This article was downloaded by: [Carnegie Mellon University] On: 12 January 2015, At: 02:22 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

American Journal of Clinical Hypnosis Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujhy20

Crisis Intervention and Enhancement of Adaptive Coping Using Hypnosis Bruce A. Baldwin Ph.D.

a

a

University of North Carolina School of Medicine , USA Published online: 22 Sep 2011.

To cite this article: Bruce A. Baldwin Ph.D. (1978) Crisis Intervention and Enhancement of Adaptive Coping Using Hypnosis, American Journal of Clinical Hypnosis, 21:1, 38-44, DOI: 10.1080/00029157.1978.10403955 To link to this article: http://dx.doi.org/10.1080/00029157.1978.10403955

PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/ page/terms-and-conditions

THEAMERICAN JOURNAL OF CLINICAL HYPNOSIS Volume 21, Number 1, July 1978 Printed in U.S.A.

Crisis Intervention and Enhancement of Adaptive Coping Using Hypnosis1

Downloaded by [Carnegie Mellon University] at 02:22 12 January 2015

BRUCE A. BALDWIN Ph.D. University of North Carolina School of Medicine

Crisis intervention as a therapeutic modality is widely accepted, yet little attention has been directed to integrating this therapeutic modality and hypnosis. Hypnosis is compatible with the goals and structure of crisis intervention by: (a) helping clients to attain a relaxed milieu for therapy that counters many of the negative effects of the crisis state, (b) potentiating the effects of a range of therapeutic techniques associated with various therapeutic orientations, and (c) providing additional techniques unique to hypnosis that are useful in facilitating adaptive crisis resolution. Hypnosis enhances adaptive coping while catalyzing client progress toward the primary goal of crisis intervention: the restoration of client functioning to at least a precrisis level as quickly as possible.

Crisis intervention is a therapeutic model that defines a framework within which therapists respond to a normative life event: the emotional crisis. Crisis theory had its conceptual origins in the work of Eric Lindemann (1944) and was later established as a viable therapeutic model by Gerald Caplan (1964) and others. Crisis intervention is oriented toward active and adaptive response to current stressful situations which a client has been unable to cope with effectively. Crisis theory also defines a structure within which therapists are able to modify their personal therapeutic orientations and techniques in ways that will facilitate adaptive coping. An emotional crisis is experienced by most individuals at some time during development or in meeting the vicissitudes of life. It is characterized by intense dysphoric

affect that results from inability to cope with and resolve adaptively a problematic (and usually interpersonal) situation. Caplan (1964) explains: The essential factor influencing the occurrence of a crisis is an imbalance between the difficulty and importance of the problem and the resources immediately available to cope with it. The usual homeostatic, direct problem-solving mechanisms do not work, and the problem is such that other methods which might be used to side-step it also cannot be used (p. 39).

During an emotional crisis, psychological disequilibrium is experienced as an imbalance between affect and cognition. Cognitive abilities are diminished and affective responses to the situation become dominant. The individual in crisis feels overwhelmed and the intensification of dysphoric affect over time further erodes selfconfidence, problem-solving skills, and For reprints send to Bruce A. Baldwin, Department of Psychiatry University of North Carolina sense of control. There is often confusion School of Medicine, ChaDel Hill, North Carolina and distortion Of the Crisis Situation with 27514. loss of perspective and narrowing of alter38

Downloaded by [Carnegie Mellon University] at 02:22 12 January 2015

CRISIS INTERVENTION USING HYPNOSIS

native responses perceived viable. Psychological immobilization is frequently compounded by loss of external supports as the effectiveness of internal resources diminishes. Fortunately, emotional crises are selflimiting and resolution ‘(adaptive or maladaptive) usually occurs within four to six weeks. Crisis resolution is not necessarily determined by previous experience or by character structure (Paul, 1966), and the crisis therapist is aided by the client’s increased capacity for both affective and cognitive learning during this period of vulnerability. The crisis therapist strives to insure that crisis resolution is adaptive and in the direction of personal growth and enhanced coping ability. With such resolution, regression and/or learning maladaptive responses are avoided, and the crisis therapist has made a preventive intervention that reduces the probability of future, similar crises.

