Functional Purpose: A Psycho-Semantic Approach To Auditory Hallucinations
This paper presents elements of the Psycho-Semantic model in relation to auditory hallucinations, and its value in hypnotherapeutic treatment. This paper was first presented at the 'Hearing Voices' Conference run by the Discourse Unit, Department of Psychology and Speech Pathology, Manchester Metropolitan University, on July 8th 1995. This paper was published in proceedings of Conference and was subsequently re-published in the European Journal of Clinical Hypnosis (Volume 3, Number 2, 1996).
Author: M.J.L. Garrett, Director, Psycho-Semantics Institute, Southampton
The purpose of this paper is to show how and why, aspects of the Psycho-Semantics Model are relevant and useful for the treatment of spontaneous auditory hallucinations. The PS model comprises an integrated structure of theoretical sub-models, conceptual devices and an operational methodology. The total PS model is outside the scope of this paper, so only those aspects germane to spontaneous auditory hallucinations will be described. Some of the terminology used has a very specific definition within the PS model. All such terminology will be defined as it is introduced. The paradigm presented here derives from communication theory (Watzlawick. Bavelas & Jackson 1967) which treats behavioural and cognitive symptoms as communications.
The paper begins with a brief explanation of our working models of:
the conscious/unconscious processes;
the state commonly known as hypnosis;
and the phenomena of spontaneous auditory hallucinations.
The paper then addresses functional purpose and it's application to 'voices', before describing, in brief, the operational methodology used. Finally, two case histories are detailed, demonstrating the model in action. Working model of the conscious/unconscious processes
The model of the mind used in this paper, is that of a system of inter-connected processes with a variable boundary between those normally described as 'conscious' (or in awareness) and those that are seen as 'unconscious' (or out-of-awareness). The nominalisation of these process-descriptions, and the subsequent semantic confusion between the verb meaning (i.e., being 'conscious' of) and noun meaning (i.e., the 'conscious' observer) makes the subject replete with confusion. To clarify the confusion we shall utilise the computer metaphor.
In a computer, the programs (software) can also be categorised as in or out of 'awareness', if the human/machine interface is seen as the 'observer'.
The boundary between the 'in' and 'out' of awareness processes is constantly changing depending on what is 'system-critical'. Although made up of semi-autonomous processes, the 'unconscious' acts as a co-ordinated structure with homeostasis as it's primary goal. One definition of dysfunction is an instability in the normal negative feedback mechanisms that maintain homeostasis (Watzlawick, Bavelas & Jackson 1967).
To summarise the above: the 'unconscious' is here defined as 'thinking processes not available to conscious examination at a given moment'. This necessarily includes motor and sensory systems as well as cognitive processes. Awareness of unconscious processes is manifest as internally observable affect and thought, and externally observable behaviour.
Working model of hypnosis
Hypnosis is usually defined as: a state of awareness induced by specific techniques and affecting changes in thought, perception, and behaviour. (Hassett & White 1989).
After two centuries of controversy it is still the subject of much dispute. Social theories of hypnosis, such as those propounded by Orne & Evans (1965) and Barber (1969 & et al 1974) contend that the 'hypnotised' subject is attempting to conform to the social role defined by the situation and the demands of the hypnotist. These theories have most often been tested by comparing populations of hypnotised and simulating subjects. The researchers then show the impossibility of identifying the respective populations from their behaviour (Orne 1971). This methodology is subject to several flaws. Firstly, it has been shown that the act of simulating trance is a very useful technique for actually inducing trance (Erickson 1980a). This implies that even a simulating population could actually be in trance. Secondly, the argument of social compliance applies equally to the reverse situation. A hypnotised subject subjectively convinced that he/she was not hypnotised, in order to please the researcher. The only 'proof' of the subject's non-hypnotised state is the self-report. Even in non-hypnotised subjects, the validity of internally experienced phenomena is highly prone to mis-interpretation (e.g., the drunk who is convinced that he is sober). In the author's opinion, more common-sense objections, to social compliance theories, come to mind when watching major surgical procedures being carried-out under hypnosis, and without anesthetic.
A commonly-held belief is that hypnosis is synonymous with suggestibility. In his first published paper, Erickson (1932) described experiments with over 300 subjects in thousands of trance situations where "hypersuggestibility was not noticed". He believed that hypnotic suggestion is a process of evoking and utilising a subject's own mental resources in ways that are outside the subject's awareness (Erickson & Rossi 1976).
