The Generative Presence of Relatedness

Abstract

In this guest editorial, the authors introduce a special issue of the American Journal of Clinical Hypnosis that focuses on relational factors of hypnosis in psychotherapy. The authors have invited a number of esteemed colleagues to comment on aspects of the therapeutic relationship, and how it informs and influences the processes, techniques, and outcomes of hypnosis and therapy. In addition to summarizing each of these articles, this article analyzes the major relational themes that present across the articles.

Keywords:

• attunement
• hypnosis
• relational hypnotherapy
• relational psychotherapy
• therapeutic action
• therapeutic alliance
• therapeutic presence
• therapeutic relationship

This special issue of the Journal was inspired by the 60th Annual Meeting and Workshops of the Society held in Orlando, Florida in Spring, 2018, which focused on relationship factors in hypnosis and hypnotherapy. The depth and richness of the presentations and workshops lead the Journal’s Editor-in-Chief to request this special issue which includes many of the presenters from that meeting and which we hope captures the exciting zeitgeist which made that meeting so memorable.

Few topics have captured as much attention as the relational context which surrounds clinical interventions in all the healing disciplines. Whether framed in terms of social context and influence, transference, alliance, rapport, trust, attunement, or empathy, relationship factors have consistently been noted to correlate with therapeutic response and to mediate or predict behavioral change in literally thousands of clinical and empirical studies (Duncan, Miller, Wampold, & Hubble, 2011; Hubble, Wampold, Duncan, & Miller, 2011; Kazdin, 2007). This appears to be especially true in behavioral interventions and psychotherapy (Norcross, 2002). In particular, the emphasis has been placed on the crucial role of transference and therapeutic alliance factors as determiners of therapeutic process and efficacy in many forms of psychotherapy (Gelso & Carter, 1985, 1994; Norcross & Lambert, 2018). These variables have also been explicated as critical in hypnosis and hypnotherapy in helping to produce trance and to mediate the degree of trance depth and absorption (Banyai, 1998; Diamond, 1984, 1987) as well as factors central to the process and outcome of hypnotherapeutic interventions (Baker, 1981, 2000).

Early models of hypnosis were strongly influenced by psychoanalytic theory and frequently described hypnosis as a special form of transference which produced a regression and created therapeutic action (Gill & Brenman, 1959; Kluft, 2018; Watkins, 1954). As therapeutic models became more bi-dimensional and influenced by interpersonal, ego psychological and intersubjective theories, the therapeutic alliance became a more central construct in the discussion of process and outcome in psychotherapy (Safran & Muran, 2000). A recent meta-analytic synthesis of 295 independent studies covering more than 30,000 patients published in the last 40 years (Fluckiger, DelRe, Wampold, & Horvath, 2018) examined the role of relationship factors with a particular focus on the alliance and its relation to treatment outcome across a wide range of strategies and treatment approaches. A significant and robust correlation was found confirming the prevailing opinion among psychotherapy researchers that relationship variables are among the most powerful factors which determine and influence therapeutic process, the specific actions of treatment interventions, and the efficacy and effectiveness of all forms of psychotherapy (APA Presidential Task Force, 2006; Orlinsky, Ronnestad, and Willutzki, 2004).

In this issue of the Journal, we have invited a number of esteemed colleagues to continue and to expand the conversation about the therapeutic relationship and how it influences the process of hypnosis and a variety of therapeutic strategies and techniques. The hope is that this discussion will not only increase awareness of relationship factors but will also enhance the thoughtful application and management of these factors when clinicians utilize hypnosis in therapeutic work or conduct research on hypnosis in the laboratory or in clinical settings.

In considering the body of work in this issue, a few themes emerge which are reflective of the relational focus of these articles. Each of these themes starts with the letter “I”, a significant aspect of the sense of “We”-ness which is at the heart of the articles included. We are relational beings, and our existence is informed by our interactions with others, beginning with our earliest attachment figures. Even within each individual, there is a matrix of relationships: between mind and body, between thoughts and feelings, between inner and outer, and between parts and the whole systemic self.

