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

Hypnosis and Therapy for a Case of Vomiting, Nausea, and Pain a

Stephen R. Lankton a

Phoenix, AZ, USA Published online: 05 Jun 2015.

Click for updates To cite this article: Stephen R. Lankton (2015) Hypnosis and Therapy for a Case of Vomiting, Nausea, and Pain, American Journal of Clinical Hypnosis, 58:1, 63-80, DOI: 10.1080/00029157.2015.1040298 To link to this article: http://dx.doi.org/10.1080/00029157.2015.1040298

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American Journal of Clinical Hypnosis, 58: 63–80, 2015 Copyright © American Society of Clinical Hypnosis ISSN: 0002-9157 print / 2160-0562 online DOI: 10.1080/00029157.2015.1040298

Hypnosis and Therapy for a Case of Vomiting, Nausea, and Pain Stephen R. Lankton

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Phoenix, AZ, USA

In this case study the author illustrates the treatment of idiopathic gastrointestinal (GI) symptoms that practitioners sometimes encounter and for which none of the usual medical explanations apply. In this case, the symptoms have deeply personal and intricate causes that are explicated for the reader. A 20-year old female was vomiting six to eight times a day, accompanied with pain and nausea, for 2 years. She had medical intervention for almost that same duration. She had numerous uneventful medical tests, her gall bladder removed, and had exhausted hope for a medical cure. Working with a resource-building approach in therapy her vomiting was stopped within 6 weeks and her nausea in the following 7th week (or 13th session). Hypnosis was used during each session along with a protocol referred to as Self-Image Thinking (Lankton & Lankton, 1983/2008, 1986/2007; Lankton, 2008) to rehearse novel experiences and behaviors that she would implement in her social environment each week. She provided yearly follow-up phone contacts for 3 years and the latest contact was 1 month before this article was written. She remains symptom-free. Keywords: resource-building therapy, family re-organization, hypnosis, hypnotic rehearsal, nausea, self-image thinking, vomiting

The vast majority of articles published on the use of hypnosis in the treatment of nausea and vomiting primarily concern post-surgical (a large proportion of people have a problem with vomiting after surgery due to side effects of general anesthesia), and pregnancy-related or chemotherapy related nausea and/or vomiting (Anbar, 2008; Laser & Shenefelt, 2012; Lew, Kravits, Garberoglio, & Williams, 2011; Montgomery et al., 2010; Pan, Sean, Ness, Fugh-Berman, & Leipzig, 2000). The hypnosis literature on nausea and vomiting addressing pain, nausea, and vomiting resulting from pregnancy or cancer treatment is not that relevant to the case presented in this article. As Palsson stated, “the treatment approaches with hypnosis for these symptoms have been diverse and more often than not poorly described or not described at all in the published article” Palsson (November 27, 2014). Therefore, the following detailed description of the analysis of the causal dynamics and case history, and “the hypnosis rehearsal as a key treatment component well described in a successful intervention can Address correspondence to Stephen R. Lankton, P.O. Box 17491, Phoenix, AZ 85011. E-mail: [email protected] Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/ujhy.

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very well stand-alone without any [further] nausea/vomiting literature context” Palsson (November 27, 2014). In one potentially related case, Fujita, Terao, and Tanaka (2003) treated a student who improved his symptoms of heartburn and nausea by means of “a change in selfrecognition with an image of independence” (p. 469). This is a general statement of what is explained here through details that specifically illustrate both the protocol and the content of such self-recognition and self-image changes facilitated with hypnosis.

