Treating Trauma with Hypnosis

2010-10-08T23:50:00Z

Robert Kupferman, LCSW

www.rkhypnotherapy.com

917-517-2447

Robert Kupferman, LCSW

www.rkhypnotherapy.com

917-517-2447

The Use of Ericksonian Hypnotherapy

in the Treatment of PTSD

And its relationship to EMDR, Cognitive and Psychotropic Modalities

Seminar presented by Robert Kupferman, LCSW

to staff of Mt. Sinai Hospital WTC MMTP and MHIP

on August 20, 2010.

At the end of this seminar, attendees will be able to:

1. Understand the basic concepts of hypnosis and Ericksonian hypnotherapy.

2. Understand the role of Ericksonian hypnotherapy and its compatibility with other treatment modalities in treating PTSD.

PTSD: Clinical Definition

The diagnostic criteria for PTSD, stipulated in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV-TR), may be summarized as:

A: Exposure to a traumatic EVENT

This must have involved both (a) loss of "physical integrity", or risk of serious injury or death, to self or others, and (b) an intense negative emotional response. (DSM-IV).

B: Persistent REEXPERIENCING

One or more of these must be present in the victim: flashback memories, recurring distressing dreams, subjective re-experiencing of the traumatic event(s), or intense negative psychological or physiological response to any objective or subjective reminder of the traumatic event(s).

C: Persistent AVOIDANCE and emotional numbing

This involves a sufficient level of:

avoidance of stimuli associated with the trauma, such as certain thoughts or feelings, or talking about the event(s);
avoidance of behaviors, places, or people that might lead to distressing memories;
inability to recall major parts of the trauma(s), or decreased involvement in significant life activities;
decreased capacity (down to complete inability) to feel certain feelings;
an expectation that one's future will be somehow constrained in ways not normal to other people.

D: Persistent symptoms of increased AROUSAL not present before

These are all physiological response issues, such as difficulty falling or staying asleep, or problems with anger, concentration, or hypervigilance.

PTSD and Normal Functioning

In the normal course of our lives an EVENT happens. We can refer to this as a STIMULUS.

We integrate the experience by REMEMBERING.

We edit the experience by FORGETTING.

We make meaning of the experience to be better PREPARED.

PTSD as a clinical diagnosis is really an intensified version of the above. The normal becomes abnormal and interferes with normal functioning.

With PTSD the EVENT was catastrophic and the STIMULUS intensifies as the STRESSOR.

REMEMBERING becomes REEXPERIENCING.

FORGETTING becomes AVOIDANCE.

PREPAREDNESS becomes AROUSAL.

NORMAL	EMOTION	PTSD Symptom Cluster	PTSD	EMOTION
STIMULUS		A	STRESSOR EVENT
REMEMBERING	Curious	B	REEXPERINECING	Anxiety
FORGETTING	Editing	C	AVOIDANCE	Depression
PREPAREDNESS	Focused	D	AROUSAL	Obsession

The purpose of PTSD treatment:

Reduce the maladaptive intensity of the symptoms to levels that become adaptive tools.

Re-integrate dissociative features of mental functioning

The Central Nervous System: PTSD vs. Normal Functioning

When the brain’s limbic system (hippocampus and amygdale) suspects danger, it cues the Autonomic Nervous System (ANS) to activate the sympathetic nervous system and deactivate the parasympathetic system. During traumatic threat the hippocampus is suppressed (where memory is filed in time and space) and the amygdala is activated (where terror is remembered independent of time and space). In normal reexperiencing of trauma there is an appropriate balance between the hippocampus and the amygdala. In PTSD reexperiencing the amygdala influences more than the hippocampus.

When danger is real the normal functional response is an appropriate level of fight, flight or freeze. When danger is false (cued by PTSD) the response may be maladaptive including acute and chronic levels of fight, flight and/or freeze. The recurring response in the reexperiencing phase seems to replicate the remembered response for survival in the original trauma. I have mostly witnessed in many of my patients the freeze response in reexperiencing trauma reflecting the freeze response in the original trauma.

The autonomic nervous system operates in an either/or manner. Either the sympathetic (fight/flight/freeze) system dominates or the parasympathetic (rest and digest) system dominates. If the body is relaxed (parasympathetic) the processing of distressing material becomes tolerable as the sympathetic system has been suppressed. See dissociation.