39

Psychotherapy. ” It is paraphrased for use with crisis therapy as follows: “The ‘work’ of crisis resolution is accomplished within the time negotiated for its completion.” 2. Crisis Intrevention is Goal-Specijic . Structuring time limits for crisis therapy and defining specific, appropriate goals for that time are instrumental in adaptive crisis resolution. Conceptualizing behaviorally specific goals enhances client acceptance of and responsibility for change. Goals for crisis therapy emphasize learning new and more adaptive responses to problematic interpersonal situations and on modification of feelings and attitudes that have, previously, supported maladaptive responses to stress (Montgomery & Montgomery, 1975). Therapist-client agreements on time-limits and goals also prevent undesirable diffusion of the therapeutic process. 3 . Crisis Intervention is PresentOriented. Crisis intervention focuses on the present stressful situation. Many (if not most) crises have psychodynamic bases. THESTRUCTURE OF CRISISINTERVENTION These aspects of an emotional crisis define The crisis model has now been defined in the precipitant (Hoffman & Remmel, 1975) a well-conceptualized corpus of principles that when formulated link present stress to and techniques. Although there are persist- past experience. In crisis therapy, the ent myths and misconceptions associated present stressful situation is used as a vehiwith use of this approach (Baldwin, 1977), cle for resolution of the reactivated deterthe active role of the therapist (and by ex- minant conflicts whenever possible. The tension, that of the client) is realistic and psychodynamic components of emotional essential to crisis intervention. Several crises are not neglected, but are limited to structural characteristics of crisis therapy those directly related to the present unrenecessitate a more active therapeutic solved problem. As responses to a present process. stressor are modified, dynamic aspects of 1. Crisis Intervention is Time-Limited. the crisis situation may become apparent Fundamental to the crisis model is early and can be worked through to support adapdefinition of time limits for the therapeutic tive coping and prevent future crises. contact. Upper limits of eight to ten visits 4.The Outcome Criterion for Crisis In(average four to six visits) are common in tervention is Delimited. In contrast to clinics using this approach. These temporal longer-term and less structured forms of boundaries provide a context for the therapy, crisis intervention has a definite “work” of crisis resolution and motivate and stable outcome criterion: to help the the client to attain defined goals within a client to reestablish at least a precrisis level defined time. Appelbaum (1975) discussed of functioning as quickly as possible and at this effect as “Parkinson’s Law of the least psychic cost. Attaining specific

Downloaded by [Carnegie Mellon University] at 02:22 12 January 2015

40

BALDWIN

negotiated goals may help the client to establish a more adaptive and mature level of functioning than before the crisis, and that is a therapeutic bonus. The crisis therapist does not strive for resolution of deeply rooted conflicts or for restructuring major aspects of personality. Once adaptive responses to a present situation are attained that relieve stress and resolve the crisis, referral for additional therapy is considered as needed. These four areas of structural limitation define the boundaries within which the crisis therapist works to achieve lasting (albeit limited) change. An emotional crisis creates a state of vulnerability to maladaptive learning, but is as well an opportunity for growth and maturation that may occur quite quickly when compared to therapeutic progress during noncrisis states. These boundaries require a more direct posture of the therapist without unnecessary directiveness or therapist control, and account in large measure for the “action” orientation of the crisis model. HYPNOSIS I N CRISIS INTERVENTION Mental health professionals schooled in different therapeutic orientations have successfully adapted their personal therapeutic styles to the crisis intervention framework. Hypnosis is useful in and compatible with crisis intervention as it: (a) helps clients to attain a relaxed milieu for therapy that counters many of the negative effects of the crisis state, (b) potentiates the effects of many therapeutic techniques associated with various therapeutic orientations, and (c) provides additional techniques unique to hypnosis that are useful in facilitating adaptive crisis resolution. Because the emotional disequilibrium of the crisis state impairs adaptive coping, effective intervention is more difficult unless the dysphoric affect is brought under control. Relaxation training as an active coping skill (Goldfried and Trier, 1974) is particu-

