Communicative styles of directive, non-directive hypnosis and universal hypnotherapy.
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 179 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 252 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"4816",title:"Face Recognition",subtitle:null,isOpenForSubmission:!1,hash:"146063b5359146b7718ea86bad47c8eb",slug:"face_recognition",bookSignature:"Kresimir Delac and Mislav Grgic",coverURL:"https://cdn.intechopen.com/books/images_new/4816.jpg",editedByType:"Edited by",editors:[{id:"528",title:"Dr.",name:"Kresimir",surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"52872",title:"Eating Disorders: A Treatment Apart. The Unique Use of the Therapist's Self in the Treatment of Eating Disorders",doi:"10.5772/65697",slug:"eating-disorders-a-treatment-apart-the-unique-use-of-the-therapist-s-self-in-the-treatment-of-eating",body:'\n\nAlthough considered mental health disorders, eating disorders (ED) carry dire physiological risks and complications resulting from severe and prolonged dietary restriction [1]. Ranking among the 10 leading causes of disability among young women [2], they have the highest mortality rate of any psychiatric disorder [3–5]. Symptom presentation is diverse and unique to each patient, demanding an equally diverse and integrative treatment process and path to recovery. Though the agenda of any treatment process will be responsive to the demands of the therapeutic moment, it is the eating disorder practitioner\'s focused intentionality, goal clarity, and sustained vision of complete and comprehensive recovery that best serve the process. Every moment of care is a pivotal moment in care, demanding precision in judgment and incisive decision‐making to avoid, or redirect, a treatment process that may have gone off course or become ineffective. The work of conducting ED treatment can be as challenging for the therapist as for the patient. Both patient and professional face the challenges of tolerating and accommodating the ambiguities and frustrations of an inevitably unpredictable, yet critical, healing process. By modeling steadfast commitment to treatment engagement and goals through a mindful therapeutic attachment, therapists empower and embolden their ED patients to follow their lead.
\nWith disease origins in genetics and in brain structure and function, the risk of death by suicide in patients with Anorexia nervosa (AN) is 57–58 times the expected rate in similar age and gender populations [6]. Crude mortality from suicide or medical complications from starvation or compensatory behaviors associated with the illness is 9% [7, 8]. The impact of ED symptomatology on the individual is wide‐ranging and potentially irreversible. Through the loss of muscle mass, the malnourished heart decreases in size, affecting heart rate and blood pressure. The main causes of sudden death in ED are those related to cardiovascular complications [9]. Twenty‐five percent of individuals with AN experience a chronic or continuously relapsing course [7, 8].
\nCerebral atrophy due to enduring AN was initially thought to lead to an irreversible reduction in gray matter volume [10]. It was later proven that long‐term weight restoration might eventually lead to a restoration of gray matter and structural normalcy, though not to fully normalized functionality [11]. Anorexic patients with amenorrhea or irregular menses, even after structural brain changes had been resolved, displayed significant cognitive deficits across a range of tasks [12]. Co-occurring conditions central to the ED diagnostic process carry significant implications for ED treatment and prognosis. Depression, anxiety, mood disorders, attention‐deficit/hyperactivity disorder (ADHD), posttraumatic stress disorder (PTSD), diabetes, food allergies, gastrological disorders, addictions, and personality disorders create the warp and weft of the integrative fabric of these disorders.
\nLow weight and higher cortisol levels are correlated with greater structural brain abnormalities [13]. Malnutrition is of particular concern during the critical stages of early brain development in childhood, adolescence, and young adulthood. “Epidemiology and diagnosis, medical complications, nutritional concerns, psychological issues, treatment, and treatment outcome for adolescents [and children] with ED differ from those for adults, with particular emphasis on pivotal medical and developmental issues unique to the peripubertal period” [14]. Profound and diverse emotional effects of ED on mind and body can be deeply traumatic to patients who in many cases are too young and emotionally undeveloped to have acquired the skills required to cope with the challenges of disease, as well as recovery, processes. The development of new cases of ED has been steadily increasing since 1950 [15, 16]. Children under the age of 12 admitted to the hospital for ED rose 119% in less than a decade [17].
\nSince the fourteenth century, with the first diagnosis of AN, there has been “historical drift” in the rapid acceleration in new presentations of eating‐related pathology as seen in symptom variability and gender representation [17]. Diagnoses have become increasingly differentiated and refined in their definition. Forms of AN have become distinguishable as “restrictive, or purging type.” Bulimia nervosa (BN) is diagnosable as “purging, or restrictive type,” the diagnostic differentiation denoting distinctive personality characteristics. Eating disorders not otherwise specified (EDNOS) and binge eating disorder (BED) are examples of the evolution of eating disorder pathology. Binge eating disorder is the most likely ED diagnosis to be missed, as the intermittent patterns of binging and starvation result in a normal and constant weight. The onus is on the enlightened clinician to probe actively, and with sensitivity and reassurance during diagnostic assessments to uncover these and other hidden ED, as well as related problems that might include activity disorders/excessive exercise with the intention to lose weight, orthorexia, diabulimia, body image disturbances, night eating syndrome (NES), rumination, chew and spit (CHSP), body dysmorphic disorder, etc.
\nOf particular significance within the ED field, historical progression is evident in the introduction of the diagnosis “avoidant/restrictive food intake disorder” (ARFID), replacing feeding disorder of infancy and early childhood in the American Psychiatric Associations’ Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [18]. The manual describes ARFID as “an eating or feeding disturbance (e.g., apparent lack of interest in eating, food‐avoidance based on the sensory character of food, and/or concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs.” Pediatricians all too frequently miss this diagnosis in infants, children, and adolescents whose patterns of weight and height appear to be normal on growth charts. It is left to ED experts to recognize and understand these atypical “picky eating” disorders, so as to guide increasing numbers of patients and parents to early diagnosis and integrative treatment options. The ever‐changing course of ED presentation demands the practitioner\'s commitment to professional continuing education, intellectual curiosity, and the willingness to recognize and accommodate the evolution of developments within the ED field through clinical responsiveness within mainstream practice.
\nIronically, it is the rare graduate school of mental health practice that offers curriculum specialty training in the treatment of ED. A student studying for her Master\'s degree at a highly reputed school of social work inquired as to why the absence of ED‐related courses. She was told that specialty training was “unnecessary and redundant” based on the proliferation of generic courses that address the emotional issues underlying and driving these diseases. These educators and administrators were of the mind that the methodology for treating ED consists of “techniques and approaches indistinguishable from those offered by any highly skilled mental health clinician.” This widespread misconception is not uncommon in teaching curriculums that fail to recognize ED as neurophysiological, and potentially lethal, diseases in their own right.
\nIn actual fact, clinical strategies, techniques, and methodologies for ED treatment management and recovery are, in many respects, not unlike those that are applicable to more generalist types of mental health care. However, the lethality of these disorders, the integrative nature and demands of their treatment, and the need for the therapist\'s unique use of self in confronting the challenges they present, clearly set these diseases apart in their manner of treatment. “Though in some respects elusive, the tools of this treatment trade are actually supremely accessible; in many respects they are disarmingly simple and hardly strangers to us. We know them all; we know how to implement them. We have only to learn why, how and when to offer which of our previously acquired techniques and skills. The outcomes we seek lie in the use of self in response to the unique demands of the ED patient and treatment moment [19]”.
\nIf not actively healing, ED pathology becomes increasingly entrenched, reshaping the structure and function of the brain. By fragmenting the patient\'s core self and taking over its role as “director of operations,” the ED creates radical changes within the patient\'s personality and physiology. Compounding treatment challenges, parents or life partners of ED patients invariably find themselves confused and helpless in the face of their loved one’s emotional withdrawal. The typical ED patient\'s ambivalence about, and resistance to recovering puts therapists and patients at cross‐purposes from their very first treatment encounter, and beyond. The ED therapist comes to the treatment process seeking a commitment to a recovery process that will restore life quality and reintegrate the patient\'s fragmented core self. The patient typically enters the treatment process denying disease, or clinging to the ED for his or her very survival. Emotionally flexible therapists need to use themselves deftly, exercising nuanced creativity and skills in facilitating and sustaining a meaningful therapeutic connection capable of evoking the patient\'s motivation to heal.
\nFor those who believe that the best therapist to treat an eating disorder is one who has suffered from an ED, I would counter that assumption with the notion that one need not be a horse in order to become a horse doctor. Approximately one‐third of all ED practitioners have struggled with, and recovered from, a clinical ED. “The lifetime prevalence of an ED among professionals was 33.2% for females, and 2.23% for males. Note that 38.8% of treatment facilities reported hiring clinicians with a history of an ED” [20]. Practitioners who have suffered an ED are likely to have developed an exquisite sensitivity to the experience of ED patients. However, just as easily they could find themselves experiencing what is known as countertransference, an emotional reaction of the therapist to the subject\'s contribution. Triggered by the resonance of dormant issues, countertransference reactions could impede the quality of therapeutic responsiveness.
\nThe empathic, emotionally integrated and developmentally evolved ED therapist who is a seasoned and sensitive veteran of life and its challenges within any context, should be qualified to manage and competently treat these disorders. The practitioner\'s own self‐integration and emotional flexibility is a springboard for “response‐ability,” preparing him to intercept and accommodate the unexpected curve balls of the ED recovery process. In particular, it is the practitioner\'s skillful use of self within a trusting and mindful therapeutic connection that enhances the patient\'s internal strengths, evoking her faith in her own capacity to heal, and in the treatment process as a vehicle for change. In accruing self‐trust within this connection, the patient ultimately comes to rely on her own newly acquired, sustainable coping capacities that far outweigh the benefits of her past reliance on her ED, now becoming irrelevant and obsolete.
\nLike the patients they treat, therapists too, strive to grow and develop as human beings throughout the course of personal and professional life experiences. The effective eating disorder practitioner will have accessed and encountered himself, putting his own emotional and cognitive “house in order” in preparation to access and connect with the patient who seeks to accomplish the very same goal. Through self‐reflection and self‐acceptance, the emotionally flexible therapist becomes capable of retrieving and integrating the emotional aspects of his own psyche that may have been lost, denied, avoided, or repressed in the creation of his or her own self‐integrity. Through an active and palpable presence within the therapeutic moment, the therapist\'s self‐integration inspires healthy role modeling. The ED patient\'s successes will be dependent not only upon what the therapist thinks and knows, but on modeling after the way he thinks, acts, and responds.
\nThough diverse and broad‐spectrum ED treatment techniques and strategies enhance learning and change, healing occurs essentially through the process of the recovery journey itself. Emotional, cognitive, and behavioral learning required for recovery is enhanced within the framework of a powerfully human and loving therapeutic connection. The therapist\'s use of self within the context of the therapeutic relationship can be seen as the global positioning system (GPS) that charts the route to full recovery, replete with “rerouting” directions for the inevitability of wrong turns and setbacks as part of the journey. Ultimately, patients acquire the practice and resiliency they need to navigate life\'s roads confidently on their own. The ED healing process becomes a metaphor for life itself… for human tasks that evolve toward maturational development through the stimulus of learning within the context of nourishing human relationships. It is not uncommon for recovered individuals to express gratitude for having had the opportunity to define, refine, and refresh the “gestalt” of their very existence through the process of ED healing.
\nAs the treatment process is steeped in patient resistance and denial, and often complicated by mood, personality, and attachment disorders, the ED patient population is capable of arousing intense emotions within practitioners. The ED corrodes the patient\'s internal strengths, impairing judgment and the capacity to benefit from treatment. The ED individual fears giving up a disorder that (falsely) promises a guarantee of competency and self‐control in the face of life\'s exigencies and unpredictability. Even on the verge of full recovery, patients describe a sense of “longing” for their ED. ED therapists need to prioritize attention to the patient’s potential to return, by default, to old behavioral symptoms, such as recurring weight loss or stagnation, binging and purging, excessive exercise, etc particularly at times of stress, even after a healthy eating lifestyle appears to be securely in place.
\nIt is not atypical to find that parents of teen or child ED patients will feel more needy of the therapist\'s attention, coaching, guidance, and support then does the identified patient. Therapists who treat ED individuals do well to have achieved a substantial degree of comfort and competency in treating complex family systems, as it is incumbent upon the practitioner who treats the individual patient to treat the family system as well. ED treatment occurs in clinical offices for 1 or 2 hours per week. The recovery process happens at home, 24/7, in the company of the entire family system, every member impacted by the ED\'s presence. If uninformed, well‐intentioned family members may inadvertently enable problems in attempting to eradicate them. Involved parents and enlightened siblings are a boon to the struggling child, treatment team, and recovery process. Therapists need to empower parents by offering permission and courage to stand up to the child who, through the voice of the ED, may attempt to dictate the parameters of care, at home and in the treatment office; ie. “I will not discuss eating, because it will make me feel more anxious and I will cry.” “I don\'t have a problem and I don\'t need treatment. I can handle this myself.”
\nWithin the context of the countertransference phenomenon (where the person in treatment redirects feelings for others onto the therapist), self‐awareness, honest intention, and clear boundaries become the therapist\'s parachute. The capacity to remain vulnerable and receptive to others, the benchmark of our humanity, allows therapists to stay real, encourage trust in the treatment relationship, and facilitate learning. Through self‐awareness and attention to the treatment process, therapists need to resist the temptation to collude with the resistant patient who consciously or unconsciously deflects the focus of attention in treatment away from the tough challenges of food talk, symptom abatement, and recovery demands. Therapists need to contain their desire to “fix” the overly dependent patient\'s problems by being overly ready to prescribe answers and solutions, a message implying that easy short cuts can resolve complex problems simply. “There is a time for expert opinion, but not in the place of first building the patient\'s own motivation as an active, not passive, participant” [21].
\nThe countertransference phenomenon need not be an impediment to treatment, but can function as a vehicle for the patient\'s learning. When faced with emotional challenges within the treatment context, as practitioners, we need to do precisely what we counsel our patients to do; that being, to take control where we can, and where control evades us, to cope as best we can in an effort to achieve treatment goals. Miscommunications and misunderstandings are common fare within any in‐depth human relationship. During times of patient discontent, the practitioner does well to readily encourage feedback of all types, particularly when it is negative, modeling transparency and a sincere willingness to accept responsibility and seek problem solutions through discussion and accommodation. Complaints typically contain invaluable learning for the patient, as well as the practitioner. Intention and goals need to be shared, and the patient’s honesty applauded. The therapist\'s response through self‐disclosure needs to be purposeful, motivated by the intention to enhance the patient\'s self‐awareness, learning, and change. When effective, it can deepen the patient\'s access to affect and the promotion of self‐regulation. “Following self‐disclosure, the therapist should immediately shift the focus back to the patient and her response” [22]. The following is an excerpt from a letter I wrote to a codependent parent of an 11‐year‐old anorexic patient, who corroborated with this child\'s choice to leave treatment precipitously.\n “…In considering N\'s leaving treatment at this juncture, what becomes apparent to me is that her malnourished brain is not equipped to make rational decisions of this sort on her own. I believe she is frightened to the point of panic, and understandably so, at the thought of meeting the required demands of recovery from a disease she feels she cannot live without. In leaving this treatment relationship, however, it appears that she is ‘shooting the messenger.’ In a situation like this, it is the parents’ trust in, and support for, the therapist and therapy process that carries the day. One of the factors that leads to, and exacerbates N\'s ED is her feeling of being out of control, overly powerful, and therefore unsafe within her own skin. By giving in to her unrealistic ploy to avoid treatment, a parent becomes an unintentional enabler of the ED. Flip side, the parent who can remain steadfast in understanding and supporting the treatment process becomes an invaluable advocate for both child and recovery. The eating disorder has to be confronted, and in the process, so must N. In observing her response to outpatient care, I believe a higher level of care would be an appropriate alternative for her under these circumstances.”
Along with clarity of intention, relentless urgency of purpose, and an integrative, goal‐driven vision of successful recovery outcomes, the ED specialist exhibits distinguishing qualities represented in the acronym V.I.A.B.L.E. [19], which stands for Versatile, Integrative, Action‐oriented, outcome‐Based, Loving, and Educative. It goes without saying that though all of the characteristics described here are essential qualities of ED practitioners, many have broad applicability to skillful generalists, as well. General psychotherapy skills alone, however, are insufficient to manage the lethality of the ED, the unique complexity of the treatment and recovery processes, and in many instances, the depth of the victims’ resistance to healing.
\nApproaches to treatment are determined by (1) the nature of the disease and its unique symptom presentation, (2) the age of the patient, (3) the patient\'s physical and developmental status, and (4) the overall emotional health and availability of the patient\'s family system. The technically skilled and seasoned ED psychotherapist needs to be capable of integrating traditional “best practice” methodologies with alternative types of interventions, to accommodate the diverse nature of ED pathology which impacts behavior, emotions, cognition, sensation, mood, physiology, nutrition, and the neuroplastic brain. The versatile practitioner\'s use of dialectical behavior therapy (DBT) and cognitive behavioral therapy (CBT) treatment techniques and strategies is designed to systematically ameliorate distortions within the patient\'s cognition, self‐perception, and judgment. The assignment of behavioral tasks to counteract habitual, ritualistic, and entrenched thoughts and actions inspires new learning, the motivation to heal, and accountability within the change process, while creating new neuronal pathways in the recovering brain. The recent advent of mindfulness‐based cognitive behavioral therapy (MCBT), designed to help people who suffer from repeated bouts of depression and chronic unhappiness, combines the ideas of cognitive therapy with meditative practices and attitudes. Dialectical behavior therapy (DBT), too, incorporates the quality of mindfulness as a central component of treatment.
