Peter J. Hawkings – Hypnosis in the treatment of Bulimia – Hypnosis in Psychotherapy
THE USE OF HYPNOSIS IN THE TREATMENT OF BULIMIA
A CASE STUDY
Peter J. Hawkins , Ph.D.
University of Sunderland
In 1980, “bulimia” was included as a diagnostic entity in the Diagnostic and Statistical Manual 111 (DSM Ill) (American Psychiatric Association, 1980) for the first time. The features of bulimia include episodic eating patterns involving rapid consumption of large quantities of food in a discrete period of time, usually less than two hours; awareness that this eating pattern is abnormal; fear of being unable to stop eating voluntarily; and depressed mood and self-deprecating thoughts following the eating binges. The presence of three of the following are also needed: eating in private during a binge; termination of a binge through sleep, social interruption, self-induced vomiting, or abdominal pain; repeated attempts to lose weight by self-induced vomiting, severely restrictive diets, or use of cathartics or diuretics; and frequent weight fluctuations due to alternating binges and fasts (American Psychiatric Association, 1980). .
Descriptions of the typical bulimic have been remarkably similar across studies. The average bulimic can be characterised as a white, single, college educated woman from an upper or middle-class family (Fairburn and Cooper, 1982) The age of onset is in the late teens, with a duration of about 4 to 5 years before the woman first seeks treatment (e.g. Fairburn and Cooper, 1982; Johnson, Stuckey, Lewis and Schwartz, 1982). Many of these women have a history of disordered eating. In almost every case the women are struggling to obtain a below normal ideal weight (e.g. Katzman and Wolchik, 1984). The frequency of binge eating episodes varies widely across studies; however, approximately 50 per cent of the bulimic women in treatment report binge eating at least daily, whilst some women only binge twice a month or even less often Gohnson et al., 1982). There seems to be a number of factors which may precipitate an eating binge in a susceptible person. Most women say that before a binge they are unduly tense, and that loneliness or boredom precipitates a binge (Leon, Carroll, Chernyk and Finn, 1985). Constant thoughts of foods and a craving to eat, which they are eventually unable to control, are also factors. A scenario might be that as the women are constantly concerned about their body image, and keep to a diet to reduce their perceived ugly shape, an episode of loneliness, unhappiness, or boredom triggers thoughts of the pleasure of the taste of food, and this leads to an eating-binge. This eating pattern can have other serious effects, such as interference with social relationships and school or job performance. Medical problems include urinary tract infection, gastric dilation, carotid gland swelling, electrolyte abnormalities, hair breakage, amenorrhea, destruction of dental enamel, fatigue, and mouth and throat ulcers.
Treatment has included hospitalisation, pharmacological approaches using anticonvulsants or depressants, behaviour therapy, cognitive behavioural treatment, group therapy and family therapy. Weiss, Katzman and Wolchik (1985) have developed a treatment programme for bulimia based on research findings that bulimic women suffer from depression, low self-esteem, poor body image, perfectionist tendencies, and a high need for approval, as well as difficulties in handling negative emotional states such as anger and anxiety, and the setting of unrealistic goals for thinness. They also suggest that bulimic women need to refine their existing coping styles and to develop competencies.
The case history that follows demonstrates many of-the treatment approaches suggested by Weiss et all (op. cit.). The approach adopted is essentially one of eclectic pragmatism embracing psychodynamic, behaviourist and phenomenological paradigms, and hypnosis (both formal’ and ‘naturalistic’) is used to enhance the therapeutic process. The approaches used include ego strengthening, dealing with negative emotions, assertiveness training, relaxation, reframing, hypnoanalysis, goal setting and action planning, and stress management.
The client .concerned was a sixteen-year old female (referred to as Katherine throughout -although this is not her real name), who was referred to the author by a local general practitioner. She was asked to provide an autobiographical account of her eating problems prior to the first therapy session.
The account written by Katherine illustrated many of the behavioural and psychological conditions of bulimia that were discussed earlier. These included preoccupation with weight and thinking ‘thin’, excessive exercise, depression, tiredness, attempts at concealment from the family vomiting, poor self-image and distorted body-image, feelings of guilt and shame following a ‘binge’, and suicidal thoughts. Statements made by Katherine included the following:
“I had always admired skinny people, and at 131 still disliked myself because I felt fat. So I ate less and less because I wanted to be skinny because to me that meant beautiful, and I wanted people to look at me and be jealous because I had the best figure.”
