Anxiety disorders comprise one of the most common categories of psychiatric disorders present in the population today (Kessler et al., 2005; Kessler, Chiu, Demler, & Walters, 2005). In addition, research indicates a link between anxiety and martial distress, with anxious individuals reporting greater martial conflict and lower levels of marital satisfaction (McLeod, 1994; Whisman, 2007; Whisman, Sheldon, & Goering, 2000). In particular, people with generalized anxiety disorder (GAD) are more likely to divorce (Hunt, Issakidis, & Andrews, 2002) and report low relationship quality with their partners compared to those with other psychiatric diagnoses (Whittchen, Zhao, Kessler, & Eaton 1994). This suggests the need for couples’ therapy interventions which address the impact of one partner’s anxiety on the overall relational dynamic. It also underscores the importance of assessing for the presence of clinical levels of anxiety when providing couples’ therapy. Likewise, when providing individual treatment for clinical levels of anxiety, it is prudent to assess for the presence of relational discord should the patient currently be in a romantic partnership.
This article presents a hypnotherapeutic protocol for short-term couples’ therapy which addresses the aforementioned subset of couples experiencing anxiety-based relational discord. The protocol is designed to complement individual treatment for anxiety disorders. In addition, implications for further treatment and empirical research are discussed. While the treatment protocol introduced has not undergone clinical trials to empirically evaluate its efficacy, it has been applied in practice with positive outcome. As such it is being introduced in the hope of furthering professional discourse on the innovative use of hypnotherapeutic interventions and to further awareness of the treatment needs of this particular patient population.
Hypnosis in the Treatment of Clinical Levels of Anxiety
Currently, cognitive behavioral therapy (CBT) is considered the gold standard in the treatment of anxiety (van Boeijin et al., 2005). However, a variety of research has demonstrated larger effect size when supplementing CBT with hypnosis (Bryant, Moulds, Guthrie, & Nixon, 2005; Kirsch, Montgomery, & Sapirstein, 1995; Schoenberger, 2000). In addition, a variety of studies provide significant evidence of hypnosis as successful in the treatment of anxiety and anxiety-related disorders (Alladin, 2008; Flammer & Bongartz, 2003; Galovski & Blanchard, 1999; Hammond, 2010; Lynn, Kirsch, Barabasz, Cardena, & Patterson, 2000; Lynn, Kirsch, & Rhue, 1996; Melis Rooimans, Spierings, & Hoogduin, 1991; Mende, 2009; Palsson, & Moss, 2007; Van Dyck & Spinhoven, 1997; Van Dyck, Zitman, Linssen, Corry, & Spinhoven, 1991; Whorwell, Prior, & Faragher, 1984). Considering the already widespread use of hypnosis as a treatment approach for anxiety, it follows that hypnosis may promote improvements when examining specific issues of anxiety within the context of partnerships.
Despite empirical evidence of hypnosis as an efficacious treatment for anxiety, there is little specifically addressing hypnotherapeutic interventions for the treatment of anxiety-related relational discord. There is, however, a rich history of hypnotherapeutic protocols for the treatment of family systems and couples’ therapy. Milton Erickson’s approach to hypnosis has been actively incorporated into strategic therapy for family counseling for decades (Gordon & Meyers-Anderson, 1981; O’Hanlon, 1987; Zeig, 1985). Erickson’s approach facilitates desired therapeutic outcomes via hypnotic suggestions to redirect and utilize patients’ pre-existing cognitions, attitudes, and behaviors toward healthier patterns of relational interaction (Erikson & Rossi, 1981). In addition, Ritterman (1983) has integrated Ericksonian approaches into family therapy by using hypnosis to directly address dysfunctional patterns that negatively impact the family dynamic.
Hypnosis attempts to alter unhealthy perceptions and cognitions in order to elicit reactions that patients may be able to transfer into their relationship (Kahn, 2010; Lankton, 2004), fostering improved communication, empathetic skills, active listening, and intimacy. A number of clinicians have found success using hypnosis techniques to shift dysfunctional relational patterns toward more positive ones in ways that will facilitate healthy relationships (Daitch & Lorberbaum, 2012; Gordon & Meyers-Anderson, 1981; Lankton, 2008; Lankton & Lankton, 1983; O’Hanlon, 1987; Parsons-Fein, 2004; Zeig, 1985). As hypnosis has been shown to be an efficacious tool for both the reduction of anxiety-induced distress and the enhancement of couples’ therapy, it logically follows that hypnosis could be an important tool for the treatment of anxiety-fueled relational discord.