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Client History and Presenting Problem The patient, whom I will call Mary, was a well-dressed, neatly-groomed, 20-year-old (she would be 21 in 2 months), Caucasian female who appeared to be her stated age and was pleasant and cooperative. She was noted to be of average build and appeared to be overweight and stated that she weighed 250 pounds (which was after losing 75 pounds due to vomiting—that is, at the onset of her symptoms she weighed 325 pounds). She was alert, and had normal posture, normal gait, good eye contact, satisfactory attention span, and normal motor skill. The client was a good historian and had normal speech. Mary reported the presenting problem to be continual abdominal pain, nausea, and frequent involuntary vomiting. She reported vomiting 3 to 8 times a day without medicine and 2 to3 times if she took the anti-nausea medication. She stated she disliked the anti-nausea medication because its administration required inserting a long needle into her thigh. She obtained a legal medical marijuana card and stated that while it helped reduce the pain and nausea she strongly disliked smoking marijuana. She stated that her nausea and vomiting began in January 2 years prior and it progressively got worse for 5 months until it reached this current frequency and had been this way for 18 months. By the time she entered therapy she had suffered these symptoms daily for a total of close to 2 years. She began seeking medical attention 2 months after the onset of symptoms. She provided signed permission so I could contact her gastroenterologist (Dr. J.), which I did. We discussed her case at length. In summary, Dr. J. stated that he had administered every test he could think of and found no medical reason for her symptoms. These tests included MRIs, blood panels, monitoring white blood cell counts, CTA scores, scoping, allergy tests, parasite tests, and neuropsychological testing. Asked if they would have any difficulty if her symptoms were to be ameliorated Dr. J. replied that there was no test his office he had not done twice, nor did he have any additional ideas for diagnosing her condition. He stated that she had used venlaxafine (Effexor) 75 mg, lamotrigine (Lamictal) 100 mg, anti-spasmodic medicines, and even the removal of her gall bladder to control nausea but nothing reduced the pain or totally stopped the vomiting. He stated that the disappearance of her symptoms would not interfere with any future medical treatment since no medical cause could be identified. Mary was diagnosed with Somatic Symptom Disorder, Persistent, and Severe 300.82 (APA, 2013). The first session

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began with the suggestions I usually use, to continue to increase her comfort level as she sat in my office and helped me develop a better understanding and assessment of her concerns.

Mary’s Therapy Sessions

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First Session She lived in her own home and occasionally dated a man who periodically stayed with her. She was close to her mother and her (2nd) stepfather who lived nearby. She had not seen her biological father since birth and had not seen her 1st stepfather since he left the family when she was 12. Her current step father had been with her mother since she was 17 years old. She stated that in January 2010 she was living in her own place, almost had her car paid off, was at the top of her class in her trade school, and she was loving life. Before her symptoms began she had graduated and became employed at a job she desired. She stated that she was a perfectionist, and happily, her life had become “perfect in every way” due to her own effort. However, her symptom began in this phase of her life and as her nausea and vomiting got worse she had to quit. Her history indicated she was self-controlled and that she valued independence and achievement. Her conversational style was business-like and articulate. The paperwork my clients complete prior to their first session includes questions concerning demographic and medical history. It also includes a self-assessment known as the Interpersonal Check List (ICL) (Leary, 1957). The ICL involved 30,000 patients and their diagnosis upon admissions at Kaiser Permanente and was also correlated to the MMPI. The nomenclature at that time made the ICL favor a Kraepelinian-type admissions diagnosis and renders a standard score (see the small circle in section “B,” used in the Leary research) of little or no help in terms of today’s DSM-5 diagnosis (APA, 2013). However, it also reveals a raw score on the ICL. Figure 1 depicts the raw score of Mary’s self-report (the darkened area from sections “P” to “E”). The self-reported raw scores present useful revelations. The ICL test consists of 128 meticulously vetted short phrases or weighted adjectives organized along a dominance/submission and affiliative/disaffiliative grid. An example of some of the 128 phrases and adjectives include: “able to give orders,” “kind and reassuring,” “bossy,” “able to doubt self,” and so on. Clients can easily complete the check list in a few minutes. As such it provides a convenient picture of a patient’s self-image and therefore the behaviors she will make available to herself as she interacts with others (within the potential limitations of this instrument). Her ICL score showed her view of herself as a person who was highly avoidant of asking for help with any emotional problem (the absence of Friendly–Submissive quadrant

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FIGURE 1 Self-report on the ICL upon intake.

scores on the lower right). She saw her predominant interpersonal style as Dominant– Friendly. This highlights her report of her independence in living, self-control, and articulate presentation in the first session. In addition, the lack of submissive behavior in her self-report points to a further dynamic of discounting her own needs and reducing awareness of them for the sake of managing others. When this was illustrated to her, she agreed and became tearful. She stated that her tears were unusual and surprised her and gave us confidence as to the ICL self-report. Following the discussion of her problem I asked her to reflect on the results of her self-reported interpersonal style and how she thought it might play a role in maintaining the problem and might also lead us to understanding a possible solution. She stated that it accurately showed that she did not ask for help and that she always avoided asking her mother for assistance. She added that she felt that she had to walk on egg-shells to keep her mother from becoming over-emotional and didn’t want to do or say anything that might upset her.

