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... be use of hypnosis with children and adolescents, as ... adults, can provide the advantage of accelerating ... augmenting the impact of psychotherapeutic inter...Yet, as in adult psychiatry, only a small minority ...child psychiatrists are trained in the use of this ...entially helpful technique. Similar reasons for this ...apply in both instances: the long...proliferation of controversies and misconcep...about the nature of hypnosis and its clinical ...This article will focus on issues pertinent to ...clinical use of hypnosis with children and adolescents, noting its indications and advantages, its limitations, and where it is contraindicated.
HYPNOTIZING CHILDREN AND ADOLESCENTS
About 70 percent of the adult population is hypnotizable to a clinically significant degree,1 and it has been clearly established that children are more hypnotizable than adults. Cross-sectional and longitudinal surveys concur in finding increases in hypnotic susceptibility scores between the ages of 5 and 10, a peak in the preadolescent years, and a gradual decline thereafter, continuing through adulthood. As with adults, there are no significant differences between the sexes in hypnotizability during childhood and adolescence.
An understanding of the major variables influencing children's hypnotizability can contribute to more effective therapeutic use of hypnosis.3 These include the patient, the parents, the therapist, and the environment.
The patient. Because his cognitive skills are not fully developed, the child generally focuses more on the immediate present. He is thus more fully absorbed in what he is doing, as is required in hypnosis. This contrasts with the usual adult waking state, which is characterized by complex intellectual processes involving logical and critical thinking and integration of different ideas across time and space. These processes constitute a potential source of resistance to hypnosis. Further, Piaget's description of the young child's natural tendency toward concrete, literal thinking helps explain the child's more ready acceptance of appropriately worded hypnotic suggestions, since they involve little consideration of the nature of the therapy, or related abstract issues. Thus, children's more limited capacity for reality-testing and the greater ease with which they interwine fantasy and reality tend to facilitate their acceptance of the hypnosis ceremony.
Emotional factors contributing to the greater hypnotizability of children include their general openness to new experience, emotional malleability, intrinsic orientation to learning new skills, and the greater ease with which they can accept regressive phenomena. In this regard, the hypnotic relationship more closely approximates the ways in which children generally relate to adults, compared to the ways in which adults usually relate to each other. A child's propensity for trusting responsiveness to suggestion, as well as his readiness to accept help from a respected adult authority, are both part of his natural developmental progress toward achieving mastery and autonomy.
The parents. As with any therapeutic intervention, parental cooperation and support will increase the likelihood of a child's responsiveness. Because of lingering popular misconceptions that hypnosis is shamanistic or dangerous, it behooves the therapist to explain to parents how hypnosis can be a safe and useful component of the therapeutic strategy, thus adding the important force of their consensual validation to enhance its acceptability to the child.
The therapist. Appropriate intervention obviously presupposes empathie understanding of the patient a... cogent assessment the existing problems and avai... resources. An important consideration is the psychiat... need for sensitivity regarding the linguistic and metal-... ical style that would be most suitable to a particular c... taking into consideration this cognitive level, ranj... experiences and emotional needs. Consideration... rapport is of particular significance in working... adolescents, who will be offended if, for example... therapist uses language and imagery that is r... appropriate for a younger child.
The environment. The physical setting for hypr... should ideally engender a sense of comfort, security,... freedom from distracting stimuli. In the social mi... consensual validation is important, not only i... parents, but also from the referring physician, nur... staff, and any others who are in a position to either ai... hinder therapeutic movement.
Indications for hypnosis. Having designated hypr... itself is not a substitute for comprehensive therapy,... first task of the child psychiatrist who uses hypnosis... devise a sound treatment strategy aimed both at mot... ing pathogenic influences in the child's life situation... at augmenting his or her capacity for emotional... cognitive self-mastery of ongoing intrapsychic confi...