First, we observe that many of the authors grapple with the question of how therapist and patient influence one another relationally during treatment. Said another way, what is it about the relationship that influences the process and outcome of treatment? How is the relationship reciprocal in its bi-directional influence, and as an extension of these questions how is hypnosis a vehicle for this relational influence that facilitates patient change?

Second, the themes of interaction and imagination are inherent in many of these pieces. During the process of therapy, what is the intersubjective space that becomes co-constructed together? Some authors see this as a shared third space that is an interaction between therapist and patient. Others view it as a co-regulation of sorts that allows the therapist to put her or his mind in the service of the psychoneurobiological adaptation of the patient. Regardless, this interactional space that exists within the therapeutic relationship is one that is imaginative. It is always present in the shared unconscious, in our right-brain to right-brain communication, in our embodied non-verbal exchanges. For this reason, when we intentionally apply the imaginative process of hypnosis to this interaction, our minds collaborate together in a creative, improvisational manner that builds new narratives in the service of healing.

Internalization and incorporation are the relational processes by which the relational experience on the outside transfers to the relational representation on the inside, and does so in a consistent and durable way. We observe some authors hypothesizing about the process by which the external attachment figure (in this case, therapist) and attachment relationship moves into the inside, becoming a part of the patient’s mind, and ultimately the structure of the self. To internalize is not enough, however. Incorporation is the consistent, repetitive application of this internalization in the patient so that it becomes a part of the structure of identity and the representation of self-experience. In this sense, the patient’s subjective experience of the other becomes the defining crucible within which the interactive experience occurs, which is then internalized to create the emerging sense of character and self. This is another area where the application of relational hypnosis is considered and explored.

Finally, integration is the relational process by which dissociated, split, or compartmentalized parts of the self become connected with one another. Because hypnosis is an absorptive, sensory-rich and imaginative process, it is seen in many of these articles as a utilizer, facilitator, and container of these relational mechanisms.

In our article, entitled “Dancing in the In-Between: Hypnosis, transitional space, and therapeutic action,” we summarize the tripartite model of the therapeutic relationship (transference/countertransference configuration, real or contemporary relationship, and therapeutic alliance) and present it from a hypnotherapeutic perspective. We describe the ways in which hypnosis can be utilized towards goals associated with each of the tripartite components of the relationship. Further, we describe the concept of transitional space, a developmental building block or scaffolding of sorts in which the patient is mastering the task of internalization of the positive functions and attributes of the therapist and therapeutic relationship. We believe that this in-between naturally integrates with the qualities of the therapeutic alliance, and that hypnosis, with its emphasis on language, imagery, attachment, and relatedness, furthers the goal and process of “putting the outside on the inside.” We call our article “Dancing in the in-between,” because this type of hypnotic relational and imaginative playing reminds us of dancing: it is shared, collaborative, rhythmic, improvisational, and playful. In addition to a detailed analysis of the literature and elaboration of our interpretation of this model, we offer to the reader technical examples of how therapists can apply this model in their hypnotherapeutic practice. Finally, we provide a detailed case example which experientially demonstrates the integration of the alliance within transitional space in the service of adaptive therapeutic change and developmental structural personality maturation.