larly suited to the crisis model. Hypnosis provides a structure within which the client learns a powerful form of relaxation that may be critical to the intervention process and eventual crisis resolution. Such training is also instrumental in helping to reestablish a sense of control that enhances taking positive steps toward crisis resolution. Further, characteristics inherent to the hypnotic state often potentiate the effectiveness of techniques associated with a range of therapeutic orientations. Several qualities of the hypnotic state (Hilgard, 1965) that enhance the effects of nonhypnotic techniques used during crisis intervention are: 1 . Redistribution of Attention. During hypnosis, the client is able to focus attention and concentrate more fully. This quality of hypnosis counters distortion of the stressful situation that often exacerbates emotional crisis. Focusing aids the problem-solving emphasis in crisis intervention and helps the client to more objectively approach a specific problem. 2 . Increased Availability of Memories from the Past. Crisis intervention entails determining the precipitant of the crisis with origins in the past. During hypnosis, the availability of memories helps in formulating the precipitant and in bringing critical insights that relate past to present. These dynamic aspects of a present crisis also help in understanding how maladaptive responses to particular stresses originated. 3. Heightened Ability f o r Fantasy Production a n d R o l e - B e h a v i o r . Many therapeutic techniques, especially those that are behaviorally-oriented, require the client to role-play or to experience novel situations in fantasy. These techniques are based on the client experiencing self in different ways with modified reinforcement contingencies. Hypnosis may enhance the vividness of fantasy productions and the depth of client involvement in fantasy experience. Positive outcomes experienced in

41

Downloaded by [Carnegie Mellon University] at 02:22 12 January 2015

CRISIS INTERVENTION USING HYPNOSIS

fantasy productions often enhance skills necessary for crisis resolution and build the confidence needed to confront a stressful situation adaptively . 4.Increased Suggestibility. During hypnosis, the client becomes more susceptible to suggestions that may facilitate adaptive crisis resolution. General suggestions such as those used in hypnotic ego-strengthening (Hartland, 1971) are useful in helping the client to establish a sense of control by mobilizing internal resources and decreasing dysphoric affect. More specific suggestions such as those given to help the client relax on a given cue are also very helpful during the course of crisis intervention. 5 . Creativity is Enhanced. Within a hypnotic state, the boundaries that define thought patterns during consciousness (i.e., those of convergent thinking) that are constricted or distorted by the crisis state are relaxed. The client becomes better able to perceive the crisis “problem” from a more constructive perspective and can creatively define and evaluate alternative modes of action to resolve the stress. Frequently, these characteristics of the hypnotic state are useful in potentiating the effects of techniques associated with different therapeutic orientations during crisis therapy. For example, the Gestalt “double chair” technique may be enhanced by increased client capacity for role-playing during hypnosis. Similarly, developing insight, a psychoanalytic technique, may be facilitated by the increased availability of memories when hypnosis is used. Behavioral techniques (i.e. , systematic desensitization) may be more effective when hypnosis is part of crisis therapy because of greater client capacity for fantasy production. In addition, other techniques developed specifically for use with hypnosis are not only helpful in crisis intervention, but greatly increase the repertoire of available intervention techniques when the crisis therapist is hypnosis-skilled.

CASEEXAMPLES

In the three case vignettes presented, goals developed with the client for crisis intervention included a combination of the following (Baldwin, Note 1): (a) decisions that the client needed help in making, (b) feelings that the client needed help in becoming more aware of or resolving, (c) insights Idy n a m i c re 1at io n s h ip s that the client needed help in becoming more aware of or understanding, and (d) tasks that the client needed help in carrying out effectively. During crisis therapy, each hour included discussion of the crisis situation and any psychodynamic issues involved, and use of hypnotic interventions to catalyze the crisis resolution process. Case # I Precipitating Event: A student pianist panicked prior to an important recital and the panic prevented him from performing. He became excessively fearful of a recurrence and developed severe anticipatory anxiety that further impaired his performing ability. Precipitant: This student was older than his peers and felt unrealistic demands to excel that had been strongly reinforced in the past by his parents. Professors, because of his age and ability, further reinforced these expectations and produced a growing fear of “failure” and of disappointing others that culminated in a panic reaction prior to a recital. Crisis Intervention: After crisis assessment, he was taught hypnotic relaxation. Hypnotic ego-strengthening suggestions (Hartland, 1971) were used to help him to feel more in control, relaxed, and better able to counter anticipatory anxiety about performing in a weekly practice group. Autohypnosis was learned to help create a relaxed and positive state (using relaxation imagery) prior to each performance. Each day he hypnotically relaxed and gave him-