Dissociation

Dissociation is the experience where a person may feel disconnected from himself and/or his surroundings. Dissociation may range from temporarily losing touch with things that are going on around you (like what happens when you daydream) to having no memories for a prolonged period of time and/or feeling as though you are outside of your body. Dissociation has been found to be a risk factor for developing PTSD. It has been shown that those with dissociative features are highly susceptible to hypnotic treatment.

Successful treatment needs to address the maladaptive dissociation and replace it with a more adaptive association. An example of maladaptive dissociation:

Maladaptive dissociation: The conscious mind may know that the sight of a low flying plane in an urban setting is normal yet the unconscious mind is reexperiencing trauma and the sympathetic system dominates. False alarm.

Maladaptive dissociation: The conscious mind may know that the sight of a low flying plane in an urban setting could be danger and the unconscious mind is relaxed causing the parasympathetic system to dominate. False complacency.

Adaptive association: The conscious mind may know that the sight of a low flying plane in an urban setting could be normal or dangerous and having the skills to allow the conscious mind to further assess the situation, the unconscious mind can respond appropriately whereby the pertinent sympathetic or parasympathetic system dominates.

Hypnosis and Hypnotherapy

Hypnosis is a natural process. It can be experienced automatically, self-induced or induced by another person. The hypnotic process suppresses the conscious mind and enhances the unconscious mind. The resulting state is more commonly known as trance. Trance is focused attention (association) implying there is remaining unfocused attention (dissociation).

For example you are at a concert. The lighting and your attention is focused on the performer while the rest of the auditorium is out of focus (dark) and out of your attention. You are in trance.

Other examples: Engrossed in a book or movie.

Daydreaming and unaware of here and now phenomena

Performing a creative act such as art, music or dance

Focusing on your athletic performance

Depending on the degree of focus or trance we have various trance state or depths.

Light trance: Slower, deeper breathing with eyes closed and relaxed muscle tone

Medium trance: Slower responses, Slumped, limp body, reduced awareness of surroundings

Deep trance: More pronounced manifestation of medium trance.

Hypnotherapy is the use of hypnosis by a trained professional for therapeutic purposes.

It is used by medical as well as mental health professionals and rather than used solely as a separate modality, its principles can are more often incorporated into other modalities

Milton Erickson and Hypnotherapy

Milton Erickson (1901-1980) is considered the twentieth century’s greatest contributor to the practice of hypnotherapy. As a psychiatrist, he pioneered the use of a more permissive style of treatment. Note that he incorporated the older authoritarian style of classic hypnosis and expanded it to include the permissive style. This is important in fitting the style to the patient’s individual needs. Many patients with PTSD had been traumatized by an authority figure and would be best served by a more collaborative, interactive style. This enhances the patient’s progress in mastering greater control in their functioning.

Ericksonian methods include the following features.

More listening to patient’s experiences, language style, preferences. This provides valuable material for the clinician to use in inducing trance and making therapeutic suggestions customized to the individual. It speeds up and enhances rapport and empathy.

Pacing and leading. Pacing refers to a present and apparent fact. This linked to leading making a more plausible expectation. “As you relax in this chair (pacing), you can let your mind consider how wonderful it will be when this issue is resolved (leading).”

Metaphors. It is very effective to use storytelling, metaphors, word play and embedding positive cognitions into the trance. The unconscious mind responds very well to suggestions. For example children who are particularly hypnotizable are more responsive to learning when their lessons are given via fairy tales and fables rather than didactic instructions. Metaphors work very well with patients having rich imaginations and may be creative in other areas of their lives.

Indirect suggestions tend to be accepted more readily than direct suggestions. Compare “Close your eyes in one minute” vs. “I wonder if you will close your eyes in one minute or two, it really doesn’t matter as your unconscious mind will just know what to do.” This removes the possibility the patient may think he is not doing it correctly and diminishes success expectations. It gives more control to the patient particularly one who has experienced lack of control from trauma.

Use of the body. Classic hypnosis assumes the patient needs to have eyes closed and be in a relaxed state. Ericksonian hypnotherapy encourages utilization of current reality as a resource. For example if a patient is fidgeting or resistant to relaxation allow or encourage the behavior (see pacing). If the patient chooses to keep their eyes open, use your own body language and facial expressions to enhance your suggestions.

Treatment Modalities Compared and Contrasted

The various modalities are more alike than different. The greatest difference is in nomenclature used in describing similar functions. All four modalities described are mutually compatible.

HYPNOSIS:

Differentiates between the conscious and unconscious mind

Integrates conscious and unconscious dissociation through trance.

