Intl. Journal of Clinical and Experimental Hypnosis, 64(1): 45–74, 2016Copyright © International Journal of Clinical and Experimental HypnosisISSN: 0020-7144 print / 1744-5183 onlineDOI: 10.1080/00207144.2015.1099402
ATTACHMENT-FOCUSED HYPNOSIS INPSYCHOTHERAPY FOR COMPLEX TRAUMA:Attunement, Representation, and Mentalization
Eric B. Spiegel
Private Practice, Philadelphia, Pennsylvania, USA
Abstract: The relational and psychological functions of attunement,representation, and mentalization are essential components of a secureattachment experience. Psychotherapeutic approaches informed byattachment theory have gained significant empirical and clini-cal support, particularly in the area of complex trauma. Despitethese advances, attachment-informed trauma treatment could benefitgreatly from the experiential wealth that clinical hypnosis has to offer.In its utilization of shared attention, tone of voice, pacing, represen-tational imagery, and hypnotic language, clinical hypnosis as a state,relationship, and technique offers psychotherapists a way of intro-ducing a healthy attachment experience and renewing appropriatedevelopmental functioning in patients who are survivors of complextrauma. In this article, attunement, representation, and mentalizationare reviewed from a hypnotherapeutic perspective.
Clinical hypnosis, the clinical utilization of hypnosis in treatment byhealth care professionals (Sugarman, 2013), has a great deal to offerpractitioners interested in attachment and development (Baker, 1981;Brown, 2009a, 2009b; Zelinka, Cojan, & Desseilles, 2014). Aspects ofhypnosis, including the state itself and the procedure through whichit is elicited, closely resemble features of attachment and will be fur-ther explicated in this article. Moreover, the therapeutic relationship isa central factor as the therapist and patient are in a delicate balance ofresponsiveness to one another as the hypnotic process unfolds (Baker,1981, 2000; Banyai, 1998; Diamond, 1984, 1987; Spiegel & Greenleaf,2005; Yapko, 2005). Factors such as alliance, trust, and reciprocity inthe therapeutic relationship all play a role in the hypnotic experience.Further, hypnotherapeutic techniques embedded in the relationshipand its process, such as tone of voice, pacing, and utilization emulate
Manuscript submitted May 11, 2014; final revision accepted November 6, 2014.Address correspondence to Eric B. Spiegel, Spiegel Psychological Services, PC, Attn:
Eric Spiegel, PhD, 132 S. 17th Street, FL 3, Philadelphia, PA 19103, USA. E-mail:[email protected]
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qualities of the healthy primary attachment relationship (Brown, 2009a,2009b; Zelinka et al., 2014).
This article proposes hypnotherapeutic applications from an attach-ment perspective within the treatment area of complex trauma.There is strong empirical evidence linking early complex trauma(abuse/neglect), the development of insecure attachment schemas (par-ticularly disorganized), and the subsequent development of border-line personality disorder (BPD) (Bateman & Fonagy, 2012; Brown,2009b; Carlson, 1998; Carlson, Egeland, & Sroufe, 2009; Choi-Kain,Fitzmaurice, Zanarini, Laverdiere, & Gunderson, 2009; Widom, Czaja,& Paris, 2009). A relational psychotherapeutic approach to treatingtrauma is understood to be a critical means for experientially rewiringunhealthy attachment schemas and re-engaging stalled developmentalprocesses connected to the original traumatic attachment relationship(Courtois, 2004; Courtois & Ford, 2013; Pearlman & Courtois, 2005;Peebles, 2008; Peebles-Kleiger, 2002). As this article will illustrate,attachment-focused hypnosis integrated into such a treatment has thepotential to significantly enhance and expedite this psychotherapeutichealing process. I propose and describe a hypnotherapeutic approachbased on the attachment principles of attunement, representation, andmentalization.
Attachment Theory: The Relationshipas a Mirror in the Development
of the Self
Attachment theory is the theoretical and empirical study of inti-mate relationships and their impact on the development of the self.According to Bowlby (1979), our lives center around intimate attach-ment relationships “from the cradle to the grave” (p. 129). Bowlby(1973) also postulated that secure attachment develops in the period ofinfant development occurring after object permanence. He emphasizedthat secure attachment provides two essential qualities to infants: (a) asafe haven, or place where infants can go to for emotional safety andsecurity, and (b) a secure base for exploration, or a launching pad foroutreach into the world with the knowledge that the attachment figureis located near enough to provide a safe haven if necessary.
Winnicott writes (1971) “the precursor of the mirror is the mother’sface. . .” (p. 1) ”. . . [the mother is] giving back to the baby thebaby’s own self” (p. 5). Appropriate mirroring contains two essentialattachment-related functions, contingency and marking, and serves tofacilitate secure attachment (Allen, Fonagy, & Bateman, 2008; Bateman& Fonagy, 2012; Fonagy, Gergely, Jurist, & Target, 2002; Wallin, 2007).
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With contingent mirroring, the attachment figure accurately matches thefacial or vocal expressions of the infant, serving to recognize and vali-date the infant’s preverbal emotional experience. Contingent mirroringis developmentally important because it allows the infant to discoverand explore his or her feelings as mental states, first seen through theother (attachment figure) but over time internalized into the self (e.g.,“If this is what my emotions look like in someone else, this is whatthey must be like inside of me”). On the other hand, marked mirroringinvolves the attachment figure inserting him- or herself into the attach-ment encounter in a way that contains the infant’s distress and providesboundary demarcation. A central component of marking is signifyingthrough the parental response that the infant feelings being contin-gently mirrored are not real. The parent is only pretending (and clearlyhas his or her own feelings that are different from the infant), soothing,and containing. For example, the parent might make a playful face afterinitially matching the infant’s distress. This serves to communicate tothe infant that his or her distress will not spill over into the world andcontaminate the parent (Bateman & Fonagy, 2012; Fonagy et al., 2002).Because preverbal experience is the predominant mode in the sensi-tive period of attachment, the caregiver’s facial expressions and tone ofvoice are more important than the actual words he or she is saying. As isthe case with contingent mirroring, when the parent consistently marksthe infant’s affect, then over time the infant is understood to internalizethis ability (Wallin, 2007).
Mentalization: How Attachment Facilitates theRepresentational Development
of the Mind
Developmental researchers have focused on the impact of parentalmirroring and related attachment experiences in the maturation ofadaptive internal representation and reflective functioning in theinfant as he or she progresses into childhood and later adulthood.Mentalization is defined as “holding mind in mind” (Allen et al., 2008,p. 3). It is both a developmental milestone and an ongoing developmen-tal capacity by which we become aware that our mental states mediatethe way we experience the world (Fonagy et al., 2002). When we pos-sess high levels of mentalization, we demonstrate this through effectivereflective functioning. A person who mentalizes is aware of and attendsto his or her own and others’ mental states, as well as differentiatesthem from outwardly expressed behaviors (Allen et al., 2008; Bateman& Fonagy, 2006, 2012).
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The construct of mentalization is relevant in that it expands uponattachment theory. Rather than viewing attachment solely as a meansand end in and of itself (e.g., that the goal would be to developsecure attachment), mentalization researchers believe that the processof attachment also serves the purpose of creating a representationalsystem that is useful for survival and adaptation (Bateman & Fonagy,2006; Fonagy et al., 2002). Mentalization-based treatment (MBT) andother approaches informed by attachment theory emphasize improvingreflective functioning and affect regulation through a relational stanceand associated techniques that make patients more aware of and curi-ous about their and others’ mental states and processes (Allen et al.,2008; Bateman & Fonagy, 2006, 2012).
Complex Trauma: Conceptualizationand Treatment
The term complex trauma refers to a repetitive and escalating seriesof traumatic events occurring over a period of time, usually in a spe-cific context, such as in an attachment relationship (Courtois, 2004).Although there can be variance in the precipitating context, complextrauma often stems from pervasive developmental abuse or neglect andinvolves significant psychological harm to a survivor’s sense of person-hood and associated psychological functions (Courtois, 2004; Courtois& Ford, 2013; Herman, 1992; Pearlman & Courtois, 2005).
Three central domains tend to be present in the presentation ofadult survivors of complex trauma (Courtois & Ford, 2013). The first isemotional and/or somatic dysregulation. When the emotional and/orsomatic response is overreactive, the survivor will feel physiologi-cally flooded and have difficulty functioning. In the opposite “freeze”response, the survivor immobilizes and cannot martial appropriateinternal resources to resume normal functioning. Neuroception influ-ences the quality and intensity of physiological and psychologicalreactions to cues in the environment. Traumatic attachment promotesfaulty neuroception, leading to inaccurate “danger!” signals and a neu-robiopsychosocial fight/flight/freeze response. Thus, traumatic dys-regulation reduces the potential for further social engagement andinternalization of healthy relational experiences (Courtois & Ford, 2013;Porges, 2011).
The second domain is dissociation, or a disruption in the experi-ence of self-integrity. Potential expressions of dissociation could includeexperiences of loss of time, loss of consciousness, and loss of one’ssense of self (Courtois & Ford, 2013). As Van der Hart and colleagues(2006) describe in their structural theory of dissociation, any kind
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of dissociation involves a segregation of personal experience acrossaspects of personality and functioning. Expressions of traumatic experi-ence can become separated from other aspects of personality and dailyfunctioning. As a result, cues that trigger traumatic re-experiencing canoften result in a profound disruption and can shift to the survivor’squality of self-integrity and self-experience.
