mother as a constant and durable internal figure across vary-ing external relational experiences. It is this stabilized, integrated, andnuanced internal archetype of mother that allows them to tolerate theinevitable and numerous moments of disappointments by the actualmother. This object constancy allows the child to understand that, eventhough “I may feel [scared, angry, withdrawn, etc.] because I sense thatmother is [angry, sad, disappointed, etc.] with me right now, I knowthat she is still a good, caring person who loves me.” From this exam-ple, one can deduce how object constancy leads to the parallel qualityof self-constancy.

Through its repeated representation of scenes evoking object con-stancy, hypnotherapy can be utilized to recapitulate this stalled devel-opmental process in our adult patients with trauma histories. Hypnosiscan be used to create varied and interesting image representations ofa person while inherently suggesting that they retain some aspect ofconstancy, despite the moment-to-moment changes. This constancy canthen be linked to constancy of self or other across changing affectiveand cognitive states (E. L. Baker, personal communication, August 17,2011). Therefore, “I can feel sad and still be Eric,” rather than “I [Eric] ama sad person” with the implication being that Eric is himself no matterwhether he is happy or sad.

I theorize that object constancy is a necessary precursor for consistentmentalization. As referenced earlier in the article, in a prementalizedstate of psychic equivalence, internal and external realities are mergedand “world equals mind” (Allen et al., 2008; Bateman & Fonagy, 2006,2012). In this concretized mode of thinking associated with BPD, thereis a failure of symbolization and a suspending of “as if” for whatappears to look, to feel, and to be real to the person in a given moment(Bateman & Fonagy, 2006). I understand psychic equivalence and a lackof object constancy to be overlapping concepts. In a mode of psychicequivalence, we cannot conceptually grasp the concept of mental statesoccurring outside of behaviors and external events (which is a lack ofobject constancy; e.g., if someone does something “bad,” they must “be

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a jerk.”), nor can we grasp that a person possesses a varied collectionof mental states and associated thoughts, feelings, and subjective expe-riences. Further, in this mode, we certainly would not be able to allowourselves to be curious about those mental experiences, whether insideof ourselves or others. Therefore, we developmentally need to be ableto possess a sense that every person has a core, identity-based selfhoodthat is inherently nuanced, integrated, and durable from moment-to-moment (e.g., self/object constancy) in order (a) to appreciate that theycan have varying mental states across those moments and (b) to be curi-ous about what those mental states might be (e.g., mentalization). It isfrom this foundation of self/object constancy, and the affective contain-ment that it provides, that one can psychologically allow a reflectivecuriosity to develop about different mental states in a single person andthe internal and external experiences that elicit them.

As representational capacities develop, the patient can move fromimaginally representing immediate experiences to constructing fantasy-based representative experiences designed to serve a particular purposein the trauma treatment, such as somatoaffective regulation, manage-ment of boundaries, internalization of adaptive relationship experi-ences, controlled reprocessing of traumatic memories, or integrationof diffuse ego states. The hypnosis literature is robust with exam-ples of utilizing representation in the treatment of trauma. Althoughthe underlying principles are similar, I believe that these represen-tational techniques are best organized into three general categories:representation of the therapeutic relationship, imagined parental fig-ure representation, and ego state representation. Although they differin their theoretical underpinnings and choices of relational healingsymbols, all three forms of hypnotic representation serve to facilitatehealthy internal working models that promote constancy and inte-gration. Hypnotic imagery creatively intersperses fantasy with realityto create more flexible, nuanced, and exploratory mental attachmentexperiences involving self and other.

