Brookside Center for Counseling and Hypnotherapy
I RECENTLY BECAME A CERTIFIED HYPNOTIST: WHAT DO I DO NOW?
by Maurice Kouguell, Ph.D., BCETS.
Brookside Center offers a Mentorship and Internship program. The following are questions most frequently asked by newly certified hypnotists.
This article is written in a format of a dialogue between the candidate (C) and myself (M) and is based on a compilation of concerns that recent certified hypnotists have asked.
C: I have recently completed a certification program and have many concerns.
M: Such as?
C: What do I say when I meet a client for the first time?
M: I always start by introducing myself and asking the client for his/her name: i.e. "I am Dr. Kouguell and you are?" I do this because once someone arrived at my office at about the time of my next appointment. I invited the person to come in and take a seat. That person was in the wrong office!
Those who are in the field of Mental Health/Counseling have learned already through their own training and supervisory hours how to proceed.
For those coming from any other background, I suggest two options: get a mentorship from a seasoned practitioner who has credentialed training in clinical interviewing. The other option is to read and learn about interviewing techniques. Reading is not an option; it must be a requirement, but nothing replaces direct supervision.
C: I have good people skills and feel very comfortable with people I meet, do you think that is not enough?
M: I am in no position to answer that question without observing your interaction
with clients. But hypnotherapy cannot exist without rapport or at least an empathetic
relationship between client and therapist. Rapport is not therapy. An empathetic
relationship is not therapy. The rapport needs to be seen in the interactive content of
the professional relationship of two individuals with clearly defined goals.
C: I can do smoke cessation and weight management. I was given scripts and told that we are now trained to do it.
M: There is so much more to hypnosis besides reading scripts and bringing about a trance.
C: But I am certified and have even taken and passed a test. I still have many concerns: What do I do? Where do I start? Where do I open an office? Where do I get my clients from? Where do I open an office? At what time in the first interview do I start doing hypnosis?
M: I understand your concerns and will be glad to answer them but what sort of practice do you have in mind?
C: Hypnosis of course.
M: Would you hypnotize anyone who comes to you?
C: Yes, that is why they are coming to see me.
M: In other words, you would hypnotize anyone coming to you because they have chosen this technique to alleviate their problem?
M: Have you learned in your training about the contraindications and the possible dangers in the use of hypnosis? Allow me to share with you highlights of some of my articles which appear on my website as well.
You will have to decide what conclusions to draw from the following. The literature points out some complications that can arise from the use of hypnosis. It seems that all established writers and researchers do suggest the importance of the knowledge of the working of the mind and applying the rule: THAT IF A PERSON CANNOT TREAT A PROBLEM WITH NON-HYPNOTIC TECHNIQUES, HE SHOULD NOT TREAT IT WITH HYPNOSIS. This is taken from Clinical Hypnosis by Crasilneck and Hall, one of the standard recognized textbooks on hypnosis. The same authors report also that hypnosis can, under certain circumstances be dangerous not only to the client, but also to the hypnotist.
C: What dangers and complications are you referring to?
M: While the hypnotic trance itself may occur comfortably and easily, Dr. Thurman Mott reports complications occurring:
To take this further, in Hypnosis Complication: Risks and Prevention, a research article by MacHovec, in The American Journal of Clinical Hypnosis (1988) he lists about 50 complications associated with hypnosis and reports that this is only a partial list. The author grouped the complications into five categories:
Dr. MacHovec defines hypnotic complications as "unexpected unwanted thoughts,
feelings or behaviors during or after hypnosis which are inconsistent with agreed goals
and interfere with the hypnotic process by impairing optimal mental functioning with no
prior incidents or history of similar mental or physical symptoms."
Summary list of complications associated with hypnosis:
anergia and fatigue antisocial acting out anxiety, panic attacks attention deficit body/self-image distortions comprehension/concentration loss confusion coping skills, impaired decompensation, psychotic-like delusional thinking depersonalization depression de-realization dizziness dreams drowsiness, excessive sleep fainting fear of fearfulness guilt headache histrionic reactions identity crisis insomnia irritability medical emergencies memory impaired, distorted misunderstood suggestion nausea, vomiting obsessive ruminations over dependency personality change phobic aversion physical discomfort, injury psychomotor retardation psychosis regressed behaviors sexual acting out sexual dysfunction somatization spontaneous trance stiffness, arm or neck stress, lowered threshold stupor symptom substitution tactile hallucinations traumatic recall tremors uncontrolled weeping.