The protocol presented in this article is primarily intended to be applied as an adjunct to the individual treatment of an anxiety disorder. Within the first one to two individual sessions, inquiry into the status of the patient’s romantic partnership, if present, is made. If determined that the protocol is indicated, the first couples’ session is scheduled within 4–6 weeks. However, I have found it helpful to have one individual session with the partner prior to the conjoint session. This individual meeting serves to establish rapport by providing the partner with the experience of being heard by the clinician as well as giving the therapist further insight into the relational dynamic from the partner’s perspective.
When an initial assessment specifies that brief couples’ treatment is indicated, the short-term protocol consists of 4–7 sessions. However, the frequency in which the sessions will be delivered is dictated by the anxious partner’s treatment progress in individual sessions. The initial conjoint session need occur early in the anxious partner’s individual treatment process for psychoeducational purposes. However, the scheduling of the remaining couples’ sessions need be timed to correlate with the anxious partner’s mastery of individual treatment objectives concerning the ability to regulate affective flooding. Additionally, implications for longer-term treatment are discussed at the close of this article.
The treatment plan outlined below is contraindicated should an initial assessment reveal the presence of any active inter-spousal violence, at which point interventions in the anxious partner’s individual treatment would shift to address physical safety concerns. Should the non-anxious partner present with any clinically significant impairment which would interfere with the ability to engage in the couples’ treatment protocol, couples’ treatment would likewise be halted and outside referrals be made. Additionally, both partners need to possess the self-regulatory skills sufficient to deescalate emotional flooding before entering the second phase of the couples’ treatment.
Delivery of Hypnotherapeutic Interventions
As the treatment outlined is hypnotherapeutic in nature, hypnotic suggestions which simultaneously engage both partners are incorporated in many of the interventions outlined in this article. Preceding each hypnotic protocol outlined, patients are given a standard hypnotic induction. I frequently begin with the Ewin Rapid Eye-Roll (Ewin & Eimer, 2006), followed by diaphragmatic breathing (Daitch, 2007, 2011; Daitch & Lorberbaum, 2012) and safe place visualization (Daitch, 2011; Hammond, 1990; Yapko, 2012). As there are a variety of effective hypnotic inductions and deepening techniques, the particular induction and deepening techniques chosen are likely to vary given the clinician’s training. As long as induction leads the patient into a sufficient depth of hypnosis (see Hammond, 1998), the difference in clinicians’ induction and deepening methods are of no concern. It is also paramount that clinicians take sufficient time to fully re-alert patients following the hypnotic intervention (see Kluft, 2012).
Phase 1: Psychoeducation (1 Session)
The initial inquiry into the status of the patient’s partnership presents the opening through which the couples’ treatment can be initiated. Once the relational disconnect has been identified and assessed and the partner brought in for an initial joint session, psychoeducation can begin. The following topics for psychoeducation, along with accompanying hypnotherapeutic interventions, are presented.
Anxiety: The Basics
The psychoeducation process begins with an explanation of anxiety. First, it is crucial that patients understand that the experience of some stress and anxiety is actually adaptive. The capacity to experience fear, stress, and anxiety allows us to mobilize to address and overcome any threats or challenges to our well-being. Problems occur, however, when the degree of fear and anxiety experienced does not “match” the environmental challenge present. Thus patients are led to understand that the goal of treatment is not to extinguish the anxious partner’s experience of anxiety and stress altogether, but rather to alter stress reactions so that they are appropriate to the environmental challenge at hand. By reframing the symptom as an internal resource that is essential to both surviving and thriving if mobilized adaptively, the Ericksonian principle of utilization (see Daitch, 2007; Erickson & Rossi, 1979; Gilligan, 1986; Hammond, 1990; Havens, 1989; Lankton, 1985; O’Hanlon, 1987; Rossi, 1980) is at work. The reframe of anxiety as a resource also supports another goal of treatment: teaching patients to tolerate discomfort of anxiety when it does arise.
As the anxious partner has a diagnosed anxiety disorder, psychoeducation regarding the specific features of that disorder, which would be a routine component of psychoeducation for individual treatment, is also appropriate to provide at this juncture. During or following the process of delivering psychoeducation pertaining to any specific symptom constellations, additional content regarding affective flooding is crucial (see below). This information is presented conversationally and then reinforced hypnotically.'
The metaphor inherent in the term “affective flooding” aptly captures the nature of the psychological state it describes: floods arise quickly, strike with overpowering force, are overwhelming to experience, and leave destruction in their wake. Further illuminating the experience of affective flooding is the knowledge that the brain is wired in such a way that it is far easier to become flooded with emotion than to self-regulate and manage this emotion with reason (LeDoux, 1996). It is crucial that patients conceptualize heightened anxiety as an experience of emotional flooding in which intense emotion overwhelms the patient’s efforts to self-regulate and otherwise cope. This understanding can transform both partners’ conceptualization of the anxiety that is impacting their relationship.