Postulating from a psychoanalytic object relations framework, Baker(1981, 2000, 2010) proposes representation of the therapeutic relation-ship because it accesses the immediate here-and-now experience of thetherapeutic encounter. This representational process begins with imag-ining immediate relational cues in the here-and-now therapeutic milieuand then, as the patient is ready, eventually shifting to an interactivescene in which the therapist is a responsive, nurturing figure who canrespond to the patient in ways that affirm, secure, and comfort her.As the patient’s capacity to imagine this type of interaction and expe-rience positive affect in response to it increases, the therapist can thenbegin to suggest representative imagery for the purpose of externalizingnegative object representations associated with the patient’s traumatichistory. In the latter stages of Baker’s object representational model, the

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therapist focuses on the integration of “bad” and “good objects, affects,and self-states. Representations of relational figures from the patient’slife are introduced into the hypnosis, and suggestions are given to give“good” characteristics to the “bad” people and vice versa. Transferentialreactions to this process are explored in hypnosis and therapy with thegoal of reducing splitting and dichotomous cognitive processes and theaffective reactions that they engender. All of this promotes a more bal-anced, integrative representation of self and other (Baker, 1981, 2000,2010).

A second type of representational approach is an imagined parentalfigure method, which utilizes representation to facilitate adaptive inter-nal representation of self and other and to secure attachment functions(Brown, 2009a, 2009b; Murray-Jobsis, 1990a, 1990b, 1993; Phillips, 2004).Initially created as a hypnotic renurturing technique used in address-ing developmental arrests in patients with trauma histories exhibit-ing features on the borderline personality spectrum (Murray-Jobsis,1990a, 1990b), it has been modified in recent years to more explic-itly address attachment themes, language, and imagery (Brown, 2009a,2009b; Phillips, 2004). This hypnotic renurturing involves the therapistpermissively directing the patient to imagine a series of attachment-based experiences with a real or imagined parent(s). The techniquesinitially create, enhance and strengthen the imagery of a secure basewith all of its secure, safe, nurturing, and bonded functions. Based uponthe patient’s response, the imagery subsequently shifts to accentuat-ing exploratory and mastery functions associated with leaving (andreturning to) the secure base (Brown, 2009a, 2009b; Murray-Jobsis,1990a, 1990b, 1993). The entire process from start to finish promotesgreater internal representation, affect regulation, coherence of mind,and mentalization that are associated with secure attachment.

In explaining the need for an attachment-based hypnotherapeuticapproach, Brown (2009a, 2009b) notes the numerous studies associat-ing insecure attachment with complex trauma diagnoses and believesthat we must shift our conceptualization of how complex traumadevelops. He believes that early attachment disruptions are the coreproblem in the representational and self-regulatory deficits present insurvivors of complex trauma, and that the subsequent trauma abuseonly serves to exacerbate those deficits. As a result, Brown has shiftedhis emphasis from controlled reprocessing of traumatic memories toattachment-based developmental repair when working with patientswho are survivors of complex trauma. According to Brown, hypnosisis a particularly effective treatment approach for attachment pathol-ogy, because it allows for the patient to have a method of visualizingand internally representing adaptive attachment relationships, such asthe therapeutic relationship, through structured imagery (Brown, 2009a,2009b).

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Brown’s (2009a, 2009b) method is designed with two attachmentgoals in mind: (a) to aid in the development of positive internal rep-resentations and (b) to teach and facilitate mastery of metacognitiveabilities for the purpose of increasing self-reflective awareness. For thefirst goal, he believes that hypnosis helps to amplify cues for secureattachment across time until the patient can consistently represent pos-itive affect and regulate negative affect. For the second goal, Browndefines metacognitive abilities similarly to Fonagy and others’ defi-nitions of mentalization and reflective functioning, namely as beingaware of one’s mental state. By creating metacognitive cues duringimagined attachment experiences, the therapist helps patients organizetheir minds. Through an emphasis on metacognition during an imag-ined positive attachment experience, Brown believes that his model willhelp patients cognitively remap their mental states, leading to improvedself-monitoring, mental organization, and regulation of affect related tomental states (Brown, 2009a, 2009b). Brown’s model is also notable forits direct incorporation of the metacognitive aspect of mentalization inits imagery.