Hilgard (1977) proposed that consciousness was capable of being split into several distinct and simultaneous streams of mental activity. Under hypnosis one of these streams handles thought and behaviour while another stream handles conscious awareness and voluntary control. This is similar to the 'parallel processing' concept in the computer field. Hilgard asked hypnotised subjects to submerge their arms in ice-water. They were then asked to report their level of conscious pain verbally and allow their unconscious to report separately via an arm, hand and pencil. The latter were to be maintained "out-of-awareness". The discrepancy between the separately reported levels of pain suggests that the unconscious part of the mind can register increasing pain while the conscious awareness of it remains low and static. It is interesting to note that hypnotised subjects show a consistently increased ability to ignore pain (Hilgard1969). Hilgard's description of hypnosis as a discreet state of dissociated awareness has been included in our model. It is also useful for describing the processes underlying auditory hallucinations.
The second explanation of hypnosis that has been incorporated into our model is the Generalised Reality-Orientation concept first proposed by Shor in 1959 (see Shor 1969). This model holds that humans have a 'background awareness' (designated the Generalised Reality-Orientation or GRO) against which to measure events and implement operative-decision-making. This reality-orientation is an abstractive superstructure of ideas and relationships based on a structured complex of recollections. From its totality are derived various concepts and functions including: reality-testing; body-image; critical self-awareness; and cognition of self, others, the world, time, place, and purpose. This reality-orientation is continually being updated by new information and experiences and so is constantly in a process of flux. In normal waking consciousness, when specific aspects of this reality-orientation are in cognitive focus, the remainder of the GRO is kept in close communication, forming a 'ground' to the relevant element being attended to. Shor proposed that "any state in which the [GRO] has faded to relative nonfunctional unawareness may be termed a trance state" (Shor 1969).
Summarising the above; hypnosis is a discreet state of dissociated awareness. This state is produced by a process by which the attention is focused on a particular set of events (internal or external) leading to a relative 'fading' of the GRO from awareness. The mind then becomes free to substitute an alternative reality-orientation that can be used therapeutically to explore creative possibilities. Any system-useful changes in the derived concepts and functions, can then be reintegrated into the GRO. In the hypnotic state a dissociation can exist between simultaneous alternative reality-orientations that are normally mutually exclusive.
Working model of spontaneous auditory hallucinations
Before dealing with spontaneous and dysfunctional aspects of auditory hallucinations, it is worth putting the subject in context. Hypnosis is one of the few fields in which auditory hallucinations are anything but 'spontaneous'. They are designated as such, here, to differentiate them from intentionally produced hypnotic phenomena.
'Voices' are usually seen as 'abnormal' because
1) they are experienced as dissociated phenomena and out of conscious control;
2) they are part of a non-consensual reality-orientation (exceptions are 'voices' perceived as being within the domain of spiritualism, shamanism or divine communication etc.).
Definitions of 'normality' that exclude dissociative, or non-volitional, experience, ignore just how common these phenomena are among a so-called 'normal' population. Examples in the auditory field are: misheard words; internal dialogue; and 'the phone that wasn't ringing'. Their are many more examples in other fields of sensory awareness. In the field of motor-activity, for instance, there is the 'involuntary shiver' experienced listening to a frightening tale. In the field of hypnosis, non-volitional sensory and motor phenomena have been used extensively for over a century and are referred to as ideo-sensory or ideo-motor responses (Bernheim 1886 & Rossi 1986). Even our common definition of 'volition' as a purely 'conscious' phenomena is the subject of much vexed debate (Dennett 1991).
These 'internal communications' become meaningful to the subject when viewed against the current GRO, and the expectations and interpretations derived from it. In the psycho-semantic model we have designated the latter two functions, jointly: perceptual filters.
Signal detection experiments (Galanter 1962) have shown how much expectations and motivation can influence the perceptual processes. Milton Erickson, (Erickson 1980b), demonstrated to what extent expectations and interpretations can affect the perceived audition of stimuli. Subjects were asked to watch a silent pendulum, though told it would make a sound. A click was produced from a second pendulum, out of the subject's view. Then the subject's ears were blocked and the sounding pendulum stopped. They were instructed (by written message) to watch the visible pendulum closely and notify the experimenter when they could first hear a sound. The subjects' ears were then progressively unblocked. In every case, the subjects hallucinated sound.
Experiments on "perceptual defences" (McGinnies 1949) demonstrate that unconscious processes can also pre-select what is to be presented to conscious awareness. McGinnies showed that subjects do not perceive emotive words at the same rate as they perceive non-emotive words. The essential point here is that the subject must cognise the word before selecting or rejecting it's perception at a conscious level.
To the role of an active filtering mechanism can be added another, even more powerful, function. Few would disagree that the assembly of linguistic structures by the unconscious is one of immense complexity (Chomsky 1986, Pinker 1994). Given our almost total dependence on these unseen processes, it is strange that we consider (linguistic) thinking a primarily volitional phenomena.
In our model, two conditions are necessary to make spontaneous auditory hallucinations dysfunctional (and therefore candidates for treatment):
1) the hallucinatory phenomena must inhabit a GRO that makes them a perceived threat to the recipient
2) the phenomena must disrupt the consensual social reality-orientation enough to make full duplex relationships difficult or impossible.