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When asked, she stated that she had no idea of how long she had held that attitude or what, if any incident or incidents, had led her to take that attitude. I asked her to consider an experiment and to use hypnosis to explore her memories of this family dynamic. She agreed and hypnosis was explained and an induction was accomplished. While she was in the trance I asked her to recall the earliest memory she could recover that involved her deciding to take care of her mother’s feeling and discount her own needs and feelings. After several minutes she reported that she recalled a memory from when she believed she was 6 years old. She stated that she was crying in bed and her mother eventually came in her room and spanked her for crying. She did not recall what she had been crying about but speculated it was that she was afraid of something. She stated, while in trance, that it was at that time she understood that she would be better off keeping her feelings private so as not to upset her mother. After trance I asked her what might have been the most serious thing she withheld from her mother. She said that she was raped by a former step-family member repeatedly over a 6 month period beginning at age 16. She certainly could not tell her mother about this. As far as she was concerned, her mother would have “thrown a terrible fit of rage” and even divorced her step-dad if she knew. Asked why this would be an undesired outcome she stated that she knew her mother was very happy with her husband and would not want to cause their divorce. She did not want to discuss the rape further. The most recent significant incident of Mary discounting her pain and needs was in 2009 at age 19. Her mother, who was also overweight, began to lose weight. Her mother lost 190 pounds. She said that her mother was ecstatic about her own progress. This upset Mary because she had been unable to lose weight and she realized that she was in denial about how much weight she needed to lose. At that time she weighed 325 pounds. She did not want to share this concern with her mother as she thought it was likely to upset her and reduce the joy of her own progress. Her vomiting began shortly after the incident of her mother beginning to lose weight. It would seem that her decision to protect her mother’s feelings by an avoidance of asking for help or recognition of her emotions paired with her perfectionism and desire to excel laid the ground work for her problem. She stated in our interview that in January of 2010, her life was perfect in every way. However, she was apparently in denial of any emotional discomfort about her excessive (325 lbs.) weight at the time (which would represent a significant blemish in a “perfect” picture). When presented with this idea during our session, she stated no one had ever mentioned this and it was an interesting idea as she had, in fact, been in denial about her weight problem and had recently realized that back then, 2 years ago at the onset of her symptoms, she was in total denial. With her permission, I used hypnosis to help her conceptualize how we could proceed in her therapy even though we had a limited time remaining in that session. Following the induction, during the treatment portion of the trance, she was asked to speak to a representation of herself as a 6 year old and instructed that young self. She followed suggestions to tell her younger imagined self that it was okay to show her emotional

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pain and that she would still be lovable. She began crying during the exercise. After reorienting to waking state, she stated that this reaction surprised her and gave her some hope that the hypothesis was right and relief may be possible. Following the initial session, it was immediately clear that her discomfort level was remarkably high and we decided to schedule her therapy contacts for two sessions per week, which we did for the following 6 weeks.

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Session Two Mary reported that since the last session she had remembered more incidents of hiding her pain from her mother. For example, one incident she reported was when she had mud on her hands and wiped them on a wooden fence—resulting in many wood-splinters. Despite the fact that they were bleeding and hurt, she says that she hid her hands from her mother. That was at age 7. Also in 2009 her mother was very disappointed to learn that Mary had smoked pot for the first time. She said her mother, in her disappointment, accused her of being just like her birth-father (whom they reportedly hated). This attribution was very hurtful to Mary, who added that she never wanted to disappoint her mother. She and I recognized that she was protecting her mother from her feelings and needs and we began to examine the extent of this difficulty. We agreed to use hypnosis to rehearse confrontations and discussions about these topics so that she could conceive of asserting herself without (or with very little) anxiety. Using hypnosis I had her first establish a base feeling of comfort and safety (which is done at the beginning of each trance). I then asked her to pose a task to her subconscious to locate the incident when she may have made a deliberate decision to hide her feelings and report any such incident to me later. In trance I asked her to imagine giving comfort to the little 7 year old with splinters in her hand. The end of trance was used to have her imagine being with her mother in 2009 and replying to her mother, “I am not like my father! It hurts me that you said that; stop saying it!” Finally, I asked her to imagine her pain as a chosen color and make a pathway of that color to her eyes . . . and let the pain come out of her eyes. After trance she reported that during the explorations in trance she had intensified pain in her stomach as she had tried to actually cry (but was only able to shed a single tear). After the hypnosis session she recalled that, at age 5, she would go to bed crying and would cry until she vomited. This happened for several nights. Her parents punished her by making her clean the bucket that contained the vomit. She cried as she reported this memory. I believe she completed the task of the session—finding the memory of the critical moment of script-decision1 (Berne, 1970; Steiner, 1974). She agreed with that and cried more. It was very clear that she understood how she decided not to show hurt and that she needed to change that. She even stated that the situation was inappropriate parenting and her parents should have tried to find out what was wrong. I added that she was moving in the right direction to: (1) have found an early defining memory, (2) know

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it was improper parenting that resulted in her harmful decision to withhold her feelings, and (3) she now needed to make a change. She agreed and continued to cry. After the 5–7 minutes of heavier crying she stopped, the session was nearly over, and I confirmed that she was okay to leave. She said she was and then suddenly said, “Oh my God, my pain has gone down!” and added, “This is the first time in 2 years my pain has gone down.” She said that she was finally encouraged and began gently crying and chuckling, saying, “These are tears of joy.”