The last domain of complex trauma is compromised interpersonalrelationships. Because the traumatic harm is often inflicted by anattachment figure, complex trauma is strongly associated with insecureand disorganized attachment (Mikulincer & Shaver, 2007; Pearlman &Courtois, 2005). Significant attachment anxiety and avoidance matchHerman’s (1992) description of oscillating posttraumatic responses ofintrusion and numbing. In this case, we can conceptualize the intru-sion and numbing as being relationally based, in the form of attachmentanxiety and attachment avoidance, since the relationship itself (and any-thing that reminds the person of it) is associated with the traumain the survivor’s mind. One manifestation of the disruption to theattachment process caused by the complex trauma is the foreclosureof mentalization. Because reconciling the inherent contradiction of theattachment figure being the abuser and/or neglecter is too great of apsychological burden to bear, the child shuts down his or her inquis-itiveness about underlying mental states as a survival tactic. Curiosityabout internal mental states in oneself or others no longer feels safe, andthe result is a tendency to see things in black-and-white, world equalsmind, concrete terms. This tendency to think in such a nonmentalizingway is referred to as psychic equivalence (Allen et al., 2008; Bateman &Fonagy, 2006, 2012; Fonagy et al., 2002). For these reasons, a treatmentaddressing the developmental, relational, and representational aspectsof an insecure attachment is understood to be vital in ameliorating thedysfunctions in self-regulation that are associated with complex trauma(Courtois, 2004; Mikulincer & Shaver, 2007; Pearlman & Courtois, 2005).
Therapeutic treatment for complex trauma is usually divided intothree phases consisting of safety and stabilization, controlled repro-cessing, and working-through/integration (Courtois, 2004; Courtois &Ford, 2013; Herman, 1992; Peebles, 2008; Peebles-Kleiger, 2002). Thesafety and stabilization phase focuses on building therapeutic alliance,enhancing the patient’s sense of safety, and developing affect regula-tion, boundary management, and associated skills. Also emphasizedin this phase is the strengthening of patients’ capacities to restabilizeafter a disruption and self-soothe (Courtois, 2004; Courtois & Ford,2013; Peebles, 2008). Once a consistent, safe and stable frame has beenestablished, the treatment emphasis shifts to controlled reprocessing oftraumatic memories in the safe holding environment. In this phase, thefocus is on reprocessing traumatic material in such a way so as to facil-itate resolution of posttraumatic symptoms (Courtois, 2004; Peebles,
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2008). Finally, the working-through phase is an opportunity for collab-oratively restructuring patients’ understandings of themselves and theworld. Consistent experiences of safety with the therapist and othersengender the development of new neurobiological templates of howself, relationships, and the world work (Peebles, 2008). The therapeuticfeatures of establishing a stable relational alliance, creating safety andsecurity, and enhancing affect regulation are seen as core aspects of atrauma treatment (Courtois, 2004; Pearlman & Courtois, 2005; Peebles,2008).
Clinical hypnosis is best understood as a component of an existingphased psychotherapeutic trauma treatment, rather than as its own sep-arate treatment (Peebles, 2008; Phillips & Frederick, 1995). Hypnosis isparticularly valuable because hypnotic interventions occur in a statethat is comparable in many ways to that of a traumatized mind (Kluft,2012; Peebles, 2008; Peebles-Kleiger, 2002). As covered earlier in thisarticle (see Van der Hart et al., 2006), the traumatized mind can befocused on traumatic experience and dissociated from other aspects ofexperience or can be dissociated from traumatic experience and focusedon other aspects of experience. We can properly infer, then, that sucha person is already in a hypnotic state under such conditions. This isbecause hypnosis by definition is a state of narrowed, focused attention(absorption) that inevitably features dissociation (e.g., all phenomenaoutside of the cone of attention) (Brown & Fromm, 1986; Hammond,1990; Kluft, 2012; Peebles, 2008; Sugarman, 2013). As a result, we canconceptualize hypnosis as a way of adaptively utilizing the traumatizedmind in the service of positive therapeutic goals.
Atunement , Representation, and Mentalization inHypnosis: Hypnotically Utilizing Qualities of
Attachment to Re-Engage Healthy DevelopmentalFunctioning in Trauma Patients
I believe that an attachment-focused hypnotherapeutic approach (a)introduces the mutative components of attachment into the traumatreatment in a more explicit and intentional manner than a tra-ditional hypnotherapeutic treatment might and (b) provides theattachment-oriented psychotherapist with a focused and experien-tial means (hypnosis) for the patient to internalize and integratethe language, phenomenological experiences, and imagery of healthyattachment experiences. By first directing attention to the sensoryand relational anchors inherent within the patient, therapeutic set-ting and therapeutic relationship (“attunement”) and then subse-quently developing the patient’s capacity to mentally represent them
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(“representation”), the hypnotherapist facilitates and strengthens theemergence of mentalization and the adaptive use of language for thepurpose of reflective functioning.
When considering the use of hypnosis to facilitate the developmentof mentalization in this type of work, it can be helpful to think ofmentalizing in an expanded sense. As described earlier in this article,mentalizing is typically operationalized in a lexical manner, requir-ing language, cognition, and secondary process functioning in order to“hold mind in mind.” Mentalizing has to do with thinking, and think-ing requires symbolic processing. However, it is also possible to hold animagery-based pictorial representational awareness that precedes but isrelated to reflective awareness of mental states. Images are both prever-bal and linguistically evocative connectors to the sensory experience,and the sensory experience is derived from the immediate here-and-now moment (E. L. Baker, personal communication, March 27, 2013).Thus, when a hypnotherapist attunes to the patient and notices aloudan indisputable observable phenomenological process occurring exter-nally (a form of utilization known as a “truism”; e.g., “your feet are onthe floor . . . your hands are in your lap . . . you’re breathing in andout”; Patterson, 2012), they are constructing an internal mental repre-sentation for the patient of the immediate sensory experience at hand(Baker, 1981).
As a result, in working in a forward, developmentally sequencedmanner, we utilize hypnotic attunement in the here-and-now to permis-sively guide the patient towards sensorimotor and phenomenologicalanchors in her1 body. This is a method for developing positive body-based awareness of somatic anchors that can become the initial buildingblocks for developing subsequent internal resources. Through thistherapeutic attunement, the patient begins to enhance her own capac-ity to be present with her body in a contained and grounding way.As the patient becomes more skilled in this type of self-directed sen-sory attunement in the space of the therapeutic relationship, attentionturns to internal representation through hypnotic imagery. At first, theimagery begins with immediate sensorimotor phenomenological expe-riences (e.g., representing the immediate moment in the patient’s mind)and then later shifts to more fantasy-based representational imagery.The latter imagery takes advantage of the patient’s developing imagina-tion to picture scenes emphasizing salient aspects of healthy attachmentand affect expression, self-regulation, and identity development. Thus,we use pictures to enhance the patient’s capacity for describing herexperiences with language. Pictures become the building blocks for
1For purposes of simplicity and differentiation, in this article I use the male gender inreferring to the therapist and the female gender in referring to the patient.
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words. As the patient’s ability to describe her experiences with wordsimproves, her self-reflective language becomes more sophisticated,which in turn informs her use of symbolic representational imagery.In the subsections below, each phase is described in greater detail.
AttunementAttunement is a term that is derived from the literature on the psy-
chotherapy relationship. While there are variations in terminology (e.g.,empathic attunement) and the focus of attunement (e.g., to affect, tocontent, etc.) by theoretical orientation, it generally refers to the abil-ity of the therapist to accurately track, to understand, and to relateto the patient’s experience as if he were that person (Kohut, 1977;Rogers, 1957). This simultaneously joined yet differentiated empathicattunement is a critical part of the bond, or attachment, betweenpatient and therapist that constitutes a healthy “working alliance” inpsychotherapy (Gelso & Hayes, 1998).
The particular power of hypnosis as a treatment tool is rooted in itsfacilitation of attunement and the joining together in trance of patientand therapist in ways that are not as easily achieved in waking ther-apy (Baker, 2000; Diamond, 1987). The bond that comes with a strongworking alliance between therapist and patient in waking state ther-apy has been shown to yield therapeutic benefits for the patient (Gelso& Hayes, 1998). Conceptually related to the working alliance, yet alsomore extensive in its depth and intensity, the hypnotherapy term “sym-biotic alliance” refers to an internalized, mental sense of togetherness inhypnosis that occurs as a result of hypnotic attunement and hypnoticphenomena. In this hypnotic joining, time becomes distorted, the hyp-notic language of the therapist becomes co-mingled with the patient’sassociated sensory experience, and the external regulatory functionsof the therapist are experienced by the patient as if they are comingfrom inside the patient (Baker, 2000; Diamond, 1987; Zelinka et al.,2014). Diamond posits that this symbiotic alliance meets Mahler’s (1968)description of a “corrective symbiotic experience” in that the patientabsorbs and experiences feelings of soothing, safety, and security byhypnotically fusing with the therapist. Like Mahler, Diamond comparesthis process to the infant’s preverbal attachment experience with itsmother. Longitudinal experimental research on the social psychobio-logical synchronization of patient and therapist in trance suggests (a)a measurable and significant attunement and synchronization betweentherapist and patient during hypnosis and (b) that hypnosis allows forthe accumulation of more proprioceptive anchors in the patient, such asthe capacity for being attached in a safe, secure, and tolerable way thatfeels good (Banyai, 1998; Varga, Jozsa, Banyai, & Gosi-Greguss, 2006).