The key feature of spontaneous auditory hallucinations is the recipient's conscious awareness of the communications. The perceptive filter used by the recipient to interpret the phenomena, determines the degree of dysfunctionality experienced. The latter can define the communication as externally or internally originated and normal or abnormal. For example, contrast our usual reaction to an involuntary shiver with the expectations and interpretations we might have if we believed it to be the first sign of demonic possession.
Both 'voices' and hypnosis are considered dissociated phenomena, so the latter is regarded as useful in exploring and resolving the former.
Functional Purpose: A Conceptual Device
Before considering 'Functional Purpose' it is necessary to define the purpose of conceptual devices, of which this is an example. Conceptual devices are used to alter, subtly, the perceptual filters through which we view the world. When cultivated as a 'habit of mind', conceptual devices change our frames of reference. This enables the therapist to ask new questions, form new explanations and devise new treatments for presented symptomology. The 'functional purpose' conceptual device proposes that all behavioural and cognitive events are purposive. No intentional entity, other then the event itself, is required. A conceptual device, very similar to this, is used by researchers working in the biological sciences. Here, the intentional entity is called 'nature' or 'natural selection'.
The functional purpose of an event is either the result achieved by that event, or the non-achieved result that then (usually) requires repetition of that event. For example, the functional purpose of a hiccup is to clear an irritation in the gut. When this has been achieved the hiccups cease. If this is not achieved then the event reoccurs. In general, a therapist is dealing with non-achieved functional purpose.
To resort again to the computer metaphor, all computer programs, either background (out-of-awareness) or foreground (in-awareness) have objectives or purposes. A program is made up of a series of injunctive statements, each of which has a 'micro-objective'. When anomalous information is displayed, or the computer 'freezes', it is because there has been:
1) a conflict has arisen between two or more objectives without an adequate resolving mechanism;
2) a program micro-objective has failed without a recovery route.
The standard operator response to the above non-achieved objectives is either to restart the program or restart the computer. Should this fail to resolve the conflict, the problem will reoccur and a detailed investigation of the conflicting objectives, or the micro-objective that failed, will have to be made. In computer terminology this is referred to as 'debugging'. This whole recovery process is analogous, in human terms, to initially attempting to restore the GRO ('talk some sense into someone', or 'bring them down to earth'). If that fails, then the human cognitive system needs 'debugging'. Therapy is called for. In our model this is undertaken by investigating the anomolous information/behaviour and seeking it's potential functional purpose with the objective of negotiating alternative ways of achieving it. Often the process of uncovering a functional purpose and acknowledging it's importance enables the subject's own 'resolution apparatus' to 'kick-in' and finish the process by itself.
Firstly, a complete problem-description is obtained and a mutually agreed set of outcomes established. It is important in this form of treatment that the subject's needs are listened to and incorporated.
Next, candidate functional purposes are established. The simplest (and most commonly used) technique for achieving this, is to reproduce the 'voices' in situ, under hypnosis if necessary, and ask them what they are trying to achieve. Meeting the subject at their 'model of the world' is a fundamental principle in the adaptive form of psychotherapy pioneered by Erickson (Erickson & Zieg 1980).
Where co-operation is less than optimal, the therapist has to analyse the 'form' in which the communications are expressed. 'Form' here includes internal logic and the linguistic structure of the communication. Special attention is given to word choice, metaphoric content, subject/object relations, sensory predicates, absent referential indices and temporal/spacial descriptors. Analysis of 'form' enables the therapist to linguistically 'pace' or 'match' the subject's internal reality. Erickson, successfully treated a psychotic in-patient who had spoken nothing but 'word salad' for five years, by transcribing, analysing and feeding-back his speech patterns (Lankton & Lankton 1983).
Having 'entered the subject's world' we are then in a position to question purpose and negotiate alternative solutions. The latter is usually accomplished using a combination of overt, and covert communication. Covert communication is here defined as a set of communication devices designed to evoke, mobilise and move the subject's associative processes in a therapeutic direction (Erickson, Rossi & Rossi 1976).
Finally, the therapeutic movement is validated by reference to identifiable changes in client affect (kinaesthetics) and/or symptomology.
This was a professional man in his early thirties. His opening comments to the author were: "I don't know if I should be seeing you, a spiritualist or a psychiatrist". Two years before, C. had split-up with his partner. Their relationship had been less than harmonious from the beginning. She was, apparently, a long-time sufferer from depression and this break-up was the last of many attempts to separate. Two days later she committed suicide. C. felt that he had been through a reasonable period of grieving and then had got on with his life.