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Between Sessions Two and Three Mary called me to report with excitement that she had had the best 2 days of her life in the past 2 years. She commented that she had talked to her mother about several topics she had previously avoided. She said she just wanted to tell me this because she was so happy. She said she was “not at 100%” but had not self-medicated with marijuana and she was happy about that as she said it hurt her lungs. Session Three She stated that she told her mother some things she had not previously told her. While talking to her mother, she stated that her mother cried but she did not allow the crying to stop her this time. She also reported that her nausea was only barely detectable once or twice in the last few days and the pain, usually at 7, was only at 3 on a 1–10 scale (with 10 being the worst). We then used hypnosis to again rehearse new behaviors in response to her mother. This began with her imagining both her mother and herself when Mary was 5-years old. In this rehearsal I directed her to imagine the little girl shouting to her mother, “I come first and I will not rescue you from your own feelings anymore.” At one point she began crying heavily. I had her conclude this experience with an imagination of nurturing the crying little girl-self using such statements as, “I love you for showing your feelings; It is okay to tell your mommy what your feel,” and so on. She said her little girl-self was scared and I asked her to continue the self-nurturing by adding comments such as, “Thanks for telling me you are scared. I will stay here and protect you. I’m proud of you for showing you are scared,” and so on. At the end of the hypnosis session she stated that prior to coming to see me she never cried and she was surprised at how much heavy crying she did in this particular session. Sessions Four and Five She reported that both her nausea and abdominal pain were low and much more bearable than they had been for years. In session 4 she was eager to report that she had an epiphany about her ex-stepfather (her 1st stepfather). This man, whom both she and her mother disliked, had reportedly been very harsh and his “discipline” bordered on cruel. She

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realized that she never felt listened to or in control of her life when she had been around him which was when she was 7 to 12 years old. She had not seen him for 7 years and she stated that even though her symptoms had already begun before surprisingly seeing him again at 19, when she saw him her vomiting and nausea became worse and resulted in her having to quit her newly acquired job. Subsequently, she found herself further shutting off any expression of her needs and feelings. Remembering her relationship with him reinforced the posture she had already taken with her mother. We used hypnosis and a Self-Image Thinking visual-experiential rehearsal protocol (SIT) to strengthen her sense of being able to stand up to him and express herself (see the details of this intervention that follows). She came out of the trance reporting that she had no pain and no nausea. In session 5 Mary admitted that she contacted her mother 6 to 10 times a day, every day. She reported that she had a lot of hostility about how her mother acted and that her mother also became angry during many of their contacts. She came to realize that this behavior was excessive and unhealthy for her. I suggested she “break up” with her mother and establish a distance that did not foster hostility between them. She utilized hypnosis and the SIT protocol to build the resources so she could begin disengaging from her mother and reduce the care and concern she exerted to keep her mother calm. Sessions Six Through Eight While Mary’s vomiting had significantly decreased she reported that she was regularly awakening with nausea and pain. The next three sessions were all similar: We wanted to attempt to diminish the morning nausea and pain. Mary wondered if the symptoms she had upon awakening had to do with unrecalled dreams or fear when she slept—a notion she took from her previous recognition that as a child she cried herself to sleep in fear of some unidentified experience. I had not yet been successful helping her recover any solid understanding of her waking (or sleeping) problems with hypnosis at this point. It was not clear to her if she was having fears or other unpleasant experiences but considering her knowledge that she was not comforted during bedtime, it was a reasonable assumption to pursue. To this end we used hypnosis and the SIT protocol with various logical resources. Interventions of SIT rehearsals for safe, comfortable, “loved,” and calm sleeping and awakening (and other variations of resources) were used each week. After the hypnosis, at the end of the 8 days that these sessions spanned, Mary reported that she felt hunger for the first time in one or two years. Sessions Nine Through Twelve Mary reported that she had not experience any nausea, pain, or vomiting at all for the last week. Our session 9 centered on relationship intimacy and eventually on her biggest secret. She realized from our discussion on emotional intimacy that she needed to tell