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Because boundary establishment, repair, and maintenance are essen-tial and defining components of psychotherapeutic and hypnother-apeutic trauma treatments (Peebles, 2008; Phillips, 2013; Phillips &Frederick, 1995), it is important to always ratify the patient’s senseof awareness, control, and mastery over these boundaries during theattunement process. Indeed, the hypnotic experience of attunementmay feel terrifying to trauma patients who experience discomfort withcloseness (Scagnelli, 1976), as is the case with high avoidant attach-ment (e.g., the avoidant dimension in fearful-avoidant/disorganizedattachment styles). However, rather than attempting to create a state ofmerger or fusion in hypnosis, we are utilizing the natural attunementthat is inherent in the hypnotic process to facilitate a number of devel-opmentally appropriate goals for the patient. One of these goals isoften utilizing the unfolding attunement to reaffirm her control overher boundaries. For example:
As you focus on the sound of my voice with each breath in and out . . .
good, that’s right . . . your unconscious mind can automatically noticeand recognize whether it would like to imagine my voice as being closebeside you like a soft lullaby or at a safe distance like an echo from faraway . . . or perhaps somewhere in between that feels just right for you.
I believe that when we attune to our patients in hypnotherapy, we doso in ways that have contingent and marked qualities to the mirroring.We share in and affirm their experience (contingent mirroring; see ear-lier examples of truisms). At the same time, we pace slightly ahead ofthem in the hypnotic process and offer suggestions from our own van-tage point about what they might expect to happen next that wouldserve to contain that experience in which we are sharing (marked mir-roring). For example, a therapist incorporating contingent and markedmirroring into his hypnotic attunement might state:
And as you continue to listen to my voice, I wonder what you willnotice first. Perhaps you will notice that your hands are becoming moreand more comfortably warm, maybe first in the fingertips and then thepalm, to just the right amount of warmth for you . . . or maybe youwill notice that with each effortless, automatic, and natural breath out,your breathing becomes more rhythmic and relaxed . . . and it reallydoesn’t matter what you notice first . . . whether it’s your hands, or yourbreath, or some other pleasant, natural process unfolding in your body. . . because you can begin to have an experience . . . perhaps slowly orperhaps more quickly . . . of feeling more and more [relaxed, comfortable,secure, anchored, grounded, present, alert; word choice would describethe attachment and trauma treatment goal that we wanted to address inthe moment].
In reviewing the above example, it is my view that a powerfullycurative process begins to unfold when accurate and positive somatic
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tracking (e.g., observing aloud a natural, automatic, and beneficialunfolding physiological process in the patient) is paired with the devel-opmentally rich qualities of vocal prosody in the hypnotherapist’s tone,pacing, and rhythm of voice. This synchronistic experience of having arelationship figure tune into the patient’s phenomenological experienceand do so in such a soothing and affirming manner is deeply satisfyingand evokes the developmental rhythms of secure attachment.
In describing the affective neuroscience of attunement, Schore (2012)writes that right hemisphere communication is analogous to primaryprocess functioning or day dreaming, which is how a hypnotic statecan be described (Brown & Fromm, 1986; Hammond, 1990; Sugarman,2013). In an attuned therapeutic encounter, Schore explains, right brainto right brain communication between therapist and patient is occur-ring. He summarizes this right brain interpersonal communication as“the music behind our words” (Schore, 2012, p. 38). As we know,musical instruments can convey great meaning in the way that theyarticulate a song. Notes of music can carry deep emotional and phys-iological resonance without a single word being uttered, as in the caseof classical or electronic dance music. In this regard, then, the hyp-notic “music”—the rhythmic manner in which the hypnotic languageis delivered—can become even more significant than the hypnoticlanguage itself in promoting healthy attachment.
Additional neurophysiological pathways of attunement exist in thehypnotic process. Mirror neurons, which are present in the prefrontalcortex, serve to help the patient and therapist emulate the motoricmovements of one another. The gestures, expressions, and posture ofthe therapist stimulate mirror neurons in the patient, much in the samedevelopmental vein as between a parent and infant. This motoric infor-mation encoded through observation of the interpersonal encounterallows the patient to imitate the therapist. It is through this imitationthat internal emotional associations begin to develop in the patient(Cozolino, 2010). Milton Erickson referred to hypnotic ideomotor induc-tion techniques and suggestions as “pantomime techniques,” becausethey accentuate the automaticity, involuntary, and unconscious motoricprocessing that exists and can be activated in the patient (Erikson, 1964,as cited in Rossi & Rossi, 2006, p. 271). Rossi and Rossi utilize the termrapport zone to refer to the empathy about others’ minds that develops inthe patient. They hypothesize that this type of mental empathy beginswith mirroring observations and repetition of movements and thentransitions into mirroring of and curiosity about internal mental pro-cesses. Through its presentation of psychosocial cues in the therapeuticencounter, hypnosis thus stimulates patient rapport zones and gener-ates brain neuroplasticity in the sensory-motor cortex and associatedareas (Rossi & Rossi, 2006).
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From the perspective of attachment researchers, it is the repetitionof experiences of joint attention inherent in the attunement that leadsto the development of self-directed attention, which in turn fostersinternal mental representation and mentalization (Allen et al., 2008;Fonagy et al., 2002). Allen and colleagues (2008) define joint attentionas a shared attentional space between caregiver and child that facili-tates the development of self-directed attention. Relatedly, they describementalization as requiring “effortful control of attention” (Allen et al.,2008, p. 36). In an effortful way, we are harnessing the executive func-tions of our mind to focus in on mental states, whether our own or thoseof others.
Comparably, hypnosis by definition is focused attention (Brown &Fromm, 1986; Hammond, 1990) that happens in a joint therapeuticspace. In a hypnotic induction, the therapist directs the patient’s atten-tion to a particular object, sensation, or experience (Brown & Fromm,1986; Hammond, 1990). As the patient focuses her attention on this ref-erence point, the therapist focuses on the patient’s responses (nonverbaland verbal) to assess for hypnotic phenomena (e.g., depth of breath-ing, muscle tone, facial cues) and the patient’s subjective reactions tobeing hypnotized. The therapist will regulate his pacing, language,tone of voice, and actual content to appropriately mirror and guide theresponses of the patient (Brown & Fromm, 1986). Furthermore, the ther-apist can utilize the joint attention present in the hypnotic therapeuticrelationship to facilitate greater patient awareness of internal experi-ences. For example, the therapist might state, “You are fascinated by thethoughts and feelings that just seem to come up in your mind” (Brown& Fromm, 1986, p. 59). Hypnotic language is utilized to enhance patientcuriosity about her inner world.
As an interesting parallel to the developmental transition from jointattention to self-directed attention, hetero-hypnosis is often a devel-opmental antecedent to self-hypnosis because the patient is learningfrom the therapist how to apply her own innate hypnotic capabilities(Levitan, 1998). Ultimately, it is the transition from joint attention to self-directed attention that paves the way for the patient’s internal represen-tation of here-and-now phenomenological experiences. This transitionwill be discussed in greater detail in the section “Representation.”
The process of attunement to positive somatosensory experiencescan serve as a metaphor for boundary management and affect con-tainment. As an example, eye closure and fractionation can functionas methods for utilizing the body (in this case the eyelids) to regulateboundaries. In the initial induction, permissive motoric suggestions canbe given to the patient with regard to controlling the degree to whichshe would like to have her eyes open or closed. Additional contin-gent suggestions can be given regarding the patient’s mastery of beingable to regulate these somatic boundaries. Assuming it is appropriate, a
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fractionation suggestion can then be given asking the patient to (briefly)open and then reclose her eyes. The suggestion to reclose her eyesis paired with another deepening suggestion emphasizing a clinicallyappropriate goal (e.g., safety, mastery, affect regulation, boundary man-agement). Thus, the fractionation not only serves to deepen the trancebut also demonstrates to the patient her burgeoning positive masteryover her body. Thus, in this regard, muscle control, boundary man-agement and trance ratification become paired together in a way thatis pleasing to the patient. An example of this and other attunementhypnosis interventions are provided in Table 1.
Attunement in hypnosis can also serve to realert or refocus thepatient on her immediate anchors during a dissociated state (e.g., blink-ing her eyes and reopening them; feeling the crisp air in her lungs asshe takes a deep, refocusing breath in, feeling the ground beneath herby pressing the soles of her feet against the floor). It can also be incor-porated as a cue in conjunction with a hypnotic suggestion for positiveaffect or cognition. For example:
When the word refocus pops up in your mind, it will be a signal to you totake a deep breath, count to three, blink and reopen your eyes slowly andclearly, and feel fully alert, present, and in control of your body.