The first sign of her 'return' was when C. entered a lift at the top of a multi-storey office block. As the lift began to descend he became aware of a powerful perfume that he identified as the one his partner had used. Exiting the lift at the ground floor, he convinced himself that someone else, wearing that particular perfume, must have been in the lift before him. A week later, while walking through a department store he heard female laughter behind him. It sounded just like that of his partner. Turning round, he was shocked to find that no-one was anywhere near him. Within a few days he was hearing her voice around the house and shortly afterwards she was commenting on his actions daily wherever he happened to be. C.'s problem was mainly cognitive and kinaesthetic with no discernible trigger event. C. described the feelings caused by the 'voices' as "like a weight across my shoulders". His question: "Am I going mad or am I being haunted?" summed-up his cognitive focus.
The author explained to C. that it was irrelevant whether the 'voices' were the product of a haunting or internally generated as, for the purposes of therapy, either would be treated in the same way. C. proved to be a good trance subject and once an adequate level had been achieved, he was told that when he opened his eyes, his ex-girlfriend would be seated opposite him. He was also told that he could remain calm and detached throughout the experience. Once C. had confirmed that she was 'apparent' to him, the author explained that he was unfortunately unable to communicate directly with her and asked C. to relay the communication in both directions. The author, through C., asked her to explain her reasons for returning. Through C. she said that he had left a lot of things undone. C. said that he had no idea what she meant. The remainder of this session, and the four successive sessions, were taken-up with teasing-out more information in the same way. It was observed that C. took very readily to this mode of 'communication' and gravitated slowly from a cautious listening role to one of active participation. The kinaesthetic 'weight' lifted slowly during the course of therapy.
At the beginning of the fifth session C. said that his ex-girlfriend had 'visited' him in a dream and told him that she was leaving for good. She wished him well for his future, and said that there was no need for him to feel guilty any longer. No 'voices' were heard after this and there had been no recurrence at the time of a follow-up call, six months after the termination of therapy. We can speculate that the cause of the 'haunting' was unresolved guilt. Perhaps because C. felt he could have done more to help her, or maybe because his grief was felt to be inadequate. One of the features of this form of therapy is that the therapist's curiosity regarding causes is seen as unnecessary to a successful resolution.
[Although this subject's hallucinations were visual as well as auditory their main effect was verbal]
G. was an unemployed man in his mid-twenties. For a period of a year he believed he was being followed around by two human-sized green lizards. He had been treated by psychiatrists and was referred to the author by a mutual acquaintance. His laconic approach to the 'lizards' (more of a nuisance than a threat) meant that his problem could be diagnosed as dysfunctional from a social point-of-view with little kinaesthetic content. G.'s perception of the 'lizards' was that they had "manifested themselves from another dimension".
In the first session the author asked G. if the 'lizards' were present in the consulting room. G. said that one was seated in a chair and the other was leaning up against a door smoking a cigarette. The author then asked if they would be prepared to talk to him via the subject. G. said that they were but that they couldn't see much point in it. The author asked them why they were following G. around. They answered that he needed protecting from himself. The author then asked why and they replied that he was too trusting. The author asked G. if he agreed with this. G. said he had been "taken advantage of" many times and particularly by his last partner who had left him for someone else prior to the appearance of the 'lizards'. The author asked G. why he felt he had been treated like that and he said that he felt socially inadequate. More specifically, he felt he lacked a sense of humour and was not very "streetwise". In the remainder of this session it became apparent that the 'lizards' could be described as being very 'streetwise' and they manifested a very dry sense of humour. Their 'attitude' to G., seemed to be a mixture of concern and wittily sarcastic criticism. Adopting both the tone and linguistic style of the lizards the author drew them into a discussion of G.'s apparent faults.
The functional purpose of the 'lizards' presence seemed to be to compensate for these perceived defficiencies. Since G. deferred to the 'lizards' it was seen as vital to obtain their co-operation. In the next session a good relationship was built up between the author and the 'lizards' and on the third session they were asked if they objected to G. being hypnotised. They agreed and once a good level of trance was achieved G. was guided through a visualisation in which he joined the 'lizards' in their 'home dimension' and allowed them to teach him what he was missing in his life. A similar process was followed in sessions four and five.
It was noticed that G.'s manner was becoming more confident so in session six he was hypnotised and taken on a 'journey' into his future where the 'lizards' could remain invisible while giving him any advice they regarded as necessary. When G. arrived for session seven his manner had changed dramatically and he remarked that he "had never felt better". When the author began to question the 'lizards' G. confessed that they were no longer with him. They had left after saying that they were "bored with this dimension". Three more sessions were required to consolidate G.'s self-confidence and a year later, in a chance meeting, G. asked the author not to mention the 'lizards' in front of his friends (an unnecessary injunction). He revealed that not only had they never returned but he now felt embarrassed at his own "delusions". He has since married and now has a baby girl.