The Tripartite Brain
It is helpful to communicate a rudimentary understanding of how the brain functions when a person is experiencing heightened anxiety. This understanding serves to diminish shame in the patient as well as soften judgment from the partner. This process begins with a verbal explanation of the neurobiology associated with the affective flooding that occurs during the experience of heightened anxiety. To do this a theoretical model of the brain first articulated by MacLean (1990) is used. In MacLean’s model, the structures in the brain can be grouped into three sections based on the order in which the human brain is thought to have evolved. First is the reptilian brain, or hindbrain, which is associated with more basic survival functions such as breathing, balance, etc. Next comes the midbrain, or mammalian brain, which is associated with the expression and experience of emotion, and finally the forebrain, associated with higher-level processes such as language, logic, and impulse control.
The Midbrain Gone Rogue
When affective flooding occurs due to, for example, heightened anxiety, the midbrain becomes hyperactive and the optimal balance between the midbrain and the forebrain activity becomes disrupted. As metaphor is a tool which allows patients to deftly grasp new or previously learned concepts, the midbrain during periods of affective flooding can be characterized as a midbrain gone rogue. An auditorily-based metaphor follows: it is as if the emotion-based midbrain is speaking through a bull horn while the logic-based forebrain delivers its message with a whisper. Emotions are amplified and the ability to successfully engage logic-based self-talk, as well as impulse control, is impeded.
Affective Flooding: Understanding the Midbrain Gone Rogue
The following hypnotic intervention reinforces the psychoeducational content regarding affective flooding using hypnotic imagery to further illuminate information conveyed:
And as you relax … everything else can fade into the background of awareness … as you focus your attention on my voice and your own internal experience … and I suggest that you take a moment to really acknowledge yourself … honor yourself … and honor your partner … recognizing that you both showed up today … and perhaps you are open to learning something new that can help you understand yourselves and each other better … that will help you both understand the anxious brain… . And you, (insert anxious partner’s name), can look forward to discovering that your symptoms make sense as you get your head around your own brain, with some increased education about how it works … and you, (insert non-anxious partner’s name), can look forward to understanding in much greater depth how to make sense of your partner’s/wife’s/husband’s reactions that are so different than yours.
Now you don’t need to be a neuropsychologist to get this … and I do know that most people as intelligent as you are have found it helpful to possess a basic understanding of the anxious brain. And you might enjoy learning that, as anxiety rises and rises, a tidal wave of activity floods the midbrain … the emotional center of the brain… . And as you know, floods arise quickly, strike with overpowering force, are overwhelming to experience, and leave destruction in their wake. And when that flooding occurs in the midbrain it’s of course harder to hear the input of the logic-based forebrain … the voice of reason and rational thought.
When you’re flooded with anxiety, it’s is as if the emotion-based midbrain is speaking through a bull horn while the logic-based forebrain delivers its message with a whisper … emotions shouting and causing alarm … and that cool, calm, logical voice, that logical part of yourself … can only whisper … has so little power to quiet your emotion. And the voices of others, too … even the voice of your partner, whom you love, only come across with the power of a whisper … drowned out by the shouts of the emotion-based midbrain.
But you can look forward, now, with pleasant anticipation to the rewards that will come to you as you increasingly understand the anxious brain … and this understanding can be for your benefit … your growth… . It can influence your feelings, thoughts, and behavior … . You may be pleased to discover that this knowledge can actually be transformative … leading to a new depth of understanding and compassion for yourself … and your partner. [Re-alert.]
Neurological Underpinnings of the Relational Disconnect
When affective flooding occurs due to heightened anxiety, logic-based input from any source, whether it be the forebrain of the affectively flooded patient or that patient’s partner, speaks with the volume of a whisper. As such, the auditory metaphor used in the previous hypnotic intervention frames the non-anxious partner’s inability to quell the anxious partner’s anxiety with rationally-based appraisals of the triggering stimuli. As soon as the non-anxious partner enters the scenario and tries to engage the affectively flooded partner with logic-based appraisals, a disconnect occurs. The anxious partner often feels unheard, shamed, and isolated as the partner’s logic-based input is not sufficient to calm affective flooding.