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her mother and stepfather about the rape she experienced at age 16. She felt that it would be a traumatic moment for her mother but that she now had the resources to deal with the encounter. Hypnosis and SIT rehearsal were used to prepare her for telling her mother and current stepfather about the rape. After the trance she agreed to discuss the rape with her parents prior to the next session. In session 10 she announced that she first told her stepfather, who responded appropriately and was a “champion” about how he handled it. He was respectful, patient, kind, and reassuring. He convinced her that he would help her tell her mother. In session 11 she announced that she had vomited every day since telling her stepfather. It appeared that her emotional sensitivity to upsetting her mother had come into the foreground and rekindled the dynamic she had been resolving up to this point. She admitted that she knew she had to tell her mother. Again, hypnosis with SIT was used and specifically targeted for her retaining her previously accomplished resources in this highly important meeting. After trance, she stated that she would have the talk with her mother that evening. At the beginning of session 12, Mary announced that she and her current stepfather (her 2nd stepfather) approached her mother that evening and much to everyone’s surprise the mother handled it very well. (Her mother cried and within a couple of weeks the mother had conceded that she needed to behave like a mother and the family dynamic changed). Surprisingly, a couple of days later, Mary also confronted the perpetrator and told him how she felt. She reported that he apologized and cried. She felt she was doing very well and we switched our sessions from twice a week to once per week. Session Thirteen She reported that over the past 6 weeks she had been free of vomiting for five of them. Having told her mother about the rape she had not again vomited. She was also pain-free. However, she still experienced some nausea each morning. It then occurred to me that while she was asking for support from people her reactions suggested that she was refusing to accept the comfort she was offered. Exploring this idea she admitted that she was uncomfortable accepting care and nurturing and would tense up or put up some sort of mental barriers so that the transactions occurred but she did not let them soak into her level of feeling. Upon discussing this she realized that she needed to overcome this reaction. Once again we used hypnosis and SIT to rehearse her accepting comfort and support. In the trance, I had her imagine doing this at different ages and helped her experience how accepting comfort felt both as a child and as a grown-up. During her next session she reported this intervention had been successful and it marked the end of her episodes of nausea. The total process took 13 sessions and occurred over a 6 to 7 week duration.

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Sessions Fourteen Through Twenty Eight The previous 13 sessions resulted in a successful cessation of her symptoms. Mary was, of course, exceedingly happy and thankful for the therapy. She had not had such ease of living or such a sense of control of her life in nearly 2 years and was quite vocal about her feelings. However, she was understandably reluctant to terminate therapy. She expressed a desire to keep seeing me for a few more sessions “just in case” she encountered setbacks or had a relapse. I agreed to see her once a week for up to eight more sessions. After that period of time we shifted to one session a month for another 8 more meetings. These sessions were discussions and occasional psychoeducational episodes concerning starting her business, dating, intimacy, and her ever-increasing socializing, visiting, and traveling. These events had all been postponed because of her previous nausea, pain, and vomiting. The only attention given to her initial presenting complaints involved her periodic reports of remaining symptom-free. After these additional weeks, she was confident that her recovery was complete and a final termination was accomplished. Follow Up Mary completed the graph below depicting how she viewed herself and her behavior during her final therapy session (Figure 2). The ICL graph reflects a reduction of her interpersonal dominance and controlling and her acquisition of a good deal of affiliate behaviors. These include, in addition to dominant–friendly behaviors, cooperative and even dependent behaviors. In my experience, the latter is present when a person is both capable of and willing to show her needs and trust others to assist. These changes in self-image reflected in the ICL graph appear to correspond to the interpersonal growth she achieved in her therapy. They served to strengthen her confidence in the success of her efforts to change. Also they strengthened her understanding that the removal of her symptoms was the result of her work to incorporate these behaviors. Mary telephoned me each year for the following 3 years during the winter holiday season, stating that she wakes up every day and wants to call me and thank me for “giving me my life back.” It should be noted that she had not seen me for any other concerns including weight loss—to my knowledge she still weighs in excess of 250 pounds. She subsequently obtained a referral from me for her mother and her step-father to obtain therapy. Discussion One angle to consider while reflecting on this case, although only speculative, is that Mary was fearful of getting attention for emotional hurt with the tools she once had as a child and young adult. It is possible that her emotional pain and disgust with this situation

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FIGURE 2 ICL Self-report graph upon termination.