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A Clinical Study of Anorectic Recovery Using Hypnosis-Aided Psychotherapy
This paper was first published in the European Journal of Clinical Hypnosis, Volume 3, Number 3, Issue 11, 1966.
Authors: M.J.L. Garrett, Debbie Brooke
The purpose of this paper is to demonstrate the speed and effectiveness of the hypnosis-aided cognitive/behavioural approach when contrasted with more common treatments for eating disorders.
The client's preceding N.H.S. outpatient treatment consisted of:
1) Monitoring of weight and blood
2) Bone densitometry scans
3) Diet management
4) Supportive Counselling
Other treatments undergone by the subject of this paper over the prior thirteen years:
1) Occupational therapies (crotchet etc.)
2) Group therapy
3) Telephone support (from a recovered anorexic)
In the client's view, only the telephone support had any direct effect on the problem, and that was mainly to offer hope (of eventual recovery). No prior treatment had a lasting effect on the symptomology (the client had actually dropped four Kg overall during the preceding phase of treatment).
N.H.S. resources are under much pressure. When available, a typical N.H.S. weight-gain programme takes around fourteen weeks. This comprises six weeks as an in-patient (24 hour care), plus eight weeks of day care (eight hours per day). The therapy usually focuses on the physical/medical aspects of the problem. Typically, these would include a mixture of 'reality-oriented group therapies' (i.e. practical training in cookery, living skills, communications, leisure, assertiveness); occupational therapies and some support in the form of counselling and/or group discussion. A diet of around 3000 calories is usually specified, toilet facilities are restricted, and clients are expected to gain around 1Kg to 1.5 Kg per week.
To obtain additional psychotherapy within the N.H.S., six-month waiting lists are not uncommon, and what is on offer still tends to be restricted to the longer term 'talking cures' like analytic or insight oriented psychotherapy and group psychotherapy. These are probably not the ideal tools for a situation where time is critical and money for extended help is scarce. Short term solution-focused approaches could be instrumental in easing this log-jam. It is the authors' hope that therapists using this style of therapy will be asked to demonstrate its speed and cost-effectiveness more often.
The authors would like to thank the N.H.S. personnel involved, for their co-operation and assistance in making this study possible. Specifically, Denis Cremin, Nurse Practitioner at the Annexe, St. Georges Hospital (the client's hospital keyworker), and Dr. Bakhru, the client's G.P. They would also like to thank the client for permitting her very personal transition to be shared with such a wide audience.
The principal model of therapy the authors are using is Psycho-Semantics.
The Psycho-Semantics Approach
PS is one of the family of therapies known as Brief, Strategic or Solution-Focused. It integrates elements of Ericksonian Hypnotherapy; General Semantics; Systems Theory and Neuro-Linguistic Programming (NLP). The whole model is beyond the scope of this paper so only those aspects germane to it will be described.
The PS model comprises an integrated structure of theoretical sub-models, conceptual devices and an operational methodology. Conceptual devices are tools that are used to alter, subtly, the way the therapist views the problem. Conceptual devices need have no provable objective reality. The value of a conceptual device is empirically established by its results. When cultivated as a 'habit of mind', conceptual devices change the therapist's frame of reference. This altered viewpoint enables the therapist to ask new questions, form new explanations and devise new treatments for presented symptomology.
In the PS model, client problems are defined as rigid patterns of thought, behaviour, or emotional-response that require the introduction of new elements to enable more flexible patterns to develop. The therapist looks at how the problem manifests in the clients life, and what factors keep it in place. One of the fundamental axioms of the PS model is that the client and their problems are distinct entities. Problems can be classified, clients are unique.
The first conceptual device used here, 'Functional Purpose', has been detailed in this publication before (see issue xx, volume xx) Briefly, the therapist assumes that all symptomology is purposive. No intentional entity, other then the cognitive/behavioural event itself, is required. 'Functional Purpose' is not necessarily the same as Secondary Gain, or the NLP concept of 'positive intention' as both the latter assume some tangible benefit to the client.
Having agreed specific success criteria with the client, the therapist begins by analysing the factors that maintain the problem state and assesses the functional purpose of the symptomology.
Once a potential functional purpose has been identified, the therapist's next task is to satisfy or (in this case) remove the need for it. A second conceptual device is used here to assist the PSI therapist in choosing the specific intervention structures required. Client problems are seen as manifesting three 'forms of stuckness'; three reasons for an inability to move forwards towards an objective. These three are: block; cyclic and oscillating. A block is a psychological 'brick wall' in the client's path; cyclic stuckness is a repetitive pattern that never resolves (e.g. continually having the same argument); and the oscillating form of stuckness is a conflict between two opposing cognitive stances. Conceptualising the problem in this way suggests specific 'families' of techniques.