Provides symptom relief

Integrates body and mind

Results with short term treatment

Allows for self treatment through self-hypnosis and trance recordings

No known side effects

EMDR:

Differentiates between the left and right brain

Integrates conscious and unconscious dissociation through bilateral stimulation.

Balances conscious and unconscious dissociation through cognitive reframing of conscious beliefs

Integrates body and mind

Results with short term treatment

Does not allow for self treatment

No known side effects

COGNITIVE:

Emphasizes the conscious mind

Generally requires long term treatment

Allows for self treatment by teaching cognitive reframing

No known side effects

PSYCHOTROPICS:

Chemically alters the reptilian brain

Provides symptom relief by reducing anxiety (reexperiencing) and depressive (avoidance) responses.

Generally requires long term treatment

Does not allow for self treatment

May have physical side effects and may affect true danger response

More Information

PTSD treatment using hypnosis

Effective treatments of PTSD: practice guidelines from the International Society fir traumatic Stress Studies / edited by E. B.Foa, T.M.Keane, Matthew J. Friedman. Chapter 12

Ericksonian Hypnotherapy

Trancework: an introduction to the practice of clinical hypnosis by M.D.Yapko

EMDR

Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures by F. Shapiro

Cognitive Therapy

Cognitive-behavioral therapies for trauma edited by V.M.Follette, J.I.Ruzek, F.R.Abueg

Psychotropics

Drug treatment for PTSD: Answers and questions in Annals of the New York Academy of Sciences Vol. 821 by M.J.Friedman

Referrals for patients

Robert Kupferman, LCSW www.rkhypnotherapy.com 917-517-2447

Training in Ericksonian Hypnosis

NYSEPH: The New York Milton H. Erickson Society for Psychotherapy and Hypnosis
Planetarium Station, PO Box 876, New York, NY 10024;.. Phone # 212-873-6459 www.NYSEPH.org

NEXT Training begins October 20, 2010.

Robert Kupferman, LCSW Bio

Education and Training

Columbia University: Master of Science in Social Work
New York Hypnosis Institute: Basic hypnosis training
New York Milton H. Erickson Society for Psychotherapy and Hypnosis (NYSEPH): advanced hypnotherapy
EMDR Institute: Basic Eye Movement Desensitization and Reprocessing
Albert Ellis Institute: Rational-Emotive & Cognitive-Behavioral Theory and techniques
St. Vincent’s Hospital Manhattan: Auricular acupuncture

Professional Credentials

NYSEPH: Member Board of Trustees, Treasurer, and Instructor in Clinical Hypnosis
ASCH: Certified in Clinical Hypnosis
New York State: Licensed clinical social worker (LCSW)
St. Vincent’s Hospital Manhattan, Trauma and Wellness Center: full time staff psychotherapist and hypnotherapist
NYC Department of Health and Mental Hygiene (NYCDHMH), Medical Reserve Corps (MRC): on call provider during times of mass emergency

Career Highlights

Specializes in trauma, depression, anxiety, grief, phobias, suicide prevention and addictions
Trains professionals in suicide prevention, disaster preparedness
Utilizes Ericksonian hypnotherapy, cognitive behavioral therapy, eye movement desensitization and reprocessing (EMDR), psychological first aid, and auricular acupuncture
Deployed as part of a select team of trauma experts working with evacuees of Hurricane Katrina, wounded soldiers returning from Iraq
Maintains insurance reimbursable private practice in hypnotherapy
Works with clients traumatized by the September 11 terrorist attack.

Memberships

American Society of Clinical Hypnosis (ASCH)
New York Milton H. Erickson Society for Psychotherapy and Hypnosis (NYSEPH)

The Use of Ericksonian Hypnotherapy

in the Treatment of PTSD

And its relationship to EMDR, Cognitive and Psychotropic Modalities

Seminar presented by Robert Kupferman, LCSW

to staff of Mt. Sinai Hospital WTC MMTP and MHIP

on August 20, 2010.

At the end of this seminar, attendees will be able to:

1. Understand the basic concepts of hypnosis and Ericksonian hypnotherapy.

2. Understand the role of Ericksonian hypnotherapy and its compatibility with other treatment modalities in treating PTSD.

PTSD: Clinical Definition

The diagnostic criteria for PTSD, stipulated in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV-TR), may be summarized as:

A: Exposure to a traumatic EVENT

This must have involved both (a) loss of "physical integrity", or risk of serious injury or death, to self or others, and (b) an intense negative emotional response. (DSM-IV).

