Case A. (Delirious Agitation, Anxiety)
The first case is an emergency. A. is a high school arts teacher who had a position in the South of Portugal (Algarve) during the past academic year. When he came back home (Center of Portugal, in a city named Leiria), in July 2007 the event that led him to our office took place. The patient, a 30-year-old man, was always a person showing a high social anxiety and obvious interpersonal difficulties. During the past academic year, A. tried to fit in with his colleagues, what led him to drink and consume marihuana. The latter caused him to start having some persecutory ideas as well as hearing voices. Perhaps related to this somehow delirious activity, A. initiated a relationship with one of his colleagues, which he regarded as a romantic relationship. However, at the end of the academic year, he confirmed that he was mistaken, and it was only an illusion of his own mind. In this emotional condition he came back to his family home (his brother and his mother, his father passed away many years ago).
It is A.’s mother who contacted us. She was in despair and worried since in the last days A. had done unpredictable things, such as going to see some friends, giving them the keys of
16 Clearly, the aim is not using the VMWH as it is established, since that would be going backwards, which is not possible. However, some of the essential elements of the VMWH can be used working with them in more detail (thus, according to the assumptions of the VMWH). For example, the therapist may spend more time explaining and training in the influence that thoughts and interpretations have on what we feel.
his car stating that he was not going to need them anymore, and then being found in the beach trying to go out of sea. Furthermore, some nights he slept inside his car or outside in the beach, he used to talk to himself as if there were somebody else, and was very agitated without being able to sleep. This information given by phone was enough to realize that this could be a case of psychotic agitation (delirious disorder). A.’s mother preferred that we assess his son first, rather than proceeding directly to his hospitalization in Psychiatry. A. was received the same day in the evening (A.’s mother called at midday).
He appeared to be a very anxious person, agitated, and with difficulties to explain what happened to him. Even so, it was possible to clarify the events he told us as well as the impact they had had on him. It was immediately clear that he was emotionally destabilized and to help stabilize him was considered as the main and immediate goal of the intervention.
The Model 1 was applied with the arm lift procedure. Taking into account that A.
responded very well, the variant of the hand and arm going up to a specific place of the head was used. Suggestions of calming down, safety, and tranquility were given. The response was excellent. The patient practiced at home during the following three days and then came back.
At that point, he showed to be calm and ready to use the procedure in self-hypnosis (without knowing anything about that). He was able to achieve what he called “meditation”.
A. came back to the office after two weeks and one month and he kept his positive progress. In these two sessions the work with him was focused on problem solving, including the hearing voices. He considered being able to proceed on his own in this matter17. Some months later he contacted us again to improve some interpersonal aspects (related to social skills), and after several weeks he had gained good results.
Previous to introduce this case in the chapter, we contacted A. again and he confirmed to be very well18.
Case B. (Traumatic Stress)
This case is an emergency too. B. is a 41 years old male who was referred by a colleague, after it was verified that he was in a trauma. Five days before, the patient along with four of his friends (among them there was a cousin of him that he considered as a brother) were hunting, a hobby all of them had some years ago. In the way back home they were involved in a serious car accident, as a result of which the patient’s cousin passed away. One of the things that most impacted B. was to see part of the brain of his cousin spread on the ground, with his head opened.
From that day on, B. hardly slept and experienced permanent and intrusive flashbacks about the accident. He also reported to suffer a high level of emotional/physiological activation (heart rate and breathing cycle accelerated), anxiety, anguish, and sadness. He had difficulties to concentrate in his job as a business man. Relative to his family his own children reminded him his cousin’s children, now without his father, and his own wife reminded him his cousin’s wife, now a widow…
17 An interesting aspect is that the patient went on hearing “voices”, generally neutral or even positive ones. The patient was able to live with those voices without any problem.
18 The total therapeutic process (including the first session) took place between July and October, 2007.
The rationale of the intervention, after talking with the patient about the therapeutic goals, was, first of all, to reduce his state of high emotional activation. To this end, the technique of breathing control was used (see Craske and Barlow, 2007). It consists in breathing in a controlled way during about 15-20 seconds (more than 12 seconds), paying close attention to the exhaling. The objective is to change the pectoral breathing into a diaphragmatic breathing. This helps reestablish an adequate balance of brain oxygenation and helps decrease the symptoms causing anxiety. The patient was trained in this procedure in the first session, and was asked to repeat it at home several times during the day. He came back two days later for the next session.
The second session was intended to deal with the link that people tend to do after the death of a close person, namely, a process of guilt that, as the time passes, fades away. We proposed B. the use of waking hypnosis to be able to proceed to vanish this process. We implemented specifically the Model 2, using the second stage (hands attracting each other) to give temporal distancing suggestions (and in this way, achieving a decrease of negative emotions): “Tell your brain that as your hands approach attracted by each other, you feel that the accident took place long time ago, long time ago... it did not happen one month ago nor a year ago... it happened long, long ago... and this is why you feel that your distress, anxiety, anguish are vanishing and decreasing...” Most part of this session was devoted to implement this procedure, first in hetero-hypnosis and then in self-hypnosis.