was unconsciously converted into her symptoms which then allowed her a great deal of attention for her physical pain as well as disgust (expressed as nausea and vomiting) and also resulted in her losing 75 pounds. However, the adjustment was a crude and unsustainable “fix” for her interpersonal and emotional problems. Please note that this explanation is posited after the fact of her cure and did not guide the conceptualization of the case or the choice of interventions. The Predominant Hypnotic Intervention and Therapy Protocol This case represents the repeated use of experiential and behavioral rehearsal done in the context of hypnosis. This procedure was repeatedly used throughout the process of therapy and the content or target for these rehearsals was developed from the insights which were revealed during the didactic portions of each session. In almost every session related to acquiring the cure, hypnosis was administered which facilitated rehearsal of new experiences and behaviors. The method of induction was the

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conscious/unconscious dissociation induction which has been detailed in several earlier publications (Lankton & Lankton, 1983/2008; Lankton & Lankton, 1986/2007). The induction ritual consists of seven stages: orienting the client to trance, fixating attention and report, establishing the conscious unconscious dissociation set, ratifying and deepening the trance, establishing a learning set, eliciting and associating experiences, and reorienting the client to the waking state (Lankton & Lankton, 1983/2008, p. 142; Lankton & Lankton, 1986/2007, p. 257). The details of this induction method are not my focus in this article or crucial to this case. They are included here simply for the sake of a comprehensive review. Any successful induction ritual is likely to have been equally effective for the use of the following protocol. Since this protocol results in the client developing visual, emotional, auditory, and cognitive mental images or representations of him or herself acting in novel ways, the protocol is titled the SIT protocol. That is, the client is led to conceptualize and experience the novel self-image—an image in which he or she can succeed with desired behaviors and necessary desired emotional and cognitive experiences. For each new change in the client’s behavior which were to be carried out in the family the SIT was used. This served three purposes: (1) the immediate acquisition of required or desired experiences, new skills, and attitudes to be carried out between the current and next session; (2) to help the client conceptualize herself as capable of the novel behavior with the desired experiences; and (3) for the client to develop a habit of using this type of thinking in preparation for future changes that may occur after therapy is completed. The SIT protocol consists of two major phases: creating a central self-image and creating rehearsal scenarios. Creating the central self-image consists of having the client develop a static, visual image of themselves such that the image would appear to the client as a person who is experiencing all of the desired resources that he or she thinks are needed to accomplish a specific upcoming interaction. In addition to the creation of the visual image of the self, the client is expected to have retrieved, revivified, and held onto each of the desired experiences which were used to enrich details of the picture. Finally, in some cases where a client is especially impoverished for interpersonal resources, the last step of phase one is to add to the picture the image of another person (or pet, or religious figure, etc.) who symbolizes support for the client having these desired resources available. Phase 2 of the protocol involves altering the background of that initial picture so that the client can imagine and rehearse him or herself using the desired resources in the target interaction. It’s important that the client be instructed to keep the desired resources constant at all times and alert the therapist if more resources are necessary. If that occurs the action can be stopped so that more enhancements can be made to the central selfimage created in phase one. Occasionally it would be necessary to have the client rehearse with scenes that are less threatening than the target situation—that is, to create a gradient of easy to hard scenarios for the client to use systematically toward building the integrity of their fantasy rehearsal

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until it is possible for them to hold onto the desired resources and imagine themselves successfully maneuvering through the target interaction. Explicit elucidation of the steps for phase one and two are summarized below. SIT Protocol (Lankton & Lankton, 1983/2007, 1986/2008; Lankton, 2008) Phase One: Create a “Central Self-Image” (CSI)

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1. 2. 3. 4. 5.

Make a list of the desired resources that seem to be needed Make a visual image of self to be used in the exercise Retrieve the desired resources one at a time by revivifying memories Add each feeling resource to the picture (so the image reflects them) Make the image a social image by adding a supportive person to it (optional)

Phase Two: Create rehearsal “Scenarios” 1. 2. 3. 4. 5. 6. 7.

Let the background of the CSI fade into a scene that is identified for rehearsing Continue to feel the desired resources in yourself Keep desired resources in CSI Rehearse it through a gradient of easy to hard (optional) Run scenes to the end Add any additional resources that may be needed Add dialogue or narration as you watch the rehearsal

The specific content for Mary’s SIT can be illustrated by looking at session 4. In that session she realized that she felt out of control and that she never felt listened to by her former step-father. Prior to the trance, step 1 of the SIT calls for identifying desired resources needed for a successful encounter. Each client will state these resources with unique labels. The therapist can be helpful in keeping the process oriented toward what is needed instead of what was present or lacking in the original stressful encounter. In the case of session 4, Mary (and I) identified four resources that she felt would have kept her from the traumatic encounter she experienced when she saw her former step-father at her place of employment. These were: (1) feeling free of control from others; (2) efficacy; (3) that her opinions mattered; and (4) feeling insulated from anything that might reduce these resources. Once the desired resources were identified, trance was begun. In the trance I asked Mary to make a visual image of herself (step 2) that we could return to and use to build the self-image. Step 3 of the protocol was to ask Mary to recall a time when she felt each of these—but one at a time. As she recalled a time that she was free from the control of others she would nod her head indicating that she had the memory. Then one to several minutes was used to help her make the memory more vivid until she could actually or almost “be” in that remembered situation and not just remember, but feel the desired feeling—in this example, feel the feeling of being free of control from others.

