When the Light Bulb Went On: The Urgency for a Pre-Hypnosis Evaluation

by Maurice Kouguell, Ph.D., BCETS

The dedication of my first book, Human Figure Drawing: A Screening and Evaluative Tool in Hypnosis, reads:

With special thanks to the clip-on reading light in my office, perceived by a client as a SEX LIGHT with special powers, pointing to the urgency for a screening technique.

The concept for my second book DAPTH: Accessing the Unconscious in the Practice of Hypnosis and Counseling came about as a result of the following incident. I had been working for a few months with a female client who had successfully reached her desired goals. At one point, seemingly totally unrelated to the session, she pointed to a clip-on light in my office and stated that she wished that I would use that sex light again. I quickly lost my sense of humor and became actively involved in my inner dialogue trying to remember if my malpractice insurance was paid up. When asked to clarify what she was referring to, she stated very casually in her normal speech pattern that after the first session she had had a wonderful sexual experience in her bedroom with her gynecologist and myself and attributed it the clip-on light. She pointed to the clip-on light and asked if I could use it again.

Shortly after that incident, Dr. Bernie Siegel was one of the presenters at a convention of hypnotherapists in 1986. As part of his presentation, he referred to drawings made by his cancer patients at different phases of their disease.

The experience with my client and Bernie Siegel's happened close enough together to prompt me to think of a technique which needed to be introduced for the assessment of the client.

A person could be behaving normally, appear to have intact thinking processes and yet, the pathology might surface at unexpected times. While it surfaces on occasion, it is always present and one needs to find a way of being aware and prepared to deal with it.

It is my opinion that before hypnosis is applied, it is wise to assess the advisability of using hypnosis.

Hypnosis is becoming a recognized and popular technique for dealing with a wide range of problems related to the mind. It has been successful in a variety of categories ranging from habit disorders to major neurotic disturbances, psychophysiologic difficulties, problems dealing with weight, addiction and dependency, to name a few. Those wishing to improve mental skills and even sports skills have benefited greatly from the use and application of hypnosis. As the mind-body connection continues to receive the place that it deserves, hypnosis, meditation, and other spiritual experiences will develop and gain more recognition in the healing arts. There seems to be little left where hypnosis is not the tool of choice. Thus, a variety of clients come to see us and frequently without having been evaluated or diagnosed.

In reviewing the literature dealing with the indications of contraindications for the use of hypnosis, there seems to be agreement in disagreement by established practitioners as to the application of hypnosis. "Psychotic individuals, pre-psychotics and patients with character disorders of an extremely infantile or dependent nature are usually not suitable subjects of hypnoanalysis." (Wolberg, 1945) While Dr. Wolberg, an established psychotherapist, psychoanalyst and teacher makes a statement which has been shared by many others, there are several other hypnotherapists who have successfully used hypnosis in the treatment of such clients.

It is interesting to note that most of the literature refers to the hypnotizability of the client as part of the hypnotist's diagnostic evaluation. For instance, patients who can be hypnotized are determined to be "good candidates" for the relief of certain symptoms. The emphasis remains on the diagnostic evaluation of the client's ability to enter hypnosis and not on the advisability of choosing hypnosis as a therapeutic tool.

As a teacher and practitioner of hypnosis, I had questions that needed to be addressed.

When a client comes for hypnosis, shouldn't there be an assessment preceding the trance induction? Should hypnosis be used because it has been requested by the client? If hypnosis is to be used, how should it be used? Should the hypnotherapist assess the client's emotional strengths or vulnerability first? How does the therapist assess the effectiveness of a session or sessions?

It appears that books written on hypnosis by psychotherapists do not discuss assessments for the application of hypnosis. Those clients have already been diagnosed. Most books written by hypnotists state that hypnosis is not dangerous. They frequently discuss how to determine one's ability at entering hypnosis but do not discuss when hypnosis should be used. One needs to question whether the ability to enter hypnosis is a criteria for using hypnosis?

Hypnotherapy is, in essence, a process of communication between the client and the therapist. The exchange of communication need not necessarily be limited to words. Individuals with repressed anger may present a certain façade but might feel quite differently from what their appearance shows. It is also possible that people choose to say things that they do not mean in order to protect their integrity at a given time. Repressing and suppressing one's feelings is a sign of our advanced society where as early as the infant can hear speak he/she is expected to respond and conform to the needs of society surrounding him and repress his own needs.

Clients frequently censor verbal information. One learns early in life that many feelings are not allowed to be expressed openly and need to be repressed. I have coined the expression "the thank you syndrome" where the child learns that he may not express his true feelings, but rather reflect what is expected of him by saying "thank you," thus pleasing his parents or other authority figures. As a result, children learn that self expression is not tolerated and with that type of behavior being repeated, the "good' child grows up with a lot of unresolved conflicts. Those feelings surface through certain unconscious behaviors (including projections of feelings or ideas) or slips of the tongue. Freud described that expression with the term parapraxis.

By parapraxis, I understand the occurrence in healthy and normal people of such events as forgetting words and names that are normally familiar to one, forgetting what one intends to do, making slips of the tongue and pen, misleading, mis-reading, mislaying things and being unable to find them, losing things, making mistakes against one's better knowledge, and certain habitual gestures and movements...An analytic inquiry, however, shows with enough certainty to satisfy every requirement that these latter factors merely operate as facilitating factors and may be absent. Parapraxes are full blown psychical phenomenon and always have a meaning and an intention. They serve definite purposes which owing to the prevailing psychological situation, cannot be expressed in any other way. These situations, as a rule, involve a psychical conflict which prevents the underlying intention from finding direct expression and diverts it along indirect paths. (Freud, 1913)

Why drawings as a tool choice for assessment?