“I did one and a half hours exercise in the morning and the evening, purposefully forgot to bring things from upstairs just so I could run up and down again to stay thin.”
“I was happy with my body when I was anorexic. I was somewhere between 5st. and 5.5st.”
“I started to miss school a bit because I was so depressed and tired. But I liked myself because I was thin.”
“I was still obsessed about exercising and my weight; even when brushing my teeth I would be doing some kind of exercise to help burn off the calories.
“One night after eating too much chocolate and feeling guilty because I was still trying to get a flat stomach, I tried to be sick but could not manage to do it.
‘The only enjoyable thing left seemed to be eating and vomiting afterwards, about twice every two weeks.”
“The thought of dieting bored me. I hated my size but I had lost control and tried to commit suicide.
I concealed what I was doing for weeks and told mum I was improving, until she found evidence in the bathroom, and buckets under my bed “
“I couldn’t sleep some nights if tJ1e following day I had a binge planned because it excited me so much.”
“I took no pride in my appearance and made no friends.”
“My wages were spent on food, and all the money saved in the building society was withdrawn to buy more food”.
Session 1:Preliminary interview
A brief history of Katherine’s problem was obtained, including when the problem began, the course of the problem, any treatment received or on going, the current position, and related problems. A brief description of the therapy approach was provided, and Katherine and her mother were invited to askquestion. The General Health Questionnaire (Goldberg and Williams 1988), and The Eating Disorders Inventory (Garner and Olmsted, 1987) were administered to provide additional information. Fees were discussed, and it was agreed that Katherine would come for 5 one-hour sessions beginning the following week.
In this first session rapport was established with Katherine, and the building of a warm trusting relationship commenced. Hope for the future was conveyed by the use of positive and optimistic language. Before leaving; Katherine was given an ego-strengthening tape and asked to listen to it at least once a day. It was explained that this was to help her relax in order to “de-stress” her mind and body to counteract anxiety and depression, and to increase her confidence in herself and her ability to control her own destiny.
Session 2: Ego-Strengthening; Self-Hypnosis for Eating
Katherine was asked to share anything that was good about her life over the past week. She described a new job that she had just started. In this session Katherine was taught self-hypnosis. The method used was Spiegel’s eye roll followed by arm levitation (Spiegel and Spiegel, 1978). In ‘trance’ she was asked to say the following three phrases: For my body nourishment is essential. I need my body to live. I owe my body this respect and attention. This approach is an adaptation of that used by Spiegel for treating obesity. Katherine was asked to repeat the exercise at least 10 times a day over the next week.
Once again Spiegel’s hypnotic induction procedure was used and Katherine was asked to imagine that she had a photograph album on her knee. She was asked to experience ‘good’ events from her past, and to ‘carry’ the good feelings into a future experience (goal-setting).
The purpose of this session was to build up Katherine’s confidence in relation to the control of her eating, to help her develop greater self-esteem, and to begin the task of goal-setting. Throughout the session she was given the opportunity to ask questions and to state her feelings about the exercises. This was an essential way of validating her as a person. She was asked to do the ego strengthening exercise throughout the week, and to continue to use the tape.
Session 3: Developing Alternative Coping Strategies
The purpose of the third session was explained, namely to develop further the ego strengthening and to help her construct alternative coping strategies for the management of anxiety. (N.B. Katherine acknowledged that she used to binge when she was anxious and upset.)