The non-anxious partner can feel equally frustrated and disconcerted in response to the anxiety-related relational disconnect which occurs. Well-intentioned, logic-based attempts to soothe the partner are ineffective as the anxious partner remains rigidly adherent to irrationally-based appraisals of both internal and external stimuli despite the non-anxious partner’s pleas to the contrary. Without intervention, this dynamic often persists without resolution.
Colors of Logic and Emotion
Following didactic psychoeducation, hypnosis is again used to enhance the patients’ grasp of the information. After hypnotic induction and deepening, both partners are directed in trance to elicit a memory of a specific time when the two of them were experiencing relational conflict due to anxiety-related emotional flooding. This passage has been adapted with permission from New Harbinger Publications Inc, © 2012, Carolyn Daitch and Lissah Lorberbaum:
Perhaps you can imagine a specific time when the two of you were neither connected nor emotionally attuned—talking but not really communicating … [if one such incident has been discussed in the couples’ session already, the clinician might suggest the patients choose this] … that’s right … and now, take your time to really get in touch with the feelings … the emotions you felt during that interaction … [encourage the amplification of negative affect] … and as the feelings come up, just sit with them, noticing them without judgment … that’s right….
Now, as you continue holding the feelings that arose for you, recall the image of the three-part brain we’ve spoken of … with its three distinct parts: the hindbrain toward the bottom, the midbrain in the middle, and the forebrain at the top… . And imagine now that you can see directly into your partner’s brain … seeing the midbrain … the forebrain….
And now, [insert anxious partner’s name], imagine that your partner is speaking from that logical, rational place. Maybe your partner is giving you the typical first response of suggestions—solutions—trying to respond to your anxiety with logic. And as you see your partner speaking to you, remember that [insert non-anxious partner’s name] is speaking the language of reason—the language of the forebrain. And now, [insert non-anxious partner’s name], imagine that your partner is speaking from that emotion-based, anxious place. And as you see your partner speaking to you, remember that [insert anxious partner’s name] is speaking the language of emotion—the language of the midbrain.
And now, [insert anxious partner’s name], as you see your partner speaking to you with the language of reason, the language of the forebrain, allow yourself to see this active part of the brain—the forebrain—light up in a cool, calm blue, while the other two parts of the brain remain dark and silent. And now, [insert non-anxious partner’s name], as you see your partner speaking to you with the language of emotion, the language of the midbrain, perhaps you can imagine seeing this active part of the brain—the midbrain—light up in a bright red of alarm, a vivid, intense color … while the other two parts of the brain remain dark and silent. [Pause.]
Now each of you can take a moment to see the words, too, that are being spoken by your partner … see the words drift from your partner’s mouth to you. … And as you see these words, [insert anxious partner’s name], allow yourself to think, There are ___’s blue words, representing the language of reason. And as you see these words, [insert non-anxious partner’s name], allow yourself to think, There are ____’s red words, representing the language of emotion.
And as you both sit here … next to one another … imagining in your mind’s eye the blue words of logic and the red words of emotion drifting toward one another … out of your mouths … take a moment to inhale … and exhale slowly … and as you exhale, perhaps a sigh of relief as you relax into the knowledge that yes, you really are speaking two different languages … so of course it feels like neither of you are hearing one another … that your message isn’t really sinking in… . And know that from this shared knowledge … this shared understanding that the languages of logic and emotion are in play … you can work to build connection and resolution … planting a seed of understanding that will continue to grow … because now that you know that two different languages are being spoken, neither of you need be lost in translation any longer. [Re-alert.]
Phase 2: Time-Out (1 Session)
Once the couple has a thorough understanding of affective flooding and its impact upon communication and connection, the time-out intervention provides the framework to engage in behavioral shift. It is in this phase that couples gain explicit tools to discontinue the problematic interactions surrounding one partner’s experience of excessive anxiety. Prior to the conjoint couples session, the anxious partner will have already been taught to identify his or her indicators that affective flooding is about to occur and initiate an immediate cease in activity, a time-out (see Daitch, 2007; Daitch & Lorberbaum, 2012). During this brief interlude the patient accesses a space which facilitates privacy. The patient would use a separate room in the house, a private office or cubicle, an outdoor area, or even a public restroom if no other area avails itself. In this planned interlude, the patient engages in a host of self-regulating techniques such as a the Ewin Rapid Eye-Roll (Ewin & Eimer, 2006), deep breathing, positive self-talk, and self-hypnosis using kinesthetic cues to access a safe place that has been previously established in-session while the patient was in trance (see Daitch, 2007; Daitch, 2011; Daitch & Lorberbaum, 2012). As mentioned earlier, this phase of the couples’ work is not to be entered into until the anxious partner has demonstrated ability to successfully engage in affect regulation which either circumvents or calms anxiety-related affective flooding.