Once the outlines of this plan have been establis... hypnosis can increase therapeutic leverage by tappinj.... patient's capacity to participate in the therapc... experience in a more intense and concentrated way. S... the patient's intensified transference and attention... focused on the treatment situation, an atmospher... receptivity enhances his capacity for reorientation... change. Moreover, where appropriate, the patient ca... taught through self-hypnosis to reproduce this respi... in his daily life in such a way that gains made in the clir... setting can be implemented and reinforced at home... ...contrast to the demonstrated ability of hypnosis in ...s to promote the uncovering of repressed material ...igh either abreaction or complex exploration in ...noanalysis," there appears to be little or no ...ntage to using it for such purposes in children.5 The ...lient conventional methods of play, drawing, story...Ig and free discussion seem better suited to fostering ...taneous expression in children than the artificially ...zed state of hypnosis.
...ie primary value of hypnosis in child psychiatry is to ...jund in its capacity to generate a new sense of ...ery, which can enhance the process of attitude...ation and facilitate the more rapid relief of disabling ...toms.6 In this sense, once a therapy plan has been ...loped, hypnosis can be· used to focus on key dynamic ...snts in a weiter of complex environmental and ...psychic variables, and present a simple, sound and ...able route by which the patient can relinquish with ...r a symptom-complex to which he has retreated ...r duress. By calling the patient's attention to the ... resourceful and effective coping methods, available, ...eremony of hypnosis can constitute an occasion for ...patient to dramatically realign his emotional...itive perspective. Thus, if the therapeutic strategy has ...judiciously formulated, the patient can, under the ...lortive-proteetive authority of the hypnotherapist, ...rporate a healthier perspective of adaptation into his
...ypnosis has been found empirically to be helpful in ... and adolescent psychiatry in treating patients with a ... range of diagnoses - those with somatiform disor... anxiety disorders, dissociative disorders, adjust... disorders, psychological factors effecting a physical ...lition, and special symptoms (e.g. enuresis, encopre...stuttering, finger-sucking, nail biting, and factitious ...aatitis). Children with clear-cut psychosis orsubstan...ganic brain damage generally lack the necessary ego strength and capacity for concentration to utilize hypnosis effectively. For selected children with borderline conditions or minimal brain dysfunction, however, hypnosis may be of value, and determination of the individual child's capacity for trance experience will help clarify whether or not hypnosis is applicable for use in dealing with a particular target symptom. Indeed, reports of some workers suggest that even psychotic patients have periods of lucidity during which they may be capable of the concentration and cooperation necessary for hypnosis. Circumscribed therapeutic changes achieved with psychotic patients using hypnosis are unlikely to be sustained, though, unless accompanied by the associated supportive measures that such persons' overall condition requires.
Hypnosis is most often introduced asan adjunct within the larger framework of ongoing individual and for family therapy, and the reader is referred to standard tests on these subjects7 as a prerequisite before beginning the use of hypnosis. Once this fact is appreciated, there are a number of indications for the supplementary use of hypnosis with such patients. They include:
Inadequate progress. In the course of psychotherapy, hypnotism may be helpful when inadequate progress has been made in the conversion of insight into changed behavior, despite the existence of potential psychodynamic resources for clinical improvement, as judged by the therapist. The patient's capacity to implement the newly planned tasks should of course be realistically assessed. The introduction of hypnosis affords the therapist the opportunity to "shift gears" from a more exploratory to a more actively directive approach.
When symptomatic behavior has become an established habit. Hypnotism may be helpful when such behavior persists on a self-perpetuating basis after having lost its original emotional significance. The increased sense of mastery afforded by hypnosis can catalyze the escape from a previously semiautomatic repetitive pattern in which the patient had felt trapped, yet lacked the confidence or motivation to overcome.
At the beginning of a therapeutic relationship. Hypnosis can be valuable at this time in advancing urgently needed behavioral changes. This presupposes that the psychiatrist's initial evaluation has furnished sufficient psychodynamic data on both the presenting problem and the child's and family's capacities for change to justify the application of hypnosis. Such an approach is particularly valid in crisis intervention, though it need by no means be restricted to such situations. The "ripple effect" of relief and increased self-confidence generated by initial symptomatic improvement generates a more conducive atmosphere for further psychotherapeutic work.8
In cases of emergency, when persistence of the symptom is based In part on pervading anxiety. Bronchial asthma is one example. Here the use of hypnosis as a relaxation technique structures the therapist's active intervention to allay the patient's anxiety through interpretation of the assumed causative factors and reassuring demonstration of the corrective resources at hand.