B: Persistent REEXPERIENCING

C: Persistent AVOIDANCE and emotional numbing

This involves a sufficient level of:

avoidance of stimuli associated with the trauma, such as certain thoughts or feelings, or talking about the event(s);
avoidance of behaviors, places, or people that might lead to distressing memories;
inability to recall major parts of the trauma(s), or decreased involvement in significant life activities;
decreased capacity (down to complete inability) to feel certain feelings;
an expectation that one's future will be somehow constrained in ways not normal to other people.

D: Persistent symptoms of increased AROUSAL not present before

These are all physiological response issues, such as difficulty falling or staying asleep, or problems with anger, concentration, or hypervigilance.

PTSD and Normal Functioning

In the normal course of our lives an EVENT happens. We can refer to this as a STIMULUS.

We integrate the experience by REMEMBERING.

We edit the experience by FORGETTING.

We make meaning of the experience to be better PREPARED.

PTSD as a clinical diagnosis is really an intensified version of the above. The normal becomes abnormal and interferes with normal functioning.

With PTSD the EVENT was catastrophic and the STIMULUS intensifies as the STRESSOR.

REMEMBERING becomes REEXPERIENCING.

FORGETTING becomes AVOIDANCE.

PREPAREDNESS becomes AROUSAL.

NORMAL	EMOTION	PTSD Symptom Cluster	PTSD	EMOTION
STIMULUS		A	STRESSOR EVENT
REMEMBERING	Curious	B	REEXPERINECING	Anxiety
FORGETTING	Editing	C	AVOIDANCE	Depression
PREPAREDNESS	Focused	D	AROUSAL	Obsession

The purpose of PTSD treatment:

Reduce the maladaptive intensity of the symptoms to levels that become adaptive tools.

Re-integrate dissociative features of mental functioning

The Central Nervous System: PTSD vs. Normal Functioning

Dissociation

Successful treatment needs to address the maladaptive dissociation and replace it with a more adaptive association. An example of maladaptive dissociation:

Maladaptive dissociation: The conscious mind may know that the sight of a low flying plane in an urban setting is normal yet the unconscious mind is reexperiencing trauma and the sympathetic system dominates. False alarm.

Maladaptive dissociation: The conscious mind may know that the sight of a low flying plane in an urban setting could be danger and the unconscious mind is relaxed causing the parasympathetic system to dominate. False complacency.

Adaptive association: The conscious mind may know that the sight of a low flying plane in an urban setting could be normal or dangerous and having the skills to allow the conscious mind to further assess the situation, the unconscious mind can respond appropriately whereby the pertinent sympathetic or parasympathetic system dominates.

Hypnosis and Hypnotherapy

For example you are at a concert. The lighting and your attention is focused on the performer while the rest of the auditorium is out of focus (dark) and out of your attention. You are in trance.

Other examples: Engrossed in a book or movie.

Daydreaming and unaware of here and now phenomena

Performing a creative act such as art, music or dance

Focusing on your athletic performance

Depending on the degree of focus or trance we have various trance state or depths.

Light trance: Slower, deeper breathing with eyes closed and relaxed muscle tone

Medium trance: Slower responses, Slumped, limp body, reduced awareness of surroundings

Deep trance: More pronounced manifestation of medium trance.

Hypnotherapy is the use of hypnosis by a trained professional for therapeutic purposes.

It is used by medical as well as mental health professionals and rather than used solely as a separate modality, its principles can are more often incorporated into other modalities

Milton Erickson and Hypnotherapy

Ericksonian methods include the following features.

More listening to patient’s experiences, language style, preferences. This provides valuable material for the clinician to use in inducing trance and making therapeutic suggestions customized to the individual. It speeds up and enhances rapport and empathy.

Pacing and leading. Pacing refers to a present and apparent fact. This linked to leading making a more plausible expectation. “As you relax in this chair (pacing), you can let your mind consider how wonderful it will be when this issue is resolved (leading).”

Metaphors. It is very effective to use storytelling, metaphors, word play and embedding positive cognitions into the trance. The unconscious mind responds very well to suggestions. For example children who are particularly hypnotizable are more responsive to learning when their lessons are given via fairy tales and fables rather than didactic instructions. Metaphors work very well with patients having rich imaginations and may be creative in other areas of their lives.

Indirect suggestions tend to be accepted more readily than direct suggestions. Compare “Close your eyes in one minute” vs. “I wonder if you will close your eyes in one minute or two, it really doesn’t matter as your unconscious mind will just know what to do.” This removes the possibility the patient may think he is not doing it correctly and diminishes success expectations. It gives more control to the patient particularly one who has experienced lack of control from trauma.