The same researcher described risk factors as most frequently involving repressed materials or unconscious needs; personality dynamics such as resistance, regression, secondary gains, misunderstood suggestions, attitudes and expectations. He also adds the risk factor to the hypnotist, which he describes as falling into two categories:
1. Professional risk factors related to a deficiency or weakness in education, training or knowledge, skill, ability or experience, which impair judgment or proficiency.
2. Theoretical bias which limits awareness of other factors or dynamics.
Kleinhauz, M and Beren, B., in an article entitled Misuse of Hypnosis: A Factor in Psychopathology, published in the American Journal of Clinical Hypnosis, talk about a client who came for smoke ending and became extremely agitated and depressed and experienced suicidal thoughts. In my own practice, and I have mentioned this at some of my workshops, I had worked with a man who came for smoke cessation and after he was relieved from the habit, he went into a severe depression. He was one of the cases that prompted my own feeling about the importance of an assessment prior to any hypnotic protocol.
Four Case Studies
Kieinhauz and Eli reported four cases of "deleterious effects of hypnosis used in the dental setting."
In the literature, authorities have been urging caution in the use of hypnosis for over 100 years. As far back as 1887, Bjornstrorn cautioned of the possible injuries and fatal effects. Janet, one of the forefathers of hypnosis, in 1925, recommended that "awakening should be postponed if a morbid symptom of any sort should intervene during the hypnotic state." Weitzenhoffer warned about special care in avoiding the adverse effects of hypnosis and related those to the "competency and integrity of the practitioner." In 1961, Meares expressed concern about premature termination. Also, Weizenhoffer warned against inappropriate symptom removal "before symptoms are suggested away some of the functions they serve should be determined."
Side Effects of Hypnotism
Numerous mild side effects occur during a hypnotic induction and at times these mild reactions might also occur following a post hypnotic suggestion.
Dr.Thurman Mott reports "numerous mild side effects occur during inductions". These are usually not reported and have not been studied systematically; however, although they do occur usually during the first induction, they might be expected to occur with psychiatric patients. The most common of these side effects during the induction could be the increase of anxiety frequently related to fears of loss of control and excessive crying and sobbing. At times patients feel dizzy and develop various degrees of nausea during the induction. Spontaneous regression to a traumatic event or period of life, although rare, does happen.
In my own practice, one of my clients during an interview, went into trance with her eyes open and relived spontaneously an earlier sex abuse experience. Most of the side effects can usually be alleviated quickly by discontinuing the induction or by proceeding with the induction and usually the side effects will disappear as the hypnotic state deepens. In either case, an appropriate technique should be applied.
The concern of symptom substitution was one danger of hypnosis reported by many
practitioners. Symptom substitution currently, because of the better training of
hypnotists, has been replaced by symptom modification which then permits the patient to
retain the symptom if it is dynamically important to do so.
Patients under hypnosis tend to accept suggestions concretely, if not literally and this might result in adverse reactions which may come as a surprise to the therapist.
For instance, Crasilneck and Hall in their text Clinical Hypnosis: Principles and Applications, discuss the case of a burned patient. While working on improving the patient's nutrition, the patient was given the suggestion that he could eat everything on his plate. One day the patient became ill and vomited on his plate and was later discovered eating the vomitus.