Communication through art preceded the development of language. The prehistoric man expressed his ideas through drawings. Those drawings expressed not only his thoughts, but also his emotions.

I believe that an assessment and exploration of the client's unconscious through a projective technique will assist the therapist in accessing and exploring the causality of the formation of the symptoms. Suggestions under hypnosis geared to bringing about change while the unconscious is receptive will be so much more effective when the hypnotherapist has some insight into the underlying difficulties and strengths of the client.

"He who would paint a figure, if he cannot become that figure, cannot portray it" --Dante

I had studied, used and taught Figure Drawings as well as the House Tree Person technique at the City College of New York. Those techniques were part of a projective battery of tests which included, but were not limited to, the Thematic Apperception Test and the Rorschach Test. These drawing tests were part of other projective tests helped in validating the interpretations.

The interpretation of art in any form is based on recognizing that there are some universal fundamental thoughts and feelings emerging from the unconscious and recognizing that there are universal symbols. In using any kind of art medium one need not be an accomplished artist, but simply allow oneself to use that vehicle for free expression. The use of art has an important place in any type of therapeutic intervention.

My two books Human Figure Drawing: A Screening and Evaluative Tool in Hypnosis and DAPTH: Accessing the Unconscious in the Practice of Hypnosis and Counseling offer additional assessment and evaluation through the use of drawings which is indispensable in hypnotherapy. The technique can also be applied to psychotherapy and any form of individual and group counseling. The uniqueness of this work is that it also allows the therapist to evaluate his own effectiveness in the therapeutic process.

With the application of this technique, the hypnotherapist will be able to gather information concerning the client's needs, fears, conflicts and goals and integrate that material in his work. Being aware of the symbolic content brought forth by the drawing will offer the therapist a direct avenue to the understanding of the client's conflicts and problems. With this information, the therapeutic intervention should become more effective for it addresses itself to unconscious material which now has surfaced. In addition, this technique will also provide the therapist with information revealing the possible pathology of the client and help decide the course of therapy.

This technique can also be applied effectively as a screening tool preceding any group induction. One cannot assume that individuals attending a group workshop are necessarily free of severe pathology just because they are of part of the workshop. Should drawings reveal pathology, the induction will have to include specific suggestions geared to the individual. Experience has taught me that maladjustments are not limited to individual clients coming to our office. The fact that a group is geared to Smoke Ending, for instance, does not necessarily exclude the presence of disturbed individuals. The same harm that can happen during an individual induction who might react very poorly to a smoke cessation program. A cursory examination of the drawings, collected prior to the group induction, might be sufficient to alert the hypnotist to certain pathologies within the group membership.

Therapists dealing with the mind must always be ready to deal with the unpredictable. For instance, what do you do when a client threatens to strangle you with his bare hands? Or what do you do when an adolescent, attending a discussion group in a public school setting during school hours, points a loaded gun at you and threatens to pull the trigger? What do you do when a client drops her fur coat and you are faced with her total nudity? What do you do when one of your clients commits suicide and how do you handle your own grief? What do you do, when under hypnosis, your client abreacts and foams at the mouth, displaying a seizure-like motor activity and urinates? What do you do when, after a hypnotic session, you receive a call from your client who complains of various fears never experienced before? With the drawings administered before the induction or counseling session, the therapists would have been better prepared to deal with the incidents.

The DAPTH™, an acronym for Draw A Person Tree House Test is a projective technique based on the House Tree Person test. The reader will be able to use these three themes individually or in combination. DAPTH™ combines the most pertinent highlights from various research and is applicable to counseling and hypnotherapy.

Administration

The administration of the DAPTH is quite simple . You hand the client an unlined sheet of white paper 8 1/2x11, a #2 lead pencil with an erasure and a support on which one could draw.

The instructions for each drawing are:

Draw a Person. On the next sheet of paper you say draw a tree and on a third sheet you say draw a house. For the first 2 drawings the paper is handed vertically, for the house, horizontally. The interpretations for each drawing are included in the manual and can be easily followed by the therapist. Specific recommendations on procedure appear in the text. The entire administration may take between 5 and 10 minutes. The analysis of course takes longer, but your findings will help you beyond words.

In addition to administering the DAPTH before the hypnotic session, it can also be administered after the session The administration of the drawings after the session provides the hypnotherapist or counselor with direction as to how successful the session was. It also gives the therapist a technique for evaluating the effectiveness of the session.

Whether DAPTH™ is administered to an individual or a group, there is a lot of information revealed. Thus, there will be comments relating to self-criticism, reactions to the task, as well as many other behavioral patterns which would be meaningful to the trained observer.

Observational skills are essential in all therapeutic relationships. They include, but are not limited to, the ability to see and interpret hear and interpret, and go beyond those sensory perceptions.

Non-verbal behavior can be as important: watching for erasure; indecisions; length of time spent on one part of the body being drawn; inability in completing the task. All these can have a significant meaning in the hands of a trained observer. One could pick up extreme cases of obsessive behavior when the person cannot give up the drawing after a long period of time or one can note the helplessness of a person, who might not appear so at all on the basis of the interview, by needing constant support and reassurance to continue with the drawing. All the aforementioned information obtained without even looking at the finished product. (Kouguell, 1992)

Those skills can be developed and are taught in the context of DAPTH. Readers are taught how to interpret the drawings and get the most out of understanding the language of the non-conscious.

[For actual examples of figure drawings and additional case studies see The Role of Art In Hypnoanalysis.]

Freud, S. Collected Papers of Sigmund Freud, Vol. 13,1913 pp.166-167
Kouguell, M .Human Figure Drawings: A Screening and Evaluative Tool in Hypnosis. 1992 pp.23-24
Wolberg.L.R. The Techniques of Psychotherapy. New York Grune and Stratton