This issue also features the return of Michael Diamond to the hypnotic fold with his article “Gazing back, playing forward: Contemporary psychoanalytic musings on the relational essence of hypnotherapeutic action.” Diamond’s writings in the 1980s on hypnotic relatedness and alliance have been influential towards our writing, thinking, and clinical practice. In this article, Diamond builds on the concepts that he addressed in his keynote presentation at the 60th annual meeting and integrates his earlier writing on relational hypnosis with his subsequent writing and interests in relational psychoanalysis. He introduces three qualities of the relational hypnotic process: scheming, dreaming, and redeeming. Diamond boldly takes on the controversial relationship between hypnosis and influence. As he clearly describes, scheming – while often portrayed in the media as malevolent – here involves the therapist benevolently influencing the patient’s unconscious and relational processes towards structural evolution (e.g., regression in the service of the ego, a la Gill & Brenman, 1959) and therapeutic change. This benevolent scheming engages multiple levels of patient involvement (relational and archaic) in hypnotic play. This hypnotic playfulness elicits the patient’s fantasies and dreams in the service of adaptive therapeutic change, which has a redeeming quality to it.

As Diamond describes in his article, therapeutic action is a relational task that involves the internalization of the attitudes and functions of the analyst/therapist on the part of the patient. It is through this process of presence and internalization that corrective relational experiences happen, which in turn become mutative and durable across time. A critical concept here is that “action” or “activity” in the session does not have to be “done,” akin to a behavior or a more discernible therapeutic task. Rather, therapeutic action is something that is felt, imagined, and put inside through the immediacy of the relational encounter of therapy and the consistent model of the analyst’s attitude and functional presence. Hypnosis, which involves play in an imaginative space, then becomes a vehicle towards therapeutic action. In this regard, hypnotherapeutic action is like a playful form of dreaming derived from the presence of the immediate moment. It allows the patient a flexibility in incorporating reality and integrating it with fantasy. Developmental arrests, such as through trauma and insecure attachment, often forestall the integration of fantasy with reality. A psychic flexibility is lost, as is the capacity to integrate the experience. Thus, in its utilization of dreaming within the container of the immediate relational crucible, Diamond demonstrates how hypnosis has the capacity to be redemptive, contributing towards transformational therapeutic change.

Diamond also invokes relational concepts of neuropsychology to describe how analyst and patient co-exist in a shared intersubjective space, which becomes a “third” in the room. This analytic third, then, is the distinct interaction of the functionality of the analyst with the reciprocal experiencing from and understanding of the patient. He describes how maternal and paternal functions of the therapist contribute in different ways towards therapeutic healing. This discussion of gender is not meant to reinforce traditional gender stereotypes, but rather to pair them with functionality and elaborate how every therapist, regardless of gender, possesses and can evoke both gender functions in sophisticated and nuanced ways towards therapeutic change. According to Diamond, the “maternal functions” incorporate the aspects of togetherness and joining inherent in the “holding container” of therapy. The “paternal functions” incorporate the qualities of separateness, differentiation, and perspective-taking. In conclusion, Diamond summarizes how hypnosis can be utilized in conjunction with each function and its associated set of developmental goals. In this regard, then, he posits that it takes more than two to tango in hypnosis (a riff on the title of his classic 1984 relational hypnotherapy article, “It takes two to tango: Some thoughts on the neglected importance of the hypnotist in an interactive hypnotherapeutic relationship”).

Interestingly, Maggie Phillips comes to the same conclusion in her article “It takes more than two to tango: Building secure attachment through hypnotic and ego-state relationships.” Ironically and fascinatingly, Phillips has a much different conceptualization of the multiple tango partners involved. Unlike Diamond, who conceptualizes the co-constructed intersubjective third space between therapist and patient as the additional tango partner, Phillips envisions the tango as being a dance between multiple ego states in both therapist and patient. Like Diamond, Phillips’ article is a revisiting of her earlier work with the integrative perspective of more recent writing and thinking.