Finally, the third representational approach, ego state representa-tion, is grounded in ego state therapy (EST), a specific approach withinclinical hypnosis that focuses on pathological dissociation in survivorsof complex trauma. Although numerous papers and books have beenwritten about EST, a succinct description of the therapy is that itfocuses on attuning to, stabilizing, and working through the trau-matic experiences of and eventually integrating the dissociated andfragmented ego states of the self (and their respective somatic, affec-tive, cognitive, and proprioceptive experiences) (Morton, 2009; Phillips& Frederick, 1995; Watkins & Watkins, 1997). Similarly to the objectrelations and parental renurturing approaches previously described,EST utilizes hypnotic representation for the purpose of developmentalrepair. However, rather than using the therapist or parent as a repara-tive relational representational symbol, EST enlists adaptive ego statesof the patient (e.g., the wise elder, shaman, calm adult, etc.) to inter-act with the developmentally arrested ego states (e.g., the child, victim,etc.). EST representational techniques for treating trauma could includeaddressing ego strengthening, such as identifying, affirming and ampli-fying a more mature ego state or experience (Daitch, 2007; Watkins &Watkins, 1997), having an internal family support circle, where a matureego state might transfer adaptive functioning to a wounded, child egostate, perhaps through soothing or comforting (Daitch, 2007; Morton,2009), symbolizing the affect of a more malevolent ego state (“blackgunpowder”) and containing it (putting it in a chest and locking thechest) in a way that creates feelings of safety (Morton, 2009), or work-ing with ego states in the past or future to work through traumaticexperiences or to imagine integrated future experiences (Hammond,

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1990; Torem, 1992). Overall, in an EST approach, representation is uti-lized with the goals of identifying and accessing the patient’s positiveinternal resources, providing a series of corrective self-experiences,and facilitating integration of the patient’s personality (Morton, 2009;Phillips, 2004, 2013).

MentalizationMentalization has received far less attention in the hypnotic liter-

ature. Nonetheless, it should be understood as a natural progressionfrom representation in the developmental process that occurs during anattachment-informed hypnotherapeutic treatment of complex trauma.As covered earlier, imagery-based representational awareness of sen-sory experience is a rudimentary building block of mentalization inthat we first must represent our sensory and affective experiencesthrough images in order to develop the thoughts and words necessaryto describe their mental meaning and to organize them into a largerframework. As imagery representation fosters lexical representation,mentalization can begin to occur more explicitly in the hypnotherapeu-tic treatment process.

By representing a variety of figures and ego states in our patients’imagination, we have the opportunity to create scenarios that heightentheir awareness and understanding of underlying mental states.As with attunement, this can be done explicitly or implicitly. For exam-ple, Murray-Jobsis’s (1990b, 1993) creative self-mothering variation ofher parental renurturing technique asks the patient to call to mind themental experience of both parent and child in playing each role. Buteven in more “passive” parental renurturing scenes where the patientis imagining having something “done” to her by the parent (e.g., pro-tecting, affirming, containing, etc.), it is the patient who is creating thisimagery (with minimal permissive guidance from the therapist) and themental associations that come with it, whether she realizes it or not.

Similarly, Daitch describes a variation of the internal parental figuremodel in which the patient imagines her actual parent as a child inter-acting with an imagined secure attachment figure. By imagining herparent as a child-like figure most likely in some kind of pain or distressand in need of a healthy parental relationship him or herself, the patientmentalizes about the mental life of her parent. Participating in this exer-cise allows the patient to imagine her parent in a different way than shehas most likely historically remembered him or her (C. Daitch, personalcommunication, March 23, 2014).

Hypnotic suggestions for mentalization can either be directly incor-porated into representational scenes or indirectly offered through sto-ries or metaphors. For direct suggestions, Brown (2009b) suggests aframework (a) of “notice the effect of __ on your state mind” or (b)

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of “notice how __ (e.g., organized) your mind feels right now.” Theseare but a few variations of direct hypnotic suggestions for mentalizingthat a hypnotherapist could offer. Alternatively, because MBT ofteninvokes the here-and-now experiences of the therapeutic relationship(Allen et al., 2008; Bateman & Fonagy, 2006), direct hypnotic sugges-tions could be given to explore the mental experiences and interactionsbetween therapist and patient. In this regard, one can apply an explicitmentalizing focus to Baker’s (1981) object relations protocol utilizing thetherapeutic relationship.

Indirect suggestions are a method for modeling mentalization with-out explicitly instructing the patient to do so. Indirect suggestionsfor mentalization can be beneficial when direct suggestions stimulateattachment anxiety or avoidance. I often tell hypnotic stories withmentalizing themes (e.g., “The Little Engine that Could—“I think I can,I think I can . . . I know I can, I know I can”—and the parallel imageryof scaling a mountain that comes with these progressing mental states).