Masking physical pathology could also be a very delicate outcome of hypnosis where the patient has pain because of a physical condition and it is now completely controlled by hypnosis. The reason for the physical discomfort is now totally overlooked thus creating other problems. Dr. Fromm, in her book Values in Hypnotherapy: Theory, Practice and Research, describes hypnosis as a state of decreased vigilance resulting in a vulnerability which involves dangers if a patient is in the hands of a poorly trained incompetent therapist using hypnosis." She states, "Most of the complications related to hypnosis occur when hypnosis is misused and these complications may be prevented by the following:
Hypnosis must be used permissively, allowing patients to determine when
hypnotherapy is used. Guidelines and methods for working with severely disturbed patients
are discussed by Murray-Jobsis in Clinical Hypnosis: A Multidisciplinary Approach
and by Baker in A Hypnotherapeutic Approach to Enhance Object Relatedness in Psychotic
Patients in the International Journal of Clinical and Experimental Hypnosis 29.136-
In summary, hypnosis, when properly used, is one of the safest tools in the healing profession. As clinicians using hypnosis to help with treatment, we need to be aware of the adverse effects when hypnosis is misused. It is necessary for any organization and any training program to promote not only the teaching of safe hypnotic techniques but also the restrictions of the use of hypnosis to the areas of competency of the practitioner.
Most clients "seeking help through hypnosis" come with difficulties, adjustment reactions and so on. Some assessment technique needs to be used and I will take the liberty here to suggest to the reader becoming acquainted with my books Human Figure Drawings: A Screening and Evaluative Tool in Hypnosis and DAPTH: Accessing the Unconscious in the Practice of Hypnosis and Counseling which are both simple and accessible in this regard.
C: Yes, we were told that we should work only with people that we can handle.
M: And how do you know that? What kind of assessment do you do in order to prevent any possible problems?
C: What kind of problems can arise?
M: With luck on your side, maybe none. But how do you know that the person coming to you may not be schizophrenic or psychotic or borderline personality and of course you know that with some of those, you must not remove their boundaries for fear of precipitating a severe reaction. Having your clients enter altered states may give them license to abandon their boundaries and result in a loss of control.
C: But what harm could possibly come from doing smoke ending?
M: Your client may be seeking help for smoke secession but he may also be mentally disturbed. Frequently those disturbances are not obvious. Having a script is helpful. But the procedure must be highly individualized for no two people are alike. To this end, one must be trained in learning about the client; i.e. reasons for stop smoking or weight reduction. It is helpful to know from the client also reasons for not giving up their habits. Knowing the history of the habit, other experience they may have had in controlling their habits. It is wise to know if the habit is their way to cope with depression or anxiety. Is the addiction their way to combat loneliness, a compensation for a feeling of insecurity? Is over-eating a way to deal with a possible fear of intimacy?
C: So what are you saying?
M: Basically that we need to be ready to deal with how the client will adjust without his cigarettes or without turning to food. If those addictions were used for coping, then how would they cope without them? You will soon realize in your practice as a hypnotist that clients will come to you instead of going to a Psychiatrist, Psychologist or Social Worker, because they might feel that there is less stigma attached to seeing a hypnotherapist rather than a psychotherapist.
C: So, what do you suggest I do?
M: Always keep the welfare of the patient as a priority. There cannot be any disagreement with the premise that before an intervention (such as hypnosis) is initiated, you need a background in abnormal psychology: read and study, study, study! You also need to know how to assess your client.
C: But we learned to take a history, isnt that enough?
M: Taking a history is fine. But did you learn what to do with it? How to interpret it? How to integrate it with other information? Taking a history is not simply giving a questionnaire. The main purpose of a history is to lead you to an understanding of your client. A history well analyzed can give you the insight if not the solution of the problems. Also, it is my strong belief and orientation that, before hypnosis is initiated, an assessment is performed.
C: In our training we were told that we should not assess our clients because we could be accused of practicing psychology.
M: While assessment remains a controversial issue, every hypnotist does it. Assessment is based on the observation of the behavior of the client and understanding what the behavior means. Part of the assessment is noticing appearance (is the client tall, short obese, skinny outgoing, feeling self conscious, timid, young, old, is the client blind, deaf or speak only a language foreign to you). The exceptional talent of Erickson, for instance, was not in his technique, but in his unsurpassed gift at observing and ability in figuring out what made his patients tick. With that unique ability he developed therapeutic techniques suitable to each individual. With each person he saw, he created a new approach. The existence, the lifestyle of each patient became his script, his method. I would like to emphasize that before we proceed with hypnosis, we need to have some idea as what we are looking for.
Through hypnosis we access the unconscious. Since we deal with both conscious and
unconscious material, we must know how to go beyond the obvious and possibly have
"a look" into the unconscious before we proceed. And, since we deal with both
conscious and unconscious material, we must know how to go beyond the obvious.