An approach described by Graham (1988, p. 57) and referred to as the ‘double mirror technique for change’, was used. Katherine was asked to close her eyes and imagine that she was standing between two full-length mirrors. She was asked to look at herself in the mirror behind her and see a reflection of herself as she was now, and then to allow the reflection to fade and become colourless. Then the following instructions were given:
“Now walk away from that mirror and look at the mirror in frorlt ofyou. Imagine yourself as you would like to be, feeling good and happy about that. See this reflection brighter, clearer, more colourful and walk towards it, and become that person. You know that this is already happening, even thought you may not filly appreciate it yet”
Katherine was then told a story about a monk who was feeling depressed. The essence of this story was that, in winter, even though the trees may appear to be dead, their roots are still very
No explanation of the story (metaphor for change) was given to Katherine, but it’ was assumed that it would influence her at an unconscious level (see Graham, 1988, p. 45). Research into bulimia suggests that eating can often be a means of coping with stress. Some common emotional triggers for binge eating are boredom, loneliness, anger and anxiety. These emotional triggers can be successfully dealt with by developing the ego-strengthening, relaxation, and reframing strategies described above. In the remainder of Session 3, Katherine was invited to consider alternative ways in which she could ‘treat’ or nourish herself apart from food. In the context of relaxation she came up with the following: taking a bath, playing her clarinet, ,making a cup of coffee, buying a magazine and reading it, phoning an friend, relaxing, and watching T.V. She was asked to imagine herself doing these things and feeling good and positive about doing so. Katherine was asked to write these down, and whenever she felt depressed or anxious to choose one of them instead of eating. (N.B. In the past she might have binged.) She was asked to carry on using the ego strengthening tape as well as the exercises learned earlier. Considerable emphasis was put on the use of such homework assignments, not only for the intrinsic value of the exercises themselves, but also for building up Katherine’s autonomy and mastery of her own life.
Session 4: Hypnoanalysis
It was explained that it would be valuable to examine some of the causes of her problem. It was proposed to us an hypnotic technique called ego-state therapy (Karle and Boys, 1987, Ch. 18). In this session Katherine used the self-hypnosis technique that she had learnt earlier. In trance she was asked to ‘go inside her mine and find that part that thinks thin’. This procedure was carrier out using ideodynamic finger responses and Gestalt techniques, in particular the ‘negotiation of parts’, were employed to work through various conflicts.
Afterwards Katherine reported that ‘the part of her mind that thinks thin’ would help her by ‘stopping her from being fat’. She said that the ‘thin’ part had agreed to be active only when she reached a weight of more than 7.5 stones. In other words she could use this ‘negative programme’ as a resource (or friend) to manage her eating behaviour. It was also established during this session that the negative programme developed when she was about ten-years old, and for a number of reasons: family relationships, self-concept, and messages about ‘thinness’ from family, T.V., advertisements etc. Further work was done using ideodynamic finger signalling. This essentially followed the approach described in Rossi and Cheek (1988) as the “retrospective approach to ideodynamic signalling” (p. 29), but with the addition of future pacing.
Session 5: Anger and Assertiveness
It has already been indicated that eating is often precipitated by a difficulty in handling negative emotional states such as anger and anxiety (the latter has already been examined with respect. to treatment strategies.) Many bulimic women appear to have difficulty expressing their emotions directly or assertively.
In this session it was explained that anger is a normal and healthy emotion, and that repressing it is unhealthy and can lead to a number of psychosomatic problems, including anorexia and bulimia. Katherine was invited to participate in an exercise which would involve her experiencing any angry feelings she had at the time when her problems commenced. During trance she was asked to participate in a guided imagery sequence which involved the evocation of anger. She was encouraged to ventilate her feelings somatically. Research has demonstrated that somatic-emotional discharge of feeling is greater therapeutic benefit than cognitive-emotional catharsis (Hawkins, 1986).
Katnerine was then asked whether there was anything in her current life that made her angry. She said that her boss did although it would be inappropriate to express it. She was encouraged to express her anger towards him using the Gestalt empty chair technique. Afterwards she said that she felt a lot more relaxed and confident.
This session helped Katherine express her anger that had been ‘bottled-up’. In this way it was hoped that the repressed dynamic underlying her problems could be dissolved, and that she could become more assertive and in control of her current life, it was therefore an ego strengthening technique as well as one aimed at dynamic resolution.
Session 6 Inner Guide
In this session Katherine was asked to close her eyes and imagine that she was in her favourite outdoor place, A guided imagery approach was used and she was asked to meet a friendly animal with whom she could share her problems and who could give her advice (Jaffe and Bresler, 1980).