Many conclusions concerning the originating causes and/or the effects of the familial dynamics could be drawn from this study. Any similar speculation by the authors has been held in the background as, in this model, it has only a marginal effect on the actual choice of interventions.
Stella (not her real name) was a young woman aged 29 years. Her presenting demeanour was childlike in posture, gesture, tonality and speech patterns. She was unwilling to make eye-contact, was easily reduced to tears and was self-deprecating to the point of aggressiveness. For the nine months preceding this study, she had been attending the Annexe of St. Georges Hospital, London, as an outpatient of the Eating-Disorders Clinic. Her weight on referral was 43 Kg (one year before) and on presentation to the PS therapist this had dropped to 39Kg.
Her behaviour was strongly obsessive/compulsive. She continuously weighed herself and weighed or measured any food she consumed and was phobic about not doing-so. She had an irrational abhorrence of fat in any form and scrutinised packet information to ensure she didn't inadvertently consume any.
Her current relationships with her family were strained. Stella has an Asian mother and an English father who was an evangelical missionary in Pakistan when they married. Both parents are very religious Christians. Stella has had trouble coming to terms with the Pakistani social structure within the family (her mother never goes out on her own and performs in an essentially subservient role to husband). Her father even 'arranged' his own marriage according to Pakistani custom. Stella was 'frightened' of the authority she perceived within her father, though he came across as being of a very gentle nature. She constantly argued with her father and yet seemed to require his permission for anything significant. He stated at one point that he would not regard her as a grown-up until she reached nine and a half stone.
The core treatment programme began on the client's second session and continued for a further seven weeks at one or two sessions per week. What follows has been necessarily edited for the sake of brevity.
As Stella had approached the therapist independently, it was agreed that the therapist should contact the hospital, and her GP, to obtain their agreement to a dual approach, thus ensuring the continuity of Stella's medical care and monitoring.
In discussion with her GP the therapist had discovered that Stella was at risk of losing consciousness at any time. The results of a recent blood test had shown Stella's physical condition to be critical. There was strong evidence that the liver was secreting enzymes harmful to the clients muscles and major organs, including the heart. She had dropped 2 Kg, bringing her weight down to 37 Kg.
If she could not increase her food intake, her only chance of survival was to be admitted to hospital. However, there was no guarantee she would be admitted to a unit specialising in eating disorders. She would be more likely to end up in a general ward, or at best in a psychiatric ward, which neither her GP or hospital therapist considered in her best interests. It was agreed with the GP that the PS therapist could take responsibility for Stella's diet and, if he were able to see her condition at least stabilise within the next 7 days, admittance to hospital could be postponed. Stella agreed to this happening. At the same time, the therapist insisted that Stella stop all exercise at the gym (previously she had been working out for 1hr.20min prior to allowing herself to eat), no bike-riding, walking, or housework. This she also accepted.
Stella described how at 16 she was sexually assaulted by a friend of the family and although they severed all links with the person concerned, she was still punished for this 'transgression'. Also around this time, she was threatened with an iron bar (by her father) for not eating her food. Her problems stem from this time in her life. She had expressed an aversion for the physical aspects of maturation including menstruation, breasts, adult female shape and pubic hair. She commented "Perhaps I am doing this to myself so that no-one will find me attractive". The therapist considered staying pre-pubescent (sexually unavailable) to be the prime 'functional purpose' in this case.
The first significant intervention was to dissociate and separate out the anorectic behaviour, and mind-set, from the client's sense of identity. This dissociative approach was suggested by the oscillatory nature of much of the client's cognitive/behavioural experience. In this technique the client is encouraged (while in light trance) to separate her problem 'part' from her healthy 'part' and give them both identities. Stella discovered the part called 'Anorexia' through the 'Healthy Part'. Anorexia refused to speak to the therapist directly. The Healthy Part, was able to describe Anorexia as: female, round in shape with a protruburence, many arms, red eyes, with fangs and totally black in colour. Anorexia also pulsated, had no legs, only feet, and found difficulty in walking. The Healthy Part, was also female, more human in shape, red in colour, wearing a white T-shirt and with mid-length brown hair. Although she was smiling, her face was unclear. In trance, Stella found Anorexia and the Healthy Part on a beautiful beach. Anorexia was facing the Healthy Part, who had her back to Anorexia. The client noticed that the T-shirt was becoming whiter, and at this point was able to allow the Healthy Part to float upwards, develop wings and remain airborne. Once in the air, she was able to reduce Anorexia in size, and then allow the tide to begin to come in. At this point Anorexia spoke, only to say "I do not swim". The client continued to allow the tide to come in until Anorexia was almost completely submerged, Although Anorexia did not drown, she was unable to come out of the water. This is where Anorexia remained until the next session, allowing the Healthy Part to take in more food without much interference.