Use of the body. Classic hypnosis assumes the patient needs to have eyes closed and be in a relaxed state. Ericksonian hypnotherapy encourages utilization of current reality as a resource. For example if a patient is fidgeting or resistant to relaxation allow or encourage the behavior (see pacing). If the patient chooses to keep their eyes open, use your own body language and facial expressions to enhance your suggestions.

Treatment Modalities Compared and Contrasted

The various modalities are more alike than different. The greatest difference is in nomenclature used in describing similar functions. All four modalities described are mutually compatible.

HYPNOSIS:

Differentiates between the conscious and unconscious mind

Integrates conscious and unconscious dissociation through trance.

Provides symptom relief

Integrates body and mind

Results with short term treatment

Allows for self treatment through self-hypnosis and trance recordings

No known side effects

EMDR:

Differentiates between the left and right brain

Integrates conscious and unconscious dissociation through bilateral stimulation.

Balances conscious and unconscious dissociation through cognitive reframing of conscious beliefs

Integrates body and mind

Results with short term treatment

Does not allow for self treatment

No known side effects

COGNITIVE:

Emphasizes the conscious mind

Generally requires long term treatment

Allows for self treatment by teaching cognitive reframing

No known side effects

PSYCHOTROPICS:

Chemically alters the reptilian brain

Provides symptom relief by reducing anxiety (reexperiencing) and depressive (avoidance) responses.

Generally requires long term treatment

Does not allow for self treatment

May have physical side effects and may affect true danger response

More Information

PTSD treatment using hypnosis

Effective treatments of PTSD: practice guidelines from the International Society fir traumatic Stress Studies / edited by E. B.Foa, T.M.Keane, Matthew J. Friedman. Chapter 12

Ericksonian Hypnotherapy

Trancework: an introduction to the practice of clinical hypnosis by M.D.Yapko

EMDR

Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures by F. Shapiro

Cognitive Therapy

Cognitive-behavioral therapies for trauma edited by V.M.Follette, J.I.Ruzek, F.R.Abueg

Psychotropics

Drug treatment for PTSD: Answers and questions in Annals of the New York Academy of Sciences Vol. 821 by M.J.Friedman

Referrals for patients

Robert Kupferman, LCSW www.rkhypnotherapy.com 917-517-2447

Training in Ericksonian Hypnosis

NYSEPH: The New York Milton H. Erickson Society for Psychotherapy and Hypnosis
Planetarium Station, PO Box 876, New York, NY 10024;.. Phone # 212-873-6459 www.NYSEPH.org

NEXT Training begins October 20, 2010.

Robert Kupferman, LCSW Bio

Education and Training

Columbia University: Master of Science in Social Work
New York Hypnosis Institute: Basic hypnosis training
New York Milton H. Erickson Society for Psychotherapy and Hypnosis (NYSEPH): advanced hypnotherapy
EMDR Institute: Basic Eye Movement Desensitization and Reprocessing
Albert Ellis Institute: Rational-Emotive & Cognitive-Behavioral Theory and techniques
St. Vincent’s Hospital Manhattan: Auricular acupuncture

Professional Credentials

NYSEPH: Member Board of Trustees, Treasurer, and Instructor in Clinical Hypnosis
ASCH: Certified in Clinical Hypnosis
New York State: Licensed clinical social worker (LCSW)
St. Vincent’s Hospital Manhattan, Trauma and Wellness Center: full time staff psychotherapist and hypnotherapist
NYC Department of Health and Mental Hygiene (NYCDHMH), Medical Reserve Corps (MRC): on call provider during times of mass emergency

Career Highlights

Specializes in trauma, depression, anxiety, grief, phobias, suicide prevention and addictions
Trains professionals in suicide prevention, disaster preparedness
Utilizes Ericksonian hypnotherapy, cognitive behavioral therapy, eye movement desensitization and reprocessing (EMDR), psychological first aid, and auricular acupuncture
Deployed as part of a select team of trauma experts working with evacuees of Hurricane Katrina, wounded soldiers returning from Iraq
Maintains insurance reimbursable private practice in hypnotherapy
Works with clients traumatized by the September 11 terrorist attack.

Memberships

American Society of Clinical Hypnosis (ASCH)
New York Milton H. Erickson Society for Psychotherapy and Hypnosis (NYSEPH)

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D: Persistent symptoms of increased AROUSAL not present before

D: Persistent symptoms of increased AROUSAL not present before

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