\nThe Maudsley Method of Family‐Based Therapy (FBT), not to be confused with conjoint family systems therapy, has been considered a “best” evidence‐based practice for treating eating disorders in young children and families. The method follows a manualized protocol dictating the roles that parents need to assume in their child\'s refeeding process. Early phases of FBT minimize the significance of the therapeutic connection between the practitioner and child where the child is not yet developmentally capable of separation from parents, or is too emotionally undeveloped to absorb and benefit from the values and insights imparted through treatment. In the latter phases of FBT, as the child becomes developmentally more self‐reliant and present, the relational context of the therapist/child connection becomes increasingly relevant.
\nAcceptance and commitment therapy (ACT) is a branch of cognitive therapy that acknowledges the centrality of the therapy relationship. Successful outcomes are achieved through acceptance and mindfulness strategies, coupled with commitment and behavioral change strategies, which result in psychological flexibility. “ACT focuses on full acceptance of present experience and mindfully letting go of obstacles as clients identify and pursue their life goals” [22]. Such mindfulness strategies in psychotherapy cultivate moment‐to‐moment awareness as a curative mechanism that serves most forms of psychotherapy across the board [22]. By attending to their own experience in the present moment, therapists become more open to, and accepting of, whatever awareness emerges in that experience and in the experience of the other, to include body sensations, affects, and thoughts. Current studies suggest that in successful treatment alliances, therapists are perceived as being warm, understanding, and accepting, approaching their patients with an open, collaborative attitude. In developing these qualities, mindfulness qualities in psychotherapy practice deepen the therapeutic relationship [23].
\nThe transdiagnostic approach to eating disorders, Unified Protocol (UP) is an emotion‐focused cognitive‐behavioral treatment developed to be applicable across the full range of anxiety and related disorders. Consisting of four core modules, it increases emotional awareness, facilitates flexibility in appraisals, identifies and prevents behavioral and emotional avoidance, and provides situational and interoceptive exposure to emotional cues [24]. “Clinicians are often faced with the difficult task of treating individuals with complex clinical presentations that require them to use multiple protocols or to tackle several problems at once, with little empirical data to guide them. Transdiagnostic treatments may help eliminate the need for multiple diagnosis‐specific treatment manuals and simplify treatment planning, overall” [25–27].
\nMotivational interviewing is also highly relevant to ED treatment in light of ongoing ambivalence about, and fear of, recovery that essentially immobilizes patients, particularly within the precontemplative stage of treatment. Through motivational strategies and tools, family involvement, therapist‐patient relationship quality, the use of medication, and behavioral contracts, therapists assess and shepherd readiness for change by suggesting realistic goals that the patient feels are within her reach. Therapists do well to use the patient\'s own incentives and logic, impaired as they may be, as a place to start: “So, am I understanding correctly that you believe the more weight you lose, the more popular you become at school? Are you saying that in the throes of your disease now, you are feeling increasingly happier and more secure?”
\nAmong the more novel adjunctive treatments for ED are those that occur through enhancing the vibrant partnership between patient and brain. Like a beaver building a dam to change the distribution of water in the aftermath of natural forces, the patient who is inspired by the therapist to “put aside an obsessive focus on the past in order to reconsider, rethink, and re‐create the course and flow of the present, has a hand in mindfully creating a far‐reaching and lasting influence on brain structure and function to affect the future” [22].
\nED are disorders of self‐sensing and self‐perception. Anorexic patients experience an altered capacity to process and integrate bodily signals. Their sensation of body parts is distorted, experienced as dissociated from their holistic and perceptive dimensions [28]. In stimulating regions of the brain that lie beyond the scope of talk therapy, neurophysiological treatment interventions that integrate brain, body, and mind have been shown to increase sensory awareness and self-awareness, both elements essential to ED recovery. Twenty‐first century research and imaging technology has demonstrated the neuroplastic brain\'s capacity to regenerate, reconfigure, and heal itself through adjunctive, noninvasive, neurophysiologically based somatosensory treatment interventions (those dealing with the embodied nervous system) by informing, integrating and healing the brain through creating connectivity between and body and brain. Various forms of somatosensory education hold the potential to facilitate recovery from ED and body image disturbances. Despite this, such practices have not yet become part of mainstream clinical ED practice.
\nDr. Moshe Feldenkrais recognized the value of systematic exploration and reorganization of sensory motor aspects of self‐image during the early part of the twentieth century. Through pleasurable, sequential forms of movement with attention, the Feldenkrais Method of Somatic Education© stimulates sensory integration by reconnecting individuals consciously with their unconscious sensorimotor repertoire. Facilitation of the method is accomplished through the verbally guided directives of a Feldenkrais practitioner in Awareness through Movement© group lessons; or through gentle, nonverbal, hands‐on Functional Integration© lessons, which connect and integrate the sensing body and brain. In a controlled study within a multimodal treatment program, ED inpatients participating in adjunctive Feldenkrais treatment were shown to increase their acceptance of, and contentment with, problematic zones of their body. Other results indicated “the development of a felt sense of self, self‐confidence, and a general process of maturation of the whole personality” [29]. Easily accessible demonstrations of short and simple Feldenkrais movements have become available via the Internet for use in professional offices and patients’ homes. ED therapists do well to encourage patients to reinforce mindful neurophysiological healing at home, as “sustained practice solidifies learning” [30]. Integrating body and brain leads to the integration of the total self, awakening the patient\'s potential for realizing new options in all life spheres. By verbally processing somatosensory experiences with the patient either during the movement experience, or in its aftermath, therapists help patients fully understand how the functions of somatic education parallel and complement the functions of the psychotherapy process by increasing awareness of a sense of mind/body wholeness and a unified perception of self.
\nTrauma‐informed yoga regulates the nervous system, bringing it from a dysregulated state to a unified, centered state. Unprocessed traumatic memories stored in the brain become recycled when triggered, creating imbalanced patterns of nervous system activation. Yoga naturally regulates the overwhelmed nervous system by bringing unconscious content from trauma‐related neurological and muscular patterns into consciousness. Teaching the use of breath, which evokes self‐regulation, and facilitating close attention to present‐moment awareness of self, yoga shifts sympathetic nervous system arousal to a balanced parasympathetic sense of calm and relaxation. Yoga has been shown to promote affect tolerance of physical and sensory experiences associated with fear and helplessness [31]. The trauma‐informed yoga practitioner needs to conduct a full assessment of the patient\'s nervous system imbalances in order to provide postural movements that accommodate the individual\'s unique needs. For ED patients suffering from co-occurring substance abuse or addictions, yoga‐breathing practices may be useful in counteracting all types of urges brought on by environmental triggers that could result in relapse [31].
\nA growing body of research points to eye movement desensitization and reprocessing (EMDR) as a highly successful, (mindful) method for treating a variety of conditions, including trauma [32]. Traumatic experience becomes locked in the brain and body. As an integrative psychotherapy approach involving interpersonal, experiential, and body‐centered techniques, EMDR processes traumatic memory stored in the brain. Given the direct correlation between the trauma of sexual abuse and the onset of ED, this methodology can be considered a helpful adjunctive resource in the treatment of ED.
\nParts of the traumatized brain remain out of synch with other parts of the brain, leaving the trauma victim unable to take in neutral information without fear, and unable to learn freely from life experience. Neurofeedback training (NFT) represents an effective alternative for modifying neurophysiological activity in the brain that contributes to specified impaired cognitive processing and emotional and behavioral dysregulation. Noninvasive instruments measure physiological activity, then “feed back” information to the user, a process that enables individuals to reverse the effects of trauma and depression by integrating brain function, and allowing the patient to change the course of neurophysiological activity to improve health and performance.
\nAnother form of noninvasive technological brain intervention that has been used successfully with ED patients includes transcranial magnetic stimulation (TMS), which sends low dose magnetic pulses to parts of the brain associated with unrelenting depression. The technique has been shown to ease depression and improve mood when medication has been insufficient to relieve depressive symptoms for patients with a severe and enduring ED (SEED).
\nThe process of recovery typically feels worse to the patient than does the pathology of disease. It is up to the psychotherapist to penetrate and break through treatment resistance to facilitate patient engagement, from the very first meeting, and throughout the recovery process. Treatment resistance can be seen in the patient\'s failure to: (1) recognize and accept the ED diagnosis, (2) engage in the treatment process, (3) attend sessions consistently, (4) attempt to comply with food plans, and (5) include parents and family in treatment where appropriate. When resistance and/or accompanying denial interferes with the treatment process, the mindful and empathic therapeutic connection and the creative use of diverse resources can become motivational. Tools existing within the clinician\'s “professional toolbox” include the following:
\nAs early as the first diagnostic session, the therapist\'s capacities to inspire, build, and nurture trust in the therapy relationship and treatment process lays the groundwork for treatment engagement, patient self‐acceptance, and healing. Instilling trust in the patient\'s existing strengths and potential for growth, particularly at treatment outset, is the glue that upholds and sustains an otherwise fragile, tentative, and ambivalent precontemplative treatment connection and process. Planting the seeds of self‐trust ultimately provides patients the stamina to sustain recovery efforts through challenging treatment junctures. Reframing a situation can recapture, refresh, and restore the healing process through trust development. As an example, by empathically reframing the ED to be the patient’s well-intentioned bid for self-survival, the therapist dismantles her fears that she is crazy and culpable. In addition, it inspires hope in the implication that she will soon become capable of discovering more reliable, less self‐destructive means of coping with discomfort and adversity.
\nPositive change can be identified in the demonstration of the patient\'s: (1) growing commitment to treatment, (2) connection with the therapist, (3) capacity to identify feelings, (4) increased capacity to recognize and verbally communicate needs, (5) growing independence and self-determination, (6) healthy eating lifestyle, (7) improved coping capacities, and (8) improved quality of daily function. By recognizing and acknowledging the elusive or disguised nature of recovery progress, personal growth, and resiliency, therapists evoke optimism and incentive to heal. Constructive life lessons frequently reside in mistakes, if not failures. J returned from college with a sad confession. She had begun to slide back into her purging patterns. “I’m a failure” was her message, clear and simple. Her doctor and nutritionist had both read her the riot act. Her lesson from me was not about how to eat better or become more disciplined, but about how to view the situation from a more positive and realistic framework, helping her to differentiate normative recovery patterns from significant relapse. “So,” I observed, “Let\'s take a look at what has changed!” I helped her see that she had become more ready to be honest with herself and with others, more acutely aware of precipitants to her regressions. Her digressions had become more contained; now isolated incidents, they were no longer the start of extended patterns of dysfunction. General problem‐solving in other life spheres improved, as had her relationships with others. Increasingly aware of her needs and feelings, she was becoming increasingly assertive in communicating those needs, both within, and outside of, treatment sessions. She was, in fact, progressing well in her ED recovery.
Though baffled, fearful, and generally uninformed, by default, parents and families become witnesses to their child\'s struggles in kitchens, bathrooms, grocery stores, and restaurants. Parents need to learn to understand the disease, its effects on their child, and the unpredictability (and necessity) of the recovery process. They need knowledge, guidance, and skills to respond effectively, and with sensitivity, to their child\'s efforts to recover, and to mediate the effects of the ED on the greater family system, particularly at meal times. Life partners of ED individuals, as well, need to learn to interpret the significance of changes they see, or may not see, throughout the course of treatment, be they in the form of progress or regression, or both. Family members need to keep pace with the ongoing development of the recovering individual\'s strengths, which will influence the ever‐changing nature of their support for their loved one throughout the treatment process. When the psychotherapist takes on the dual roles of individual and family therapist, treatment efficacy becomes streamlined, simultaneously guiding the family along the same continuum of growth and change that the identified patient travels, and at the same pace. Treating family members conjointly with the identified patient avoids the potential for the practitioner to breach confidentiality by enabling family members to speak for themselves, openly, willingly, and face to face.
\nPsychopharmacological medication is meant to help people feel, and function, better. If and when medications fail to result in either or both of these outcomes, it is clearly time for the psychotherapist to recommend a medication reevaluation, or possibly, a second opinion. When a treatment process is stagnating or regressive, a medication reassessment holds the potential to break through neurochemical barriers in the brain that contribute to entrenched resistance to healing. The psychopharmacological specialist in the treatment of ED seeks to balance brain chemistries, optimize brain function, and facilitate the patient\'s potential to benefit from the treatment experience. Malnutrition, co-occurring mood disorders, depression, anxiety/obsessive compulsive disorder (OCD), and ADHD (in some cases brought on by the disease itself) highlight the importance of the input of a skillful psychopharmacologist as part of the ED outpatient professional team. Medications are not meant to provide a cure, but to facilitate healing through the psychotherapy process. It is important to recognize that until the starving brain has been refed, the benefits of using medication will be less than optimal.
\nED patients commonly resist consideration of the medication option, fearing the unknown, the possible side effect of weight gain, or taking the “easy way out” in the face of an ED that demands willful deprivation and self‐discipline. Some patients are afraid to “contaminate” their body. Others, who consider medication to be the “last resort,” fear that they will ultimately discover themselves to be beyond help. It is critical for the knowledgeable psychotherapist to reduce the patient\'s (and family\'s) resistance to the medication option by preparing them for the medication evaluation, describing benefits and possible side effects of relevant medications, establishing realistic expectations, quieting fears, etc.
\nBecause of the breadth of factors that contribute to and co-occur with ED, psychopharmacologists need to diagnose mental health status fully, and in depth, before providing medication. Though fluoxetine (prozac) has been shown to be beneficial in treating AN and BN, medications affecting serotonin neurotransmitters can be contraindicated, creating suicidal tendencies in cases where there may be a yet undiscovered underlying mood disorder. Stimulants prescribed for ADHD can suppress appetites in patients with AN. Hormone replacement therapy, commonly prescribed for anorexic patients, does not enhance bone density, but masks the loss of natural menses. “The commonly prescribed use of estrogens for anorexic patients to bring on a period in seeking bone density enhancement may create a false picture indicating that the skeleton is being protected against osteoporosis. Thus, the motivation to regain weight, and adhere to treatment of the ED, may be reduced. Hormone and oral contraceptive therapy should not be prescribed for young women with amenorrhea and concurrent ED. The most important intervention is to restore menstrual periods through increased nutrition” [33].
\nED therapists need to be myopic, even while functioning as visionaries. The seasoned ED practitioner integrates knowledge with instinct, intention with flexibility, and diversity within structure, holding onto the “big picture” of disease and recovery even while attending to the small details of behavioral change. With ED, small changes become the stuff of vast transformations. In validating the patient\'s feelings, thoughts, and ideas, the therapist makes sense of them for the patient within the larger picture of the disorder, of the narrative of her life, and of her relationships with food, self, and loved ones.
\nAs integrationists, ED therapists piece together submerged and disparate facets of the patient\'s personality to foster the re-creation of the patient\'s true and authentic integrated self. In uncovering, discovering, differentiating, then reintegrating all parts of the patient\'s exiled self, disclosed and undisclosed, systematically and intentionally, the 1000 piece puzzle of the patient\'s holistic self slowly reassembles itself into an integrative fabric through the recovery process. As integrationists, practitioners play diverse roles in the life of the ED patient, as teacher, mentor, cheerleader, confidant, case manager, and “parent” in supporting and containing the patient to her point of readiness for flight into recovery as an autonomous, independently functioning, self‐possessed, self‐regulated, human being.
\nIn taking on the responsibility of case manager, it is up to the outpatient ED psychotherapist to put together an outpatient team of expert treatment professionals capable of tending to the broad‐based needs of the ED patient throughout the course of care. Defying compartmentalization, ED symptoms need to be recognized and professionally managed by every member of the team. Wearing diverse professional “hats,” each team member acts as a representative of the wider healing process, capable of mediating all spheres of pathology. Particularly in smaller, less diverse, rural communities, where trained and experienced professionals may not be readily accessible, the need for an integration of knowledge, skill sets, and a multifaceted use of self becomes particularly critical. Members of the professional team, including medical doctor, psychopharmacologist, individual/family therapist, and nutritionist, need to understand and “understudy” each other\'s parts, learning essentially to “speak each other\'s lines” as needed, fluently, throughout the treatment process.
\nAs an example, where an at‐risk anorexic child patient resists treatment engagement with the outpatient psychotherapist, the familiar and authoritative pediatrician may step in to become active in monitoring weight and vital signs regularly, actively demanding accountability and improvement. In the absence of timely change, the pediatrician\'s recommendation for a higher level of care potentially carries the day. In response to a patient who is starving herself, my nutritionist team partner would typically ask the patient to consider the fact that she is abusing herself, inquiring “what that might be about.” Following such an exchange, she would attend to the issue of introducing behavioral change into the patient\'s eating lifestyle. Even in the latter stages of recovery, there is rarely a session that goes by without my inquiring about how one\'s eating‐related progress is going.