Utilizing these types of sensorimotor anchoring and grounding inter-ventions in the attunement phase allows the patient to establish, tomaintain, and to appreciate a sense of “this is what it feels like to bein my body in a way that feels good.” She is developing a frameworkfor being with herself in a positive way that she can reference andreturn to as she needs to. This foundation in turn allows her to bet-ter tolerate traumatic cues that would have previously triggered rapidhyperarousal or dissociation.
RepresentationWhen a patient can direct her own attention in a sustained way, she is
better prepared to create a detailed representational picture in her mindof the phenomenon to which she is attending. Moving the patient fromtactile sensory attention of her somatic experiences (e.g., “this is whatmy foot feels like [in a sock, shoe, barefoot, etc.]” to visual mental rep-resentation of those experiences [e.g., “this is what my foot looks likein a mirror as it feels __”) strengthens representational capacities andobject constancy (Baker, 1981). It also naturally follows that, as theseinternal working models of self-experience and self-constancy developin hypnotherapy, the patient can begin to move from representing partsof her body and parts of herself to representing her whole body andwhole being; from representing “it” to representing “I”; and from repre-senting “me” to representing “we” (whomever the “we” may be; moreon this in the subsections that follow). This movement facilitates a senseof self-integration.
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ATTACHMENT AND HYPNOSIS 57
Tabl
e1
Hyp
noti
cA
ttun
emen
t:Sk
ills,
App
licat
ions
,and
Exa
mpl
es
Skill
App
licat
ion
Exa
mpl
e
Ideo
mot
orin
duc
tion
tech
niqu
es(e
.g.,
arm
levi
tati
on,
reve
rse
arm
levi
tati
on,
Chi
asso
nte
chni
que)
Sinc
eat
tune
men
tis
bid
irec
tion
al(t
hepa
tien
tis
also
attu
ning
toth
eth
erap
ist)
and
not
rest
rict
edto
verb
alin
tera
ctio
ns,t
his
type
ofno
nver
balm
odel
ing
ispa
rtic
ular
lyhe
lpfu
lfor
pati
ents
who
are
resp
onsi
veto
mot
oric
mov
emen
t.In
mod
elin
gth
ebe
ginn
ing
ofth
eid
eom
otor
tech
niqu
e,th
eth
erap
ista
ctiv
ates
mir
ror
neur
ons
inth
epa
tien
t.
“Now
havi
ngfu
llyre
view
edho
why
pnos
isw
orks
,I’m
und
erst
and
ing
that
you
feel
read
yto
proc
eed
.Is
that
corr
ect?
Goo
d.W
elly
oum
ight
becu
riou
sto
lear
nth
atth
ere
are
man
yw
ays
ofen
teri
nga
hypn
otic
stat
e.A
ndif
it’s
alri
ghtw
ith
you,
I’d
like
tosh
owyo
uan
inte
rest
ing
way
ofbe
ginn
ing.
Why
don
’tyo
u(a
llow
your
arm
tod
rift
,lif
tup
your
arm
and
bend
itat
the
elbo
w,e
tc.)
just
like
Iam
doin
gri
ghtn
ow.A
ndal
thou
ghhy
pnos
ism
aybe
gin
sim
ilarl
yfo
rm
any
peop
le,e
ach
pers
onex
peri
ence
shy
pnos
isun
ique
ly,i
nth
eir
own
spec
iala
ndhe
lpfu
lway
.So
ina
mom
ent,
I’m
goin
gto
[put
my
arm
dow
n,et
c.]a
ndyo
uca
nfo
cus
your
atte
ntio
non
your
[arm
,fing
ers]
as[i
t/th
ey]b
egin
to...
”(O
neca
nth
enus
ein
duc
tion
lang
uage
such
asth
atfr
omH
amm
ond
[199
0].)
Uti
lizat
ion
Thi
sis
the
mos
tim
port
anta
ndun
iver
sals
kill
ofat
tune
men
t.O
neof
the
over
arch
ing
aim
sof
attu
nem
enti
sto
incr
ease
pati
ents
’abi
litie
sto
mor
eco
nsis
tent
lyan
dsa
fely
obse
rve
and
utili
zeth
eir
mom
ent-
to-m
omen
tex
peri
ence
.The
ther
apis
tin
itia
llym
odel
sit
for
them
wit
hth
ego
alof
incr
easi
ngth
eir
abili
tyto
do
itfo
rth
emse
lves
.
“And
asyo
uco
ntin
ueto
liste
nto
my
voic
e,Iw
ond
erw
haty
ouw
illno
tice
firs
t.Pe
rhap
syo
uw
illno
tice
that
your
hand
sar
ebe
com
ing
mor
ean
dm
ore
com
fort
ably
war
m,m
aybe
firs
tin
the
fing
erti
psan
dth
enth
epa
lm,
toju
stth
eri
ghta
mou
ntof
war
mth
for
you
...
orm
aybe
you
will
noti
ceth
atw
ith
each
effo
rtle
ss,a
utom
atic
,and
natu
ralb
reat
hou
t,yo
urbr
eath
ing
beco
mes
mor
erh
ythm
ican
dre
laxe
d...
and
itre
ally
doe
sn’t
mat
ter
wha
tyou
noti
cefir
st...
whe
ther
it’s
your
hand
s,or
your
brea
th,
orso
me
othe
rpl
easa
nt,n
atur
alpr
oces
sun
fold
ing
inyo
urbo
dy
...
beca
use
you
can
begi
nto
have
anex
peri
ence
...
perh
aps
slow
lyor
perh
aps
mor
equ
ickl
y...
offe
elin
gm
ore
and
mor
e[r
elax
ed,
com
fort
able
,sec
ure,
anch
ored
,gro
und
ed,p
rese
nt,a
lert
;wor
dch
oice
wou
ldd
escr
ibe
the
atta
chm
enta
ndtr
aum
atr
eatm
entg
oalt
hatw
ew
ante
dto
add
ress
inth
em
omen
t].”
(Con
tinu
ed)
Dow
nloa
ded
by [
Joan
nes
Mer
tens
] at
00:
08 0
3 D
ecem
ber
2015
58 ERIC B. SPIEGEL
Tabl
e1
(Con
tinu
ed)
Skill
App
licat
ion
Exa
mpl
e
Trui
smA
type
ofut
iliza
tion
.Her
e,w
eut
ilize
acu
eth
atw
eob
serv
ein
the
pati
entw
hose
trut
hhe
orsh
eca
nnot
den
yfo
rth
epu
rpos
eof
ascr
ibin
gth
erap
euti
cally
sign
ifica
ntm
eani
ngin
ahy
pnot
icsu
gges
tion
that
we
link
toth
etr
uism
(con
ting
ent
sugg
esti
on).
“As
you
noti
ceyo
urse
lfsi
ttin
gon
the
beig
eco
uch,
you
can
real
lyfe
elyo
urtw
ofe
eton
the
floo
r.Tw
ofe
et...
just
asth
ere
are
two
ofus
here
inth
isro
omto
geth
er...
atju
stth
eri
ghta
mou
ntof
spac
efo
ryo
u...
ascl
ose
orfa
ras
you
need
usto
be.A
ndyo
urtw
ofe
etar
eon
the
floo
r...
whe
ther
you
are
sitt
ing
orst
and
ing
...
stan
din
gst
illor
wal
king
.And
itis
righ
t,is
itno
t,th
atyo
urtw
ofe
et...
left
and
righ
t...
wal
ked
you
into
this
offi
ceso
that
you
coul
dbe
righ
ther
ean
dri
ghtn
owin
just
the
way
that
you
need
?A
ndit
isal
soco
rrec
t,is
itno
t,th
atyo
uha
vebe
enw
alki
ng...
free
ly,e
asily
,and
effo
rtle
ssly
...
onyo
urow
ntw
ofe
et...
sinc
eyo
ufir
stle
arne
dho
wto
wal
k,is
n’tt
hatr
ight
?A
ndha
veyo
uev
erim
agin
edho
wyo
ufi
rstl
earn
edto
wal
k?It
doe
sn’t
real
lym
atte
rif
itco
mes
tom
ind
inth
ism
omen
tor
not.
..
beca
use
ona
dee
ple
velt
haty
our
unco
nsci
ous
min
dca
ntr
uly
und
erst
and
and
appr
ecia
te...
inw
hate
ver
way
and
wha
teve
rti
me
isri
ght.
..
you
mus
tkno
wth
atyo
upr
ogre
ssed
from
bein
gim
mob
ile...
tobe
ing
able
toro
llup
...
roll
dow
n...
and
roll
all
arou
nd...
then
tocr
awlin
g...
atfi
rsts
low
lyor
unsu
rely
...
and
then
perh
aps
late
rm
ore
quic
kly
and
mor
eco
nfid
entl
y...
toth
enta
king
your
first
step
s...
may
beat
first
tent
ativ
ely,
then
late
rm
ore
asse
rtiv
ely
...
and
wit
hev
ery
step
that
you
took
...
you
bega
nto
real
ize
that
you
coul
dta
kean
othe
r...
one
step
coul
dtu
rnin
totw
ost
eps
...
two
step
sin
tofo
urst
eps
...
four
coul
dtu
rnin
tom
ore
...