An apt example of a mentalization metaphor is being able to “seethe forest for the trees.” I find this metaphor useful because it’s verymeaning—discerning a larger pattern from a mass of detail—describesa quality of mentalizing. I have devised an extended mentalizing tech-nique and script based off of this metaphor. In this permissive approach,the patient is asked to symbolize an image of a tree that represents aparticular mental (e.g., affective) or ego state that he or she is havingdifficulty with. Hypnotic suggestions tailored to the patient’s attach-ment dimensions and needs are given with the intention of positivelymodifying the patient’s experience of her “tree.” As mastery increases,suggestions shift to imagining, exploring, and articulating relatednessbetween this and other nearby trees. The hypnotic emphasis gradu-ally moves from a single tree to a forest of trees. Hypnotic suggestionsemphasize shifting sensory perspectives of the tree(s) and forest forthe purpose of building greater reflective functioning. This approachis designed to help patients have a greater appreciation of the diversityof their mental experiences, feelings, and thoughts; and better be ableto reflect on and to organize them into a cohesive, integrated mentalexperience.

Conclusion

In this article, I drew upon the combined literatures of attachmenttheory and clinical hypnosis in proposing an attachment-based modelof how hypnosis might be developmentally utilized in a psychother-apy treatment for complex trauma. Additionally, I was influenced bythe literature documenting the central role of mentalizing in guiding

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responses to traumatic cues and promoting overall secure attachment(Allen et al., 2008; Bateman & Fonagy, 2006, 2012; Fonagy et al., 2002).However, given the centrality of language in framing such mentalizing,I was curious about how such reflective language could be developedin the patients who need it the most. Thus, not only does this articleexplicate the elements of attachment inherent in hypnosis but it alsoconsiders how attunement and representation facilitate the emergenceof mentalization and reflective language.

An underlying assumption of attunement is that the process of devel-oping safety and security begins in the here-and-now interpersonalframe of the therapeutic relationship. As the therapist attunes, observesand shares with the patient in their joint space—through careful track-ing, synchrony, pacing, vocal prosody, and language—the two worktogether to develop sensorimotor anchoring in the patient. Throughtheir joint attention to positive phenomenological processes developingin the patient, the therapist begins to utilize these processes as con-tingent suggestions for affect regulation and boundary management.Thus, the patient learns how to “be” with her body in a containing,soothing, and grounding way.

Influenced by Baker’s work on the use of hypnosis in buildingstructuralization (1981, 2010), I theorized that this sensory, “felt” expe-rience also creates a concrete and tangible foundation for subsequentrepresentation—first of the body and later of the self, other, and rela-tionship(s). Thus, mastery of one’s immediate sensory experience influ-ences the creation of images used to describe those experiences. It isin this respect then that representation expands from somatic to self-experience and from self- to relational experience. As the opportunitiesfor representation increase, the therapist has more material to work within framing and describing imaginative healthy attachment experiences.

Hypnotic mentalization utilizes these representational scenestowards the purpose of enhancing the patient’s reflective functioning.Through repeated use of varied representational imagery, the therapistaugments the patient’s capacity to use reflective language to describeher and others’ mental experiences. With an expanded vocabulary ofreflective language at her employ, the patient is now able to use herown language to assign meaning to the mental experiences highlightedin hypnotic representational imagery.

In conclusion, hypnosis is a beneficial addition to any psychother-apy for complex trauma. It experientially enhances the attachmentprocesses of attunement, representation and mentalization in the treat-ment. Doing so promotes secure attachment and a recapitulation ofstalled developmental processes, including the capacity for nuancedself-reflective language and associated mentalizing.

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References

Allen, J. G., Fonagy, P., & Bateman, A. W. (2008). Mentalizing in clinical practice. Arlington,VA: American Psychiatric Association.