Once the anxious patient’s progress in individual sessions is sufficient, the conjoint couples’ session provides the opportunity to shift communication patterns by integrating the time-out into the couple’s interactions. Given that conflict often arises surrounding the non-anxious partner’s well-meaning but unsuccessful attempts to help the anxious partner engage in affect regulation, it is necessary to change this interaction. Recalling the neurologically-based futility of logic-based attempts to deescalate affective flooding, this is more than understandable. It is the anxious partner who has the agency necessary to de-escalate his or her own affective flooding. Time-outs acknowledge this, provide the anxious partner with the opportunity to engage in self-regulation, and stop the non-anxious partner from engaging in a way that would assume responsibility for this role.
In the session the anxious partner has the opportunity, with the help and support of the clinician, to explain the time-out to the partner. Then both partners and the clinician set a protocol for the enactment of the anxious partner’s time-out so that interaction can resume once the anxious partner has regained a greater degree of affect regulation.
Phase 3: Enhance Positive Affect (1–3 Sessions)
Once the couple is actively engaging the time-out procedure to alter previously ingrained interactional patterns, the focus of the couples’ sessions shifts to enhancing positive affect. Hypnotic interventions utilizing age regression, age progression, and the juxtaposition of two feelings are employed to accomplish this treatment objective.
With age regression interventions, couples are guided to retrieve previously accessed affective states that were present during times in the past in which attuned connection and positive regard were more optimal. It is not uncommon that couples experiencing the relational difficulties that have brought them into treatment will demonstrate a sense of amnesia regarding the positive regard and attuned connection that were more frequently experienced and easily accessed at earlier stages of the relationship. Age regression (Daitch, 2007; Edgette & Edgette, 1995; Gebhard, 1961) helps elicit the positive sentiment that Gottman (2000) notes is crucial in couples’ ability to successfully negotiate conflict and disconnect.
Once both partners are in a relaxed state, the therapist directs each partner to simultaneously scan their memory banks for a time in the past that signified a more positive period in the relationship (Yapko, 1988). They are then directed to access a particular event which occurred during this time period in which feelings of connection with and warmth toward the partner was experienced. Next the therapist provides direction to help both partners vivify and intensify the affective experience of attunement and positive regard (D. Brown, personal communication, May 5, 2002).
Just as accessing positive past experiences can amplify positive affect in the present, so too can envisioning positive experience to come. With age progression interventions (see Daitch, 2007), couples are guided in trance to construct and then vivify a time in the future when the desired treatment outcome has been achieved in its entirety (Yapko, 1988, 2001, 2012). As Hammond (1990) notes, age progression interventions can be used to facilitate patients’ identification of hopes for the future. Likewise, age progression facilitates positive expectancy for desired treatment outcome (Edgette & Edgette, 1995; Hammond, 1990; Yapko, 1997, 2012), and thus bolsters the likelihood of a successful treatment outcome (Lankton, 2008; Rosen, 1982).
Juxtaposition of Two Feelings
Juxtaposition of two feelings is a hypnotherapeutic intervention which facilitates the elicitation of dual perspective to enhance positive affect. Utilizing ego state constructs, the therapist guides both partners to identify multiple parts of self that coexist. Watkins (1992) appropriately termed these distinct parts of self part-persons. In discussing ego state therapy, Hammond writes that one can “selectively amplify or diminish parts of his or her experience in order to achieve a higher purpose” (1990, p. 322). Frederick and McNeal (1993) also reference this higher, stronger, more developed part of the self. When a patient is in a hypnotic state, ego state therapy can be utilized to access the part of self that possesses sufficient wisdom and maturity (Frederick, 2005, 2014).
In the hypnotherapeutic intervention the therapist simultaneously guides both partners into trance, and then guides both to access a part of self that is more mature, temperate, tolerant, and understanding. It is this part of self that can be called upon as an internal resource when partners are in conflict, mitigating the part of self that identifies more strongly with ego states that are more easily triggered. Using the resources of the more mature ego state, the therapist guides the patients to amplify positive affect and then elicits the feelings present during relational conflict. The majority of the intervention then focuses on guiding both partners to enhance their ability to maintain these two conflicting feelings simultaneously. The following excerpt has been adapted with permission from New Harbinger Publications, Inc., © 2012, Carolyn Daitch and Lissah Lorberbaum:
Let’s start with the negative thoughts and feelings… . I suggest that you think about a particular time when you and your partner were in conflict … and now, as you think about this time … allow yourself to let any feelings of hurt, aloneness, and disappointment come up … yes … that’s right… . I’d like you to also notice whatever thoughts accompany these feelings [use example phrases that the patients have mentioned previously, e.g., How could he not understand me after living with me for so long? Why does she always make mountains out of molehills?].