The outcome of this intervention was that the therapist succeeded in introducing a more balanced diet and reducing the client's fluid intake (previously 6-8 litres of water per day, used as an appetite suppressant) With the reduction of fluids, the client began to experience the sensation of hunger again. The suggested diet was within the 1000-1100 calorie band and it was intended for Stella to keep to this calorie level for approximately 2 weeks. A rule was instigated of no fluids for 20mins prior to a meal, and no visits to the lavatory for 1hr. after eating. All visits to lavatory were to take place with either her mother or sister present, to avoid risk of vomiting. Stella's diet was based on five small meals per day with milky drinks between meals. Stella stated that she was feeling hungry all the time and asked that the quantity of food be increased.
Within days the client's skin appearance had developed less of a papery quality, and her pupils were no longer so dilated. With Stella's condition stabilised, both the GP and hospital therapist agreed to allow therapy to continue for a further 10 days, without threat of hospitalisation. The client still had to attend as an outpatient, once a week, to monitor her heart muscle and enzyme secretion.
A week after the first intervention, Stella's weight was 40Kg (an increase of 3Kg). Stella was not pleased with this increase, though consciously she did recognise that it was necessary. She was reassured that she was not 'fat' nor was it possible for her to suddenly balloon in weight. There was some seeding here for a later intervention (homeostatic awareness, last intervention).
At the next session she weighed 41Kg (an increase of 4Kg). At the client's request, the therapist did not tell her what the gain was, though did say a small gain had been made. The blood tests showed the secretion of the enzyme from the liver had reduced to the extent that weekly blood tests were no longer required. From this moment on they would be done monthly.
The therapist continued with the 'Symptom Objectification' technique enabling the client to reduce her fear of 'Anorexia'. During this session, the 'creature' ('Anorexia') appeared as a 'spoilt child' named 'Annie'.
The therapist put Stella into light trance and regressed her back to a time before her anorexia began. Stella was approximately 6 years old and felt safe and happy at boarding school. During this trance, the therapist helped Stella to draw on all the positive resources of this period. The therapist was able to get the client to ask for advice from her younger self. The younger self advised destroying Annie. 'Annie' was then pulled out of client, and carried up a hill, through woods, to where the school garbage was dumped. 'Annie' then acquired a 'sticky' quality, making it impossible for the client to be completely rid of her. With small amounts of 'Annie' stuck to the bottom of her feet, the client then decided she wanted to go off to 'play' with the younger self, and returned to normal wakeful awareness in a calm and more positive frame of mind. Stella believed that even if she had not managed to destroy the whole of 'Annie', sufficient had gone to enable her to deal with other issues (which she described as 'reality').
At the next session the client described a situation that occurred when she was under ten. Stella, her brother and sister had been receiving private tuition in Urdu from a male Pakistani. Her memory of that day was that her father became extremely angry and threw the tutor out of the home. Her mother was in tears and obviously frightened, as were Stella her brother and her sister. Her father had left the house and when he returned the following day, he said that he had spent the night praying at the church. Stella believed that the tutor 'fancied' her mother, but her mother was not prepared to discuss the matter. The emotional outburst by her father, had always been described as a 'breakdown'. It was made very clear to the children that they must never disobey nor upset their father for fear of a recurrence. Since then Stella had been frightened of her father and accepted that no matter what, his word was Law.
Stella felt that living in the family home was hampering her ability to recover. When asked 'what stops you from leaving home', Stella replied that her father would not allow her to do so until she had recovered from Anorexia [N.B. potential pathogenic double-bind]. Stella also informed the therapist that her father would not listen to anything she said with regard to her life or illness. Instead, he interrupted her and treated her as a small child. Stella asked that the therapist convey what she had been told, to the father. The therapist agreed to invite her parents to the next session, and give Stella the opportunity to speak for herself, in the way she wanted to. The therapist would assist if at any point the therapist noticed either parent refusing to listen to the adult within her.
At the next session, the therapist arranged the seating allowing for one dominant chair in the room, to find out which of the three would use this seat. As expected, the father chose this seat, so the therapist asked him to exchange seats with S. The father was willing to do this, but Stella asked that she be allowed to sit on the floor. Despite explaining to Stella that she would find it easier to address the room from a position of height, she steadfastly refused, and remained sitting on the floor. Her whole demeanour was childlike, including the tone of voice and choice of phrases. The session began with the therapist asking the parents whether there was anything they wished to ask about Stella's progress (this as the parents were paying the fees). There was nothing they wanted to ask. The therapist then explained that Stella had asked for them to attend, as she wanted to be able to explain her position and future wishes. Stella was unable to say much, but spent most of the session apologising for any problems she was causing the family, and asking for their forgiveness. In response, the father began to quote the scriptures, outlining how 'Jesus forgave those who forgave themselves'. The mother only spoke once, to assure the therapist that she was a good mother and that they all loved the daughter. Stella spent most of the time in tears, explaining to the father her guilt at not 'giving herself sufficiently unto the arms of Jesus and his love'.