A growing number who have had substantial experience with the use of hypnosis in child and adolescent psychiatry feel that there is merit in turning to hypnosis as a first resort whenever it appears likely to expedite ongoing psychotherapeutic progress, rather than trying it only as a last resort after other measures have failed or bogged down.
PRECAUTIONS, CONTRAINDICATIONS AND LIMITATIONS
When used with sound clinical judgment in an appropriately goal-directed manner, hypnosis is a remarkably safe therapeutic aid. Nevertheless, there are some precautions to be noted. Because of the particular value of hypnosis in treating somatiform disorders and psychological factors affecting physical conditions, it is most important that the possibility of undiagnosed organic pathology be considered before embarking on psychiatric treatment. One can often bring out plausible dynamics to justify the diagnosis of a conversion reaction when, in fact, a primary organic lesion is actually responsible for the presenting symptom. Conversely, the presence of a documented organic disorder, such as epilepsy, by no means precludes the coexistence of a secondary somatiform disorder (conversion of factitious seizures,... example).9'10 In cases where the diagnosis is intitj... unclear, a clinical trial of psychotherapeutic interven... may well be justified, while maintaining close liaison... cotreating medical colleagues.
It it also important to note, in instances of psychi... namically-based symptomatology, the contraindica... to using hypnosis in an attempt to coercively remo... symptom, hoping thereby to satisfy the refer... physician, or the therapist's own ego. It is inappropi... to try to deprive a patient of a symptom that is servi... defensive function without helping him restructur... perspective for alternative adaptive maneuvers that... into account his own autonomy. Attempts at b... symptom-removal through hypnosis or any other sug... tive method will not only fail, but will undermine... patient's confidence in the therapist. These pitfalls... avoided when hypnotic suggestions take into acce... existing psychodynamics, the patient's self-esteem,... his capacity to achieve designated goals.
The popular misconceptions about symptom-subs... tion or symptom-recurrence always happening folio... hypnosis arise most often either from self-fulfi... prophecies conveyed inadvertently by misguided hyi... therapists11 or from otherwise inappropriate technic... as has been amply demonstrated. Symptoms may r... even when appropriately removed with hypnos... excessive adverse life stresses are reactivated or if... psychotherapeutic support needed to consolidate gai... terminated prematurely. This observation is no r.... characteristic of hypnosis, however, than of o... therapeutic modalities.
Another limitation of note is the patient's reasor... seeking help. A growing number of references to hypr... in the popular media in recent years have attra... patients and parents who believe hypnosis will be a q... panacea for complex life problems. Patients or par... who come to the therapist with such unreal... expectations are clearly destined for disappointment... disenchantment; the patient or parents seen by... therapist in such a context clearly must be given s... clarification, after the presenting problem and rel... background have been elucidated, as to what hypr... can and cannot realistically be expected to accomp... Such clarification may then be the starting point... discussion of supplementary or alternative treatr... approaches. If the patient's problem is circumscribed... resolvable with a short-term intervention using hypn... all concerned may be readily gratified. If more protra... exploratory or supportive measures are required,... eating the patient and family about these constitute... important service to be rendered.
...iy different procedures can be used to identify, ...rage or induce hypnotic trance states. Indeed, the ...c induction technique used is almost inconsequen...the production of the trance, as long as it is ...ically acceptable to the patient. Of primary ...tance, however, is the expectation of both the ...t and therapist that the ceremonious transaction ...2n them will engender a change in the patient's ...tive experience. The operation signaling this ...e may involve any one of a myriad of disciplined ...hat involve concentration, with the associated tacit ...tation that this will lead to the patient's heightened ...if receptivity to the therapist's further comments or ...itions.