And now that you’ve connected to these upsetting feelings and thoughts … really let them come up for you in all their intensity… . And as you do this, focus your attention on your left hand … that’s right … imagining that you are placing all of that negativity into your left hand … . And envision all this negativity flowing from your mind into your left palm. [Pause.] Now, still holding these feelings in your left palm, close your fingers to make a fist … encapsulating all these negative feelings in your fist.
Now … still holding those feelings in your left fist … take a few deep breaths … letting yourself become so nicely relaxed … allowing yourself to become just a little calmer with each exhalation. [Pause for a minute of clock time.] Now deliberately shift your attention to positive feelings and thoughts about your partner … and as you do you might experience a feeling of satisfaction, of contentment, as you connect to what is most endearing about [say partners’ names] … can you hold this feeling of appreciation, perhaps with tenderness … experiencing the appreciation fully and deeply. [Pause.]
And continue to let those warm, tender feelings and the accompanying thoughts come up … in all their intensity… . And now, imagine all of these good feelings flowing directly from your heart into the palm of your open right hand… . Really feel them gathering in the palm of your hand … and hold them there, cupping this hand into a fist.
And now that you are clasping all of these good feelings in your right fist, and all the negative feelings in your left, slowly bring your hands together … interlocking your fingers so that your palms touch … allowing the positive, warm feelings to exist alongside the painful feelings … sensing the two sets of feelings coexisting in the same small space. Notice how one set of feelings doesn’t cancel out the other… . Perhaps you can now be receptive to the difficult parts as well as the good parts that are inevitable in any relationship … receptive to the difficult feelings as well as the positive … and acknowledge that at any given time, no matter how all-encompassing your negative feelings toward your partner may seem, you actually have more than that one feeling, and more than one thought, available to you… . And now, take a moment to slowly bring both your hands to your heart … resting your open palms, left palm over right on your chest, just over the place where your heart beats underneath… . This can be your cue to easily call to mind the inevitable truth that the positive and the negative can coexist … and isn’t it nice to know that you can access positive feelings toward one another … that these feelings are always available … that you actually have the positive feelings available right alongside the negative… . And when you feel ready to bring this exercise to a close, I will count slowly from 1 to 20, and you can take all the time you need to open your eyes. [Re-alert slowly with counting.]
The juxtaposition intervention challenges the assumption sometimes present for partners that relational success, as well as successful treatment outcome, is dependent upon the absence of anger, frustration, and hurt in response to one’s partner. Patients often carry the misconception that eliminating negative regard toward the partner altogether is necessary for success in treatment. The juxtaposition intervention helps patients acknowledge that relational rifts and the frustrations that accompany them are a component of relationships; success comes not from their absence, but in each partner’s ability to regulate negative affect when these rifts inevitably do arise.
Phase 4: Differentiate (1–2 Sessions)
The experience of attunement is fundamental to the success of any intimate relationship. Siegel (2007, p. 290) comments “[S]uch resonant states feel good as we feel ‘felt’ by another, no longer alone but in connection. This is the heart of empathic relationship, as we sense a clear image of our mind in the mind of another.” Yet when one partner has an anxiety disorder, each partner’s appraisal of environmental stimuli and interoceptive stimuli can differ sharply. As discussed earlier, highly valenced anxiety inducing stimuli are often neutral or mildly valenced for the non-anxious partner. When this occurs, the ability to sense a compassionately held representation of the self in the mind of one’s partner can be challenged.
To address this relational impediment it is crucial to help couples differentiate between the concept of shared connection and shared perspective. When individuals sustain the belief that their partner need share their perspective in order to feel supported and aligned, differences in perspective run the risk of perpetuating seemingly irreparable ruptures in attunement. Teaching couples to embrace a template of relationship in which differing perspectives are not only expected but validated provides a basis to repair anxiety-based ruptures in attuned connection, and sometimes can circumvent such ruptures altogether.
Following psychoeducation regarding accepting and even valuing differing perspectives, couples are taught basic skills to validate one another’s differing perspectives and emotions in response to shared environmental stimuli. In teaching validation the following tenets are conveyed:
Partners can validate one another even in the absence of an understanding of the reasoning behind the other partner’s perspective.
Partners can validate one another even when they strongly disagree with the other partner’s perspective or appraisal of a situation.
Engaging in validation is crucial when a lack of understanding, strong disagreement, or both arise.
The act of validation does not require or imply agreement with the partner’s perspective.