But
now
I’d
like
tote
llyo
uso
met
hing
real
lyin
tere
stin
g...
wou
ldyo
ulik
eto
know
wha
ttha
tis?
Bef
ore
...
ther
ew
astw
o...
and
one
...
and
alth
ough
you
may
have
prev
ious
lyth
ough
ttha
titw
asap
pare
ntth
ata
pare
ntta
ught
you
how
tow
alk
...
you
real
lyto
okyo
urfi
rsts
teps
the
mom
entt
hey
letg
o,is
n’tt
hat
Dow
nloa
ded
by [
Joan
nes
Mer
tens
] at
00:
08 0
3 D
ecem
ber
2015
ATTACHMENT AND HYPNOSIS 59
righ
t?A
ndal
thou
ghit
can
feel
good
toha
veso
meo
neho
ldyo
urha
ndan
dw
alk
byyo
ursi
de
...
that
can
happ
enw
hene
ver
and
how
ever
you
are
read
y...
you
will
alw
ays
beab
leto
wal
kon
your
own
two
feet
...
just
asyo
uw
illal
way
sbe
able
tohe
arw
haty
oune
edto
hear
wit
hyo
urow
ntw
oea
rs..
orse
ew
haty
oune
edto
see
wit
hyo
urow
ntw
oey
es...
orsm
ellw
haty
ouw
antt
osm
ellw
ith
your
own
two
nost
rils
.And
each
ofth
ese
two
belo
ngs
toth
eon
eth
atis
you
...
and
hold
ing,
wal
king
,he
arin
g,se
eing
,sm
ellin
g...
are
just
the
begi
nnin
gof
allt
hew
ond
erfu
lth
ings
that
you
can
do
...
and
that
do
isal
soa
be...
And
isn’
tnic
eto
know
that
you
can
bew
ith
your
self
inal
lthe
sew
ays
that
feel
good
?A
ndyo
uca
nfe
elm
ore
and
mor
eco
mfo
rtab
lebe
ing
wit
hyo
urse
lf...
whe
ther
itis
byyo
urse
lfor
wit
hso
meo
neel
se.”
Pros
ody
&Sy
nchr
ony:
Paci
ng,r
hyth
man
dto
neof
voic
e
Mea
ntto
repl
icat
eea
rly
heal
thy,
dev
elop
men
talr
hyth
ms
ofat
tach
men
t.T
heke
yis
tost
ayin
step
wit
hth
epa
tien
t’sm
omen
t-to
-mom
ent
expe
rien
cew
hile
slig
htly
lead
ing
ind
irec
ting
wha
tone
obse
rves
next
and
the
mea
ning
one
give
sto
the
obse
rvat
ion.
The
ther
apis
t’svo
ice
isin
anin
stru
men
td
esig
ned
toev
oke
rhyt
hm,
tone
,and
effe
ct.
Imag
ine
spea
king
the
abov
eex
ampl
ew
ith
part
icul
arat
tent
ion
toal
tern
atio
nsof
volu
me,
pace
,and
enun
ciat
ion
ofsy
llabl
es.
(Con
tinu
ed)
Dow
nloa
ded
by [
Joan
nes
Mer
tens
] at
00:
08 0
3 D
ecem
ber
2015
60 ERIC B. SPIEGELTa
ble
1(C
onti
nued
)
Skill
App
licat
ion
Exa
mpl
e
Eye
clos
ure
/
Frac
tion
atio
n1.
Em
phas
ize
cont
rolo
fbo
und
arie
s(e
yelid
sop
en/cl
osed
/d
egre
es)
2.Fo
ster
curi
osit
yin
sim
ilari
ties
/d
iffe
renc
ebe
twee
nin
tern
alan
dex
tern
alst
ates
and
expe
rien
ces
3.M
anag
ed
isso
ciat
ion
orab
reac
tion
thro
ugh
eith
erre
-ale
rtin
gfr
omor
dee
peni
ngtr
ance
[Ati
niti
aley
ecl
osur
e]“a
ndis
n’ti
tnic
eto
know
that
your
eyel
ids
can
rem
ain
open
orbe
gin
tocl
ose
byth
emse
lves
...
soon
eror
late
r...
just
inti
me
...
wat
chas
itha
ppen
s...
easi
ly...
auto
mat
ical
ly...
inw
ays
you
coul
dn’
thav
epo
ssib
lykn
own
you
wou
ldkn
ow.A
ndm
aybe
your
eyel
ids
wou
ldlik
eto
rem
ain
open
...
orm
aybe
they
’dlik
eto
clos
e...
orpe
rhap
sth
ey’d
like
tocl
ose
alit
tle
...
asth
eyre
mai
nm
ostl
yop
en...
or,
onth
eot
her
hand
,the
yco
uld
rem
ain
open
alit
tle
...
asth
eycl
ose
alo
t...
oryo
uco
uld
keep
one
eye
open
and
clos
eth
eot
her...
Idon
’tkn
ow,
and
itre
ally
doe
sn’t
mat
ter...
butt
he‘I
’tha
tis
you
know
sju
stw
haty
oune
edri
ghtn
ow,i
sn’t
that
righ
t?Ju
stas
you
can
expe
rien
ceex
actl
yth
eri
ghtd
egre
eof
com
fort
that
you’
dlik
eto
feel
inyo
urbo
dy
inth
ism
omen
t...
wha
teve
ris
righ
tfor
you
...
you’
llbe
able
tofe
elit
clea
rly
...
asea
syas
A-B
-see
ing
clea
rly
insi
de
...
even
wit
hyo
urey
elid
sse
cure
lycl
osed
...
.and
now
you
can
see
inyo
urm
ind
,can
you
not,
that
your
eyel
ids
are
like
your
own
pers
onal
doo
r...
and
you
can
open
and
shut
this
doo
rto
goou
tsid
eor
insi
de
exac
tly
asyo
une
ed.A
ndju
stas
you
can
use
this
doo
rto
lety
ours
elfg
oou
tand
then
in...
orin
and
then
out.
..
you
can
keep
othe
rsou
twhi
leyo
ure
mai
nse
cure
lyon
the
insi
de
...
oryo
uca
nle
toth
ers
join
you
and
bew
ith
you
asyo
une
ed...
and
som
etim
esit
isen
joya
ble
tobe
wit
hju
styo
urse
lfan
dot
her
tim
esyo
um
ight
enjo
yth
eco
mpa
nyof
som
eone
who
myo
uca
ntr
ust.
..
and
your
unco
nsci
ous
min
dkn
ows
just
wha
tis
righ
tfor
you
inea
chm
omen
t.A
ndw
ould
itbe
alri
ghtt
obr
iefl
yop
enyo
urey
esfo
rju
sta
mom
ent?
”[A
tpo
inti
ntr
ance
offr
acti
onat
ion.
]“T
hat’s
righ
t...
good
.Tak
ea
mom
entt
ore
orie
ntyo
urse
lf.A
ndno
w,w
hene
ver
you
are
read
y...
your
eyes
can
clos
eal
lby
them
selv
esag
ain
...
mor
eea
sily
than
they
did
befo
re...
and
you
can
feel
even
mor
e[c
omfo
rtab
le,s
ecur
e,an
chor
ed,e
tc.]
than
you
wer
ea
mom
enta
go.”
Dow
nloa
ded
by [
Joan
nes
Mer
tens
] at
00:
08 0
3 D
ecem
ber
2015
ATTACHMENT AND HYPNOSIS 61
Arm
cata
leps
yIn
add
itio
nto
rati
fyin
gth
etr
ance
expe
rien
ce,t
his
hypn
osis
tech
niqu
ebe
com
esan
imm
edia
te,s
enso
ry-b
ased
sym
bolo
faff
ectc
onta
inm
ent.
“Let
’sob
serv
eso
met
hing
toge
ther
that
you
may
find
help
ful.
..
wou
ldth
atbe
alri
ght?
I’m
goin
gto
tell
you
som
ethi
ngab
outo
neof
your
arm
s...
pick
one
...
good
...
that
mig
htsu
rpri
seyo
u.B
utyo
um
ight
find
that
you
are
plea
sed
tod
isco
ver
how
surp
rise
dyo
uar
e...
orsu
rpri
sed
tod
isco
ver
how
plea
sed
you
are
...
asyo
ube
com
eaw
are
ofth
is.”
[Not
e:th
erap
istg
ives
sugg
esti
onfo
rpo
siti
vean
tici
pati
onin
the
even
ttha
tca
tale
psy
orim
mob
iliza
tion
has
nega
tive
trau
mat
icim
plic
atio
ns.]
“As
you
focu
syo
urat
tent
ion
onth
isar
m,y
ouca
nim
agin
eit
beco
min
gve
ryst
rong
...
sove
ryst
rong
and
thic
kan
dso
lid...
and
ofco
urse
we
can
mov
eso
lidob
ject
sw
hen
and
asw
ene
edto
...
butf
orno
wIw
ond
erw
heth
eryo
um
ight
imag
ine
the
arm
asbe
ing
stif
fand
rigi
din
its
stre
ngth
...
that
’sri
ght,
stif
fand
rigi
dan
dhe
avy
...
asst
iffa
ndri
gid
and
heav
yas
anir
onba
r...
beca
use
anir
onba
ris
stif
fand
rigi
dan
dhe
avy
and
iner
tand
unbr
eaka
ble
...
good
...
and
your
arm
isso
stif
f...
and
rigi
d...
and
heav
y...
just
like
anir
onba
r...
that
you
wou
ldn’
teve
nbe
able
tom
ove
itif
you
trie
d.G
oah
ead
and
try.