Kayerine imagined a dog that she had as a pet when she was a child. The dog (whose name was Fudge) advised her to look after herself and to respect her body. Katherine later said that this exercise was the most significant of the treatment sessions.
She was also encouraged to examine aspects of her body image, using the Body Mirror Exercise described in Weiss et al., (1985, p83), This concentrates on helping the individual experience himself or herself more positively. Katherine experienced no problems in doing this.
This was the final contracted sesssion and considerable progress had been made over the three months. Katherine was feeling more positive about herself with respect to her body, her sexuality, and her life. She no longer had problems concerning food, relationships had improved, she had menstruated for the first time, and she was generally enjoying life. One year later there had been no remission of the symptoms.
The therapeutic style adopted reflects a balance between directive and non-directive approaches and was clearly, client-centred. The non-directive aspect was essentially implicit, in that it was not part of a formally adopted model. Respect, empathy, unconditional positive regard and genuineness were important core conditions of the approach. Katherine was invited to participate in a way which allowed her to assume responsibility for herself. The explicit treatment programme was essentially based on the Cartesian philosophy of “I think, therefore I am”, and was promulgated through the use of a wide range of hypontherapeutic stratagems.
HYPNOSIS IN PSYCHOTHERAPY
Peter J. Hawkins Ph.D.
School of Sciences, University of Sunderland
The popular view of hypnosis, which has its origins in the work and ideas of Mesmer, Braid, and other nineteenth, century hypnotists, is that it is a specially induced trance state in which the individual loses, to a greater lesser degree, their critical faculties. In essence, this means that there is a depontiation of their logical, and conscious mind, which allows the unconscious mind to become dominant. The person is then able to be more creative because the constraints imposed by the ‘logical’ mind are minimised. In this case the individual is more suggestible than normally. For example, someone with chronic and intractable pain whose normal state of reason and logic would prevent them from believing that the pain could be resolved (in whatever way), could in the ‘trance’ state take a therapeutic suggestion (provided by the therapist) that the pain could be given away to a friendly animal for safe-keeping. The latter action is not logical or reasonable, but given a well-motivated client can be accepted during a state of trance.
. Before the induction the counsellor has to adequately prepare the client for the ‘hypnotic experience’, and then provide the necessary therapeutic interventions that are required for the presenting problems. The preparation involves a number of factors: dealing with any resistance; providing the patient with information concerning the procedures; and clearing up any misunderstandings concerning the nature of hypnosis. This increases motivation and also enhances the client-therapist relationship (i.e, rapport). This phase can be’ considered to be the pre-induction phase and may be considered part of the induction procedure, as well as an important aspect of the therapeutic process. The next stage is the hypnotic induction per se, of which there are many techniques.
Induction methods can be broadly divided into two category traditional methods or formal methods of induction, and induction and naturalistic methods. Formal induction techniques generally involve the client in focussing. As clients concentrate and narrow their field of attention, there is, ipso facto a reduction in peripheral consciousness and consequently a blocking of critical faculty and an in suggestibility. Clients can focus on something external to themselves. This may be visual, e.g. an object (the tip of a pen, a spot on the wall etc); auditory music, bird songs, listening to stories; olfactory (smelling a flowers, incense); tactile (being touched, as in massager) . Focusing may also be internal: the client focuses on an image suggested by the counsellor, such as being in a quiet, relaxing place; or becoming aware of bodily sensations. As the client engages in these activities the counsellor usually makes suggestions concerning relaxation, tiredness and heaviness of the eyes, etc. There are many traditional techniques and the reader is referred to Karle and Boys (1987), Hartland (1971), for comprehensive accounts of such induction methods, It is important to note here that the focussing techniques described above also occur “naturally”, e.g when absorbed in a book, watching a film, listening to music, describing a traumatic event to the counsellor.
Naturalistic methods are informal because there is no apparent induction, and consequently the explanation of hypnosis is different. The induction occurs as part of natural conversation or behaviour (i.e. meta-communication) and therefore cannot be discerned consciously by the client.
The assumption made is that the unconscious ‘understands’ and processes the covert communication. It could also be said that the therapy and the induction are one and the same thing, ego telling a story containing therapeutic metaphors induces ‘trance’ (because the client is focussing by listening) but is also therapy. A definition of hypnosis can now be offered.