\nApart from parents of child patients, life partners and siblings become witnesses, and potentially effective supporters of ED recovery as well, when properly prepared for the task. Siblings of adolescents with AN have been shown to demonstrate poorer psychosocial adjustment than their peers, both before and after the identified patient\'s FBT recovery efforts. Clinicians and parents need to become aware of sibling difficulties and to offer additional support if required [34].
\nWhen a family member contacts me by phone or email to discuss concerns about his or her loved one\'s recovery, my response is always inclusive, welcoming them to attend conjoint family sessions for open and mutual discussions. The patient who refuses to participate in an occasional conjoint meeting with family or partner raises a therapeutic issue that demands attention and resolution.
\nAny concerns about privacy disclosures or confidentiality breaches when the family joins the individual patient in conjoint family treatment become unfounded, a non-issue, as family members are brought together to air their own immediate concerns and issues, willingly, and by choice, to one another. Except in extreme instances of dysfunction within family systems, parents or spouses need to become part of the fabric of treatment, in various ways, to varying degrees, and at various points within the healing process.
\nIn those instances where a married ED patient enters treatment, the marital dyad becomes the primary family system. Involving the spouse in treatment potentially enriches and facilitates the identified patient\'s recovery.\n C. was a compulsive exerciser, waking at 3:00 AM to make time for eight hours of exercise daily. She would fulfill her computer‐based employment responsibilities while exercising on machines. Interfering with the lives of family members in the context of daily living and travel, her compulsions began to undermine her marriage. Ultimately, C\'s husband felt compelled to supercede the eating disorder by taking control of his wife\'s behaviors, threatening to leave the marriage if she did not comply with his directives to give up exercise completely. Having done so, as she restored her weight, her extreme body image discomfort finally prompted her to seek ED treatment. This patient refused to consider taking medication to diminish her anxiety, compulsions and occasional panic attacks. It became apparent that C\'s husband needed to attend a conjoint couple\'s therapy session to become educated about her need for a gradual increase in her own self‐regulation as part of her recovery. The session facilitated a plan for a treatment arrangement at home allowing her to attempt to return very gradually to a normal degree of exercise in the hope of overcoming her compulsive urges towards extremes in behaviors and thinking in all areas of life. Conjoint sessions provided the backdrop for a more complete recovery and a healthier, stronger marriage.
Levels of care for ED treatment range from the most restrictive (hospitals and long‐term residential facilitates) to less restrictive alternatives (group partial hospital programs (PHPs), intensive outpatient programs (IOPs), and individual outpatient therapy with an outpatient team of ED experts providing \ntherapeutic, medical, psychopharmacological and nutritional services to individuals and families. The latter is the least restrictive outpatient level of care, allowing the patient to remain in her home environment with the support of loved ones, fulfilling her life roles at school or work, side by side with friends. A higher level of care becomes a consideration primarily when the patient faces immediate physiological or emotional risk, requires forcible refeeding, or when the outpatient team alternative proves unworkable due to the patient\'s treatment resistance or progress stagnation. Higher levels of group care enforce refeeding, provide cognitive and behavioral immersion, offer emotional exposure to peer support, and enhance internal strengths and coping resources, ultimately setting the stage for the patient to make subsequent long term progress through recovery efforts within less restrictive outpatient care.
\nChoosing the appropriate care level, at the right time, can optimize the course of treatment for each individual patient, impacting one\'s engagement in treatment, one\'s time spent in treatment, the nature of the weight gain process, and the extent to which emotional goals are attained. In some instances, the referral to a higher level of care, at the right moment, could potentially insure that the window of readiness for treatment engagement and healing is captured rather than lost forever. In transitioning into or out of a program successfully patients and parents need preparation to understand what to expect and to establish realistic goals for themselves within the upcoming experience.
\nA pediatrician who universally prescribes higher levels of care as a child\'s initial entry into ED treatment in order to “save parents time and money,” believes it is more efficacious to bypass the option of diagnostic assessment through an outpatient treatment team of ED professionals. Such a universal prescription misleadingly implies that restrictive environments are more beneficial than those permitting recovery within the context of daily living; that all patients, and all recoveries, are alike; and that restrictive treatment programs “cure” ED patients.
An ED waits for no one. Unless it is healing, the condition is progressing. The diagnosis of an ED is frequently elusive. Through a deep understanding of these diseases, seasoned therapists develop a capacity to anticipate or intuit their presence, a skill rooted in diagnostic acuity. Within the context of human connection, the astute therapist reads ‘between the lines’ of the therapeutic moment, guiding an inquiry and early detection of physiological, developmental and emotional gaps in the patient\'s psyche and body image.\n E was a 29‐year‐old woman who began treatment with me for depression and relationship problems. In response to her description of her college days where she spoke of herself as being perfectionistic, highly compulsive, and depressed, I chose to wonder aloud if she had ever struggled with an ED or other eating related issues. “My God!” she responded. “How did you know? I have never told a soul!” By understanding the emotional configuration of her personality, I was able to intuit and surmise the possible existence of a past or ongoing ED. In learning that my hunch had been correct, I better understood the breadth and depth of her treatment needs.
Learning to identify suspicious clusters of symptoms potentially shines a light on existing, future, or past ED that might otherwise have remained undisclosed. In making the educated guess, therapists learn to “connect the dots” of conversation and affect. At times, making an eating disorder diagnosis can be much like observing a disparate grouping of stars and seeing a constellation. By anticipating the unspoken (based on information that has been offered), by discerning which topics require further investigation, and by actively probing the possibility of earlier patterns of behavioral impulsivity and compulsions such as self‐mutilation/cutting, childhood shoplifting, promiscuity, substance abuse, and excessive exercise, therapists become capable of revealing hidden, or yet undisclosed, underlying ED and co-occurring conditions.
\nED offer little leeway for cursory assessment of both the disease and recovery status, throughout the course of treatment. An ongoing diagnostic assessment of recovery, which may be considered the flipside of an ongoing diagnostic assessment of pathology, enriches the treatment process, motivating new directions for growth and change. Assessment of recovery status might reveal a possible resurgence of resistance and regression, which could signify a worsening pathology. Recovery derailments can be gradual or sudden, temporary or enduring, minor or significant, at times warranting consideration of a higher level of care or tapping additional personal and professional resources (family, team, psychopharmacological medication) for support, as needed. Effective ED treatment demands ongoing positive change in the form of recovery progress, both immediate and long term, behavioral and emotional, throughout the duration of care.
\nThe ED therapist moves and motivates people with the intention of moving and motivating the healing process. Authoritative action, not to be confused with authoritarian demands, produces desired outcomes. Micromanagement and the imposition of directives, judgments, projections, or boundary intrusions replicate the role of the overly controlling ED, denying the patient self‐determination, a most pivotal component of recovery. In response to the momentum behind a forward‐moving disease, therapists need to carefully monitor, then shepherd, the pacing of recovery change. Except in the case of young children who are developmentally unprepared to take on the tasks of self‐determination throughout recovery, or of highly resistant patients whose malnourished brains have impaired their capacity to make responsible decisions, the use of “soft power” can produce positive outcomes. The nonjudgmental therapist’s radical acceptance of the patient can redirect the forces of resistance..\n An 18-year-old anorexic patient declared, “I can fix myself. I don\'t need therapy.” I replied, “I’m all for that plan. You are, and will always be, the primary person responsible for your own recovery. I am basically here as a coach, cheerleader and collaborator. So why don\'t you try to follow your own meal plan this week, and let\'s talk about how things go when we meet again. Be sure to journal your efforts, so together we can gauge your progress and determine your next steps.
Action‐based behavioral tasks and strategies, such as the patient\'s journaling, or in‐office meals eaten in the company of the therapist, create accountability, and can become strong motivators for change. As important diagnostic tools, such strategies can shed light on an elusive process of ED recovery change.\n A recovering anorexic patient, who had made brilliant progress in integrating regular and nutritious meals into her life, spoke of having skipped lunch three times one week because of mounting stressors at work. After legitimizing her urges, and identifying the feelings that evoked them, I discussed the normalcy of an occasional and intermittent regression during eating disorder recovery, not to be considered a relapse. I requested that she attempt to resume eating lunches daily and journal her efforts and struggles, successes and failures, to be assessed together in our quest for understanding and problem‐resolution during our next meeting. In another instance of an anorexic patient\'s strong resistance to considering the inclusion of lunch into her eating lifestyle, I planned to conduct the next few sessions over lunch together, side by side, in‐office or at a restaurant, supporting her efforts, providing exposure, processing fears.
Actively engaged practitioners model energy, initiative, and resolve. A study showed that when therapists make referrals to higher levels of care and encourage patient follow through, of those patients who were offered a phone number, 37% made contact; when the counselor took initiative to place the referral call for the client, 82% completed the referral [21]. The therapist who chooses to remain passive, nondirective, or more like a friend by avoiding tough therapeutic issues in an effort to protect the patient’s comfortability and trust, enables the ED. “Toughness” is a sign of a practitioner\'s clear intention to support positive change.\n In reminiscing about her ED treatment, a recovered patient once commented, “You knew things that were in my head and heart even before I did, and you recognized what I was capable of doing even before I did. Best of all, I couldn\'t get away with anything because you knew the drill, and were not afraid to challenge me.”
Healing therapeutic connections ride on the therapist\'s capacity to sustain the fragile balance between discomfort and learning, and between learning and change.
\nIf one technique does not work, it is incumbent upon the practitioner to find another that will. As a therapist, I am a Machiavellian proponent of doing what works, whatever that may entail. Nontraditional, “outside‐the‐box” treatment alternatives have been shown through evidence‐based controlled studies to carry the potential to achieve positive outcomes for ED. If an intervention works for a single individual, offering that option to other ED individuals becomes a legitimate and viable option. At age 13, M and her mother attended outpatient therapy sessions together for several months and saw a pediatrician and nutritionist weekly. Despite this, her AN remained intractable. Whatever weight she was able to gain, she readily lost. Still, she resisted medication and a higher level of care. Insisting that she could ‘recover on her own,’ her resistance to recovery intensified and she began to miss therapy sessions. In my effort to rescue a now fragile treatment process, I offered M the unique opportunity to discontinue therapy temporarily, going it on her own, utilizing the knowledge that she had already gleaned through treatment to date. This plan stipulated the singular requirement that she see her doctor weekly for monitoring of weight and vital signs. I also extended an invitation to her mother to attend coaching sessions with me regularly, without M, which she readily accepted. Feeling ‘heard,’ and grateful to be allowed to try her own hand at recovery, after 3 weeks, M requested permission to join her mother in her return to treatment.
In her absence from treatment, M made peace with the idea of seeking a higher level of care. She ultimately agreed to attend an intensive after‐school outpatient program, under the stipulation that if she did not gain sufficient weight there, she would enter a higher‐level full‐day partial hospital program. Having been offered an opportunity for self‐determination, M felt an enhanced sense of trust and connection with me. Prior to starting higher‐level care, she reached out to me on several occasions for my support and reassurance about what was now her own decision.
T was a 12 year old who had begun her descent into AN; at the start of her session, she sat in the car, bawling. Her mother rang my doorbell to ask what to do, as her daughter refused to get out of the car for her third therapy session. I instructed her to return to the car and speak with her daughter, setting clear but loving limits, and making authoritative demands… T would either come into the session to continue her outpatient work, or she would need to enter an ED program. Crying hysterically, T refused to get out of the car. At that point, I donned my boots and jacket and began this session on the street, in front of my office, in the snow. I told her how relieved and optimistic I felt to see that she was finally beginning to get in touch with her feelings, which made her so much more accessible to getting the help she so richly deserved. Reframing and educating, meeting and joining with her where she was, I applauded her integrity and courage in expressing herself. Standing up to her mother would hopefully become a prelude to standing up to her ED. Feeling genuinely understood, T began to experience hope and a sense of relief as she followed me into my office that day, where we proceeded to have a break‐through session. [19]
In an imperfect world of ED treatment and recovery, hard and fast rules may occasionally need to be bent in offering the most practicable solutions for patients. In nuanced decision‐making, ED therapists become models of thought and action.\n An intake therapist at a renowned outpatient treatment center refused to assess a patient for admission because she needed two more pounds to reach her ‘safe’ body mass index goal. This patient was asked to attend an in‐patient program to restore her weight first, in the interest of “optimizing the therapy process.” Though motivated to achieve recovery through a higher level of care to support her re‐feeding efforts, the patient became caught up in a catch‐22. She would either have to enter a financially prohibitive in‐patient milieu, or gain the required pounds in a less restrictive environment. Both alternatives were daunting to her. Though declared medically stable by a medical doctor who was monitoring her weekly, her recovery efforts floundered. By disregarding the “psycho” and “social” aspects of the bio/psycho/social disease, this intake counselor placed too much emphasis on the criteria of weight alone in determining the patient\'s preparedness for treatment. This diagnostic assessment needed to take into consideration the patient\'s readiness and motivation for recovery, her financial constraints, and her medical monitoring, in addition to her weight. A short‐term weekly contract for a stipulated amount of weight gain, in‐program, might have been a more appropriate and workable alternative.
As neurobiological disorders with their origin in genetics, EDs were declared legitimate “biologically based mental illnesses” by the Academy for ED in 2006, deserving of medical insurance coverage. Congress succeeded in eliminating discrimination in health care coverage against people who have mental health disorders in the passage of the Emergency Economic Stabilization Act of 2008, which took effect in 2010. Despite these advancements, insurance coverage for ED treatment remains spotty, with some companies denying coverage totally and others denying longevity of coverage. Some insurance companies appear to be more amenable to providing coverage for diagnostic codes that indicate less serious, more ephemeral, types of diagnoses. In some instances, companies have considered the normal weight ED patient not appropriate for coverage.
\nIn dealing with insurance companies, advocacy from personal and professional mentors needs to be active and focused. Communications need to be traced to the top of the bureaucratic pyramid in seeking assurance that the company assumes appropriate responsibility for its decision against coverage for the ED patient, particularly if a patient\'s health is at risk. The insurance company needs to be made aware of their liability if they refuse to cover a patient who dies for lack of care. Most insurance carriers allow families to appeal the refusal of coverage, and some now hire in‐house employees to assist consumers in such appeals. Most higher‐level ED programs and facilities offer the assistance of a specialized coordinator/advocate, hired to intercede and develop trusting relationships with insurance companies for the benefit of patients. Some residential programs offer scholarships for patients who would otherwise be unable to afford to take advantage of a costly, but life‐saving, treatment milieu.
\nAccording to Daniel Siegel, “Relationships are woven into the fabric of our inner world. We come to know our own minds through our interactions with others” [35]. Emotional, cognitive, and behavioral learning is enhanced within the framework of a powerfully human and loving therapeutic connection. “Love is not something that we generate; it is found in the activity of intimately attending” [22]. Because ED are disorders of relationship and attachment, the quality of relational connection or attunement between the ED therapist and patient is pivotal. The healing connection between therapist and eating disordered patient becomes the prototype and practice ground for all healthy relationships, as the conduit for the return of the ED patient\'s exiled core‐self. Though the patient\'s resistance to letting go of the disorder may be a primary source of the ED clinician\'s initial treatment challenges, the quality of the therapy relationship is frequently the “deal breaker” when ED treatment fails. Conversely, it can be the quality of the treatment connection that transforms the therapist\'s goals and intentions into fertile seeds of successful outcomes within a safe and trusting treatment environment. Studies have found that “…the model of therapy simply does not make much difference in therapy outcome. Empathy accounts for as much and probably more outcome variance than does specific intervention” [22]. Empathy not only helps the patient to feel better and feel “felt,” it may create a new state of activation with coherence in the moment that improves the capacity for self‐regulation [35].
\nThe foundation of the healing therapeutic connection exists within brain physiology. Neuroimaging studies of structural brain changes associated with the process of relationship within psychotherapy demonstrate that relational experiences in psychotherapeutic treatment result in detectable changes in the brain. “The aim of the talking cure…from the neurobiological point of view is to extend the functional sphere of influence of the prefrontal lobes” [30]. “The intention of therapy is to work through the effects of isolation and disconnection, as they play out in life and in therapy, toward the goal of reconnection and restoration of mutual connection. For the patient, this results in a greater capacity to act, increased clarity, enhanced self‐worth, and the desire for more connection, while remaining present and accessible in his or her shared humanity” [22]. According to Christopher Germer, “Given that there is little empirical evidence that (treatment) effectiveness improves with experience, continuing education, licensing, professional degree, clinical supervision, or any other marker of professionalism, and given the importance of the therapeutic relationship, the larger challenge is to find a way to help cultivate the qualities of excellent therapists” [22].
\nMindfulness in psychotherapeutic practice creates strong connections between people. The mindfulness process requires the therapist\'s and patient\'s attention and “presence” within the treatment moment, where the inception of psychotherapeutic change takes place. Daniel Siegel describes presence as “being aware, in a receptive state of what is happening as it is happening. This receptivity correlates with a brain state in which there is intentionality, awareness, conscientiousness, and nonjudgmentalism in interacting with others, promoting rewarding relationships” [36]. Mindfulness in psychotherapy practice allows patients a greater capacity to choose whether to act on one\'s urges, a concept that is particularly relevant to the treatment of BN, characterized by impulsivity and self‐dysregulation. Mindfulness in psychotherapy stimulates the patient\'s ever‐changing neuroplastic brain to learn. As the brain learns, people change and heal; as people change and heal, the brain alters in structure and function, ultimately stimulating further changes.