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It is not necessary for the therapist to know the incident in the client’s life from which the experience arose—just that she is feeling it as strongly as she wishes to experience it. Step 4 of the protocol is to modify the image of herself that she previously visualized. The modification should result in a picture of the self with the desired feeling, as I suggest in trance, so “any observer would know she is having that feeling.” Once the client nods or acknowledges in any prearranged way that that step is accomplished, steps 3 and 4 are repeated for all of the identified feelings until all of them are both reflected in the image of the self and also a part of the felt experience of the client. Suggestions such as the following are used: Hold on to the feeling of being free of control while you also remember a time that you felt a sense of efficacy. Let me know when you have the memory. Good. Now, I want you to again enhance the memory until you can feel the feeling of efficacy: Remember where it occurred . . . who was there, if anyone? . . . what did you see? . . . what were the colors? How much was in focus for you? . . . was there any movement? . . . recall the temperature, the smells . . . what was being said, or what did you hear? . . . keep enriching the memory until you can put yourself right back there enough to get the feeling of efficacy and let me know when you have it.

Again, this is to be added to the image of self and the previous feelings that image already illustrates. Suggestions such as the following are used: Now bring back the image you have of yourself with the feeling of being free from control and add the feeling of efficacy. Be sure to hold on to both of those feelings as you achieve this and let me know when you can see the picture of yourself with both feelings and also keep the feeling in your body as you sit there watching it.

This process is repeated for all of the required or desired experiences that the client originally identified. The final and optional operation of phase 1 is to ask the client to add an image of a supportive figure to the original image. This could be a trusted friend or pet or even an imaginary figure who might add support or confidence for her to retain the desired feelings. This step is not often needed for most clients. However, for clients with very low access to their strengths and resources it can be a crucial extra step. Adding another person to the image also paves the way for helping the client’s imagination bridge the gap between this static image of the self and the imagination of social interaction required in phase 2. Once the process of phase 1 is completed it is sometimes useful to ask the client if she is satisfied that having these feelings is sufficient for the task. In Mary’s case the task was standing before her former step-father and asserting that she is not afraid of him nor is she going to allow him to intimidate her into remaining silent, and that she is not under his control and deserves to be heard. Phase 2 of SIT requires that the client use the constructed image to visually and experimentally rehearse the novel therapeutic behaviors in a previously stressful situation or encounter. The first step of phase 2 is to let the background of the CSI fade into a scene

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where the client wished she had had the desired resources. The suggestions used at this point are such as the following:

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While continuing to feel the desired resources as you sit here, change the background of the image of yourself so that you see yourself at your place of employment. Now continue to watch the image of yourself holding those desired feelings both in the picture and in your body and see your former stepfather walk into the scene. Keep feeling the desired feelings and watching yourself with those feelings interact with your former stepfather. Listen to what you say and notice how what you’re hearing and saying is different from what you did in the original scene.

In certain situations it will be necessary to ask the client to rehearse confrontations in smaller steps. In the above example there was no gradient of difficulty. Instead, Mary was asked to immediately encounter her former stepfather in the image. In those situations where the client has been significantly more traumatized, or less resourceful, it might be necessary to introduce several intermediate stages of visualization prior to a confrontation with the most feared memory. In that case the rehearsal might have had Mary watch herself walk around the office seeing all the office equipment while she keeps the desired feelings. The next step might be to have her observe interactions with friendly employees while she keeps the desired feelings. The next step might be to have her interact with employees who are not quite so friendly and eventually lead up to an interaction with the rejecting former stepfather. It was important that Mary watch the entire event with stepfather from beginning until there was a logical conclusion and the scene ended. Suggestions that are used at this point include, “and watch yourself walk away from that interaction still holding onto the desired feelings and feeling them in your body.” This is to ensure a continuity of desired feelings that remain after the rehearsed encounter. If at any time Mary should have faltered in her interaction with her ex-stepfather it would be appropriate to: (1) stop the interaction and ask her to put the image aside for a moment, (2) identify what other feelings or resources she feels that she needs in order to successfully complete the encounter, (3) retrieve those desired feelings as previously achieved, and (4) continue to complete the visual-experiential rehearsal. This process of retrieving desired experiences, creating the visual experiential selfimage, and rehearsing the use of these experiences played an essential role throughout Mary’s case. This process was used in almost every session in order for her to imagine nurturing herself, confront her former stepfather, confront her mother, sleep through the night and wake up without nausea, and so on. The empowerment which this provides clients appears to make this protocol an important tool for treatment during hypnosis for some aspect of almost every imaginable presenting problem. However, it should be emphasized that SIT is not intended to be the sole intervention for any problem or even for similar cases of Somatic Symptom Disorder. This case, as do all others, involves unique interpersonal and intrapersonal dynamics and proper diagnosis and treatment will vary with each case.