Hypnosis is a psychological state in which the person ‘s critical faculty or logical mind is suspended or diminished leading to an ill crease In the probability ‘of the acceptance of therapeutic interventions, In this state all of the so called hypnotic phenomena can be suggested by the therapist and consequentlyby the patient, e.g. analgesia, anoressia, post-hypnoticbehaviour, ideodynamic behaviour, dissociation. This state can occur naturally or may be formally induced by the therapist, in cooperation with the patient, or by the patient themselves (as in self-hypnosis).
It is within this hypnosis context or environment that counselling and psychotherapy occur. The counselling interventions are the primary strategy and the hypnosis is the secondary strategy orfacilitating strategy. The secondary strategy is the application of the professionals’ intervention skills, eg. surgery, dentistry, counselling, psychology… Being able to facilitate or initiate the hypnosis process does not qualify the professional to utilise primary strategies!
In experimental research into hypnosis various scales have been developed to measure the hypnotic capacity of the client (e.g. Spiegel & Spiegel, 1978). A good review of the various scales is provided by Fellows (1988), it may be argued that it is important for the counsellor to have a diagnostic profile of the client in order to determine the most effective therapeutic approach. In practice very few clinicians make use of such instruments because it is now assumed that even clients with very low capacity can still benefit from hypnosis by utilising the imaginal capacities that they have, and particularly their ‘skills’ in producing specific phenomena, In contrast. to this view is the one that suggest that the capacity test is an important tool to be used in the initial phase of counselling. It introduces clients to hypnotic procedures and also helps to develop the trusting relationship between counsellor and client, as well as providing important diagnostic information.
Hypnosis and Psychotherapy
It is essential to clarify the relationship between hypnosis and counselling at this point. This is presented in Figure 1. Hypnosis is understood to be a facilitating or catalytic strategy, helping the client to develop particular phenomena (e.g. dissociation, ideodynamic signals, time)
It seems reasonable to assume that during a counselling session, clients will ‘naturally’ go into hypnosis (as defined above) because (1) they focus on the counsellor -voice, eye contact etc. (2) as they talk about their problems they will create internal images (related to seeing, hearing …) along with associated feelings, and consequently will go into a ‘trance’. They can also be induced into the hypnosis ‘trance’ state using direct or indirect methods. As a result of being in a trance state they are more suggestible, and there is also an increased possibility that they will be able to produce many of the hypnotic phenomena (e.g. regression, dissociation, time distortion, amnesia) if these facilitate the therapeutic process.
The two major strategies in psychotherapy and counselling are those emphasising behaviour/symptom changes, i.e. symptom management approaches, and those, which emphasise dynamic resolution, i.e. psychodynamic approaches (see Fig. 1.). In the context of clinical practice these two approaches are frequently, and necessarily, used together. Many practitioners of hypnosis assume that the client has inner resources for change, and that hypnosis is required in order for the these “unconscious resources” (creativity; potentiality, healing) to be accessed, and utilised for positive therapeutic gains.
These same assumptions relating to self-actualisation and inner potential are of course made by counselling psychologists who practice from humanistic perspectives.
The most commonly used methods (in hypnosis) for symptom management are relaxation, ego strengthening, and suggestion. For example, the client could be asked to relax utilising a form of passive progressive relaxation or autogenic training. Utilising ‘imaginary scenes’ is also very common, e.g. visiting a garden or a favourite outdoor place associated with peacefulness and calmness. The therapist helps the client build-up the images by making suggestions, which ideally include all the sensory modalities (visual, auditory, olfactory, tactile, and kinaesthetic. When relaxed (and in’ ‘hypnosis’) the therapist can provide suggestions concerning the treatment of the symptom. As in the example on page 1, a client with chronic pain could be offered a suggestion to give the pain away to a friendly animal ( Jaffe & Bresler, 1980). The friendly animal could become a client’s counsellor: helping them to engage in the therapeutic process. A client who is highly kinaesthetic may be asked ‘if she would like to reach high and put the pain on the top shelf’ (Asbury, 1994). There are many therapeutic solutions to a client’s problems and the counsellor needs to be creative to help the client find the solutions, i.e the answer is ‘within’ and not ‘without’. A guide to’ possible therapeutic interventions are adequately provided by Karle and Boys (1987), and by Gihson and. Heap (1991).