”[U
pon
rati
fica
tion
]“A
ndis
n’t
itam
azin
gto
beco
me
awar
eof
how
stro
ngth
atir
onba
ris
?Iw
ond
erw
hati
twou
ldbe
like
toim
agin
ea
who
leco
ntai
ner
mad
eou
toft
hats
ame
iron
.Str
ong
and
solid
and
unbr
eaka
ble
...
and
able
toho
ldju
stab
out
anyt
hing
secu
rely
insi
de
...
You
can
nod
your
head
asit
com
esto
min
d.
Goo
d.N
ow...
allo
wan
unpl
easa
ntfe
elin
gor
sens
atio
nto
com
eto
min
d...
and
asit
doe
s,th
e‘y
es’fi
nger
can
rise
tole
tme
know
whe
nyo
uar
eaw
are
ofit
...
and
now
imag
ine
that
this
feel
ing
orse
nsat
ion
isfl
owin
gou
tofy
ou...
allt
hew
ayd
own
thro
ugh
the
arm
s...
and
hand
s...
and
outt
hefi
nger
tips
...
and
into
this
iron
cont
aine
r...
that
’sri
ght.
..
and
you
can
becu
riou
san
din
tere
sted
...
like
asc
ient
istc
ond
ucti
ngan
expe
rim
ent.
..
toim
agin
eho
wth
ese
feel
ings
and
sens
atio
nsap
pear
as
(Con
tinu
ed)
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62 ERIC B. SPIEGEL
Tabl
e1
(Con
tinu
ed)
Skill
App
licat
ion
Exa
mpl
e
they
leav
eyo
urbo
dy
...
may
beth
eylo
oklik
ea
colo
red
liqui
d...
orso
me
othe
run
ique
imag
eth
atco
mes
tom
ind
...
you
coul
dsh
are
wha
tyo
uar
eno
tici
ngal
oud
ifyo
uw
ante
dto
...
and
then
...
whe
neve
ryo
uar
ere
ady
...
you
coul
dcl
ose
the
top
ofth
eco
ntai
ner
and
secu
rely
lock
all
ofth
eco
nten
tsin
sid
eth
eco
ntai
ner...
know
ing
that
itis
stro
ngen
ough
toho
ldth
em.A
ndyo
uca
npa
yat
tent
ion
now
tow
haty
our
bod
yfe
els
like
afte
rit
has
rele
ased
thes
ese
nsat
ions
,thi
sen
ergy
...
Wha
tdo
you
noti
ce?”
[Aft
erhy
pnot
icex
plor
atio
n,co
nsid
erof
feri
nga
post
hypn
otic
sugg
esti
onfo
rth
eun
cons
ciou
sto
secu
reth
eco
ntai
ned
affe
ctin
the
way
that
itne
eds
toaf
ter
the
sess
ion
isov
er].
[Not
e:A
subg
roup
ofpa
tien
tsw
illm
ove
thei
rar
ms
atth
ehy
pnot
icsu
gges
tion
for
cata
leps
y.T
his
coul
dbe
anin
dic
atio
nof
poor
hypn
otic
resp
onse
.But
just
aslik
ely,
itco
uld
also
bea
sign
ofth
epa
tien
t’sd
efen
sive
/pr
otec
tive
func
tion
ing.
Shou
ldth
isoc
cur,
prov
ide
sugg
esti
ons
that
reaf
firm
the
pati
ent’s
sens
eof
cont
rol.
For
exam
ple,
“tha
t’sri
ght.
..
good
...
isn’
titn
ice
tokn
owth
atyo
uco
uld
mov
eyo
urar
mif
you
real
lyw
ante
dto
?!Yo
uar
ed
isco
veri
ngm
ore
and
mor
eal
loft
hew
ays
inw
hich
you
are
stro
ngon
the
outs
ide
...
and
insi
de.
And
Iwon
der
wha
tyou
run
cons
ciou
sm
ind
will
do
next
toal
low
you
tofe
elev
enm
ore
stro
ngan
dse
cure
and
prot
ecte
d.”
]
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ATTACHMENT AND HYPNOSIS 63
Post
hypn
otic
sugg
esti
onPo
sthy
pnot
icsu
gges
tion
sar
eim
port
anti
naf
firm
ing
for
the
pati
entt
hati
tis
poss
ible
for
her
topo
siti
vely
attu
neto
and
bew
ith
hers
elfo
utsi
de
ofth
eth
erap
yse
ssio
n.T
hese
sugg
esti
ons
then
beco
me
cues
for
tran
sfer
ring
this
attu
nem
entt
oex
tern
alen
viro
nmen
ts.
Dai
tch’
s(2
007)
“OK
sign
al”
tech
niqu
eis
anex
celle
ntex
ampl
ein
that
itis
afo
rmof
sens
orim
otor
anch
orin
gan
dal
soa
cue
for
apo
sthy
pnot
icsu
gges
tion
.In
this
exam
ple,
the
ther
apis
task
sth
epa
tien
tin
hypn
osis
toal
low
thei
rth
umb
and
fore
fing
erto
com
eto
geth
eron
thei
row
nan
dto
uch.
The
ther
apis
tdir
ects
the
pati
entt
ono
tice
the
sens
ory
aspe
cts
ofth
etw
ofi
nger
sto
uchi
ngan
dth
engi
ves
aco
ntin
gent
sugg
esti
onfo
ra
posi
tive
affe
ctiv
eas
soci
atio
nw
ith
this
sens
ory
expe
rien
ce.T
heth
erap
ist
obse
rves
alou
dth
atth
epa
tien
tis
mak
ing
the
“OK
”si
gnw
ith
her
fing
ers.
Furt
her,
ever
yti
me
that
her
fing
ers
touc
h,it
can
rem
ind
her
ofth
epo
siti
vefe
elin
g(s)
,sen
sati
on(s
),an
dex
peri
ence
(s)t
hats
heha
dd
urin
gth
ehy
pnos
isse
ssio
n,as
wel
las
leth
erkn
owth
atev
eryt
hing
will
beal
righ
t.R
e-al
erti
ngT
his
can
bea
hypn
otic
met
hod
for
refo
cusi
ngth
epa
tien
ton
imm
edia
tese
nsor
yan
chor
sd
urin
ga
dis
soci
ated
stat
e.
“...
and
whe
nth
ew
ord
‘re-
focu
s’po
psup
inyo
urm
ind
,itw
illbe
asi
gnal
toyo
uto
take
ad
eep
brea
th,c
ount
toth
ree,
blin
kan
dre
open
your
eyes
slow
lyan
dcl
earl
y,an
dfe
elfu
llyal
ert,
pres
ent,
and
inco
ntro
lofy
our
bod
y.”
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Hypnotic representation also serves to further the previously incom-plete formation of self and object constancy, which is a necessarycomponent of boundary formation and self-integration (Baker, 1981;Phillips, 2013). This is particularly relevant and helpful for adult traumapatients who have Borderline spectrum personality organization (e.g.,features of BPD) and will be described in greater detail below. In expli-cating her concept of object constancy, Mahler (1968) theorizes thatin the third year of appropriate development, children achieve objectconstancy, in which they can internalize a positive, loving, and sooth-ing image of their mother and integrate it into moments of distress inwhich they experience their mother as “bad,” due to misattunementto their needs. Thus, with this milestone, they are able to experiencetheir mother as a constant and durable internal figure across vary-ing external relational experiences. It is this stabilized, integrated, andnuanced internal archetype of mother that allows them to tolerate theinevitable and numerous moments of disappointments by the actualmother. This object constancy allows the child to understand that, eventhough “I may feel [scared, angry, withdrawn, etc.] because I sense thatmother is [angry, sad, disappointed, etc.] with me right now, I knowthat she is still a good, caring person who loves me.” From this exam-ple, one can deduce how object constancy leads to the parallel qualityof self-constancy.
Through its repeated representation of scenes evoking object con-stancy, hypnotherapy can be utilized to recapitulate this stalled devel-opmental process in our adult patients with trauma histories. Hypnosiscan be used to create varied and interesting image representations ofa person while inherently suggesting that they retain some aspect ofconstancy, despite the moment-to-moment changes. This constancy canthen be linked to constancy of self or other across changing affectiveand cognitive states (E. L. Baker, personal communication, August 17,2011). Therefore, “I can feel sad and still be Eric,” rather than “I [Eric] ama sad person” with the implication being that Eric is himself no matterwhether he is happy or sad.