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In Mary’s case it was central to helping her change the way she related to the family members and other significant people and also instrumental in how she was able to get others to relate to her. Jay Haley has pointed out that in many cases symptoms develop because of an inability to properly define social roles between people (Haley, 1963). Most problems are a result of the breakdown of communication between people—the result of disordered communication. I’ll summarize Milton Erickson (1977) who once stated that “cure” is having the resources necessary in the context where they are needed. I find this notion a helpful guide in designing interventions. And the use of the SIT protocol is often a fail-safe way to help clients learn to build those resources.

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Conclusion This study concerned a motivated 20 year old woman who for nearly 2 years awoke with nausea, occasional pain, and involuntarily vomited 6 to 8 times every day. Previous to seeking psychotherapy, no medical findings were conclusive regarding the cause or medical cure. She did, however, respond to psychological exploration and treatment via hypnosis. Common triggers for her symptoms, occurring daily, involved situations in which she discounted her own need for emotional expression and comfort. These included both her present and significant unresolved needs from her past. These moments were exacerbated by her unexamined decision and habit of attempting to keep her mother from becoming emotionally upset. An experiential and rehearsal-based protocol used via trance provided the necessary therapeutic procedure for her to successfully re-adjust her interpersonal life and reaction to these triggers. Somatic Symptom Disorder was not listed in the DSM-IV, however discussing Somatization Disorder, perhaps the closest match, Maxwell, Ward, and Kilgus (2009) stated “The primary goal of treatment is not to eliminate patients’ physical complaints but to improve their functioning” (p. 422). It appears that their view should perhaps be attenuated to account for each individual’s level of insight, the presence of which may be a deciding variable in achieving a cure. This case illustrates that both the cessation of the symptom and an improved life-functioning may be achieved in a client with good insight and the proper therapy. The key element in this case might also be characterized in several ways (and by several theories). In terms of family systems theory change was the result of the establishment of proper boundaries between the parental and child sub-systems (Haley, 1985; Minuchin, 1974; Satir, 1964). In terms of ego-oriented dynamic therapy, strengthening of the ego resulted in the patient’s ability to verbalize the fear of needs and those needs all led to a change in how she cared for herself (Hartmann, 1958). Gestalt therapy would explain that her pains and needs were no longer forced into the background to keep her “mother’s-little-helper” role in the foreground—the reorganization of this gestalt created a more satisfying self-regulation (Perls, 1947). Transactional analysis theory would posit that Mary accomplished a redecision of an early Child ego state script-decision

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facilitated by means of a “rarely taught . . . positive” method (Goulding, M., personal communication, November 1, 2008, 5:37 a.m.; Goulding & Goulding, 1979; Lankton, S., 2010). Cognitive behavior therapy could illustrate that the patient came to understand and replace the inappropriate thoughts that she used in order to put her needs aside and protect her mother’s feelings. While each of these theoretical explanations contains an important variable, supported by observation, of what transpired when change occurred, even taken as a unit these may not convey the key transformative ingredient and thus make replication difficult for most readers. For me, this ingredient was the holding of the necessary affective, emotional, attitudinal, and other experiential personal requisites associated with the contexts in which change was sought. The SIT protocol can guide therapists and clients to increase the potential for making such associations. Identifying the correct target for implementing the SIT protocol may sometimes be difficult to discern. This is why interventions need to be informed by adequate theory. Outcome research in these areas will provide a welcome platform for further development. Note 1. “A script is an ongoing program, developed in early childhood under parental influence, which directs the individual’s behavior in the most import aspects of his life” (Berne, 1970, p. 418). “The script, then, is a decision the young person makes by choosing between his own autonomous needs and expectations, and the pressures of injunctions he encounters in his primary family group” (Steiner, 1974, p. 68).

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