Many clients are distressed and experience feelings of hopelessness and helplessness. Ego , strengthening is valuable for a number of reasons and by
itself may be sufficient to help the client deal with some of their problems (Hartland, 1971). A number of ego-strengthening techniques are reported (Karle and Boys, 1987). Hawkins (1991) working with a bulimic client found that regression to a past event, when the patient experienced feelings of control, was very useful. The patient then ‘holds onto the feeling’ and imagines themselves dealing with the current problem using ‘time progression’, and maybe hallucinating a date by which the changes will be achieved. Other ego strengthening techniques include: imagining a photograph album or scrap book containing past positive experiences and events, metaphors and stories (e.g. the story of the oak tree), positive suggestions, without imagery.(Karle & Boys, 1987). The techniques describe above can be easily taught to the client who then practices them at home, perhaps by using a tape made by the counsellor (a form of self-hypnosis)
Psychodynamic (or hypnoanalytical) approaches assume that the presenting problem is being dynamically maintained by repressed historical experiences or current conflicts. In order to resolve the problem the client needs to access the repressed experiences in order to gain insight and to ‘work through’ the associated feelings in order to re-evaluate the conflictual material. A number of hypnoanalytical procedures have been described (Hartland, 1971; Karle & Boys, 1987). One such approach is ideodynamic finger signalling which can be used as a procedure for uncovering unconscious material (unconscious search process) in a much shorter time than the traditional psychoanalytical approaches (Rossi and Cheek, 1988).
Ideodynamic signalling is a utilization approach that is particularly useful for uncovering repressed traumatic events, and their associated distressed feelings, re1ated to current psychological and psychosomatic problems (Rossi & Cheek, 1988; Cheek & LeCron, 1968; Erickson & Rossi,
1981) .The method rapidly accesses state bound 1 information that may not be available to the client’s conscious verbal levels of functioning, and consequently allows them to reframe their problems psychosomatically. Because the levels of dissociation can be therapeutically managed by the cooperation of the counsellor and client, the possibility of negative iatragenic reactions are considerably minimized. It is also recognized that the repetitive recursive, and sequential reviewing of the original experience is often
necessary in order to break through the traumatic amnesia (Scheff, 1979).
Rossi and Cheek (1988) argue that, “The induction and maintenance of a trance serve to provide a special psychological state in which clients can re-associate and reorganize their inner psychological complexities and utilize their own capacities in a manner in accord with their own experiential life” (p. 14) A practical guide for applying this approach has been developed by Hawkins (1993, 1994).
Utilizing the Unconscious Search Process
In the context of both symptom management and psychodynamic approaches, clients would be initiated into an unconscious search for the solutions to their problems’. This might be in relation to ‘finding’ alternative and creative ways to manage particular problems, or to ‘understanding the etiological and maintaining dynamics’. Such unconscious searching and reviewing continues outside of the formal counselling sessions, and to this extent counseling is continuous. In order to utilize this powerful phenomenon it is important, that clients keep some record of its manifestations/.e.g. dreams, feelings; unexpected thoughts and images. I believe that clinical hypnosis is now in the ascendant, with its use in psychotherapy and medicine well established. Its value has now been ‘indicated’ across a wide range of problems including pain, psychosomatic illnesses (gastrointestinal disorders, respiratory disorders, cardiovascular problems, genitourinary problems, and musculoskeletal behavioural problems (smoking, eating problems), obstetrics and gynaecology, sexual problems, anxiety states, stress). Hypnosis can also be used in family therapy and group counselling (Hawkins, 1994b). For the practicing counselling psychologist, hypnosis may provide a powerful context to facilitate their preferred therapeutic approach and to manage therapeutic process, although it should be recognized that it is not a panacea, and will not enhance poor clinical practice. It is ‘crucial that counsellors who use hypnosis to facilitate their work, evaluate what they are doing, and make sure that they receive adequate training and supervision in its use (Hawkins, 1994a).