This article invokes Phillips’ recent collaborations with both Stephen Porges and Peter Levine to conceptualize the role of hypnosomatic resourcing in hypnotherapy and ego state therapy. Phillips has long been a proponent of utilizing principles of attachment in hypnotically working with ego states in trauma treatment. What has evolved over the years has been her utilization of principles of somatic experiencing in devising hypnotherapeutic suggestions to turn on ventral vagal safety. Referencing and expounding upon Porges’ (2011) polyvagal theory, Phillips describes how the social engagement of the relational therapeutic encounter is critical in re-wiring patients’ ventral vagal neuroception away from danger towards safety. A critical component that she elaborates upon in her article is the role of therapeutic co-regulation of dysregulated patient ego states. Phillips emphasizes that this co-regulation is not an action or task-oriented process, but rather a therapeutic presence (Geller & Porges, 2014) towards – as in an engaged mode of being with - patient experiencing. Indeed, she emphasizes, it is imperative to resist the urge to “do” something and instead be with our patients’ suffering, pain, and difficult experiences. It is this kind of present, engaged right brain-to-right brain experiencing that leads to healing. We note that Phillips, although approaching her subject from a somewhat different literature base than Diamond, is ultimately making a similar point with regards to his description of therapeutic action. Shared relational experience of being is a driver of healing.

In this article, Phillips presents her 3 R’s model of hypnosis: resourcing, re-regulation, and repairing and/or re-wiring. Resourcing incorporates the body to shift trauma-laden relationships with somatic experience. Re-regulation involves the process of co-regulation describes above to shift nervous system responses to traumatic triggering. Finally, repairing and rewiring involves therapeutic principles of attachment to build integrated ego state and self-relational change. Phillips provides three evocative case examples to illustrate the hypnotherapeutic principles and applications associated with each of the 3 R’s in her model.

David Alter, co-author of the book Staying sharp: 9 keys for a youthful brain through modern science and ancient wisdom, is an expert in the neuropsychological and psychotherapeutic integration of brain neuroscience with clinical hypnosis. In his article for this issue, entitled “In the intersubjective space: Hypnosis through a neuropsychological lens,” Alter addresses the intersubjective interaction between patient and hypnotherapist, as seen through a neuropsychological prism. This article explores the intersections between attachment, neuroscience, and hypnosis. His metaphoric use of a matryoshka doll in this article is an apt one, because Alter analyzes the neuropsychological and neurophysiological aspects of multiple dimensions of relatedness: intrapersonal somatic relatedness, interpersonal relatedness, sociocultural relatedness, and evolutionary relatedness. A core aspect of Alter’s article is his description of how narratives become stagnant and potentially harmful in their embodiment and lived experience; and, conversely, how hypnosis and the therapeutic relationship can be utilized to foster new, adaptive embodied narratives that facilitate neuroplasticity. He demonstrates how careful attunement to and utilization of patient somatic experiencing can lead to profound experiential shifts in the therapeutic process and outcomes. Alter delineates how subtle non-verbal somatic presentations contain seeds that hypnotic suggestion can cause to positively bloom in the flowering of neuroplasticity. In addition to examining larger biological, existential, and sociocultural themes in relational neuroscience and hypnosis, Alter also provides cogent clinical applications and case examples from which the reader can discern distinct takeaways about how to utilize hypnosis in psychotherapy from a relational neuropsychological perspective.

In Julie Linden’s article, “Relationship factors in the theater of the imagination: Hypnosis with children and adolescents,” the developmental principles underlying this entire special issue come to life in their origin: childhood. As Linden informs the reader, relationally focused hypnotherapy with children and adolescents is very much influenced by the actual developmental maturity of the client, in addition to her or his psychological age. It is imperative that the therapist consider the propensity towards literalism (vs. symbolism) and the limited attention span of children. Given this, the hypnotherapy may be more concrete and move at a faster pace than with adults. On the other hand, because children (especially younger children) live in a world of play and imagination, they are particularly well suited to hypnotic imagery. Further, there is a greater sense of imaginative immediacy, and as a result, child clients can be much more easily enlisted in the generation and utilization of such hypnotic imagery.