I theorize that object constancy is a necessary precursor for consistentmentalization. As referenced earlier in the article, in a prementalizedstate of psychic equivalence, internal and external realities are mergedand “world equals mind” (Allen et al., 2008; Bateman & Fonagy, 2006,2012). In this concretized mode of thinking associated with BPD, thereis a failure of symbolization and a suspending of “as if” for whatappears to look, to feel, and to be real to the person in a given moment(Bateman & Fonagy, 2006). I understand psychic equivalence and a lackof object constancy to be overlapping concepts. In a mode of psychicequivalence, we cannot conceptually grasp the concept of mental statesoccurring outside of behaviors and external events (which is a lack ofobject constancy; e.g., if someone does something “bad,” they must “be
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a jerk.”), nor can we grasp that a person possesses a varied collectionof mental states and associated thoughts, feelings, and subjective expe-riences. Further, in this mode, we certainly would not be able to allowourselves to be curious about those mental experiences, whether insideof ourselves or others. Therefore, we developmentally need to be ableto possess a sense that every person has a core, identity-based selfhoodthat is inherently nuanced, integrated, and durable from moment-to-moment (e.g., self/object constancy) in order (a) to appreciate that theycan have varying mental states across those moments and (b) to be curi-ous about what those mental states might be (e.g., mentalization). It isfrom this foundation of self/object constancy, and the affective contain-ment that it provides, that one can psychologically allow a reflectivecuriosity to develop about different mental states in a single person andthe internal and external experiences that elicit them.
As representational capacities develop, the patient can move fromimaginally representing immediate experiences to constructing fantasy-based representative experiences designed to serve a particular purposein the trauma treatment, such as somatoaffective regulation, manage-ment of boundaries, internalization of adaptive relationship experi-ences, controlled reprocessing of traumatic memories, or integrationof diffuse ego states. The hypnosis literature is robust with exam-ples of utilizing representation in the treatment of trauma. Althoughthe underlying principles are similar, I believe that these represen-tational techniques are best organized into three general categories:representation of the therapeutic relationship, imagined parental fig-ure representation, and ego state representation. Although they differin their theoretical underpinnings and choices of relational healingsymbols, all three forms of hypnotic representation serve to facilitatehealthy internal working models that promote constancy and inte-gration. Hypnotic imagery creatively intersperses fantasy with realityto create more flexible, nuanced, and exploratory mental attachmentexperiences involving self and other.
Postulating from a psychoanalytic object relations framework, Baker(1981, 2000, 2010) proposes representation of the therapeutic relation-ship because it accesses the immediate here-and-now experience of thetherapeutic encounter. This representational process begins with imag-ining immediate relational cues in the here-and-now therapeutic milieuand then, as the patient is ready, eventually shifting to an interactivescene in which the therapist is a responsive, nurturing figure who canrespond to the patient in ways that affirm, secure, and comfort her.As the patient’s capacity to imagine this type of interaction and expe-rience positive affect in response to it increases, the therapist can thenbegin to suggest representative imagery for the purpose of externalizingnegative object representations associated with the patient’s traumatichistory. In the latter stages of Baker’s object representational model, the
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therapist focuses on the integration of “bad” and “good objects, affects,and self-states. Representations of relational figures from the patient’slife are introduced into the hypnosis, and suggestions are given to give“good” characteristics to the “bad” people and vice versa. Transferentialreactions to this process are explored in hypnosis and therapy with thegoal of reducing splitting and dichotomous cognitive processes and theaffective reactions that they engender. All of this promotes a more bal-anced, integrative representation of self and other (Baker, 1981, 2000,2010).
A second type of representational approach is an imagined parentalfigure method, which utilizes representation to facilitate adaptive inter-nal representation of self and other and to secure attachment functions(Brown, 2009a, 2009b; Murray-Jobsis, 1990a, 1990b, 1993; Phillips, 2004).Initially created as a hypnotic renurturing technique used in address-ing developmental arrests in patients with trauma histories exhibit-ing features on the borderline personality spectrum (Murray-Jobsis,1990a, 1990b), it has been modified in recent years to more explic-itly address attachment themes, language, and imagery (Brown, 2009a,2009b; Phillips, 2004). This hypnotic renurturing involves the therapistpermissively directing the patient to imagine a series of attachment-based experiences with a real or imagined parent(s). The techniquesinitially create, enhance and strengthen the imagery of a secure basewith all of its secure, safe, nurturing, and bonded functions. Based uponthe patient’s response, the imagery subsequently shifts to accentuat-ing exploratory and mastery functions associated with leaving (andreturning to) the secure base (Brown, 2009a, 2009b; Murray-Jobsis,1990a, 1990b, 1993). The entire process from start to finish promotesgreater internal representation, affect regulation, coherence of mind,and mentalization that are associated with secure attachment.
In explaining the need for an attachment-based hypnotherapeuticapproach, Brown (2009a, 2009b) notes the numerous studies associat-ing insecure attachment with complex trauma diagnoses and believesthat we must shift our conceptualization of how complex traumadevelops. He believes that early attachment disruptions are the coreproblem in the representational and self-regulatory deficits present insurvivors of complex trauma, and that the subsequent trauma abuseonly serves to exacerbate those deficits. As a result, Brown has shiftedhis emphasis from controlled reprocessing of traumatic memories toattachment-based developmental repair when working with patientswho are survivors of complex trauma. According to Brown, hypnosisis a particularly effective treatment approach for attachment pathol-ogy, because it allows for the patient to have a method of visualizingand internally representing adaptive attachment relationships, such asthe therapeutic relationship, through structured imagery (Brown, 2009a,2009b).
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Brown’s (2009a, 2009b) method is designed with two attachmentgoals in mind: (a) to aid in the development of positive internal rep-resentations and (b) to teach and facilitate mastery of metacognitiveabilities for the purpose of increasing self-reflective awareness. For thefirst goal, he believes that hypnosis helps to amplify cues for secureattachment across time until the patient can consistently represent pos-itive affect and regulate negative affect. For the second goal, Browndefines metacognitive abilities similarly to Fonagy and others’ defi-nitions of mentalization and reflective functioning, namely as beingaware of one’s mental state. By creating metacognitive cues duringimagined attachment experiences, the therapist helps patients organizetheir minds. Through an emphasis on metacognition during an imag-ined positive attachment experience, Brown believes that his model willhelp patients cognitively remap their mental states, leading to improvedself-monitoring, mental organization, and regulation of affect related tomental states (Brown, 2009a, 2009b). Brown’s model is also notable forits direct incorporation of the metacognitive aspect of mentalization inits imagery.
Finally, the third representational approach, ego state representa-tion, is grounded in ego state therapy (EST), a specific approach withinclinical hypnosis that focuses on pathological dissociation in survivorsof complex trauma. Although numerous papers and books have beenwritten about EST, a succinct description of the therapy is that itfocuses on attuning to, stabilizing, and working through the trau-matic experiences of and eventually integrating the dissociated andfragmented ego states of the self (and their respective somatic, affec-tive, cognitive, and proprioceptive experiences) (Morton, 2009; Phillips& Frederick, 1995; Watkins & Watkins, 1997). Similarly to the objectrelations and parental renurturing approaches previously described,EST utilizes hypnotic representation for the purpose of developmentalrepair. However, rather than using the therapist or parent as a repara-tive relational representational symbol, EST enlists adaptive ego statesof the patient (e.g., the wise elder, shaman, calm adult, etc.) to inter-act with the developmentally arrested ego states (e.g., the child, victim,etc.). EST representational techniques for treating trauma could includeaddressing ego strengthening, such as identifying, affirming and ampli-fying a more mature ego state or experience (Daitch, 2007; Watkins &Watkins, 1997), having an internal family support circle, where a matureego state might transfer adaptive functioning to a wounded, child egostate, perhaps through soothing or comforting (Daitch, 2007; Morton,2009), symbolizing the affect of a more malevolent ego state (“blackgunpowder”) and containing it (putting it in a chest and locking thechest) in a way that creates feelings of safety (Morton, 2009), or work-ing with ego states in the past or future to work through traumaticexperiences or to imagine integrated future experiences (Hammond,
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1990; Torem, 1992). Overall, in an EST approach, representation is uti-lized with the goals of identifying and accessing the patient’s positiveinternal resources, providing a series of corrective self-experiences,and facilitating integration of the patient’s personality (Morton, 2009;Phillips, 2004, 2013).
MentalizationMentalization has received far less attention in the hypnotic liter-
ature. Nonetheless, it should be understood as a natural progressionfrom representation in the developmental process that occurs during anattachment-informed hypnotherapeutic treatment of complex trauma.As covered earlier, imagery-based representational awareness of sen-sory experience is a rudimentary building block of mentalization inthat we first must represent our sensory and affective experiencesthrough images in order to develop the thoughts and words necessaryto describe their mental meaning and to organize them into a largerframework. As imagery representation fosters lexical representation,mentalization can begin to occur more explicitly in the hypnotherapeu-tic treatment process.
By representing a variety of figures and ego states in our patients’imagination, we have the opportunity to create scenarios that heightentheir awareness and understanding of underlying mental states.As with attunement, this can be done explicitly or implicitly. For exam-ple, Murray-Jobsis’s (1990b, 1993) creative self-mothering variation ofher parental renurturing technique asks the patient to call to mind themental experience of both parent and child in playing each role. Buteven in more “passive” parental renurturing scenes where the patientis imagining having something “done” to her by the parent (e.g., pro-tecting, affirming, containing, etc.), it is the patient who is creating thisimagery (with minimal permissive guidance from the therapist) and themental associations that come with it, whether she realizes it or not.