At the following session the therapist discussed the client's behaviour with her parents. She accepted that when in her fathers presence she found it difficult to behave in an adult manner. The reason for this, she believed, was that she had been brought up to always accept his fierce temper and dominant position within the family. Stella felt drained and exhausted after the previous session and asked that she be allowed to discuss only what had taken place after the session, when the family had returned home. In the event, the father had left for the church and normal family life was resumed. Stella found it hard to understand why none of the family wished to discuss the session with her. The authors concluded that Stella was covertly requesting unconditional permission to grow-up and the parents were ignoring the covert communication.
The next intervention addressed Stella's block to 'growing-up', the need for prior permission. The technique used, Resourced Maturation, enabled Stella to 'give herself permission' to grow-up. In a light trance Stella was regressed to a time in her life when she felt herself to be most in control. The kinesthetic resource state was then auditorily anchored before she was regressed to the first in a series of traumatic events connected with her current problem. At each traumatic event Stella was encouraged to 're-write' the scenario, step by step, so that she could relive it as she would have wished it to be (with the resource kinesthetic in place). This continued till she reached a 'comfortable and safe moment' in which she felt content with the outcome achieved. Stella was then told to 'grow-up' that 'earlier self' till she reached the next trauma in the sequence, where the process was repeated. This continued till the therapist succeeded in 'growing her up' to the present day. The intervention finished by 'future-pacing' her to the age of thirty-five, to ensure that the maturation process would continue. It is worth pointing-out that in this technique the therapist need have no knowledge of the traumatic events themselves. The client's minimal cues are monitored as feedback on her current kinesthetic status, and a pre-conditioned I.M.R. (a head-nod in this case) is used to report the conclusion of each phase.
At the next session the 'client contract' was reviewed. Stella was asked whether she wanted to continue therapy, or whether it had finished with her gaining sufficient weight to avoid hospital admission. She stated that she wanted to continue in therapy to sort out the emotional issues that still troubled her. She wanted to find a job, and a way to "recover her dignity". This, she felt, was deliberately taken from her, by her father's sarcasm and a refusal to discuss her desire to resume food preparation for herself. The latter was something that the therapist, at Stella's request, had asked him to encourage. During the weekend she had spoken to a friend from Church, who had offered Stella accommodation. The same friend had driven her to two places to pick up job application forms. Just before leaving, she asked to be allowed to add pasta to her diet and a larger quantity of jams.
When weighed at the next session, Stella was 46Kg (a 9Kg increase). Stella's demeanour continued to show growing maturity. She found adding pasta to her diet easy and pleasant and asked to be allowed to add baked beans. She was now up into the 1500 calorie band, though unaware of it. There was a marked 'filling out' of her thighs, arms and buttocks. Her stomach was slightly swollen (as expected with weight increase). Pleasingly, Stella was not upset by this filling out.
Reviewing the case, the authors decided this was the point to enhance Stella's autonomy, reduce her dependence, and increase her trust of herself, as the final part of the maturation process. In common with other obsessive/compulsive disorders, anorexia carries an almost superstitious fear of letting go of ritual, as if the ritual were the only certain control the client possessed over their life. Stella had often expressed this fear, paradoxically, as fear of dying by forgetting to eat if she stopped her compulsive routine. During a sustained session, both authors seeded and then introduced in deep trance, a mixture of indirect suggestions and metaphors. The common theme was 'listening to inner guidance'. For example: 'God's living instructions are built into us' (pacing Stella's religious beliefs); 'even a tree listens to an inner plan to know how to grow'; 'we all have built-in homeostats which tell us when to blink, breathe, sleep, etc. and we never worry whether those instinctual processes will fail us'. It was from this point that Stella's obsessive measuring fell away and she felt she could trust her internal signals to know what to eat and when.
Further interventions for the anorexia were considered probably unnecessary. Outcome
Stella's weight, when checked ten weeks after the start of treatment, had reached 53Kg. She has given-up measuring food and eats what she enjoys. She has discovered the pleasure of trying new foods. Stella is arranging to move out of her parent's home and find her own accommodation. She has got a job and begun to socialise. Both her GP and her hospital therapist agreed that once Stella's B.M.I. passed 17 she was no longer classifiable as an anorexic. It is now 17.7. Progress continues to be monitored.
Two-Year follow-up showed client still free of anorectic behaviour and still enjoying life.
Timescale of Core Therapy: Eight weeks
Photographic Record of Progress
At Initial Intervention 37 Kg. (Note veins proud of skin surface.)
After One Week 40Kg.
After Four Weeks 42 Kg.
Weeks 49 Kg.
After three more weeks of treatment the subject's weight had stabilised at 53 Kg.