As Linden’s title suggests, the hypnotherapeutic “theater of the imagination” is one in which narratives are ascendant and, significantly, flexible. Because hypnotherapy with younger clients can occur in the midst of primary relational conflicts and/or traumas as opposed to after them, narratives about such experiences are less entrenched, rigid, and inflexible. In such a theater, hypnotherapy makes use of our innate human capacity and desire to play and enlists this love of play towards making a play, that is, creating a narrative play that tells a modified and adaptive positive story of healing. In this regard, we are reminded of Alter’s emphasis on the role of developing narratives in hypnosis to facilitate brain neuroplasticity. Importantly, content is determined by context, as Linden notes, and it is the unfolding relationship between therapist and client that shapes these hypnotherapeutic narratives. According to Linden, “Clinical presence, authentic, attuned and sensitive, matters on the stage of life.”

Linden makes compelling use of clinical examples in her article to demonstrate two key areas: (1) mental functions associated with specific developmental stages and experiences, and (2) types of internal resources that hypnosis can unlock or develop in the path towards therapeutic change. For example, she demonstrates the role of imaginative involvement in elaborating concrete thinking, such as in her use of a “worry switch” with a 6-year-old child client. In other examples, she demonstrates how attunement and ego strengthening suggestions help reframe the need for adolescent “resistance”, and further the process of separation and individuation within a secure therapeutic attachment relationship.

Our co-authored article with Carolyn Daitch, Michael Diamond, and Maggie Phillips, entitled “Hypnosis and the therapeutic relationship: Relational factors of hypnosis in psychotherapy” is a hybrid article of sorts. The genesis of this article was our panel discussion together on “Hypnosis and the Psychotherapy Relationship” at the ASCH 60th Annual Meeting. The context and process of our collaborative dialogue brought to life the very topic that we were discussing. It was fascinating to exchange ideas on a subject that we all care about deeply and that lives in our daily clinical work. After the panel ended, we all agreed that it would be beneficial to write up the conversation for publication. In doing so, what originally began as an edited transcription morphed into something ultimately more comprehensive and meaningful through the review process of the Journal. Our article begins by providing the background on the discordance between the rich relational basis and history of hypnosis, on the one hand, and the paucity of attention to relational factors informal attempts to define hypnosis, on the other. With this in mind, we discuss the factors that led to the creation of this panel discussion, and the larger questions about relational hypnotherapy and psychotherapy that we hoped to address.

In our discussion, we cover a number of relationally oriented therapeutic and hypnotherapeutic themes central to this special issue: attunement, intersubjectivity, transitional space, therapeutic action, and co-regulation, amongst others. More apparent in the moment than the breadth of these topics, however, was the interactive process between the panelists: the inspired exchange of ideas and clinical anecdotes. We hope that this collaborative and relational spirit comes across in the pages of this article.

Embedded within the edited transcription of our discussion, we offer several additional commentaries on themes in the discussion that we believe merit elaboration. These include an analysis of the basis and function of somatosensory attunement in the hypnotherapeutic process; and attention to the process of “contact trance” in the intersubjective relational space. At the conclusion of the article, we summarize the major themes of our discussion and offer recommendations for further research and clinical practice.

We are indebted to Mary Jo Peebles for her willingness to join our special issue at a late stage in the process, and for her flexibility in writing a response to an article that continued to evolve as the process went on (see above). In her Commentary piece on our panel article, entitled “Longing and fear: The ambivalence about having a relationship in psychotherapy,” Peebles writes about the various relational tensions experienced by the therapist within the process of the therapeutic enterprise. She begins her article by pondering how relational factors could have inexplicably been omitted from previous attempts to define hypnosis. This line of questioning leads to the hypothesis that perhaps more generally as human beings we tend to omit aspects of relatedness from operational definitions because we are ambivalent about the experience of closeness in relationships. Peebles then accentuates and elaborates upon the historical and contextual ambivalence of psychotherapy as a field, and psychotherapists as individual practitioners, to engage in and sustain the requisite intimacy of the therapeutic relationship and all of the inevitable surprises and enactments that it holds. She observes that the intimacy of relationally focused psychotherapy requires from the therapist both the ability to be present in a nuanced and sophisticated manner, and the willingness to do so.