Similarly, Daitch describes a variation of the internal parental figuremodel in which the patient imagines her actual parent as a child inter-acting with an imagined secure attachment figure. By imagining herparent as a child-like figure most likely in some kind of pain or distressand in need of a healthy parental relationship him or herself, the patientmentalizes about the mental life of her parent. Participating in this exer-cise allows the patient to imagine her parent in a different way than shehas most likely historically remembered him or her (C. Daitch, personalcommunication, March 23, 2014).
Hypnotic suggestions for mentalization can either be directly incor-porated into representational scenes or indirectly offered through sto-ries or metaphors. For direct suggestions, Brown (2009b) suggests aframework (a) of “notice the effect of __ on your state mind” or (b)
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of “notice how __ (e.g., organized) your mind feels right now.” Theseare but a few variations of direct hypnotic suggestions for mentalizingthat a hypnotherapist could offer. Alternatively, because MBT ofteninvokes the here-and-now experiences of the therapeutic relationship(Allen et al., 2008; Bateman & Fonagy, 2006), direct hypnotic sugges-tions could be given to explore the mental experiences and interactionsbetween therapist and patient. In this regard, one can apply an explicitmentalizing focus to Baker’s (1981) object relations protocol utilizing thetherapeutic relationship.
Indirect suggestions are a method for modeling mentalization with-out explicitly instructing the patient to do so. Indirect suggestionsfor mentalization can be beneficial when direct suggestions stimulateattachment anxiety or avoidance. I often tell hypnotic stories withmentalizing themes (e.g., “The Little Engine that Could—“I think I can,I think I can . . . I know I can, I know I can”—and the parallel imageryof scaling a mountain that comes with these progressing mental states).
An apt example of a mentalization metaphor is being able to “seethe forest for the trees.” I find this metaphor useful because it’s verymeaning—discerning a larger pattern from a mass of detail—describesa quality of mentalizing. I have devised an extended mentalizing tech-nique and script based off of this metaphor. In this permissive approach,the patient is asked to symbolize an image of a tree that represents aparticular mental (e.g., affective) or ego state that he or she is havingdifficulty with. Hypnotic suggestions tailored to the patient’s attach-ment dimensions and needs are given with the intention of positivelymodifying the patient’s experience of her “tree.” As mastery increases,suggestions shift to imagining, exploring, and articulating relatednessbetween this and other nearby trees. The hypnotic emphasis gradu-ally moves from a single tree to a forest of trees. Hypnotic suggestionsemphasize shifting sensory perspectives of the tree(s) and forest forthe purpose of building greater reflective functioning. This approachis designed to help patients have a greater appreciation of the diversityof their mental experiences, feelings, and thoughts; and better be ableto reflect on and to organize them into a cohesive, integrated mentalexperience.
Conclusion
In this article, I drew upon the combined literatures of attachmenttheory and clinical hypnosis in proposing an attachment-based modelof how hypnosis might be developmentally utilized in a psychother-apy treatment for complex trauma. Additionally, I was influenced bythe literature documenting the central role of mentalizing in guiding
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responses to traumatic cues and promoting overall secure attachment(Allen et al., 2008; Bateman & Fonagy, 2006, 2012; Fonagy et al., 2002).However, given the centrality of language in framing such mentalizing,I was curious about how such reflective language could be developedin the patients who need it the most. Thus, not only does this articleexplicate the elements of attachment inherent in hypnosis but it alsoconsiders how attunement and representation facilitate the emergenceof mentalization and reflective language.
An underlying assumption of attunement is that the process of devel-oping safety and security begins in the here-and-now interpersonalframe of the therapeutic relationship. As the therapist attunes, observesand shares with the patient in their joint space—through careful track-ing, synchrony, pacing, vocal prosody, and language—the two worktogether to develop sensorimotor anchoring in the patient. Throughtheir joint attention to positive phenomenological processes developingin the patient, the therapist begins to utilize these processes as con-tingent suggestions for affect regulation and boundary management.Thus, the patient learns how to “be” with her body in a containing,soothing, and grounding way.
Influenced by Baker’s work on the use of hypnosis in buildingstructuralization (1981, 2010), I theorized that this sensory, “felt” expe-rience also creates a concrete and tangible foundation for subsequentrepresentation—first of the body and later of the self, other, and rela-tionship(s). Thus, mastery of one’s immediate sensory experience influ-ences the creation of images used to describe those experiences. It isin this respect then that representation expands from somatic to self-experience and from self- to relational experience. As the opportunitiesfor representation increase, the therapist has more material to work within framing and describing imaginative healthy attachment experiences.
Hypnotic mentalization utilizes these representational scenestowards the purpose of enhancing the patient’s reflective functioning.Through repeated use of varied representational imagery, the therapistaugments the patient’s capacity to use reflective language to describeher and others’ mental experiences. With an expanded vocabulary ofreflective language at her employ, the patient is now able to use herown language to assign meaning to the mental experiences highlightedin hypnotic representational imagery.
In conclusion, hypnosis is a beneficial addition to any psychother-apy for complex trauma. It experientially enhances the attachmentprocesses of attunement, representation and mentalization in the treat-ment. Doing so promotes secure attachment and a recapitulation ofstalled developmental processes, including the capacity for nuancedself-reflective language and associated mentalizing.
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References
Allen, J. G., Fonagy, P., & Bateman, A. W. (2008). Mentalizing in clinical practice. Arlington,VA: American Psychiatric Association.
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Anhangs-fokussierte Hypnose in der Psychotherapie komplexer Traumata :Anhaftung, Verkörperung und Mentalisierung
Eric B. SpiegelAbstrakt: Die relationalen und psychologischen Funktionen von Anhaftung,Repräsentation und Mentalisierung sind essentielle Komponenten einersicheren Anhaftungserfahrung. Psychotherapeutische Ansätze mit anhangs-theoretischer Information haben vor allem auf dem Gebiet des kom-plexen Traumas signifikante empirische und klinische Unterstützungerfahren. Trotz dieser Vorstösse könnte eine anhangstheoretisch informierteTraumabehandlung in großem Maße von dem Erfahrungswert, die die klin-ische Hypnose zu bieten hat, profitieren. In der Utilisierung von geteilterAufmerksamkeit, Stimmlage, Pacing, repräsentativer Imagination und hyp-notischer Sprache, bietet klinische Hypnose Psychotherapeuten als Zustand,Beziehung und Technik einen Weg, um eine gesunde Bindungserfahrungeinzuführen und angebrachtes entwicklungsgemässes Funktionieren beiPatienten zu erneuern, die Überlebende komplexer Traumata sind. In diesemPaper werden Anhaftung, Verkörperung und Mentalisierung aus hypnother-apeutischer Sicht untersucht.
Stephanie Reigel, MD
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L’hypnose axée sur l’attachement en psychothérapie pour traumatismescomplexes: harmonisation, représentation et mentalisation
Eric B. SpiegelRésumé: Les fonctions relationnelles et psychologiques de l’harmonisation,de la représentation et de la mentalisation constituent les éléments essentielsde l’expérience d’un attachement sécurisant. Les approches psychothérapeu-tiques, alimentées par la théorie de l’attachement, ont acquis un soutienempirique et clinique important, notamment dans le domaine des trauma-tismes complexes. Malgré ces avancées, le traitement des traumatismes fondésur l’attachement pourrait grandement bénéficier de la richesse expérienciellequ’offre l’hypnose clinique. Dans son utilisation de l’attention partagée, duton de voix, du rythme, de l’imagerie figurative et du langage hypnotique,l’hypnose clinique en tant qu’état, relation et technique, offre aux psy-chothérapeutes un moyen d’introduire un attachement sain et de renouvelerles bonnes capacités développementales fonctionnelles chez des patients quiont survécu à des traumatismes complexes. Dans cet article, l’harmonisation,la représentation et la mentalisation sont examinées selon un point de vuehypnothérapeutique.
Johanne RaynaultC. Tr. (STIBC)
La hipnosis enfocada al apego en psicoterapia para trauma complejos:Sintonía, representación y mentalización.
Eric B. SpiegelResumen: Las funciones relacionales y psicológicas de sintonía, repre-sentación y mentalización son componentes esenciales de una experienciasegura de apego. Los acercamientos psicoterapéuticos informados por lateoría del apego han ganado sustento empírico y clínico significativo, par-ticularmente en el área de trauma complejo. A pesar de estos avances, eltratamiento al trauma, informado en el apego, podría beneficiarse en granmedida de la rica experiencia que la clínica hipnótica puede ofrecer. En suutilización de atención compartida, tono de voz, cadencia, visualizacionesrepresentacionales, y lenguaje hipnótico, la hipnosis clínica, como estado,relación y técnica, ofrece a los psicoterapeutas una forma de introducir unaexperiencia de apego saludable y renovar un funcionamiento del desar-rollo apropiado en pacientes sobrevivientes de un trauma complejo. En esteartículo se revisan la sintonía, representación y mentalización desde unaperspectiva hipnoterapéutica.
Omar Sánchez-Armáss Cappello, PhDAutonomous University of San Luis Potosi,Mexico
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