\nRecognizing and addressing the patient\'s newly emerging, fledgling strengths throughout the course of treatment reinforces the patient\'s self‐acceptance and empowerment, facilitating trust in the therapeutic connection, but not without reservations. Low self‐esteem and the fear of becoming fat and out of control render some ED individuals wary about trusting the therapist\'s positive affirmations. In the face of a complimentary observation, the self‐hating patient may distrust the accuracy of the therapist\'s perceptions. ED patients may also fear (1) recovery from a much coveted disorder, (2) the therapist\'s terminating treatment before she feels ready, and (3) being expected to demonstrate strength and competency that she does not possess. Through a deeply sensitive understanding of the ED mind, and carefully worded subtleties of self‐expression, the knowledgeable practitioner can avoid making well‐intentioned comments that might inadvertently raise anxiety or stimulate regression in the ED patient.\n “You are looking great,” can all too easily be interpreted as “You have gained weight and look fat.” “You don\'t have too much weight to gain,” a comment offered as encouragement to an anorexic teen with a dysregulated eating lifestyle, would clinch the patient\'s belief that she is already fat and that continuing to follow her meal plan would only make her fatter. A pediatrician mentioned the “benefits of eating fatty acids” in encouraging the inclusion of fish in an anorexic adolescent\'s diet; that patient resolved never to eat fish again.
It is never too late to repair a moment of distortion by investigating and processing it, clarifying and resolving misinterpretations, either as they occur, or after they have happened. The therapist’s full transparency behind a misconstrued but well‐intentioned comment can deter a patient\'s anxiety and potential for recovery derailment. Patients feel reassured and become capable of developing increasing trust in the therapist who substantiates positive comments by citing the origin of a complimentary observation and the thought process behind it.\n “Here\'s what has led me to remark about what I see as your substantive progress and the growing strengths you have achieved.” Is there any part of what I am saying that you might accept as being an accurate description of yourself? “You know, when I offer positive feedback to you, I am aware that it must be difficult for you to hear because of how poorly you think of yourself. Can you tell me what it feels like for you to hear the positive things I am saying about you?”
It is not unusual for patients who may idealize their therapist to forego sharing what they consider to be shameful self-revelations, for fear of giving rise to judgment or disapproval. Therapists might anticipate and diffuse such a dynamic by wondering aloud “if such a thing might ever happen within our own treatment relationship.” Welcoming a potential problem by putting it ‘on the table’ can stave off its occurrence, creating an atmosphere of total acceptance.
\nAnother strategic tool that therapists might use to nurture and reinforce a genuinely caring connection with patient and family is to offer ready accessibility between sessions when needed, throughout care, always within the confines of exquisitely honed professional boundaries. I invite and welcome contact with patients who are in crisis, and with parents who have inquires or observations that deserve immediate attention. The process of learning and change exists in life, both within, and beyond, the therapeutic hour.
\nThe impact of ED pathology on the malnourished brain typically fosters cognitive distortions and illogical beliefs, which give rise to self‐destructive thoughts and actions. ED therapists need to anticipate and address cognitive distortions, myths, and misconceptions about ED, educating patients and parents about the realities of these disorders, and their impact on the brain, mind, and body. Educating oneself first is prerequisite to educating others. Because misconceptions about ED are widespread, it is essential for professionals to know, and patients to learn, what is true and what is not. EDs are not exclusively female disorders, nor are they disorders of childhood. “Ten million men will suffer from an ED in their lifetime, and 13% of women over 50 have ED symptoms. Note that 70% of them will not seek treatment due to stigma, as well as lack of education, diagnosis, and access to care [37].” Two misconceptions that prevent ED individuals from seeking recovery assistance are the beliefs that ED are addictions, and therefore they are incurable. In fact, the genetic clusters in familial deoxyribonucleic acid (DNA) that predispose an individual to ED onset may contain substance and ‘process’ addictions, which are addictions to activities. However, ED are not addictions (primary, relapsing diseases of the brain). In addition, EDs are curable in approximately 80% of patients who receive effective care and who are willing to seek complete recovery [37].
\nA professional\'s lack of education about ED and their treatment can be misleading and potentially dangerous for the ED patient in recovery.\n An anorexic patient spent three years with a highly regarded psychiatrist who refused to acknowledge her ED as a pivotal aspect of her personhood or treatment. His theory was that “her symptoms were too complex to be an ED.” He perceived the ED symptoms as being tangential and secondary to other “more core” co‐occurring problems, assuming that once these were treated and resolved, the ED would disappear. She ultimately left this therapist to seek specialized ED treatment. His parting warning was, “Don\'t let anyone “treat you like an ED patient. Your problem is much deeper than that.” This physician was right in his allusion to the fact that her problems ran deep and wide, though wrong in thinking that an ED diagnosis and treatment would exclude the recognition and treatment of a myriad of commonly co‐occurring conditions. In the face of a complex and integrative system of comorbidity, attention to one\'s eating lifestyle and weight‐regulation issues not only saves lives, but also can provide a behavioral foothold in unmasking, and simultaneously treating, co‐occurring problems.
The role of weight in the diagnosis and treatment of ED is perhaps the most misleading of all the commonly held misunderstandings about ED and their recovery. Patients need to understand that severe and prolonged dietary restriction and weight loss can lead to serious physical and neurological complications. At the same time, they need to understand that weight restoration alone in an underweight ED individual is not a predictable criterion for recovery. Most patients and parents, and all too many professionals, believe that the only requirement for medical rehabilitation for an ED is removing the immediate danger of death due to malnutrition. This is not the case. In fact, electrolyte imbalances due to purging behaviors in a normal weight ED patient can lead to sudden death.
\nWeight “restoration,” is not to be confused with weight “gain.” They both represent one single strand of the larger fabric of ED healing. Weight gain and normalizing blood tests and vital signs are significant in indicating improved eating and brain function, marking the patient\'s potential to achieve a full, integrative ED recovery, cognitively, emotionally, physically, and neurophysiologically. For the anorexic patient, full and sustainable weight restoration to the body\'s “set point,” along with restoration of the menses and hormonal normalization, will ultimately normalize brain function and development. Attaining one\'s set point weight, marking full weight restoration and a normalized function of brain and body, leads to the reversal of amenorrhea. Each person has a set point weight to which he or she naturally gravitates. Bodily fluctuation from that point may diverge a few pounds in either direction, but the fit body at its set point weight will rarely gain or lose weight beyond its natural range.\n I conceptualize the set point weight as being like an ocean\'s tide. When the moon is new, gravitational forces may not exert a pull on a body of water as strongly as when the moon is full. The rising tide, be it slightly higher or lower, always approaches, (but does not exceed,) a certain point on the shore… with the exception of tropical storms or other natural forces. The set point weight is equally consistent, expected to fluctuate ever so slightly, but always hovering close to the water line.” [19]
It is ultimately the patient\'s healthy and fearless relationship with food, restoration of weight to set point, normal hormonal health, and reintegration of the fragmented core self that become the cornerstone of a full ED recovery.
\nRegular weigh‐ins can be an important accountability tool for the underweight patient. Patients who fear that any amount of weight gain will lead to the loss of self‐control through binging and obesity, do best when weighed “blind,” so their weight remains undisclosed to them, even while available to clinicians and parents when appropriate. It is counterproductive for clinicians to identify an “ideal weight” or to offer anorexic patients the “carrot” of reaching a specific “target weight” as their goal. The body mass index (BMI) has been proven an unreliable reflection of a healthy nutritional state [38]. No one, not a nutritionist, patient, or physician, can set an arbitrary target weight and expect its achievement to lead to recovery. The body alone, through the process of ingesting healthy, balanced, regular meals, is the only accurate determiner of its ideal weight for its own unique structure and function.
\nIf a nutritionist or physician says, “It is important for you to gain another five pounds (to reach the low end of normal on the growth charts,) the patient hears,” “Five pounds is all I need to gain in order to get everybody off my back;” “Five pounds gained will still allow me to stay skinny without being considered sick. If I gain 6 pounds, I will have become fat.” Patients’ misconceptions about food and weight need to be corrected. Such false notions include: food is fattening; the more one eats, the more weight one gains; when it comes to food, less is more; healthy eating is fat‐free and sugar‐free eating. Patients and families need to learn that food restriction damages the functions of the healthy metabolism, which burns calories and fat.
\nWithin the context of eating disorder recovery, “almost recovered” does not apply. The term “relapse” should not to be confused with the patient\'s choice not to recover to one\'s set point weight during treatment. Full recovery, marked by the reintegration of the core self and the emotional flexibility that comes with it, obsoletes the usefulness of an ED as a coping tool. Where there has been a full ED recovery, ensuing life crises may at times evoke a brief return to disordered behaviors, but such regressions will invariably be temporary, if not momentary. Most will be reversible through the ex‐patient\'s coping skills or through a few “refresher” treatment sessions. This, in light of the reality that no small change in the direction of healing is lost on the receptive brain. Having learned to walk does not preclude one\'s capacity to crawl, though the evolutionary benefits of becoming upright and using feet for locomotion clearly creates the brain\'s incentive to continue to use the most efficacious and practicable alternative. “So smart is the brain, when we permit it, even after doing something a million times the wrong way, doing it right even one time feels so good that the brain‐body system recognizes it immediately as right” [39].
\nIn treating the ED patient, practitioners also treat the patient\'s brain. The ED professional community needs to develop a greater breadth and depth of understanding of the organ that they treat. In addition, they need to educate their patients to do the same, in recognizing the brain\'s role in evoking ED pathology and in fostering ED recovery. The brain is an embodied system, extending beyond its skull case [32]. Sensory receptors throughout the body communicate with the cranial brain via the spinal cord through “bottom up” stimulation. By educating patients and families about the ever‐increasing accessibility of neurophysiological interventions available for mainstream ED practice, the vast potential to create a brain/body partnership in healing can provide direction, optimism, and a sense of “can‐do” within the process of recovery.
\nHuman experience affects brain change, and brain change, in turn, affects human experience. In light of the diversity of symptom presentation and bio‐psychosocial consequences of ED, the integration of a variety of differentiated treatment approaches and clinical interventions best accommodate the integrative needs and demands of the ED patient within the treatment moment. The more varied and integrative the experience, the greater is the possibility of changes facilitating the healing reintegration of the fragmented self. ED treatment techniques such as the Feldenkrais Method, trauma‐informed yoga, Nia, dance therapy, and Tai Chi, in offering movement with attention, access the more primitive subcortical regions of the brain where talk therapies do not reach, thereby globally upgrading and integrating brain function.
\nPractitioners cannot be assured that skill mastery and an expert use of self, alone, will guarantee successful recovery outcomes within the first round of treatment efforts. Some partially recovered patients may choose to terminate treatment prematurely, feeling emotionally unprepared or unwilling to face and resolve the underlying emotional issues driving the disorder. Other patients, who have made significant progress in the recovery of healthy eating behaviors, may choose not to fully restore their weight to set point range. In both instances, they will leave treatment with their ED in tow. In order to sustain recovery gains, recovery must be within all spheres of pathology.
\nLife experience can be a potent teacher to those who have left treatment to practice and hone their new coping skills on their own. Recovered patients come to realize the extent of the residual ED\'s limitations on happiness within their present lives. Where the eating disorder treatment relationship has been of quality and the work meaningful, partially recovered ex-patients may return to psychotherapy for relatively short stints when needed, after months or even years have passed, seeking to resolve emotional tasks left unfinished. Resuming treatment a second time around holds great potential for the patient to develop a healthier relationship with self and others, fully closing the circle of a complete recovery. The return to “refresher” treatment has particular potency within the first two years following termination of initial treatment efforts.
\nN, a highly effective businesswoman, after struggling with her anorexia for 20 years, was able to recover a healthy enough eating lifestyle to adequately nourish her brain and body through her first round of care, which included treatment programs and extensive outpatient treatment. She found safety, however, in her decision to cling to remnants of her disease, so she never stopped restricting certain foods, and continued to obsess over distortions in body image. Ultimately, she became embroiled in an emotionally abusive love relationship with a bully who kept her as enslaved emotionally as did the tyranny of her eating disorder. N returned to treatment to hone and build upon the skills she had previously acquired, to develop the courage and wherewithal to stand up to, and free herself from, the victimization of this love relationship. In recognizing how her relationship with this man paralleled the nature of her connection to her ED, she developed an increased sense of self‐determination, and ultimately, empowerment to leave him. Breaking out of her habitual patterns of co‐dependency and powerlessness facilitated her self‐esteem, upgrading her life quality and moving her closer to a full ED recovery.
An adult anorexic female who had developed seizures as a result of malnutrition, precipitously left ED treatment after developing a healthy eating lifestyle that restored much of her lost weight, and ultimately put an end to her seizures. It appeared that she was not ready to respond to my encouragement to complete her recovery by working through critical issues of low self‐esteem and co‐dependent passivity within her important life relationships. Having left treatment without fully recovering, she developed other self‐destructive habits (mild addiction processes) to replace her ED behaviors. Three years went by before she sought treatment again to work through relationship problems with her defiant teenage son and with her husband, who wished for a deeper emotional connection and expressions of intimacy.
Having matured and mastered the changes she had begun to achieve in her initial round of care, she returned to care having become developmentally ready to augment and practice, through life experience, the emotional strides she had made in her earlier ED treatment. She came to understand that her precipitous departure from her initial treatment was based on her feelings of worthlessness and the sense that she did not deserve to improve the quality of her existence more than she had done. Her renewed treatment reinforced her self‐esteem, self‐determination, and self‐integration. Her marriage became stronger as she became stronger, her son began to heal through her newly empowered parenting, and she achieved a state of self‐forgiveness and self‐acceptance that led to an unfamiliar, but genuine, sense of well‐being. The self that had been lost to her for so long had made a palpable comeback, leaving her feeling happier and fully grounded. No longer feeling socially awkward, timid, and insecure with others, her renewed spontaneity, emotional courage, and empowered flexibility led her to the sense that she had become “a new person.”
Where a patient’s enduring symptoms of pathology stem from the characterological nature of personality structure, expectations for recovery and growth may show less promise in some cases. Characterological disturbances in ED patients are generally less amenable to change, despite the therapist\'s expertise and commitment to the patient and treatment process. Such diagnoses are hard to discern, especially in youngsters, and may remain unknown, hidden, or otherwise undefined during much of the treatment process. Though characterological personality dysfunctions carry significant consequences for treatment, prognosis, and interpersonal dynamics within the therapeutic attachment, their presence does not necessarily preclude ED recovery, nor the achievement of substantive maturational gains and emotional development throughout the process of treatment. In facing the challenges of treating these complex disorders and personalities, therapists need to learn to take as good care of themselves as they do of their patients, keeping expectation for themselves, as well as their patients, realistic. In such cases, professional consultation can be affirming and validating, enlightening one\'s work, refreshing one\'s awareness that each patient carries his or her own genetic and biologically determined predilections toward healthy or unhealthy functioning that must be taken into consideration, respected, and managed.
\nIn treating the adolescent brain, unpredictable and acting out behaviors become the norm. Practitioners need to recognize and accommodate the not yet fully formed adolescent brain under the influence of emerging hormones, which will be less capable of positive responsiveness to treatment as seen in the patient\'s less than responsible judgment, choices, and behaviors. Treating ED adolescents begs the question of how to distinguish the chaotic and underdeveloped functioning of a normal adolescent brain, from the malnourished ED brain that awaits refeeding, or from the brain of a young patient with serious mental health conditions that might ultimately warrant a diagnosis of characterological personality dysfunction(s). The distinction, which typically will remain unclear during adolescence, essentially lies in the extent of disruptive and disingenuous functioning in the context of the patient\'s daily life. Conditions that may connote a more serious prognosis for adolescents include: an irrevocable quality of manipulating others; an extreme lack of empathy for loved ones; a refusal to appreciate the consequences of one\'s actions; and a cognitive structure that is based upon persistent lying. Asking all adolescent patients to stretch beyond the reach of their brain development best serves their treatment. Therapists need to approach the adolescent patient with clear expectations and requirements, firmly backed by empathy [17].
\nCurrent data suggests that eating disorder recovery lies in a complex interplay between weight status, normalization of stress hormones, and global hormonal well‐being for optimal brain function and ongoing brain maturation [17]. Four core principles of effective eating disorder treatment include: (1) changing the neurobiological context, to include nutritional rehabilitation, weight normalization and stability, without the interruption of compensatory behaviors as symptom substitutions; (2) treating psychiatric comorbidities to remission; (3) addressing external environmental changes; and (4) connecting to maintenance factors for recovery [17].
\nUnique requirements of the emotionally evolved, flexible, and integrated eating disordered psychotherapist find their roots in one\'s commitment to a steadfast clarity of intention and purpose throughout an action‐based, goal‐driven treatment dynamic. Setting the facile eating disorder therapist apart from the generalist psychotherapist is his capacity to master, and then transcend, left‐brain technical skills through right‐brain empathic intuition in neurophysiological connection with the patient\'s right brain. The practitioner\'s self‐acceptance precedes his capacity for full acceptance of the ED patient. It takes a special kind of professional to find gratification in a journey that is typically as arduous as it is extensive. It is the “phoenix” of the patient\'s reemerging unified self that arises “out of the ashes” of a debilitating disease, however, that makes the treatment of eating disorders as gratifying, and at times, as joyful, as it is challenging.