Downloaded by [Carnegie Mellon University] at 02:22 12 January 2015

42

self ego-strengthening suggestions to reinforce confidence about his musical abilities. Discussion in therapy focused on the precipitant of the crisis and the origins of his fears of not meeting his and others’ expectations. As these conflicts were identified in the present crisis situation, hypnotic intervention that stressed positive behavior rehearsal was initiated using imagery obtained from the client. Autohypnotic relaxation continued on a daily basis during this process. As the client began to experience more success in his playing, use of paradoxical imagery (Frankl, 1975) was introduced into the therapy. This imagery, enhanced through hypnosis, helped him work through his fear of failure and of disappointing others. The imagery centered on a very flamboyant failure in an important musical performance. He was instructed to exaggerate this failure and to publicize it widely to disappoint others (and himself) even more profoundly. This client was soon able to resume playing confidently and well during performances. Both client and therapist felt that there was a significantly decreased chance of future crises of this type occurring after the crisis intervention process.

BALDWIN

and anxiety. These presenting symptoms were associated with a need to keep interpersonal distance from most of her peers whom she feared would not accept her if she was more open. Crisis Intervention: After gaining initial understanding of this client’s present crisis situation and the precipitant, she was trained in hypnotic relaxation. Regression techniques were used to help her to reexperience particular events during her early adolescence (and the affect associated with these events) that had created insecurity about herself as a young woman and her negative body image in particular. Much of this affect had been kept from awareness through use of intellectual defenses. Hypnotic imagery enabled her to contrast her present physical self with her previously developed negative body image. Through this comparison process, she brought her body image “up-to-date. Her compensatory need to excel academically as a means to validate herself was easily established and conceptualized as the precipitant of her crisis. Hypnotically-enhanced behavior rehearsal combined with ego-strengthening suggestions (Hartland, 197 1) helped to build more positive feelings about herself as a woman. She soon began to accept in vivo interpersonal risks of rejection (her greatest fear) by allowing others to know her more fully as a woman. Concurrently, she reduced her reliance on narrowly defined sources of self-validation (i. e . , through academic achievement). Her growing positive feelings about herself as a woman permitted her to tolerate academic disappointment (although this remained difficult) as her crisis was adaptively resolved. ”

Case #2 Precipitating Event: A young woman, just prior to college graduation, became depressed and anxious due to mounting fears that she would not be admitted to graduate school. These feelings were exacerbated by a rejection notice from one university that seemed to confirm her fears. Precipitant: A negative body image and generally poor feelings about herself as a woman, retained since adolescence when she was quite overweight, led this client to place disproportionate emphasis on academic achievement to maintain self- Case #3 Precipitating Event: A young man was esteem. When this source of self-validation referred by a physician who saw him was threatened by possible rejections from shortly after his first sexual encounter. He graduate schools, the result was depression

43

Downloaded by [Carnegie Mellon University] at 02:22 12 January 2015

CRISIS INTERVENTION USING HYPNOSIS

had failed to ejaculate and this greatly increased his concern about his masculinity. He had never been able to ejaculate during masturbation (although occasionally ejaculation occurred during sleep). He became very anxious about his sexual ability and the effect this problem might have on future relationships with women. Precipitant: With minimal and distorted information about sexual functioning obtained directly and indirectly from his parents, this client developed many ambivalent attitudes about his sexuality. This ambivalence created anxiety about sexual expression and a need to highly control his sexual responses. Crisis Intervention: Initial therapeutic intervention focused on providing factual information to this client about human sexuality (both male and female), including psychological factors that influence sexual functioning. He was taught hypnotic relaxation and was given general egostrengthening suggestions using Hartland’s (1971) approach. This helped reduce the anxiety generated by his failure to function sexually that exacerbated preexisting doubts about his sexual adequacy. Using hypnotic regression techniques, this client was helped to reexperience particular interactions with his parents that had generated discomfort with sexuality in general and insecurity about his own adequacy in particular. This client was not highly psychologically-minded and awareness of the precipitant of his crisis came with difficulty. Many of the sexuality-related messages from his parents were quite indirect but nonetheless influential in shaping his sexual attitudes. Defining and conceptualizing more clearly the conflicts and doubts about his sexuality led to better understanding of the origins of his ejaculatory incompetence. The client was taught autohypnotic relaxation to further reduce sex-related anxiety. Autoerotic imagery was developed

and integrated with hypnotic behavior rehearsal to permit him to relax while responding to sexual stimuli. Given permission and instruction to masturbate at home using these techniques, he soon began to ejaculate during masturbation easily and naturally as he became desensitized to sexual stimuli. A referral was made for further therapy to resolve other aspects of this client’s interpersonal problems.