In a fascinating and timely section, Peebles describes a continuum of the complexity of relational factors, the subject of our special issue. She explains that intimacy between therapist and patient occurs along five dimensions: emotional openness, process discussion, action, self-disclosure, and therapeutic goals. These five dimensions influence the intersubjective experience of six relational factors: rapport, alliance, transference, countertransference, attunement, and enactment. Peebles thoughtfully describes each dimension and factor and its role in the therapeutic process.

Peebles also reflects on the special role of hypnosis in psychotherapy, and some of the unique inherent opportunities and risks. Peebles focuses on attunement in particular, and explicates the complex interpersonal and interior relational communication that occurs between therapist and patient during hypnosis. She also discusses the use of hypnosis to potentiate the healing qualities of the relationship in psychotherapy. For both of these areas, Peebles educates the reader about important internal and interpersonal aspects for therapists to be aware of during this relational hypnotherapeutic process.

There are many implicit and explicit messages in Peebles’ writing. For example, she notes that psychotherapy has a range of complexity with regards to treatments and treatment goals. She astutely observes that not all psychotherapists are dispositionally and/or contextually suited for more complex relational treatment. Rather than this potentially being viewed through a negative prism, however, she gives therapists permission to acknowledge and accept this reality when it exists.

However, from our view, one important function of this article is to dilate the idealization defenses of therapists who identify themselves as having the ability to engage in the complex work of intense and intimate therapeutic relatedness. One could argue that she is asking these therapists “are you sure you are inclined and prepared to engage in this work right now?” Through her historical review of enactments in treatment relationships of Breuer, Freud, Jung, Ferenczi, Reichmann, and Greenson, Peebles demonstrates how the unexpected intimacy of the therapeutic encounter caused reputable therapists to make questionable choices that blurred boundaries in their treatment roles.

With the citation of Gabbard’s (1995) unequivocal perspective that all therapists are vulnerable to being affected by therapeutic intimacy in ways that can harm patients, Peebles ends her article with a section on prevention. Personal therapy and ongoing training and consultation are recommended as methods for enhancing reflective functioning and self-awareness in the therapist. She describes the complexity of potential interactional and internal effects a therapist must attend to. “In considering these options,” Peebles writes, “it is respectful to oneself to assess frankly and non-judgmentally whether or not our temperament and/or desire, at this particular point in our life, recommends us to therapeutic work demanding intense, deep relational connection. The answer may be no, and that is ok.”

As we conclude this introduction to the Special Section of the Journal, we are aware that for you, the reader, this is the end of a beginning. There are more articles for you to read in this Section, and more connections to be drawn between the stimulating ideas presented here and your own clinical practice and experiences as a therapist. For us, these words feel like the beginning of an end, as our time as co-editors of this Section comes to an end. Writing this introductory article has been the capstone of a robust, scholarly process working with each of the authors in this section; and seeing a brainstorming process germinate into rich, comprehensive articles which we hope will advance the field of hypnosis. As we reflect upon this conclusion, what we will relish the most in this process was the gift of presence – the array of relationally infused moments of creative collaboration with our collaborators, who continue to inspire us with their brilliance. Thank you to David Alter, Carolyn Daitch, Michael Diamond, Julie Linden, Mary Jo Peebles, and Maggie Phillips for your hard work and your wisdom. We also would like to thank the Editor-in-Chief of the Journal, Stephen Lankton, for approaching us with this idea at the 60th annual meeting, and for your help guiding us through the publication process of this Section. Finally, we would like to thank you, the reader, for your interest in hypnosis and relational psychotherapy, two areas that are deeply interwoven and facilitative of one another. We hope that in reading these articles you feel a sense of invitation to a relationship which is implicit in each of the articles.