International Handbook of Clinical Hypnosis - E-Lib FK UWKS

180 INTERNATIONAL HANDBOOK OF CLINICAL HYPNOSIS
supportive therapy relationship, the real therapy world is much more complex. As
every therapist is aware who has worked with psychotic and personality disorder
patients, the development and maintenance of a positive and constructive transference
relationship can be extremely dif®cult and sometimes impossible. Therefore,
the development of a therapeutic hypnotic process with these patients
dependent as it is on transference) can be equally dif®cult and sometimes impossible.
With the goal of developing and maintaining a positive and constructive
transference relationship with the severely disturbed patient, hypnotic work with
these patients will generally emphasize acceptance and support. However, within
this framework of support the therapist must be able to set limits. These limits will
most likely be viewed by the patient as non-supportive and may disrupt the positive
transference. It is the therapist's job, then, to maintain reasonable and stable limits
while trying to maintain as stable a positive transference relationship as possible.
This is a dif®cult task to say the least. But it is the crucial task of any therapy with
the severely disturbed patient. In addition, the therapist must also be able to
monitor the dependency relationship and the support to ensure movement toward
growth rather than promoting pathological dependency or helplessness.
In order to develop a positive relationship/transference with a severely disturbed
patient suf®cient to support the utilization of hypnosis, the particular issue of the
patient's concerns and fears over control and trust in the relationship must generally
be addressed. In all intimate relationships and perhaps more so in the hypnotic
relationship) there is potential for loss of control and for anxiety regarding such
loss. In the case of the severely disturbed patient, these anxieties tend to express
themselves as a fear of abandonment or an opposite fear of incorporation/engulfment
due in part to the signi®cance of these fears in the pathology and history of
these patients). In working with the severely disturbed patient, we have learned to
mitigate these dual fears of abandonment and engulfment by utilizing autohypnosis,
stressing patient autonomy and mastery in hypnosis, permitting eye-opening to
check out physical separateness and control, maintaining limits that protect against
merging, utilizing hypnotic imagery to create needed distance, and the therapist
modeling the safety of the hypnotic trance.
In general, current hypnotherapy work with personality disorder and psychotic
patients is based on a conceptual framework that is rooted in the psychoanalytic
and developmental approaches to the treatment of severe disturbance. The symptoms
of severe disturbance are considered to be best understood as manifestations
of the patient's failure to progress along normal stages of human development
Baker, 1981; Baker & McColley, 1982; Bowers, 1961, 1964; Brown, 1985; Brown
& Fromm, 1986; Kernberg, 1968; Kohut, 1977; Murray-Jobsis, 1984, 1990, 1991b,
1992, 1993, 1996; Scagnelli, 1976, 1980; Winnicott, 1965).
Within the context of a developmental model, the symptoms of severe disturbance
can be seen as being related to problems and con¯icts around initial
awareness of self and issues of separation-individuation. Thus, the symptoms of