The patient felt very relieved and showed to have good ability to use self-hypnosis. There was another session four days after this one, in which B. was told to practice several times per day this procedure (at least once in the morning, afternoon, and night). The next sessions were one and two weeks later respectively. That is, second session four days after the first one;
third session seven days after the second; and fourth session, 14 days after the third session.
It is worth pointing out that this kind of emergencies is, by nature, acute and its treatment has preventive characteristics. For example, in this case, everything indicated that the patient would be vulnerable to develop post-traumatic stress. However, since the intervention worked out successfully, several days after the trauma, that development never reached to an end.
Indeed, an unpublished recent exploratory study conducted by one of the authors (Pires and Peralta, 2008) suggests that the cognitive involvement subsequent to the exposure to unpleasant scenes increases drastically the dysphoria, above all depressive feelings, decreasing the appreciation of neutral or positive scenes. Therefore, by “withdrawing” the patient from the cognitive involvement in the traumatic event, as well as allowing him/her to feel safe, may be very relevant in order to the post-traumatic stress does not develop further.
Case N. (Panic Disorder with Agoraphobia)
The patient is a 30-year-old male that had been suffering from panic disorder with agoraphobia since he was 17 years old and had always been under pharmacological treatment.
The treatment lasted 6 months and it revealed to be a very complicated case. The patient not only was completely limited (he did not go anywhere alone or too far away from his home), but he also was under much medication (two antidepressants, two benzodiazepines,
propanolol, and a mood stabilizer). For that reason, the first months the intervention was focused on reducing gradually the medication19.
As it is known, the choice treatment for panic disorder is conducted through the implementation of exposure variants, such as in vivo exposure (agoraphobic aspects), and interoceptive exposure (inner/somatic aspect of panic). Even so, many patients are reluctant to go through such procedures, above all to the interoceptive exposure. This patient was not an exception to these cases. After a negotiation process with the patient, we agreed to proceed with gradual in vivo exposure. At this time the patient was no longer taking medication20.
Just as we expected, there were substantial difficulties and resistance. N. admitted to be a
“coward”: he did not bear to cope with agoraphobic situations. In this context, the use of hypnosis was put forth as an alternative. The Model 1 was applied and the statue scene was used to generate in the patient a feeling of distancing regarding the fear, and to suggest courage by means of some coping scenes of hard adversities in a mountain area. The important goal here was to elicit his feeling of courage and associate it to the word “courage”, in a way that he would be able to use it subsequently during the exposure. Then this situation was trained in vivo while in waking hypnosis. Therefore, these were the first steps to work with the exteroceptive exposure.
The procedure was repeated several times, whenever it was necessary to “unblock” the agoraphobic coping. Meanwhile, it was possible to initiate interoceptive exposure that the patient accepted this time.
It is important to emphasize that even though he exposure has been the basis of the treatment, the use of hypnotic techniques was essential for the effective treatment implementation. Hypnosis allowed overcoming the patient’s difficulties to cope with phobic situations.
Case T. (Phobia to Eat)
The patient is an 11 years old male child who quitted eating solid food, taking only liquids after the death for asphyxia of a neighbor child. The latter21 was alone at home and tried to swallow a too big amount of food without chewing, and ended up asphyxiating herself.
The patient’s parents realized what was happening to the child several weeks after the problem was already consolidated and started by asking for help to the Pediatrician. Due to they did not obtain any result, they turned to a Psychologist, also without any result. Then they looked for another Pediatrician who referred the case to us. Meanwhile, several months had passed. In this way, the case became a complicated case at the same time that was an emergency because the problem was already causing an impact on the child’s health.
As a general rule, in cases involving children a simple approach of the Model 2 has shown to be useful. Inasmuch as children tend to be very suggestible, the exercise of the hands attracting to each other is applied without too many details. Additionally, according to
19 We counted on a physician’s collaboration.
20Even though from a clinical perspective, the patient did not have at this time any improvement, he considered that the medication, after all those years, had not solved his problem and had caused him several problems (“side effects”).
21 This child had trisomy 21.
our experience, children like to keep their eyes opened. The intervention in this case was conducted in several stages that where established in accordance with the goals estimated as necessary at each moment. First, it was thought helpful to proceed to a sort of “oblivion” of the event that brought about the phobic situation, in order to facilitate the ingestion of solid and harder food in his mouth. During the exercise of “hands attracting each other” it was suggested that as his hands approached to each other, the above-mentioned event would turn distant, more and more distant, further in time until it had completely disappeared. After this procedure, there was a break to assure that the oblivion was working. As soon as it had worked it appeared helpful to produce in the patient the sensation of hunger in a way that he could eat a bite of a sandwich that his mother had brought. The procedure was the same one with the hands trying to cause sensations of hunger. The suggestions resorted to a detailed description of the somatic and cognitive signs of hunger, and to the anticipation of the pleasure of satisfying the hunger, producing salivation. In this stage, the psychologist’s intervention (hetero-hypnosis) was alternated with the performance of the child (self-hypnosis). The instruction was: “Tell your brain…” Before terminating, and in order to prepare for future sessions, it was suggested to T. that the exercise of the hands attracting to each other would be helpful to make changes in the brain so that the food turned tastier…22 Also, T. was told that this training is called self-hypnosis.