\nI extend my deepest appreciation to my husband Lou, and my talented daughter, Elizabeth, who edited this chapter skillfully and with love.
\nThe author’s long-term work in the fields of hypnology and hypnotherapy revealed restrictions associated with the lacks of consistency and interdisciplinarity of the research and practice.
The phenomenon of animal hypnosis, identified in all higher vertebrates and, therefore, genetically determined [1, 2], as a rule, is not evaluated by modern hypnologists as a homolog of human hypnosis. The belonging of humans to mammals gives no chance for selective “loss” of basic, genetically determined protective mechanisms of hypnosis. If the ability of hypnotization in humans is genetically determined, how one can be fundamentally non-hypnable? In this logic, situational hypnability/non-hypnability is the result of the interaction of cultural and personal representations about hypnosis with the perception of actual hypnotization, personal request for hypnotization, but not the implementation of some primary, essential level of hypnability. What is the point of populational and longitudinal studies of hypnability and creation of great amount of appropriate psychometric tools for its estimation? What is measured in reality, hypnability or suggestibility? Where is the analysis of the results of clinical practice in which the vast majority of hypnotherapist’s patients are hypnable?
It should be noted that the general trend for searching of interrelations between genetic factors and brain activities, especially in cases of mental disorders [3, 4], is accepted by modern hypnology [5, 6]. In the logic of the cognitive hypnosis paradigm, the relationship of the dopamine-related catechol-O-methyltransferase (COMT) [5] and the serotonin-related 5-HTTLPR polymorphisms to measuring hypnotizability was studied [6]. The study of connections between genotype and the hypnotizability, determined both by questionnaires, outside hypnosis, and in combination with real hypnosis [7] concretizes interrelations of dopaminergic and serotonergic genotypes and the subjective different experiences in hypnosis. From the standpoint of clinical hypnotherapy, which demonstrates efficiency in the treatment of anxiety and affective disorders [8], the fact of cross-association of the Val158Met catechol-O-methyltransferase genetic polymorphism simultaneously with (1) anxiety disorders (ADs) [9] and (2) hypnotizability [6] becomes significant.
The long-term process of accumulation of genetic data associated with the phenomenon of human hypnosis in the future can lead to a comparison of human and animal hypnosis. The search for the genetic basis of universal protective hypnosis reaction in humans and animals has not yet been realized.
The brain of all higher vertebrates operates in the fundamental circadian cycle of the steady states (modes) of sleep and wakefulness. The phenomenon of animal hypnosis represents a protective adaptation to the behavioral situations of an insoluble impasse [10, 11], which includes a holistic systemic pattern associated with immobilization (catalepsy); decrease or cessation of pain sensitivity; and situationally determined duration. Sleep and wakefulness form a category of circadian-conditioned, fundamental, stable states, whereas the phenomenon of hypnosis belongs a qualitatively different category of behaviorally situationally developing state that ends when the situation is resolved successfully. Such a logic allows us to distinguish between two basic genetically determined categories or classes of states in the activity of the brain: (1) circadian-conditioned sleep and wakefulness and (2) situationally determined (animal) hypnosis.
Russian neurophysiologists Bogdanov and Galashina [1, 2, 12] in the study of animal hypnosis in rabbits had revealed that the single case of animal hypnosis has long-term (1 month) neurobiological action; is followed by functional regress of neuronal activity in the networks, with reorganizational transduction of pathways of coded information, and restoration of neuronal activity after hypnosis; and stimulates and optimizes the learning in a previously actualized area of the behavior. So, experimental data indicate a powerful neurobiological effect of animal hypnosis, and increasing the effectiveness of learning in a previously actualized area acquires a fundamental therapeutic value in human hypnosis [12].
Being a homolog of animal hypnosis, human hypnosis extensively and variably implements a genetically defined neurophysiological pattern of adaptive response to behavioral impasse, complementing the range of triggers by symbolic impasses, due to thinking, culture. Moreover, traditional culture, and then therapy, channeling the use of the given neurophysiological pattern-state in various ways creates different types of its utilization and nominalization, defining it as hypnosis, trance, meditation, relaxation, etc.
The extreme adaptive and regressive nature of animal hypnosis (to overcome the behavioral impasse) determines the presence in this phenomenon of explicit systemic neurobiological and general biological adaptive mechanisms, which are inevitably realized in human hypnosis. Thus, the acceptance of conclusion about the fundamental unity of animal and human hypnosis not only stimulates the theoretical analysis of this phenomenon and development of related therapeutic practices but also targets the areas of research and outlines potential results.
In the 1970s to 1980s, the author conducted an extensive research on the characteristics of reproduction and the impact of hypnosis-induced colors and images in the interest of their utilization in hypnotherapy of anxiety disorders [10, 11].
In the 1970s, Russian hypnology was based on Pavlov’s theory of hypnosis, and the phenomenology of hypnosis was completely studied [10]. In an attempt to use color suggestion for additional directed (sedative, activating, based on the psychology of color) effects, the author began to use regular suggestion of blue color for the therapy of anxiety disorders. Like the Western colleagues, the author believed in the direct implementation of the “correct” hypnotic suggestion and expected that in deep hypnosis, patients would directly realize the suggestion of concrete blue color. Results of the suggestion, “To see the blue color, to see it constantly,” turned out to be much more complicated (see Figures 1–4): (1) “vision” of color occurred not only in deep but also in medium hypnosis, i.e., in most patients; and (2) in addition to blue, other chromatic and achromatic colors and visual images were realized. Since the identified phenomenology of realization of color suggestion was not previously known, the author began its independent study, which lasted 10 years. Four voluminous studies were conducted:
The study of patterns of reproduction of hypnotically inducted colors and images, depending on the hypnosis depth (healthy subjects, 62; neurotic patients, 131)
The study of the phenomenon of chromatic and achromatic transformations of the blue color (healthy teenagers, 44; healthy adults, 63; neurotic patients, 158; patients with organic disorders, 156)
The study of spontaneous structures in the reproduction of hypnotically inducted colors (105 patients)
The study of the psychophysiological effects of hypnotically inducted color sensations and images (totally 85 healthy individuals, 90 patients)
The post-hypnotic drawings of hypnotized subjects, reflecting the reproduction of induced blue color: “To see, to represent, to feel the blue color.” Illustrations from the author’s monograph.
The phenomenon of the chromatic transformation of hypnotically induced color. Posthypnotic drawings of subjects.
The phenomenon of the achromatic transformation of induced blue color. Posthypnotic drawings of subjects.
Patterns of reproduction of color and image in dependence of hypnosis depth. Posthypnotic drawings of subjects. Note: picture’s systematization was based on independent estimation of hypnosis depth during hypnosis session.
For each study, special questionnaires were developed. Results obtained in the 1970s and 1980s were published in two author’s monographs, given in the reference; therefore, this chapter contains only the main, valid results.
The experience obtained in the study of the hypnotic reproduction of color sensations and images is probably unique in its focus on the identification, fixation, and detailed analysis of the spontaneous variability of the hypnotized response to suggestions in hypnosis. The study is focused not on assessing the effective achievement of a particular suggested result but on spontaneous responses to “banal” suggestion or spontaneous trance characteristics during hypnotherapy. Therefore, the phenomena described by the author fall out of sight of modern researchers of color suggestions in hypnosis [13, 14].
As a result of our research, a new systematization of the reproduction of suggested colors was obtained. It included (1) patterns of reproduction of the induced color and image in different depths of hypnosis; (2) the description and interpretation of a phenomenon of chromatic transformation of the induced color; and (3) the description and interpretation of a phenomenon of achromatic transformation of the induced color.
We described the spatial and temporal differences in the reproduction of color and image in medium and deep hypnosis. In medium hypnosis induced colors and images are reproduced two-dimensionally (flat) and wavelike damped. In deep hypnosis induced colors and images are reproduced three-dimensionally and stable over time. The hypnosis maximum depth is characterized by “effect of presence,” when hypnotized find himself “in the reality of image”—the image becomes sensory multimodal.
The phenomenon of chromatic transformation of the induced color manifested in the reproduction of another color instead induced (e.g., red, yellow, green—on induction of blue). The study pointed to the connection of this phenomenon with infantilism—as personality characteristics of a hypnotized subject: (1) age-related (adolescents) and (2) disorder-related (dissociative disorders).
The phenomenon of achromatic transformation of the induced color manifests in decolorization of induced colors (into black, gray). According to our findings, the phenomenon of achromatic transformation of reproduced colors in hypnosis intensely increased in cases of brain organic disorders, which lead to the idea of its connection with low level of brain activation. The experimental verification confirmed the hypothesis. We received a change in the initial reproduction of blue color by psychopharmacological increase (imipramine) and decrease (chlorpromazine) of the level of activity of the reticular formation of the brain. A single use of imipramine (25 mg 1 h before a hypnotic session) validly improved color reproduction, and a single use of chlorpromazine (25 mg 1 h before a hypnotic session) caused a total achromatic transformation in all subjects.
The obtained results allowed us in the 1980s to 1990s to develop the secondary-phenomenological approach of the study of hypnosis [10, 11]. It is based on the following: (1) Identification of patterns of reproduction of induced colors and images depending on the hypnosis depth, age, healthy subjects, and anxiety and organic disorders. (2) Comparison of hypnotic visual phenomenological patterns with neurophysiological models of brain activation system, visual afterimages, age dynamics of hemispheric asymmetry, and construction of the neurophysiological model of hypnosis. (3) Comparison of modern data of hypnosis neurophysiology.
The secondary-phenomenological approach allowed us to move from the systemic phenomenological description of visual hypnosis to its neurophysiological modeling.
The secondary-phenomenological approach to the study of hypnosis is fundamentally close and presents the precursor of the methodology of studying neuronal correlates of consciousness developed in modern psychology of consciousness [15], in which the implementation of consciousness patterns is related to the neurophysiological activity of the brain that provides them.
In the 1980s to 1990s, we have investigated the biological mechanisms of hypnotherapy and hypnosis phenomenon of spontaneous nociception [10, 11]. The study of the biological mechanisms of hypnotherapy was based on results of systemic clinical research of blood system in dynamics of hypnotherapy of anxiety and organic disorders.
The study was based on a fourfold analysis of 29 blood components (clinical, biochemical, immunological): (1) at the beginning of therapy, before and after a hypnotherapy session and (2) at the end of therapy, before and after a hypnotherapy session. The groups of the study include 113 patients with anxiety disorders of neurotic (78 subjects) and organic (35 subjects) genesis. The description of the biological mechanisms of hypnotherapy was based on the valid data of statistical analyzes (parametric, nonparametric, factorial).
The last 30 years, we have conducted research on therapy and hypnotherapy communication mechanisms. These studies formed the basis for the description of the communicative component of hypnotherapy [14].
Studies have allowed us to develop the integrative theory of hypnosis, represented by neurophysiological, biological, and communicative components [10, 11, 16].
The development of hypnosis is achieved through the creation of primary (for man and animal) or secondary (symbolical) hypnogenic situations which restricts the ability to make decisions and/or its behavioral expressions. Hypnosis development results in a qualitative reorganization of the brain activation system functioning from distribution to generation of activity. The functions of distribution and generation of activity are realized by morphologically different structures within the activating system of the brain.
Deepening of hypnosis from wakefulness to somnambulism is based on the growth of opportunities for brain activation; deep hypnosis opportunities for brain activation are comparable to the waking state.
Hypnosis development in right-handers is associated with a regressive transfer of the left hemisphere regulatory activity to the right hemispheric functioning mode. In comparison with the ontogenetic shift of hemispheric specialization, this is a reversed process of the whole brain function reorganization to right hemispheric principle. This conclusion was published in 1996 [10]. A year later, in 1997, the authoritative American hypnotist published a review with the characteristic title [17]: “Relateralizing hypnosis: or, have we been barking up the wrong hemisphere?”
Subsequent functional magnetic resonance imaging (fMRI) research showed [18, 19] high levels of activity in areas responsible for visualizing scenes (the occipital lobes) and for analyzing verbally presented scenarios (the left temporal lobe), a heightened activity in the prefrontal cortex, and a higher connectivity between different brain regions in highly hypnotizable people. In hypnosis, a perception of color, real or hallucinated, led to the activation of the fusiform area with more clear effects in the left cerebral hemisphere than the right.
Functional regression of thinking processes promotes prevalence of figurative thinking and activates attributive projectivity of thinking. Hypnotic reproduction of sensations and images involves attributive projectivity and reflects entirely personal traits and states and body functioning; this opens a way for projective transformations of problems and symptoms of psychogenic and somatic disorders. In the waking state, phenomenal models of the world and the self, stored in the subject’s memory, are superimposed on the current perception of the external world and the perception of self. In hypnosis subject’s phenomenal models of the world and the self are superimposed, projected on the limited self-perception, which leads to the formation of limited (intra-perceptual) hypnotic reality and expanded (intra-/extra-perceptual) hypnotic reality. All the phenomenal content of consciousness of the subject in hypnosis deeply and fully reflected his current psychological and bodily condition.
Hypnotization generates hypnogenic stress. Hypnotherapy activates the systemic readaptation processes that are reflected in changes in neurohormonal and neurotransmitter secretions; activities of the immunological system; activation of protein, bilirubin, and cholesterol exchange; etc.
Hypnotherapy activates protein metabolism and activity of several enzyme systems of the organism. Hypnotherapy has a positive influence on the metabolism of bilirubin. The activation of cholesterol metabolism, characterized by a significant reduction of its concentration in the blood, has a significant clinical importance. The observed decrease of cholesterol concentration in blood, normalizing its metabolism in the process of hypnotherapy, means the restoration of activity of cell membranes, cells, organs, and tissues, slowing down their aging.
The stressful nature of hypnosis limits its therapeutic application, in that excessive intensity of hypnogenic stress may result in the maladaptation. Prolonged hypnotherapy may actually decrease and exhaust adaptable resources of an organism.
Hypnosis in clinical situations enables the possibility of a spontaneous (without specific suggestions) change of pain sensations.
In the 1980s during the course of group hypnotherapy in a therapeutic clinic, based on the universal hypnotherapy (UH) technique [10, 11, 17], which has no analgesic suggestions (see below), the author was faced with cases of spontaneous relief of acute (traumatic) pain after the session and opposite cases of the causeless appearance and amplification of patients’ bodily pain during a hypnotherapeutic session, with its subsequent reduction in chronic disorders. Repeated cases of spontaneous modulation in hypnosis of pain in cases of acute and chronic pathological processes required explanation; therefore, using a special questionnaire, all such cases were studied. Over the 5 years of observation, the hypnotherapeutic dynamics of pain in acute traumas (15 patients) and in chronic pathological processes (mainly neurointoxications—167 patients) was studied. This study was clinical-phenomenological; the dynamics of the severity of pain were correlated with the results of other objectivizing methods of clinical research and the conclusions of relevant specialists. Data ware obtained on patients who received accidental injuries or dental care (bone fractures, sprains, tooth extraction) during an intensive short-term hypnotherapy of anxiety disorders (10–12 1-h sessions 3–5 times a week). The phenomenon of spontaneous hypnotic nociception became an unexpected, but regularly repeated, finding. Therefore, the question is not in the existence of the phenomenon of spontaneous hypnotic nociception but in the scientific understanding of its mechanisms.
The author’s explanation of the phenomenon of spontaneous hypnotic nociception was based on the model of the structure and function of the nociceptive and vegetative regulation systems [20], according to which the pain impulse on the way from the pathological zone to the cerebral cortex can be damped by the damping system of the brain at three levels (spinal cord, thalamus, cerebral cortex), with the parallel activation of the hierarchical system of vegetative regulation of the pathological zone; this model satisfactorily explains the phenomenon of spontaneous hypnotic nociception [10, 11].
Western hypnology in the last 70 years in its development has paid a considerable attention to the research and practice of suggestive hypnotic analgesia. Researchers in experiment and practice have always been interested in only directed hypno-suggestive analgesia and its mechanisms, which essentially brought the phenomenon of spontaneous hypnotic nociception beyond the scope of any analysis.
It should be noted that studies of hypnotic analgesia have become the cornerstone in the development of modern hypnology, since after a long discussion they have led to the recognition that hypnosis is an altered state of consciousness [21, 22, 23, 24, 25, 26]. Brain mechanisms underlying the modulation of pain perception under hypnotic conditions involve cortical as well as subcortical areas including anterior cingulate and prefrontal cortices, basal ganglia, and thalami [21]. It is demonstrated that hypnotic analgesia is characterized by a loss of coherence between the brain areas, reflecting “an alteration or even a breakdown of communication between the subunits of the brain” [20, 23, 24, 26]. Recently, in addition to experimental neurophysiological studies of the differences in the brain mechanisms of pain perception by high and low hypnotizable [27], analogous genetic studies have appeared [28]. Due to these studies, it became known that hypnotic assessment may predict lower responsiveness to opioids, and inefficient opioid system may be a distinctive characteristic of highs [29], and modulation of hypnotic pain responses is connected with differential recruitment of right prefrontal regions, which are involved in selective attention and inhibitory control [27].