... eye-roll lévitation method of Spiegel,12 is partic...useful in clinical settings and the wording of its ...ctions for inducing hypnosis can readily be ...ied according to the age and individual needs of a ...child or adolescent. This method affords a quick ...nient, semiquantitative and reproducible way of ...iring hypnotizability; this has advantages both for ...;il and research purposes. Further, this method has ...Jemonstrated to have satisfactory statistical correla...ith existing standardized scales that are laboratory...but which are much more cumbersome and time...lming.13
...egeYs Hypnotic Induction Profile12 provides a ...natie method of clinically measuring and correlating ...patient's pattern of response to signals for eye ...ments, arm lévitation, posthypnotic motor compli...and posthypnotic subjective experience. By using ...standard format for hypnotic induction, these ...us measurements are combined to convey a ...Osite index of the patient's relative ability to ...tain a disciplined level of concentration and ...ration in a relaxed, dissociated state. Degrees of ...otizability are designated on a scale of 0 to 4, with 0 ...ating non-hypnotizability and 4 indicating maximal ...'nsivity.
...with any psychotherapeutic technique, written ...iption can provide only a basic frame of reference to ...h practical clinical experience must be added if an ...tive clinical methodology is to he cultivated and ...ed. A growing number of didactic workshops held ...dically at continuing medical education forums ...nd the country currently are available to convey this ...iting personal exposure.
...ide from ascertaining hypnotizability, administra...of Spiegel's Hypnotic Induction Profile has another ...ntage: It is a helpful way of providing the patient with a "practice exposure" in which to experience hypnosis free from concern about its therapeutic applications. Once this has been accomplished, the demonstration of the patient's hypnotizability generates enhanced confidence that a new resource is available with which to tackle the problem in question. As long as the child or adolescent is hypnotizable to some degree, there is a reasonable basis of proceeding with its clinical application. It has not yet been established to what extent the degree of hypnotizability in children and adolescents constitutes a significant variable in determining the pattern of clinical response. At least as important as the patient's hypnotizability would appear to be the patient's constellation of other ego strengths, family resources and the skill of the therapist in integrating these into an effective therapeutic strategy.
Using this approach, the patient can now be guided back easily into the trance state. His attention is focused on postulated causes of the presenting problem. Emphasis is placed on his capacity to reorient his own contribution to it autonomously by directing his thoughts and efforts along new lines. Often a symptom has evolved as the patient's symbolic expression of unresolved intrapsychic conflict. This is interpreted to the child at a level he can understand; at the same time he is offered a more felicitous adaptive metaphor with which to confront his life situation. The stage is thus set for him to incorporate a more "grown up" or "mature" coping mechanism, with the associated intrinsic appeal this has for children and adolescents. These thoughts can be summarized in a dialectical format of two or three short statements which convey the crux of the new orientation; this is often helpful in dramatizing and reinforcing the ceremony of hypnosis as the occasion for a new mastery experience. Alternatively, particularly for younger children or those with less verbal ability, a visual or experiential image can be utilized to convey the sense of mastery that is central to the desired therapeutic reorientation. Thus the child can be told, where appropriate, to imagine a scene in which his favorite television or sports hero provides support and encouragement for a new approach to solving a given problem.
It is often helpful to teach the patient self-hypnosis. This further encourages autonomous carry-over of key therapeutic messages for implementation in daily life circumstances. The therapist can make this easier for older children and adolescents by having a set of general instructions for self-hypnosis printed, with room left to insert the therapist's particular message for each patient. (This will be illustrated in a clinical example below). For younger children in some cases, the parents may be recruited as surrogate hypnotherapists to administer the exercise at home. In these instances, it is best to do initial hypnotic induction of the patient without the distracting presence of the parents. Once the patient has mastered it, the parents can appropriately be brought back into the room to observe the technique so that they, in turn, can administer it to him at home. Alternatively, a tape recording of instructions and suggestions can be used to help bridge the gap between the treatment setting and the home.
Further discussion of hypnotic technique with children3 along with a variety of case summaries illustrating specific applications of this approach in therapy6'9 are available elsewhere. Here only a brief clinical vignette will be used to highlight how hypnosis can play a pivotal role in therapeutic reorientation.