Baker, E. L. (1981). An hypnotherapeutic approach to enhance object relatedness in psy-chotic patients. International Journal of Clinical and Experimental Hypnosis, 29, 136–147.doi:10.1080/00207148108409154

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Anhangs-fokussierte Hypnose in der Psychotherapie komplexer Traumata :Anhaftung, Verkörperung und Mentalisierung

Eric B. SpiegelAbstrakt: Die relationalen und psychologischen Funktionen von Anhaftung,Repräsentation und Mentalisierung sind essentielle Komponenten einersicheren Anhaftungserfahrung. Psychotherapeutische Ansätze mit anhangs-theoretischer Information haben vor allem auf dem Gebiet des kom-plexen Traumas signifikante empirische und klinische Unterstützungerfahren. Trotz dieser Vorstösse könnte eine anhangstheoretisch informierteTraumabehandlung in großem Maße von dem Erfahrungswert, die die klin-ische Hypnose zu bieten hat, profitieren. In der Utilisierung von geteilterAufmerksamkeit, Stimmlage, Pacing, repräsentativer Imagination und hyp-notischer Sprache, bietet klinische Hypnose Psychotherapeuten als Zustand,Beziehung und Technik einen Weg, um eine gesunde Bindungserfahrungeinzuführen und angebrachtes entwicklungsgemässes Funktionieren beiPatienten zu erneuern, die Überlebende komplexer Traumata sind. In diesemPaper werden Anhaftung, Verkörperung und Mentalisierung aus hypnother-apeutischer Sicht untersucht.

Stephanie Reigel, MD

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74 ERIC B. SPIEGEL

L’hypnose axée sur l’attachement en psychothérapie pour traumatismescomplexes: harmonisation, représentation et mentalisation

Eric B. SpiegelRésumé: Les fonctions relationnelles et psychologiques de l’harmonisation,de la représentation et de la mentalisation constituent les éléments essentielsde l’expérience d’un attachement sécurisant. Les approches psychothérapeu-tiques, alimentées par la théorie de l’attachement, ont acquis un soutienempirique et clinique important, notamment dans le domaine des trauma-tismes complexes. Malgré ces avancées, le traitement des traumatismes fondésur l’attachement pourrait grandement bénéficier de la richesse expérienciellequ’offre l’hypnose clinique. Dans son utilisation de l’attention partagée, duton de voix, du rythme, de l’imagerie figurative et du langage hypnotique,l’hypnose clinique en tant qu’état, relation et technique, offre aux psy-chothérapeutes un moyen d’introduire un attachement sain et de renouvelerles bonnes capacités développementales fonctionnelles chez des patients quiont survécu à des traumatismes complexes. Dans cet article, l’harmonisation,la représentation et la mentalisation sont examinées selon un point de vuehypnothérapeutique.

Johanne RaynaultC. Tr. (STIBC)

La hipnosis enfocada al apego en psicoterapia para trauma complejos:Sintonía, representación y mentalización.

Eric B. SpiegelResumen: Las funciones relacionales y psicológicas de sintonía, repre-sentación y mentalización son componentes esenciales de una experienciasegura de apego. Los acercamientos psicoterapéuticos informados por lateoría del apego han ganado sustento empírico y clínico significativo, par-ticularmente en el área de trauma complejo. A pesar de estos avances, eltratamiento al trauma, informado en el apego, podría beneficiarse en granmedida de la rica experiencia que la clínica hipnótica puede ofrecer. En suutilización de atención compartida, tono de voz, cadencia, visualizacionesrepresentacionales, y lenguaje hipnótico, la hipnosis clínica, como estado,relación y técnica, ofrece a los psicoterapeutas una forma de introducir unaexperiencia de apego saludable y renovar un funcionamiento del desar-rollo apropiado en pacientes sobrevivientes de un trauma complejo. En esteartículo se revisan la sintonía, representación y mentalización desde unaperspectiva hipnoterapéutica.

Omar Sánchez-Armáss Cappello, PhDAutonomous University of San Luis Potosi,Mexico

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ATTACHMENT-FOCUSED HYPNOSIS IN PSYCHOTHERAPY FOR …nvvh.com/wp-content/uploads/2015/12/IJCEH-64-1-03.pdf · trauma. In this article, attunement, representation, and mentalization