Returning to the phenomenology of spontaneous nociceptive sensations in hypnotherapy, we need to note that it is characterized by the following features.
Acute pathological processes are characterized by one-step regressive dynamics of hypnotic nociception.
Chronic pathological processes are characterized by two-stage dynamics, including consistently associated progressive and regressive stages. The progressive stage of the dynamics of nociceptive sensations is observed at the beginning of hypnotherapy. At this stage, the strengthening or the appearance of nociceptive sensations in the area of localization of chronic pathological process occurs. On the regressive stage, the weakening or disappearance of nociceptive sensations caused by a chronic pathological process occurs.
The dynamics of the hypnotic nociception in acute and chronic pathological processes turns on spontaneously and has a positive therapeutic vector, being determined by the hypnogenic mechanism of readaptation. It can be strengthened by specific hypnotic suggestions.
Hypnotization and hypnotherapy can be considered as a goal-oriented communication—the communicative process. The hypnotic communicative process includes two basic components: cultural and interpersonal. The cultural component determines the varying boundaries, volumes, dynamics, and potential effectiveness of hypnotherapy while the interpersonal its specific implementation. The cultural and interpersonal components of hypnotherapy interact typologically, since culture defines historically determined patterns—communication styles that actualize the style sets of cultural and interpersonal components. Communicative styles, formed in the space of everyday communication, are then transferred to hypnotherapy, acquiring specialized features. The historical evolution of cultural communicative styles will generate the evolution of communicative styles of hypnotherapy. However, “within” hypnotherapy, a change in communicative styles will be perceived as an independent, personified process. The evolution of hypno-communication develops from classical and directive to non-directive hypnosis. In Russia, the style of universal hypnotherapy [29, 30] further appeared.
Directive hypnosis is a product of the European nineteenth century, with its class-hierarchical communicative style. Therefore, its communicative, being dominantly authoritarian, is based on the idea of direct “guiding” of “hypnable” patient by the hypnotherapist to a positive therapeutic result.
Non-directive hypnosis appeared in the 1970s, during the cultural heyday of individual rights and freedoms, with a manipulative management style in society. Its communicative style (Erickson’s model) is based on the verbal, non-directive, and manipulative management of the patient, taking into account his or her non-verbal reactions, which uses non-directive adjustment and management, and on the idea of finding an adequate use of the resources of the wise unconscious, which uses thematic metaphors and descriptions, as tools for accessing resources.
The communicative style of universal hypnotherapy is built on a biopsychosocial paradigm; takes into account and rebuilds relevant cultural representations about hypnosis in the interests of therapy; uses primary positive cognitive-behavioral models and biological mechanisms of hypnotherapy; actively applies the non-verbal component of communicative interaction during hypnotherapy; attracts and potentiates the patient’s recovery activity during the session and the entire course of hypnotherapy; and contributes to the formation of semantic therapeutic, aimed at active recovery and improvement.
A real hypno-communication is inevitably wider and deeper than the prescribed methodological frameworks. But the communicative style forms a therapeutic “core” that determines the initial selectivity, process, and the results of hypnotherapy. Table 1 compares the communicative styles of directive, non-directive hypnosis and universal hypnotherapy.
Feature | Directive hypnosis | Non-directive hypnosis | Universal hypnotherapy |
---|---|---|---|
The conscious use of cultural representations about hypnosis | No | No | Yes |
The use of cultural beliefs about hypnosis | Yes | Yes | No |
Therapeutic transformation of cultural beliefs about hypnosis | No | No | Yes |
Features of verbal communication | Spelling out prescriptive text | Algorithm of non-directive adjustment, management taking into account the trance microdynamics | Stimulation of positive directed activity of the patient using feedbacks |
Non-verbal communication | Spontaneous use to support directive management | Mirroring and management reflecting the trance microdynamics | Active semantically directed use of non-verbal feedback channel |
The ratio of activity of the therapist and patient | The dominant activity of the therapist | Reliance on the client’s internal activity to utilize the resources of the unconscious with the dual activity of a therapist in realization of a client’s and his own trance | Stimulation of the patient’s increasing motivational activity during therapy with the creation of a semantic therapeutic space |
Using of feedbacks | Intuitive, for the regulation of directive management | Conscious feedback in the form of adjusting and maintaining tracking mimic reactions, breathing, muscle tone, body postures, with reduced ideomotor feedback | Hypnotization, dehypnotization, body-oriented work is completely built on the feedback of verbal and non-verbal levels |
Goal setting | Local restrictions overcoming by suggestion of alternative positive states, positive conditioning | Patient’s access to the wise unconscious, its unlimited resources for problems solving + partial use of the principles of the “classical” approach | Stimulation of the patient’s active assimilation of the basic positive mechanisms of healthy mental homeostasis |
Therapy limitations | Non-hypnability, hypomania | Hypnosis resistance | Therapy cessation |
Communicative styles of directive, non-directive hypnosis and universal hypnotherapy.
Thus, hypnotherapy should be considered as a systemic therapeutic space, which includes four components: a culture-dependent communicative, defining the communicative style of hypnosis and hypnotherapy, which, as a rule, is attributed to the nature of hypnosis; the methodological component; the biological component of hypnosis, with neurobiological, analgesic, and general adaptive effects; and the component of the patient’s personal response to the disorder and its therapy.
The regressive rearrangement of brain functioning to a prepubertal level, caused by hypnosis, sharply increases the subject’s learning ability and the assimilation of suggestive therapeutically significant information.
The biological effects of hypnotherapy provide broader prospects for its clinical application. The therapeutic effectiveness of hypnotherapy is restricted by the presence and volume of stress-readaptive resources of the subject’s organism and psyche. Technically, “correctness” of hypnotherapy is important, but it is not the only condition for treatment success. The absence or reduction of the hypnotherapy biological effect should be expected in patients undergoing a long-term treatment with adrenal hormonal medications and cases when the medication blocks or reduces the hypnotherapy biological readaptation effect (antidepressants, tranquilizers).
The integrative theory of hypnosis and hypnotherapy focuses on the basic systemic mechanisms of hypnosis and hypnotherapy, available for verification and concretization. Therefore, the constant accumulation of hypnosis research data (e.g., 3–9, 13, 14) will rather complement and expand its basic positions.
Thus, the default mode network—a large neural structure connecting different parts of the brain—was recently described [28, 31, 32]; its function is to provide a high level of activity even when the person is not engaged in a focused mental work. Recent experiments have described an increase in activity and an increase in the volume of the default mode network when practicing mindfulness meditation [33] and yoga [34].
According to the integrative theory of hypnosis and hypnotherapy, hypnosis development results in the reorganization of the brain activation system functioning from distribution to generation of activity. It was supposed that the functions of distribution and generation of activity need to be realized by morphologically different structures of the brain. So, the proposed system of activation generation of the brain activation system now is determined as a default mode network.
More than three decades ago, the author developed a new method called universal hypnotherapy, so named because of its efficacy in both individual and group forms of therapy for a wide range of anxiety disorders [10, 11, 16, 23, 30, 35, 36, 37, 38, 39]. UH is rooted in the traditions of the Russian school of hypnotherapy, which shares its basic principles with positive approach (concept of resilience and resourcefulness) [29, 30] and mindfulness-based psychotherapeutic methods.
The author understands mental health and mental stability as an active adaptive state and process, which are spontaneously and actively maintained [16], whereas anxiety disorders break down the psyche’s natural homeostasis. On the basis of research of therapy outcomes, we had described a model of the Personal System of Psychological Adaptation (PSPA) [11, 16, 29, 30, 40]. PSPA is a spontaneously activated homeostatic dynamic structure which forms during ontogenesis and creates a hierarchy of adaptive mechanisms from the earliest, most simple types to mature, complex, individualized, and personal ones which can be used as coping mechanisms. The hierarchic PSPA can be represented as a spherical multilayered model involving the following components: (1) a concentric structure of layers-levels of the hierarchic organization of adaptation mechanisms that form an expanding sphere around a “center” or the “self,” the self who decides which outer layers will be predominantly activated; (2) a system of connections between each of layers-levels of the sphere; and (3) the highest mature level of the hierarchy of multilayer level mechanisms of psychological adaptation that has the capability of transforming the interactions between the underlying levels.
PSPA dynamics may express themselves in regressive, reactivating, or progressive (forming) transformations. In the case of regressive dynamics, the underlying levels, ontogenetically antecedent to it, become primarily active and assume the role of regulatory functions overriding more advanced functions; this results in the reorganization of the system of radial and spherical connections and development of new clusters not present at the previous stages of PSPA ontogenesis. Reactivation dynamics involves the reconstruction of the function initially of the top layer level of psychological adaptations and of PSPA “normal functioning” which has been disturbed by its previous regressive dynamics. The formation of PSPA dynamics is possible through the development of a higher layer level which would overcome the insufficiency and defectiveness of previous psychological adaptations of underlying levels. In cases of anxious maladaptation, weakening in the higher level of adaptive mechanisms causes the lower level of adaptive mechanisms to acquire greater behavioral significance. According to our model [11, 16, 21, 29, 38], psychotherapeutic interventions are especially suitable for cases of anxiety disorders in which there is a regressive activation of early ontogenic adaptation mechanisms.
Our empirical research on hypnotherapy outcomes [10, 11, 16, 29] has revealed that the dynamics in cases of efficient hypnotherapy with complete improvement in anxiety disorders is consistent with the mechanism of reactivation and, for organic disorders, with the mechanism of PSPA formation; in cases of partial improvement, the psychological dynamics for anxious disorders corresponds to PSPA incomplete reactivation, and for organic disorders it corresponds to PSPA incomplete formation.
UH method is based [10, 11, 16, 29, 30, 35, 36, 37, 39, 40, 41] on the activation of hypnotherapy biological healing potential leading to readaptation and to physiological and psychological self-regulation; more specifically, this includes stimulation of positive personal states and values and further depends on an individual’s holistic positive engagement in recovery and in future steady adaptation. This process should lead to the creation of a positive goal-oriented semantic field enabling clients to act on hypnotic suggestions which should shape positive behaviors and therapeutic transformations.
UH is built on positive stimulation of patient’s self-holistic activity all over hypnosis session: from hypnosis induction to therapy and final dehypnotization.
The specific techniques include distancing from stressogenic experiences and negative states, along with utilizing projective transformations and visualization of color. One of the most important hypnotherapeutic goals refers to the stimulation of a holistic personal positive activity that would promote recovery and future steady adaptation. In this respect, the strength of a patient’s motivation to recover and to improve his or her state has a direct impact on the outcome. That is why stimulation of positive therapeutic motivation (PTM) to improve one’s condition and to recover is considered, in universal hypnotherapy, to be its main therapeutic objective. Work with a patient’s PTM starts on the first diagnostic session and becomes the foundation of the therapeutic contract; such motivation is maintained during the course of therapy and is acknowledged when the course is finished.
During the diagnostic session, after discussing the clinical diagnosis and possible prognosis of therapy and establishing a confidential relationship, a patient’s motivation and wish to recover and/or to actively achieve the desired psychotherapeutic outcome are reviewed. Motivation for improvement, or for recovery, is directly or indirectly stimulated and maintained during the course of subsequent therapy, both within and outside of the hypnotherapy format. Indirect stimulation of the PTM is maintained by continuous encouragement of the patient’s activity within the course of therapy, but also directly during the sessions of UH at all its stages.
Positive dynamics, commencing with the hypnotic induction, can be enhanced by showing the patient changes in symptoms, from session to session, based on a self-evaluation utilizing a graphic linear scale (ranging from the most negative to the most positive state); this allows for a comparison of results between sessions and identification of interim and general dynamics. Any increase in a patient’s motivation for recovery and its behavioral manifestations is acknowledged and emphasized, during and at the end of therapy, as his or her tangible achievement in the process of positive adaptation. Furthermore, hypnosis is used to facilitate change.
Our understanding of hypnosis is that it leads to functionally regressive stages in brain functioning that trigger prepubertal imaginative thinking [10, 11, 29, 30] and promotes the reverse transformation in a regulatory hierarchy in which the meaning of words dominates over feelings, mental states, and perceptual experiences. Such a reorganization makes it possible in hypnosis to elicit actual feelings and mental states which could be utilized for positive transformation (i.e., confidence, calmness, freedom, self-efficiency and self-sufficiency, etc.) enabling the patient to experience positive personal states and values.
One of the most effective technique in dealing with specific symptoms includes somatic projective catharsis which requires awareness of personal control and limitations, along with the recognition of positive change in a person’s condition, even though it may not be consciously known how it was achieved. The highest level of conscious differentiation occurs in the visual domain; it is less in the auditory and even less in the proprioceptive modalities [10, 11, 38, 39].
From a practical clinical perspective, catharsis is achieved after a client is informed that the perception of any event in one domain may also be reflected in another perceptual domain. Subsequently, it is proposed to the patient to become aware of anything unpleasant, negative, and painful that is a result from past experiences—memories, feelings, and also any feelings in his or her breast (i.e., heaviness or tension which occurs when a person is offended or derogated); if a person begins experiencing such a feeling, it is suggested to him or her to breathe it out. When after some attempts, the unpleasant feeling is diminished and each subsequent inhaling becomes easier, it is suggested that also the remaining part of the feeling can be breathed out. Breathing out the unpleasant sensation (i.e., heaviness or tension) is assigned to a client as a task to be carried out independently and to be continued until the maximum liberation from this unpleasant feeling is obtained, which is typically associated with a sense of peace.
Yet another technique utilizes visualization. The author’s research [10, 11, 41] into the impact of color sensations and images induced in hypnosis was a stimulus for its integration with hypnotherapy for anxiety disorders. We have experimentally shown [10, 11, 37] that for the purposes of relaxation, the imaging of a blue color is the most suitable approach. That is why repeated blue color induction (with an interval of 1–2 minutes) is used during hypnotherapy sessions for the creation of a color-relaxing background to accompany the verbal suggestions.
Experimental data has shown that in mild and deep hypnosis, color inductions have a direct psycho-vegetative and emotional impact on a human being, and this impact is different from the one in the waking state because of the intensification of the activating potential of colors and the reduction of their sedative effect. The visualization of colors, induced in hypnosis, is accompanied by three phenomena of a neurophysiologic and psychological nature. The first one is achromatic transformation, when following hypnotic suggestion, chromatic colors (blue, green, yellow, red) are seen as achromatic (i.e., gray, black, brown). According to our experimental and clinical investigations, achromatic transformation phenomenon is the manifestation of a low level of activity of the reticular formation which is the brain activating system [10, 11, 41]. We should note that achromatic transformation is clinically significant; specifically, induced color visualization is restored as the patient’s condition clinically improves [10, 11, 41]. The third phenomenon—chromatic transformation of colors induced in hypnosis—manifests as the recognition of another color, not the one which was suggested to the patient to be imagined. According to our data, the phenomenon of chromatic transformation of visualized color is conditional on an individual’s personal characteristics associated with personal maturity. Therefore, the phenomenon of induced color chromatic transformation which is typically observed in children is reduced in healthy adults, but is increased in dissociative and somatoform disorders.
The phenomenology of induced color characterizes the depth of hypnosis; in mild hypnosis, visualized color is flat (two-dimensional) and changes sinusoidally; in deep hypnosis, it becomes three-dimensional and remains stable (in both healthy and emotionally disordered people).
The mind’s ability to dissociate can be utilized for distancing from stressogenic experiences. It has been shown in psychological research [36, 42] that people’s normal experiences proceed through subjective separation or distancing from the events, without cognitive distortion of their essence. Pathological attempts at psychological adaptation lead to events of the past events being confounded by cognitive deformations and distortions of events. Already more than 30 years ago, we noted that hypnotherapy allows for the normal experiencing of events and for subjective distancing while eliminating pathological adaptation mechanisms that distort the experience [3, 4]. To normalize the process of experiencing, we have elaborated a method of two-stage distancing with respect to current and past events; the first step serves for distancing from the current personally stressogenic events, and the second step is designed for distancing and resolving past stressogenic, negative, and traumatic experiences.
The mechanism of normal experiencing of current events presents the basic mechanism for the stable functioning of a healthy psyche; therefore, the author considers the sustainable inclusion of this mechanism in anxiety disorders as a key point in successful therapy. During UH the patient gains the ability to stably distance himself both from the current experiences and their projections into the future and from the past experiences.
Since the 1980s cognitive-behavioral therapy (CBT) has developed techniques based on modifications of ancient Vipassana meditation [43, 44, 45, 46, 47, 48]: mindfulness-based stress reduction (MBSR) [49, 50] and mindfulness-based cognitive therapy (MBCT) [51, 52]. These techniques, producing “the third wave” of CBT evolution, have expanded the range of therapeutic efficacy for anxiety disorders, including generalized anxiety disorder (GAD) [53, 54].