Case illustration. Tom, age 9, was referred for psychiatric consultation after persistent complaints of visual difficulty over a period of several months yielded inconsistent findings on routine visual testing, Tom had a history of five hospital admissions between the ages of six and eight for the diagnosis and treatment of a right temporoparietal astrocytoma. In addition to numerous diagnostic studies and an initial craniotomy for tumor resection, four additional admissions were required for drainage of recurrent cyst formation, resection of recurrent astrocytoma and radiotherapy. In ade... Tom lost his mother at age 7 as a result of breast c... Sequelae of Tom's tumor and surgery included... hemiparesis and left homonomous hemianopsia.
At the initial interview, Tom appeared to be a fr... and verbal child who showed minimal concern abo... reported worsening of his vision over the pr... months. He attributed the worsening to watchin... much television or to reading too much. The psych... supportively reviewed with Tom the neurologist's... of a stable neurological exam with the excepti... inconsistent findings on visual testing that could b... understood as a response to the cumulus of emo... tensions and traumas that Tom had sustained. Ton... volunteered that he was having some school-adjus... problems and some conflicts at home with his fath... his housekeeper. The psychiatrist noted how tro... feelings could generate physical symptoms, especie... someone with previous physically based distre... disability. This, in turn, set the stage for introducir... idea of a "relaxation exercise" to help Tom overcori... troubled feelings and improve his physical functici... These issues were reviewed in detail with Tom's fi... together with discussion of the secondary gain i... often associated with conversion disorders and the... to deal with them concomitantly.
Tom's hypnotizability was evaluated and he wast... to be a grade-2 to -3 (mid-range) on the Hyp... Induction Profile. Tom was then offered the folic... dialectical construct to review in a self-induced hyp... trance:
1) Worried feelings can cause tension.
2) Tension can cause trouble seeing.
3) By relaxing this way, I can reduce the tensio... see better.
He was advised to practice the self-hypnosis ex... several times a day, with the option of doing it eith... his own or with his father's assistance. Written ins... tions were provided to facilitate the process.
The next office visit disclosed that the visual symp... had cleared within a few days. Tom was pleased with... he correctly perceived to have been his own accom]... ment of successfully implementing a strategy for s... tom-mastery offered by the therapist. Further discu... of school-adjustment difficulties led to psychok... testing, which disclosed a learning disability and... ported the diagnostic impression of an attention-d... disorder. Appropriate analeptic medication and e... tional therapy were provided, resulting in impi... school adjustment. Supportive psychotherapy was... provided to consolidate Tom's gains and help him... with areas of family adjustment and peer relations... ...this instance, hypnosis provided the starting point of ...irapeutic relationship by facilitating symptom...uishment. Essential to this was the delineation of ...resenting symptom as a somatic metaphor for retreat ...face of seemingly overwhelming stress. This was the ...for developing a therapeutic alliance geared to ...gthening Tom's capacity to face existing challenges ...appropriate help when needed, but with an ...iated emphasis on self-reliance when possible. He ...iad no recurrent visual symptoms or other conver...disorders over the succeeding five years.
...PARATION OF THE ...IENT AND FAMILY
...tablishment of a trusting rapport is a prerequisite for ...tive therapeutic application of hypnosis. Under ...rabie circumstances, this rapport will be established ...tig diagnostic evaluation. If hypnosis then appears ...ated, a tentative dynamic formulation is presented to ...patient, the parents, and the referring physician in ...opriate terms. Along with this, the associated ...estion is offered that hypnosis may serve as a helpful ...apeutic aid. In lay terminology, hypnosis can often ...be explained as a "relaxation exercise," one that can ...the child concentrate on a new approach to dealing ...his problems. Concomitantly, of course, there may ...mportant areas of educative therapy for the parents. ...educative therapy should be designed to help them ...lify those aspects of their own behavior that may have ...iributed to the genesis and maintenance of the ...enting problem.