Frequently some therapists profess to have found truth in a certain theoretical
orientation or technique. Experience has taught me the importance of a theoretical and
academic background. It has also taught me how unwise it is to fit the client into a
theory or a predetermined method or technique simply because it is favored by the
C: So are you saying that I need to assess every case?
M: If you agree that there are goals that are expected then you need to know your client, recognizing the importance of going beyond what the client is describing as being factual. The conscious level is what we are aware of in ourselves and in our clients. I believe that the goal of any therapy is to take into account the client's perception of reality and to alter it so that it becomes comfortable.
C: I dont understand!
M: We must know what makes a client "tick" and also what makes us "tick".
C: What do you mean, "what makes the client tick"?
M: I mean what is below the fašade or the surface that the client presents: how we can access the unconscious.
C: Can we?
M: I believe we can and need to do so
M: I have found that the use of drawings is an excellent tool as discussed in my
two books Human Figure
Drawing: A Screening and Evaluative Tool in Hypnosis and DAPTH: Accessing the Unconscious
in the Practice of Hypnosis and Counseling.
A person could be behaving normally, appear to have intact thinking processes and yet, the pathology might surface at unexpected times. While it surfaces on occasion, it is always present and one needs to find a way of being aware and prepared to deal with it.
It is my opinion that before hypnosis is applied, it is wise to assess the advisability of using hypnosis.
If we see ourselves as operators, then we need to know how to operate that
precious commodity, the person. If we see ourselves as students of human nature, then we
need to know about human nature. Knowing both can only enrich our competency. Dissension
between, and a debate about, the merit of one philosophy over another will only lead to a
narrowing of our scope and limit the freedom necessary for learning. Learning standard
inductions must be required. Knowing the difference between guided imagery and other
states needs to be mastered. Quick, rapid, spontaneous techniques need to be known. But
above all, any practitioner working with people must know human nature.
As a teacher and practitioner of hypnosis, I had questions that I needed to address.
When a client comes for hypnosis, shouldn't there be an assessment preceding the trance induction? Should hypnosis be used because it has been requested by the client? If hypnosis is to be used, how should it be used? Should the hypnotherapist assess the client's emotional strengths or vulnerability first? How does the therapist assess the effectiveness of a session or sessions?
It appears that books written on hypnosis by psychotherapists do not discuss assessments for the application of hypnosis. Those clients have already been diagnosed. Most books written by hypnotists state that hypnosis is not dangerous. They frequently discuss how to determine one's ability at entering hypnosis, but do not discuss when hypnosis should be used. In my opinion, the ability to enter hypnosis is not a criterion for using hypnosis. Individuals with repressed anger may present a certain fašade but might feel quite differently from what their appearance suggests. It is also possible that people choose to say things that they do not mean in order to protect their integrity at a given time. Repressing and suppressing one's feelings is a sign of our advanced society where as early as the infant can hear and speak he/she is expected to respond and conform to the needs of society surrounding him and repress his own needs. And there is a way to assess.
C: How do you do that?
M: By re-administering the DAPTH at regular intervals and examining changes in the drawings.
C: So what specifically can you get from the drawings?
M: The hypnotherapist will be able to gather information concerning the client's needs, fears, conflicts and goals and integrate that material in his work. Being aware of the symbolic content brought forth by the drawing will offer the therapist a direct avenue to the understanding of the client's conflicts and problems. With this information, the therapeutic intervention should become more effective, for it addresses itself to unconscious material which now has surfaced. In addition, this technique will also provide the therapist with information revealing the possible pathology of the client and help decide the course of therapy.
This technique can also be applied effectively as a screening tool preceding any group induction. One cannot assume that individuals attending a group workshop are necessarily free of severe pathology just because they are of part of the workshop.
C: And where can I learn about that technique?
M: Students in this program will learn how to use this instrument. This will be part of their training.
C: Is there anything else that is unique to your program.
M: After completing their training, students can continue to consult with their mentor. They will also be acquainted with various styles and techniques necessary for their practice.
M: Through supervision students will also learn how to understand and deal with their own feelings.
C: Thanks. You gave me a lot to think about.
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