Since these techniques also use the principle of distance experiencing, the author with the co-worker performed a comparative analysis of UH and CBT mindfulness-based techniques [36, 37], which revealed a significant similarity, consisting of (1) the formation of distancing, metaposition, and positive perception and (2) stimulation of personal integration and self-identity and working with body control and breathing control. UH and mindfulness-based techniques differ in parameter of experiences without judgment, duration of therapy, the need for meditation, and self-hypnosis after the end of therapy. UH explores only the principle of distancing, out of religious-philosophical connotations, it is the most short-term (10–15, rarely up to 20 sessions), and it does not require the continuation of self-hypnosis.
Yet another technique uses an individual’s abilities to generate bodily sensations. Indirect suggestions of feelings of warmth (mostly) and coolness (in some areas of the body) are used for projective body work in universal hypnotherapy. Areas chosen for suggestion of warmth are the parieto-occipital zone with projection “inside head,” posterior surface of the neck, shoulders, area of the left half of the breast (from the front), precostal space, and epigastria; suggestion of coolness while inhaling is directed to the nose, temples, and the zones, where it is needed. These suggestions establish experiences of warmth and coolness in the body which replace other less pleasant feelings.
The process of normalization requires restoration of restful sleep. That is why increasing the quality of sleep is one of the objectives of UH in which suggestion refers to the positive phenomenological model of restful sleep (falling asleep in the evening and in the morning waking up without remembering sleeping itself).
Before finishing the session of universal hypnotherapy, the therapist needs to seed suggestions about positive feelings taking place in the following order: body comfort, lucidity of thinking, and a good mood state.
A session of UH lasts for about 35–40 min, which includes (1) hypnosis induction and four (2–5) therapeutic parts.
Hypnosis induction in UH is completely based on the realization of motivational activity of the hypnotized person, in the algorithm of bodily feedback with himself and implements the scheme: the hypnotized person is focusing on the desire to enter into hypnosis, mentally saying the phrase: “I want to enter into hypnosis,” being ready (if the phrase dominates the person’s mind for 20–30 s), giving the signal by raising any hand. The therapist touches the brush, suggesting that if the hand is spontaneously lowered, there happens a transition to hypnosis; the completion of the movement means the completion of the hypnotization. The therapist in immediate feedback briefly describes the characteristics of the movement of the hand and the behavior of the hypnotized, who perceives this as therapist’s control of the induced movement.
The given method of hypnosis induction is contrary to cultural beliefs about hypnosis. Therefore, before the first induction, the therapist implements a special connecting script, which transforms the cultural model of hypnosis and allows the hypnotized person to accept fully the proposed method. It is effective in the vast majority of therapy-motivated patients (more than 99%), which allows patients in single and group format to enter hypnotic trance quickly and deeply.
The first part of UH therapeutic session is focused on somatic projective catharsis, whereas the second part of UH session consists of the following steps:
The induction of blue color, which is then repeated periodically with an interval of 1–2 min during the whole session
The enhancement of positive mental states and values
A two-step procedure of distancing from stressogenic experiences and resolving negative states or disorders and developing hypnotic self-suggestions that would shape positive behavior
The suggestion of sleep normalization
The third part of the session is represented by body projective work with a periodic induction of blue color. The fourth part of the session basically corresponds to its first part (but does not use projective “breathing”), and additionally the need to continue with modeling positive states is emphasized along with enhancing the positive dynamic and motivation for recovery.
So, the first and the third parts in the composition of the UH session focus on body projective working, using breathing techniques and inducement of pleasant feelings of warmth and coolness; it also emphasizes a personal activity and a personal responsibility to continue the work in the same manner. The goals of body projective work are liberation from symptom, normalization of functioning, and relaxation.
The second and third parts of the session actualize the feelings—states of confidence, calmness, and freedom; they also focus on distancing from stressogenic experiences and on resolution of negative states or disorders, with the development of positive behavioral models that would offer an alternative for pathological behavior and provide suggestions for sleep normalization.
The therapeutic influence on the client is achieved by providing a meaningful sensory stimulation through three channels (verbal, visual, and proprioceptive): active positive modeling of problem situations; repeating semantically significant components of the script which may be presented in the archaic folk song style—couplet-refrain—with induction of blue color as being the refrain; and presenting suggestions with the proper speech intonation.
UH has an integrated and focused content of the suggestions that support each other; as a result, regardless of whether a single individual component of therapy is effective, the whole therapeutic structure remains considerably efficient. UH creates a system of multilevel impacts stimulating a patient to assimilate actively his or her primary ideas, mental states, and experiences; its positive cognitive-behavioral models could be later implemented in real life, in order to eliminate psychopathology and to promote effective problem-solving. The application of UH creates a positive therapeutic semantic field and a goal-oriented therapeutic process.
At the end of the hypnotic session, the patient is informed about the upcoming dehypnotization according to a feedback scheme: a spontaneous return movement of a previously lowered hand is suggested, and when the hand returns to its initial position, the session is finished. The rate of dehypnotization is determined by the hypnotized person.
The last two decades have become a time of significant increase in AD.
In the 2000s, the author applied UH for the treatment of panic disorder (PD) and GAD, adding a psycho-educational component to the therapy complex determined initially as a cognitive-oriented psychotherapy, later named by author positive-dialogue psychotherapy (PDP) for anxiety disorders. PDP has demonstrated sufficient clinical efficacy in the treatment of anxiety disorders (PD, GAD). In 2010, the author with the co-worker [35] conducted a controlled study of the effectiveness of PDP for anxiety disorders. Assuming a partial similarity of UH to mindfulness-based CBT methods, the study used additional psychometric estimation of mindfulness effect.
Patients were recruited through an Internet advertisement on the site of Moscow Research Institute of Psychiatry soliciting for individuals with anxiety symptoms and panic attacks (PA) to take part in a clinical study of psychotherapeutic treatment of anxiety disorders. Psychotherapeutic treatment was offered for free. Inclusion criteria were that patients: (1) be between 18 and 60 years and (2) fulfill diagnostic criteria for either PD or GAD. Exclusion criteria were: (1) suicidality, (2) other psychiatric disorders as a primary diagnosis (schizophrenia spectrum disorders, affective disorders, personality disorders), (3) severe somatic diseases in the decompensation stage, and (4) parallel participation in other psychotherapeutic programs.
These criteria allowed for the presence of isolated comorbid depressive and phobic symptoms, provided that patients had AD as a primary diagnosis. Patients with initial pharmacological treatment (antidepressants, anxiolytics, tranquilizers) were also included in the study. The possibility of termination of pharmacological treatment as their state improves during the therapy was discussed with such patients. The pharmacological treatment was terminated at all patients after 5–6 psychotherapeutic sessions. Figure 5 illustrates the patient flow in the study.
Research design.
After a preliminary telephone screening, eligible participants (N = 63) were invited for a structural clinical interview based on the criteria of the research version of ICD-10 [10]. Participants also completed a number of self-reported questionnaires for baseline assessment.
After diagnostic evaluation and completion of all questionnaires, patients were randomly assigned to a treatment group or a waiting-list group. In the treatment group, patients went in therapy immediately and completed the self-report questionnaires at the end of the therapeutic process. Patients on a control waiting-list group were informed about a certain order for the beginning of the therapy and that they had to complete the questionnaires two times (the second time was 3 weeks after the first). The evaluation of psychometric data of this group was carried out 3 weeks before the treatment, just before the start of treatment and at the end of treatment. The control waiting-list group was a control group for itself and for the first group.
PDP is based on the protocol developed by the author [14, 15]. The therapeutic intervention consists of three main components: (1) psycho-educational; (2) causal cognitive-orientated; and (3) hypnotherapeutic.
The psycho-education component includes a didactic material covering the following information about: (1) anxiety as a normal reaction of mobilization, needed to cope or avoid a dangerous situation; (2) anxiety disorder and the phases of its development for PD and GAD, because of the “swinging” of anxiety reaction by a combination of social, biological, and psychogenic factors; and (3) possibilities of psychotherapeutic treatment of AD based on (a) the resolution of current psychogenic issues, (b) the excluding intoxicating mechanisms (if there are any), (c) the coping with phobic component (if it’s present), (d) the general increase of adaptive resources of the organism (through lifestyle rationalization), and (e) the normalization of vegetative regulation by psychotherapy or combination of psychotherapy with pharmacotherapy. The psycho-educational component of PDP is realized during the first therapy session, in an individual or group format.
The causal cognitive-orientated component of PDP has the following objectives: (1) Individual assimilation of the psycho-educational component. (2) Normalization of patient’s traumatic experiences during a PA (if there are any). (3) Stimulation of patient’s coping of anxiety triggers, restrictive behaviors, and phobias. (4) Stimulation of a healthy lifestyle with normalization of vegetative regulation. (5) Development of patient’s autonomous understanding and coping with problem situations. (6) Development of skills of positive thinking and attitude.
The causal cognitive-orientated component of PDP is used during 2–7 sessions for about 20 min.
The hypnotherapeutic component of PDP uses the method of UH [10, 11, 29, 30, 36, 37, 39, 40, 41] which contains the following therapeutic interventions: (1) Increase of self-identity and self-integrity. (2) Transformation of patient’s projections of his/her psychogenic and somatic-sensorial content. (3) Use of sedative and detachment influences of reproduced colors. (4) Stimulation of detachment of stress experience and completion of negative states and experiences based on modeling and realization of positive correct behavior. (5) Repeat of the interventions mentioned above (1–4). (6) Creation in hypnotherapy a positive vector semantic space for patient’s active therapeutic changes.
The UH, done in the second part of a 1-h session of PDP, lasts for 40 min. The frequency of PDP sessions is three times a week; the total number of sessions varies from 8 to 15 (till the stable improvement of patient’s state).
The symptomatic questionnaire SCL-90-R is a Russian adaptation of N. Tarabarina [55]. In our research the following scales were used: DEP, depression; ANX, anxiety; and GSI, general severity index, a measure of the overall psychological distress. The Spielberger State-Trait Anxiety Inventory (STAI) is a Russian adaptation of Hanin [56]. The following tools were also used: Beck’s depression inventory (BDI) [57]; Sheehan Clinical Anxiety Rating Scale (ShARS) [58]; and Five-Factor Mindfulness Questionnaire (FFMQ) [59], its short version. The FFMQ was adapted for Russian-speaking population by the authors. The Mindful Attention Awareness Scale (MAAS) [60] was adapted to Russian-speaking population by the authors.
The statistical analysis was made with the use of the program “Statistica 10.” The following data were compared, using this program: (1) Initial data of the therapeutic group and the waiting-list control (WLC) group. (2) Initial data of the WLC group and the data of the WLC group at the beginning of the therapy. (3) Initial data of the primary therapeutic group and the WLC group at the point of the beginning of the therapy. (4) Initial and final data of the combined therapeutic group and the data from the WLC group (initial and at the point of the beginning of the therapy). (5) Initial and final data of the subgroup of monopsychotherapy (MPT) and the subgroup of psychotherapy with gradual discontinuation of psychopharmacotherapy (PT + PPT). (6) Initial and final data of the subgroup of PD and the subgroup of GAD.
Gender and demographic and psychometric characteristics were used in the statistical analysis. The methods of descriptive statistics (M, SD) and nonparametric statistics (Wilcoxon’s test, Mann–Whitney test) were used. To evaluate the effect size, Cohen’s unbiased d-index was used [61, 62] (d ≤ 0.20, small effect size; d ≤ 0.50, moderate effect size; d ≤ 0. 80, large effect size). The effect size was calculated using a pooled standard deviation. χ2 was used to compare the degree of improvement between groups.
Patients’ gender and demographic and diagnostic characteristics are presented in Tables 2 and 3. Apart from the type of anxiety disorder, the presence of the accompanying psychopharmacotherapy at the beginning of the treatment was taken into consideration.
Total (n = 52) | Primary therapeutic group (n = 27) | WLC group (n = 25) | ||||
---|---|---|---|---|---|---|
n | % | n | % | n | % | |
Gender (female) | 35 | 67.3 | 20 | 74.1 | 15 | 60.0 |
Age (M, SD) | 31.6 | 10.4 | 30.9 | 9 | 32.5 | 12.1 |
Education | ||||||
High | 41 | 78.8 | 20 | 74.1 | 21 | 84.0 |
Student | 6 | 11.5 | 2 | 7.4 | 4 | 16.0 |
Vocational school | 4 | 7.7 | 4 | 14.8 | ||
Secondary school | 1 | 1.9 | 1 | 3.7 | ||
Marital status | ||||||
Married/partner | 23 | 44.2 | 12 | 44.4 | 11 | 44.0 |
Single | 27 | 51.9 | 15 | 55.6 | 12 | 48.0 |
Divorced | 2 | 3.8 | 2 | 8.0 | ||
Diagnosis | ||||||
PD | 29 | 55.8 | 16 | 59.3 | 13 | 52.0 |
GAD | 23 | 44.2 | 11 | 40.7 | 12 | 48.0 |
Months science onset (M, SD) | 54.5 | 77.4 | 51.5 | 53.7 | 58.4 | 100.8 |
PPT | 20 | 38.5 | 12 | 44.4 | 8 | 32.0 |
Patient characteristics.
Primary therapeutic group—group that began therapy right after the screening; WLC group—waiting list control group; PPT—number of subjects with psychopharmacotherapy.
Scale | Total (n = 52) | Primary therapeutic group (n = 27) | WLC group at screening point (n = 25) | WLC group right before the therapy (n = 25) | MPT group (n = 32) | PT + PPT group (n = 20) | PD group (n = 29) | GAD group (n = 23) | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
M | SD | M | SD | М | SD | M | SD | M | SD | M | SD | M | SD | M | SD | |
SCL-90 DEP | 1.66 | 0.82 | 1.58 | 0.75 | 1.59 | 0.81 | 1.74 | 0.90 | 1.56 | 0.64 | 1.81 | 1.06 | 1.68 | 0.77 | 1.62 | 0.91 |
SCL-90 ANX | 1.85 | 0.93 | 1.75 | 0.87 | 1.75 | 0.89 | 1.96 | 1.00 | 1.76 | 0.80 | 2.01 | 1.11 | 2.09 | 0.81 | 1.542 | 1.00 |
SCL-90 GSI | 1.29 | 0.62 | 1.23 | 0.66 | 1.33 | 0.58 | 1.35 | 0.58 | 1.21 | 0.41 | 1.42 | 0.86 | 1.40 | 0.62 | 1.14 | 0.61 |
STAI-S | 37.35 | 11.11 | 38.59 | 10.25 | 36.16 | 11.12 | 36.00 | 12.04 | 34.25 | 6.66 | 42.301 | 14.74 | 36.80 | 10.83 | 38.09 | 11.71 |
STAI-T | 55.08 | 9.79 | 54.63 | 9.86 | 53.72 | 6.71 | 55.56 | 9.90 | 52.69 | 8.10 | 58.90 | 11.19 | 55.53 | 10.12 | 54.45 | 9.52 |
BDI | 19.54 | 10.24 | 19.96 | 10.74 | 19.80 | 10.20 | 19.08 | 9.87 | 18.44 | 8.92 | 21.30 | 12.09 | 19.93 | 10.89 | 19.00 | 9.49 |
ShARS | 48.77 | 25.47 | 49.11 | 21.75 | 51.76 | 22.10 | 48.40 | 29.43 | 45.38 | 24.95 | 54.20 | 25.99 | 56.67 | 25.03 | 38.003 | 22.37 |
FFMQ-SF | 71.54 | 9.28 | 72.60 | 8.62 | 71.68 | 8.95 | 70.40 | 9.99 | 71.70 | 7.34 | 71.28 | 11.95 | 72.46 | 9.02 | 70.28 | 9.68 |
MAAS | 3.90 | 0.72 | 3.97 | 0.76 | 3.87 | 0.70 | 3.82 | 0.68 | 3.85 | 0.75 | 3.97 | 0.67 | 3.97 | 0.82 | 3.79 | 0.55 |
Means and standard deviations at screening point and right before the therapy.
p < 0.01 (comparing to MPT group).
p < 0.03 (comparing to PD group).
p < 0.007 (comparing to PD group).
SCL-90 DEP, ANX, GSI—depression, anxiety, and global severity index of symptom checklist 90; STAI-S—Spielberger Anxiety Inventory, state anxiety; STAI-T—Spielberger Anxiety Inventory, trait anxiety; BDI—Beck Depression Inventory; ShARS—Sheehan Clinical Anxiety Rating Scale; FFMQ-SF—Five-Factor Mindfulness Questionnaire, short version, total score; MAAS—Mindfulness Attention Awareness Scale; MPT group—monopsychotherapy group; PT + PPT group—psychotherapy + psychopharmacotherapy group with later psychopharmacotherapy withdrawal.
Twenty-nine participants (55.8%) were diagnosed with PD (11 of them were taking psychopharmacological medications at the beginning of the therapy); 23 participants (44.2%) had GAD as the main diagnosis (9 of them were taking psychopharmacological medications at the beginning of the therapy). The basic clinical, demographic, and clinical-psychometric criteria of the main and control groups were compared using the Mann–Whitney test and χ2 test for independent samples. The two groups did not show significant differences in all the parameters, but STAI-S score (which was significantly different in the groups of MPT and PT + PPT (p = 0.01)) and SCL-90 ANX (p = 0.03) and ShARS (p = 0.007) scores were significantly different in the PD and GAD groups (Tables 1 and 2). That fact witnesses a general success of the randomization.