...learly, anything that effectively accelerates the impact ...herapeutic intervention has significant economic and ...lie health implications. It is obvious that a child ...ihiatrist must have a sophisticated grasp of the subtle ...complex factors operative in the diverse intrapsychic, interpersonal and environmental fields that surround his patient. Yet, it is by no means clear that the patient must attain a full level of insight in order to achieve effective therapeutic results. Extended analytic working-through can certainly add new dimensions of self-understanding to those with the . resources to utilize that approach. However, for the many for whom a protracted and costly approach is simply not possible, hypnosis affords an opportunity to achieve certain therapeutic results more rapidly. Helping a patient actively to surmount a developmental obstacle is clearly different from helping him overcome it gradually by greater reliance on his own efforts. There is merit to have both of these approaches available to the child psychiatrist so that either or both can be applied where indicated.
INTEGRATING HYPNOSIS WITH ASSOCIATED PRACTICES AND MODALITIES
In addition to the already-noted introduction of hypnosis into a larger individual and/ or family therapy framework, other considerations also warrant mention. Any therapeutic -strategy oriented towards symptomrelief must both take cognizance of and deal with the secondary gain features of the symptom. With children, the long-range therapeutic benefits of a procedure may be particularly difficult for the patients to appreciate. It is therefore essential that any ongoing secondary gain features of a symptom be diminished or eliminated; indeed, this is critical for the symptom's removal to be sustained. This can often be achieved by means of parental counseling, environmental manipulation or a behavior modification program. The therapist's awareness of the operating contingencies of reinforcement and what can be done to influence them are vital to the success of any psychotherapeutic strategy, including the use of hypnosis.
FREQUENCY OF ADMINISTRATION; PATTERNS OF FOLLOW-UP
No pro forma guidelines can reasonably be given regarding optimal frequency or duration of application of hypnosis as a therapeutic adjunct. These will vary widely, depending primarily on the constellation of features that will be unique in each case. For some patients, only a few sessions may be necessary to achieve the desired therapeutic results. For others, there may be a valid role for continued or periodic use of hypnosis within the context of a more conventional and extended therapeutic format; this is determined by the patient's ongoing needs.
These same considerations apply to patterns of followup. It is usually wise to schedule some follow-up sessions in order to reinforce therapeutic gains. This is true ... when therapeutic intervention has been quickly... dramatically successful. Experience has shown tl... takes some time for a child and family to assimilate... the ramifications of the new level of adaptation.
EVALUATING THE THERAPEUTIC RESULTS
Follow-up studies show that - when it has... appropriately applied - the therapeutic results ach... with hypnosis in children and adolescents re... respectably stable over time.6'9'10 Its appropriate... entails concomitant combination with other therap... modalities, as we have stressed. Hence, it is diffici... differentiate the particular contribution of hypnosis... to compare its efficacy to that of other modalities... controlled way. A reasonable interim goal is to rent... clinical judgment about the impact of hypnosis ... introduced in the course of ongoing psychotherapy,... method of doing this entails using the patient as his... control, and evaluating the therapeutic responses bt... and after hypnosis is added.5
While much remains to be learned about hypnosis,... its therapeutic applications, the results of such studi... date suggest that it can be a valuable psychotherap... tool. It therefore merits inclusion in the education... practice of psychiatrists treating children and adoleso...
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3. Gardner. G. Hypnosis with children. J Clin. Exp. Hypn. 22 (1974).
4. Williams. D. Hypnosis as a psychotherapeutic adjunct with childr... Noshpitz. J. and Harrison, S. (eds.): Basic Handbook of Child Psychiatry, V... 3. New York: Basic Books, 1979. pp. 108-116.
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10. Williams. D., et al. The impact of psychiatric intervention on patieni... uncontrolled seizures. J. Nerv. Ment. Dis. 167 (1979). 626-631.
11. Spiegel. H. Is symptom removal dangerous? Am. J. Psv. 123(W!)... 1283.
12. Spiegel. H. and Spiegel, D. Trance and Treatment. New York: Basici... 1978.
13. Frischholz. E., et al. The relationship between the hypnotic ind... profile and the Stanford hypnotic susceptibility scale. Form C: A replicattoi... J. Clin. Hypn. 22(19SO). 185-196.