The act of validation acknowledges the innate value of the other’s perspective, as well as the validity of the other partner’s emotions.
The following hypnotherapeutic intervention further facilitates this learning:
Now that you are relaxed … you can discover how easily you can move into a more flexible and open state of mind … and we know that in hypnosis you can enjoy a kind of cognitive flexibility that sometimes is difficult when you are stressed or anxious. And as you look forward to achieving that flexibility of thinking, perhaps you can take in some new ideas …
Of course, it’s only human to wish that your partner always agreed with you, saw the world just as you see it, and shared your opinions, feelings, and convictions… . But you know and I know that this just doesn’t always happen. Inevitably the two of you and will sometimes disagree … or have trouble even understanding your differences … and this is especially likely when one of you views the world with anxious eyes and the other does not … because when this is the case … you each have a fundamentally different experience of life… . And this capacity to have such different perspectives, such different experiences … such a different take on the same situation … can create a chasm between the two of you … a chasm that widens with each instance the two of you fail to really “get” the other’s side.
It’s as if you each were standing on two different sides of a canyon … a deep, dark gulf separating each side … and no matter how much you longed to reach one another … longed for the support and comfort that shared perspective brings … the canyon is just too wide … the sides too far apart … the gulf between, too deep… .
Would you be willing to imagine this canyon? One side formed with rocks that are deep reds … or perhaps any color that represents to you the language of emotion … and the other side formed with rocks of a cool blue-gray hue … or the colors that seem to you to be fitting for the language of logic… . And now see yourselves on your respective sides … gazing at one another across the precipice … wishing and longing to connect, but not knowing how… .
And isn’t it nice to know that connection is possible … it is possible to leap across this chasm … you have the ability to do so right now … by simply being curious about your partner’s perspective … and this curiosity has the power to transport you … to lift you from your moorings and gently carry you across the chasm … as if carried by a gondola or a magic carpet … placing you down gently on your partner’s side of the cliff… . And now imagine yourself standing on that other side of the cliff … seeing the world through that differently-colored hue … feeling the relief that comes as you take-in the sights that before you simply couldn’t even fathom… . And now take a moment to say to yourself “of course it makes sense to see the world differently when I’m standing on this side… .” [At this point you might take some time to elaborate the different perspectives, drawing on specific knowledge about the couple.]
And now … in your mind’s eye … see yourself gently soaring back to your side of the chasm … taking the knowledge of your partner’s perspective back with you … and now with your feet firmly planted on the ground … knowing that you have stood at both vantage points … taken in both views … you can take a moment to acknowledge that both vantage points are equally real … equally valid … just different. [Pause.]
And it’s so understandable, when we’re in conflict, to dig our heels in firmly to the ground of “our side,” to stay fixed and rigid on our side of the rock … but true connection requires generosity … compassion … and flexibility … which you can embrace as you awaken the curiosity that allows you to traverse the chasm … freeing yourself from your moorings … allowing you to welcome the views from both sides … and in doing so the space between no longer has the power to divide you … to keep you apart … it is simply a space that is acknowledged … and surpassed. [Re-alert.]
Facilitating Rehearsal and Transfer (Used in All Sessions)
The final key to success involves facilitating the occurrence of the behavior change and psychotherapeutic growth that the in-session interventions seed. While treatment interventions outlined here are all delivered within the clinician’s office, much of the success of treatment is determined by the patients’ ability to apply skills learned in the therapist’s office to interaction outside the therapy room. It is well documented that patients’ willingness to engage in therapeutic homework has been correlated to successful treatment outcome (Burns & Spangler, 2000; Coon & Thompson, 2003; Kazantzis & Lampropoulos, 2002). Likewise, a key component of treatment involves in-session interventions which directly facilitate the transfer of new skill sets into the interaction that the couples will engage in once outside the therapist’s office. The three core components of interventions used to promote rehearsal and transfer are outlined immediately below:
The homework contract: upon entering the therapeutic relationship, homework is outlined as a condition of treatment and the rationale behind this delineated.
Explicit homework assignments: each week, homework assignments are given to supplement the hypnotherapeutic interventions presented in-session. This may consist of the direction to engage in self-hypnosis while listening to tapes of the in-session hypnotic interventions, or may be to practice taking time-outs or regularly engage in the therapeutic exercises presented to facilitate differentiation.
Hypnotherapeutically facilitated visualization of engagement in homework activities: at the close of each session, the couple is once again guided into trance and led through a visualization of engaging in the given homework activities in the coming week.