The duration of the illness till the moment of the beginning of the treatment was also significantly different in the groups of MPT and PT + PPT (18.1 months and 112.8 months, accordingly; p < 0.0001). The mean duration of psychopharmacotherapy before the treatment in the group PT + PPT was 37.6 months. In all these cases (except 2) during this period the patients received more than two different psychopharmacological courses. These data allow us to call the PT + PPT group a therapy-resistant group.
Eleven out of 63 patients (17%) dropped out before the end of the treatment. Four patients could not visit sessions due to time limitations, 7 patients dropped out without any explanation, and 52 patients finished the therapy. The mean duration of the therapeutic course for these patients was 13.5 sessions of PDP. However, in the MPT group, the mean number of sessions was 11.5, and in the PT + PPT group, this number was significantly higher—16.7 sessions (p = 0.0005).
Psychotherapy results according to psychometric data are shown in Tables 4–6.
Scale | Therapy group (n = 52) | Waiting list control group (n = 25) | |||||
---|---|---|---|---|---|---|---|
M | SD | d (before-after) | M | SD | d (before-after) | d (between the groups) | |
SCL-90 DEP | |||||||
At baseline | 1.66 | 0.82 | 1.59 | 0.81 | |||
At the end of treatment | 0.941 | 0.83 | 0.87 | 1.742 | 0.90 | 0.18 | 0.92 |
SCL-90 ANX | |||||||
At baseline | 1.85 | 0.93 | 1.75 | 0.89 | |||
At the end of treatment | 0.931 | 0.84 | 1.04 | 1.962 | 1.00 | 0.22 | 1.12 |
SCL-90 GSI | |||||||
At baseline | 1.29 | 0.62 | 1.33 | 0.58 | |||
At the end of treatment | 0.741 | 0.59 | 0.89 | 1.352 | 0.58 | 0.03 | 1.04 |
STAI-S | |||||||
At baseline | 37.35 | 11.11 | 36.16 | 11.12 | |||
At the end of treatment | 24.811 | 10.11 | 1.18 | 36.002 | 12.04 | 0.01 | 1.01 |
STAI-T | |||||||
At baseline | 55.08 | 9.79 | 53.72 | 6.71 | |||
At the end of treatment | 48.121 | 9.27 | 0.73 | 55.563 | 9.90 | 0.22 | 0.78 |
BDI | |||||||
At baseline | 19.54 | 10.24 | 19.80 | 10.20 | |||
At the end of treatment | 9.651 | 7.41 | 1.11 | 19.082 | 9.87 | 0.07 | 1.08 |
ShARS | |||||||
At baseline | 48.77 | 25.47 | 51.76 | 22.10 | |||
At the end of treatment | 22.041 | 14.99 | 1.28 | 48.402 | 29.43 | 0.13 | 1.13 |
FFMQ-SF | |||||||
At baseline | 71.54 | 9.28 | 71.68 | 8.95 | |||
At the end of treatment | 80.121 | 8.06 | 0.98 | 70.402 | 9.99 | 0.13 | 1.07 |
MAAS | |||||||
At baseline | 3.90 | 0.72 | 3.87 | 0.70 | |||
At the end of treatment | 4.351 | 0.71 | 0.63 | 3.824 | 0.68 | 0.07 | 0.76 |
Treatment effect.
p < 0.0001 (comparing to the baseline figures).
p ≤ 0.0001 (comparing to therapy group).
p < 0.001 (comparing to therapy group).
p < 0.002 (comparing to therapy group).
SCL-90 DEP, ANX, GSI—depression, anxiety and global severity index of symptom checklist 90; STAI-S—Spielberger Anxiety Inventory, state anxiety; STAI-T—Spielberger Anxiety Inventory, trait anxiety; BDI—Beck Depression Inventory; ShARS—Sheehan Clinical Anxiety Rating Scale; FFMQ-SF—Five-Factor Mindfulness Questionnaire, short version, total score; MAAS—Mindfulness Attention Awareness Scale; MPT group—monopsychotherapy group; PT + PPT group—psychotherapy + psychopharmacotherapy group with later psychopharmacotherapy withdrawal.
Scale | PD group (n = 29) | GAD group (n = 23) | |||||
---|---|---|---|---|---|---|---|
M | SD | d (before-after) | M | SD | d (before-after) | d (between the groups) | |
SCL-90 DEP | |||||||
At baseline | 1.68 | 0.77 | 1.62 | 0.91 | |||
At the end of treatment | 0.821 | 0.83 | 1.05 | 1.094 | 0.83 | 0.59 | 0.33 |
SCL-90 ANX | |||||||
At baseline | 2.09 | 0.81 | 1.54 | 1.00 | |||
At the end of treatment | 0.891 | 0.72 | 1.52 | 0.983 | 1.00 | 0.53 | 0.10 |
SCL-90 GSI | |||||||
At baseline | 1.40 | 0.62 | 1.14 | 0.61 | |||
At the end of treatment | 0.721 | 0.60 | 1.08 | 0.782 | 0.59 | 0.57 | 0.10 |
STAI-S | |||||||
At baseline | 36.80 | 10.83 | 38.09 | 11.71 | |||
At the end of treatment | 24.131 | 9.77 | 1.20 | 25.723 | 10.73 | 1.06 | 0.15 |
STAI-T | |||||||
At baseline | 55.53 | 10.12 | 54.45 | 9.52 | |||
At the end of treatment | 48.201 | 10.66 | 0.69 | 48.002 | 7.20 | 0.74 | 0.02 |
BDI | |||||||
At baseline | 19.93 | 10.89 | 19.00 | 9.49 | |||
At the end of treatment | 10.131 | 8.29 | 0.99 | 9.002 | 6.16 | 1.20 | 0.15 |
ShARS | |||||||
At baseline | 56.67 | 25.03 | 38.00 | 22.37 | |||
At the end of treatment | 20.401 | 13.78 | 1.75 | 24.273 | 16.56 | 0.67 | 0.25 |
FFMQ-SF | |||||||
At baseline | 72.46 | 9.02 | 70.28 | 9.68 | |||
At the end of treatment | 79.181 | 8.17 | 0.78 | 81.323 | 7.95 | 1.20 | 0.27 |
MAAS | |||||||
At baseline | 3.97 | 0.82 | 3.79 | 0.55 | |||
At the end of treatment | 4.451 | 0.70 | 0.62 | 4.203 | 0.71 | 0.61 | 0.35 |
Treatment results in PD and GAD groups.
p < 0.0001 (comparing to baseline figures).
p < 0.001 (comparing to baseline figures).
p < 0.005 (comparing to baseline figures).
p < 0.02 (comparing to baseline figures).
SCL-90 DEP, ANX, GSI—depression, anxiety and global severity index of symptom checklist 90; STAI-S—Spielberger Anxiety Inventory, state anxiety; STAI-T—Spielberger Anxiety Inventory, trait anxiety; BDI—Beck Depression Inventory; ShARS—Sheehan Clinical Anxiety Rating Scale; FFMQ-SF—Five-Factor Mindfulness Questionnaire, short version, total score; MAAS—Mindfulness Attention Awareness Scale; MPT group—monopsychotherapy group; PT + PPT group—psychotherapy + psychopharmacotherapy group with later psychopharmacotherapy withdrawal.
Scale | MPT group (n = 32) | PT + PPT group (n = 20) | |||||
---|---|---|---|---|---|---|---|
M | SD | d (before-after) | M | SD | d (before-after) | d (between the groups) | |
SCL-90 DEP | |||||||
At baseline | 1.56 | 0.64 | 1.81 | 1.06 | |||
At the end of treatment | 0.621 | 0.45 | 1.67 | 1.456 | 1.05 | 0.34 | 1.03 |
SCL-90 ANX | |||||||
At baseline | 1.76 | 0.80 | 2.01 | 1.11 | |||
At the end of treatment | 0.661 | 0.46 | 1.64 | 1.373,7 | 1.11 | 0.56 | 0.84 |
SCL-90 GSI | |||||||
At baseline | 1.21 | 0.41 | 1.42 | 0.86 | |||
At the end of treatment | 0.531 | 0.25 | 1.91 | 1.084,7 | 0.80 | 0.39 | 0.92 |
STAI-S | |||||||
At baseline | 34.25 | 6.66 | 42.30 | 14.74 | |||
At the end of treatment | 22.001 | 7.85 | 1.64 | 29.302,6 | 11.81 | 0.94 | 0.73 |
STAI-T | |||||||
At baseline | 52.69 | 8.10 | 58.90 | 11.19 | |||
At the end of treatment | 44.751 | 5.32 | 1.13 | 53.503,5 | 11.61 | 0.46 | 0.97 |
BDI | |||||||
At baseline | 18.44 | 8.92 | 21.30 | 12.09 | |||
At the end of treatment | 8.441 | 4.99 | 1.35 | 11.603 | 10.02 | 0.84 | 0.40 |
ShARS | |||||||
At baseline | 45.38 | 24.95 | 54.20 | 25.99 | |||
At the end of treatment | 18.381 | 10.38 | 1.38 | 27.903,6 | 19.19 | 1.11 | 0.62 |
FFMQ-SF | |||||||
At baseline | 71.70 | 7.34 | 71.28 | 11.95 | |||
At the end of treatment | 80.601 | 7.76 | 1.17 | 79.404 | 8.65 | 0.75 | 0.15 |
MAAS | |||||||
At baseline | 3.85 | 0.75 | 3.97 | 0.67 | |||
At the end of treatment | 4.311 | 0.65 | 0.64 | 4.402 | 0.80 | 0.57 | 0.12 |
Treatment results in MPT and PT + PPT groups.
p < 0.0001 (comparing to baseline figures).
p < 0.001 (comparing to baseline figures).
p < 0.005 (comparing to baseline figures).
p < 0.01 (comparing to baseline figures).
p < 0.001 (between the groups).
p < 0.01 (between the groups).
p < 0.05 (between the groups).
SCL-90 DEP, ANX, GSI—depression, anxiety and global severity index of symptom checklist 90; STAI-S—Spielberger Anxiety Inventory, state anxiety; STAI-T—Spielberger Anxiety Inventory, trait anxiety; BDI—Beck Depression Inventory; ShARS—Sheehan Clinical Anxiety Rating Scale; FFMQ-SF—Five-Factor Mindfulness Questionnaire, short version, total score; MAAS—Mindfulness Attention Awareness Scale; MPT group—monopsychotherapy group. PT + PPT group—psychotherapy + psychopharmacotherapy group with later psychopharmacotherapy withdrawal.
The combined psychotherapy results are presented in Table 4. Comparing before and after data in the main group and analyzing these data in comparison with WLC group data, we can observe a significant decrease of all clinical scales’ scores in the main group (SCL-90 DEP, SCL-90 ANX, SCL-90 GSI, STAI-S, STAI-T, BDI, ShARS) practically to the level of the nonclinical norm.
For the STAI-T scale, the effect size is moderate (0.73); for the other six clinical scales, the effect size is large (from 0.87 to 1.28). The mindfulness scores (FFMQ-SF, MAAS) increased significantly with large (FFMQ-SF = 0.98) and moderate (MAAS = 0.71) effect sizes. There were no such changes in the WLC group during 3 weeks of waiting period.
Psychotherapy results in the PD and GAD groups are shown in Table 5. Significant changes of all clinical scales’ scores are observed in both groups. There were no statistically significant differences between the groups at the end of the therapy. The effect size for clinical scales (SCL-90 DEP, SCL-90 ANX, SCL-90 GSI, STAI-S, STAI-T, BDI, ShARS) was bigger in the PD group, in which for all the scales it was large (from 0.99 to 1.75), but moderate for STAI-T (0.69). In the GAD group, the effect size was moderate (from 0.53 to 0.74) for five scales (SCL-90 DEP, SCL-90 ANX, SCL-90 GSI, STAI-T, ShARS) and large (from 1.06 to 1.20) for two scales (STAI-S, BDI). Changes in mindfulness scores in the PD group were moderate (FFMQ-SF, 0.78; MAAS, 0.62); in the GAD group, the effect size was large for FFMQ-SF (1.20) and moderate for MAAS (0.61).
Results for the groups of MPT and psychotherapy with gradual withdrawal of psychopharmacotherapy (PT + PPT) are presented in Table 6. It is important to notice significant differences between MPT and PT + PPT groups at the end of the therapy according to six scales of 9 (SCL-90 DEP, SCL-90 ANX, ACL-90 GSI, STAI-S, STAI-T, ShARS), which is confirmed by a larger effect for the MPT group. Comparing before and after the scores in the MPT group, there is a significant decrease of all scales’ scores to the level of the nonclinical norm (SCL-90 DEP, SCL-90 ANX, SCL-90 GSI, STAI-S, STAI-T, BDI, ShARS). For all seven scales, the effect size is large (from 1.13 to 1.91). Mindfulness scores increased significantly with large (FFMQ-SF = 1.17) and moderate (MAAS = 0.64) effect sizes.
Comparing before and after the data in the PT + PPT group, a moderate significant decrease was observed for six clinical scales’ scores (SCL-90 ANX, SCL-90 GSI, STAI-S, STAI-T, BDI, ShARS). There were no significant changes in SCL-90 DEP scores. The effect sizes are large for three scales (STAI-S, 0.94; BDI, 0.84; ShARS, 1.11), moderate for one scale (SCL-90 ANX, 0.56), and weak for two scales (SCL-90 GSI, 0.39; STAI-T, 0.46). Mindfulness scores significantly increased with a moderate effect size (FFMQ-SF, 0.75; MAAS, 0.57).
Results of this controlled study show high effectiveness of PDP for PD and GAD, which is confirmed by mainly high or moderate size effects in psychometric data.
The correctness of distinction of the groups of MPT and PT + PPT is confirmed by statistical analysis of psychometric data. The effectiveness of MPT is significantly higher than the combination of PT + PPT, while the duration of MPT is significantly lower.
The use of instruments in this research for mindfulness evaluation (FFMQ-SF, MAAS) was justified, because for the first time the significant increase of these parameters (with moderate effect size) was shown for the UH (PDP). Additionally, the effectiveness of the PDP was compared with MBCT [53] and MBSR [54] methods for several psychometric clinical scales and mindfulness scales (see Table 7), which demonstrated comparable effect sizes for the three methods. The received data expand the representation about mindfulness phenomenon, taking it beyond the boundaries of traditional meditation and bringing closer to the basic mechanisms of UH activation of the psychological process of normal coping by means of distancing.
Authors | Diagnosis | Intervention | No of subjects | Scales | M1 | S1 | M2 | S2 | D-unbiased |
---|---|---|---|---|---|---|---|---|---|
Evans and co-authors | GAD | MBCT | 11 | BDI | 13.8 | 7.9 | 8.82 | 8.5 | 0.56 |
MAAS | 3.68 | 0.66 | 4.2 | 0.58 | 0.78 | ||||
Vollestad and co-authors | AD | MBSR | 31 | BDI | 17.3 | 9.3 | 8.5 | 9.1 | 0.93 |
SCL-90 GSI | 1.3 | 0.6 | 0.7 | 0.7 | 0.9 | ||||
FFMQ | 113.8 | 21.6 | 128.2 | 22.3 | 0.64 | ||||
Tukaev and Kuznetsov | GAD and PD | PDP (UH) | 52 | BDI | 19.54 | 10.24 | 9.65 | 7.41 | 1.11 |
SCL-90 ANX | 1.85 | 0.93 | 0.93 | 0.84 | 1.04 | ||||
SCL-90 GSI | 1.29 | 0.62 | 0.74 | 0.59 | 0.89 | ||||
SCL-90 DEP | 1.66 | 0.82 | 0.94 | 0.83 | 0.87 | ||||
FFMQ | 71.54 | 9.28 | 80.12 | 8.88 | 0.99 | ||||
MAAS | 3.9 | 0.72 | 4.35 | 0.71 | 0.63 |
The comparison of PDP (UH) MBCT, MBSR efficiency, and mindfulness effect in therapy of anxiety disorders.
PDP is clinically effective for the treatment of PD and GAD, comparing with the WLC group.
PDP is more effective in the MPT format than in PT + PPT format.
PDP is effective in the PT + PPT format, so it can be used for a successful therapy on patients recurrent and resistant to PPT.
UH produces a distinct mindfulness effect comparable to that for mindfulness-based CBT.
In this chapter, the author attempted to describe briefly and systematically some of the results of his experimental, theoretical, and clinical studies in the field of hypnosis and hypnotherapy.
The integrative theory of hypnosis allows us to consistently explain a number of features of the hypnosis phenomenon related to hypnotization and analgesia, improving learning ability (suggestibility) and biological effects and providing a wide range of therapeutic applications and the evolution of the communicative style of hypnotherapy. The universal hypnotherapy presents the practical embodiment of the developed theoretical understanding of hypnosis, which in the controlled study has showed a high efficacy in the treatment of anxiety disorders.
The fact that UH, developed independently in the 1970s to 1980s of the twentieth century, was later assigned to the category of methods of positive psychology and psychotherapy, the author considers natural, associated with the fundamental prevailing of positive susceptibility of hypnotic (functional child) psyche. The therapeutically valuable feature of this technique is its pronounced mindfulness effect, which we explain as reactivated by therapy homeostatically significant mechanism of normal experiencing.
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