REMARKS CONCLUDING In the literature on hypnosis, case examples in which hypnotic techniques were successfully used in short-term treatment (i.e., within the limits of the crisis intervention framework), focus is primarily on symptom reduction or removal rather than on facilitating adaptive coping and creative problem-solving. Crisis theory as a reference framework within which hypnotically enhanced therapy is carried out seems to have been neglected. It is the structure defined by crisis theory rather than the techniques per se that defines the crisis therapist whether hypnosis is used or not. Moss (1967) aptly summarized the stance of the crisis therapist (or hypnotherapist) when using this model: It is recognized that current problem situations may reactivate past unresolved conflict areas; however, treatment does not involve extended psychoarcheological explorations, nor is it concerned with intrapsychic manifestations to the exclusion of immediate, meaningful, real life problems (p. 257).

In one relevant study (Moss et al., 1965), experienced therapists who used hypnosis in their clinical work were compared to others who did not. It was found that those using hypnosis were more active during therapy, were more supportive of clients, were environmental manipulative, and manifested a more flexible approach to the treatment of client problems. These qualities are necessary for effective crisis inter-

44

CAPLAN,G. Principles of preventive psychiatry. New York: Basic Books, 1964. FRANKL, V . E. Paradoxical intention and derefelection. Psychotherapy: Theory, Research and Practice, 1975, 12, 226236. GOLDFRIED, M. R. & TRIER,c. s. Effectiveness Of relaxation as an active coping skill. Journal of Abnormal Psychology, 1974, 83, 348-355. HARTLAND, J . Further observations on the use of “ego-strengthening ” techniques. American Journal of Clinical Hypnosis, 1971, 14, 1-8. Department of Psychiatry HILGARD, E. S. Hypnotic susceptibility. New York: University of North Carolina Harcourt, Brace & World, 1965. School of Medicine HOFFMAN, K . L. & REMMEL, M. L. Uncovering the Chapel Hill, N.C. 27514 precipitant in crisis intervention. Social Casework, 1975,56,259-267. LINDEMANN, E. Symptomatology and management REFERENCE NOTE of acute grief. American Journal of Psychiatry, 1. BALDWIN, B.A. Crisis assessment. Unpublished 1944, 101, 141-148. outline, December 1976. MONTGOMERY, A. G. & MONTGOMERY, D. J . Contractual psychotherapy: Guidelines and strategies for change. Psychotherapy: Theory, Research and REFERENCES Practice, 1975, 12, 348-352. A P P E L B A U M ,S. A . Parkinson’s law in Moss, C. S. Brief crisis-oriented hypnotherapy. In J . E. Gordon (Ed.), Handbook of clinical and expsychotherapy. International Journal of perimental hypnosis. New York: Macmillan, Psychoanalytic Psychotherapy, 1975,4,426-436. 1967. BALDWIN, B. A. Crisis intervention in professional practice: Implications for clinical training. Ameri- MOSS, c. s. RIGGEN, G . , COYNE,L. & BISHOP, W. Some correlates of the use (or disuse) of hypnosis can Journal of Orthopsychiarry, 1977, 47, 659by experienced psychologist-therapists. Interna670. tional Journal of Clinical and Experimental HypBALDWIN, B. A. A paradigm for the classification of nosis, 1965, 13, 39-50. emotional crises and implications for crisis intervention. American Journal of Orthopsychiatry , PAUL,L. Crisis intervention. Mental Hygiene, 1966, ~ 7 8 48, , 53g55i. 50, 141-145.

vention, and are found in experienced crisis therapists. While not all emotional crises are equally amenable to the crisis approach (Baldwin, 1978), the hypnosis-skilled crisis therapist has available an important dimension of intervention in brief therapy emphasizing adaptive coping and creative problem-solving .

Downloaded by [Carnegie Mellon University] at 02:22 12 January 2015

BALDMN

Crisis intervention and enhancement of adaptive coping using hypnosis.

This article was downloaded by: [Carnegie Mellon University] On: 12 January 2015, At: 02:22 Publisher: Routledge Informa Ltd Registered in England and...
560KB Sizes 0 Downloads 0 Views