By delivering hypnotherapeutic interventions which directly facilitate therapeutic homework, couples are not only provided with therapeutic homework, but hypnosis is utilized as a tool to seed positive expectancy, increase compliance, and facilitate greater treatment success. In addition, patients have the opportunity to develop an increased sense of agency as they are explicitly taking an active part in their recovery. Rather than feeling the passive recipient of a therapeutic intervention or, on a larger level, a course of treatment, the homework contract and its implementation can allow for patients’ success on multiple levels.
The presentation of any treatment protocol I apply would be incomplete without discussion of the importance of individualizing treatment. Just as hypnotic interventions can be enhanced by the utilization of a patient’s preferred sensory modalities and life experiences, so too can therapeutic protocols be enhanced by the clinician’s sensitivity to the patients’ feedback with respect to the applicability of a particular intervention. I am a proponent of adapting interventions or even applying different interventions that might be better suited to a patient’s individual needs based on patient feedback.
This is especially the case when patients demonstrate resistance. Erickson not only respected the patient’s right to be resistant, he welcomed the resistance and used it in the therapeutic process: “If they bring in resistance, be grateful for that resistance… . Whatever the patient brings to you in the office, you really ought to use” (Erickson & Rossi, 1981, p. 16). For this reason I recommend that clinicians have a plethora of therapeutic tools in their repertoire should a patient’s response to a particular intervention not be yielding the desired therapeutic outcome. A wide variety of hypnotherapeutic interventions that can additionally be incorporated into this treatment protocol have been put forth to achieve this purpose (see Daitch 2007; Daitch & Lorberbaum, 2012). Likewise, in my own application of the protocol above I leave ample room for the individualization of treatment.
Unfortunately, individualization of treatment hinders the standardization of protocols, making it more challenging to empirically test the efficacy of such treatments. As such, the treatment protocol put forth in this article has not undergone clinical trials to empirically evaluate the protocol’s efficacy. The protocol does, however, provide implications for further research.
The completion of the current protocol also presents the possibility of longer-term couples’ treatment. Once explicit interventions are put into practice giving the couple the opportunity to engage in behavioral shifts and enhance attuned connection, the nature of the couple’s bond and the systemic relational aspects of symptom development and maintenance can be addressed. This can be a longer-term treatment objective that I encourage couples to pursue. In relationships which are negatively impacted by one partner’s anxiety, emotional support tends to be more unidirectional and an over-dependent bond can result. In a relational configuration I see frequently when anxiety is present, the non-anxious partner is the principal provider of emotional support and takes on an excessive amount of responsibility. This role remains largely rigid.
The counterpart in the anxiety-based over-dependent configuration is the anxious partner, whose role of being cared for and emotionally supported remains equally rigid. Given that the experience of clinical levels of untreated, chronic anxiety can undermine the anxiety sufferer’s sense of agency, the self-concept that maintains this role rigidity is understandable. However, individual psychotherapeutic treatment that runs parallel with the couples sessions has provided the anxiety sufferer with interventions that facilitate affect regulation and increased agency. Thus in the final stages of the couples treatment a window of opportunity exists in which therapeutic interventions can facilitate a shift in the relational dynamic that capitalizes on the anxiety sufferer’s newly gained sense of agency. Suggested therapeutic interventions for this stage of treatment, then, facilitate the development of bi-directional emotional support and, concomitantly, the development of the role flexibility necessary for this to occur.
In conclusion, brief couples’ treatment both complements the anxious partner’s individual treatment and provides an opportunity to shift the relational dynamic of the partnership to lessen discord and enhance positive affect, empathy, and attunement. It also sets the stage for longer term treatment to facilitate an even greater shift in the relational dynamic. Through the couples’ hypnotic treatment, significant individual gains for each respective partner can be achieved as well. The non-overtly anxious partner not only gains an understanding of the etiology and treatment of anxiety but gains an enhanced understanding of the suffering of the anxious patient, which facilitates increasing awareness and empathy. Likewise, the anxious partner shifts from self-absorption to awareness of the partner with compassion and learns to engage in perspective taking which increases both awareness and empathy. For both partners, the relationship can become a source of support rather than contention.
The use of hypnotic interventions for the treatment of anxiety-related relational discord offers coupes a powerful vehicle for change. Hypnosis increases cognitive flexibility and can bypass ego defenses and conscious resistance. As such, it effects changes in attitude, understanding, and generates new responses and communication patterns that are beneficial to both the anxious and non-anxious partners. This article highlights the value of embracing creativity to develop and employ hypnotherapeutic interventions for specialized target populations. Hypnotically-based couples’ treatment is an important adjunct to individualized treatment addressing clinical levels of anxiety.
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