After finishing hypnosis, the patient said that he had a stomachache that felt like...
hunger. He ate in a natural way, to his mother astonishment, as if he had never had such a problem. The following sessions took place every other day during a week in which we went to his house at dinner time. T. stayed alone with us while his parents went to the living room.
The first few minutes were spent in remembering the good flavors of food, the advantages of eating well to obtain energy to be able to jump and study. Right after this, the mentioned exercise “to turn food tastier” was utilized. T. was told the following: “Very well, now you are in self-hypnosis and are going to eat until you do not feel like eating more. You will be able to move, to watch TV, to drink water, etc. You will remain alone. When you are finished, call me. See you later.”
Two weeks later we went to the patient’s house again to observe his progresses and reinforce the procedure. Everything was going well. In the next few months a follow-up by phone was performed. More than three years has passed and there has not come up any problem.
Case C. (Depression, Pharmacological Iatrogeny)
This case is framed in what we consider as “difficult cases”. Indeed, in our clinical practice a kind of case very common is chronic depression. To be precise, they are depressed patients who initiated a pharmacological treatment many years ago, and with the passing of the years, not only do not improve the initial clinical situation, but also present clear symptoms of emotional, cognitive, and behavioral deterioration, most of all as a result of the own treatment iatrogeny. As a rule, they are people without motivation and hopeless, with
22 This procedure was necessary to avoid the contradiction created by doing something with the goal that he eats, whereas it has been suggested oblivion… Subsequently, his mother confirmed that when she asked him the reason to do that exercise, he replied: “it is for improving my appetite. The food I ate before was not so tasty”.
severe difficulties in their jobs (they are on sick leave many times or retired). Despite all this, they are not able to leave the medication since those times they have tried, they go through strong withdrawal syndrome and their physicians reject such a possibility. In this way, the situation becomes very complicated and the first objective is the relief of the side effects of the medication. This may take a more or less long period of time. During this time, a detailed intervention is carried out. That is, education, restructuring of the psychological components essentials for a comprehensive and in-depth psychological treatment. From our approach, hypnotic techniques can be useful in different points. Let us proceed explaining these points with this illustrative case. The patient is a 41 years old woman who has been depressed for nearly 6 years. She is married and has two children. She has many difficulties in her job as a lawyer, since she has reasoning and memory problems and repeated work absences. She is on psychiatric pharmacological treatment since the start of the problem, namely, an antipsychotic (risperidone), two antidepressants (fluoxetine and fluvoxamine), and two benzodiazepines (alprazolam and triazolam). This prescription is the most recent from a very long list.
Building of a context of hope. It consists in creating positive and favorable expectancies toward this new process of help23. We turn to the Model 1. After proceeding as it was described above, we can pass to the following scenario: “Now, you can be in any place. Do you like going to the beach in a summer’s evening where there are few people and the sea is very calm? If so, imagine yourself walking by the seashore, walking on the wet sand. You know that the sand is wet because you are walking barefoot. Turn to face the sea. Today the sea is very calm and smooth. The seagulls fly along with the air current. In the background, some ships hardly move on the horizon. You are happy and satisfied. Actually, a few months have passed since your health improved and you feel better. Smile… Smile while looking at the sea and the seagulls, while thinking that all the efforts are really worthy. At the beginning everything seemed to be impossible, but then, little by little you overcame all the difficulties.
You have become a better person. Take a deep breath… notice the smell of the sea… You are satisfied… Now, you know that, in life, there are good things and not as good things, and the latter are difficulties, obstacles that can be overcome.
This kind of scenario was repeated with some variants during the first weeks in order to reinforce and develop positive expectancies in a way that the therapeutic process became more feasible.
Hypnosis and withdrawal. In this case hypnosis was also used to cope with withdrawal symptoms that the patient reported to be the most distressful, that is, pain and anxiety. This procedure had to be repeated inasmuch as all the medications dosage reduction had effects of withdrawal of variable intensity.
The period in which the withdrawal of the medication took place lasted about two months. Just before the complete withdrawal the patient was ready and felt like starting with behavioral activation. Actually, there were few things left to do after this. The same rationale was applied and usual elements of cognitive-behavioral therapy for depression were used, such as behavioral activation and correction of dysfunctional cognitions, and benefitting from
23 Sometimes, the patients are so medicated that it is necessary to wait a few weeks of medication reduction to be
23 Sometimes, the patients are so medicated that it is necessary to wait a few weeks of medication reduction to be