7 décembre 1991, Bruxelles Hypnotherapy Introduction After several decades of studies carried out in the United States and in Eastern and Western Europe, including the work of Dr. L. Chertok, the state of hypnosis is no longer regarded by specialists in the field as a marginal phenomenon. Ridded of the romantic and spiritual connotations which have been attached to it, freed from the role of the scapegoat of psychoanalysis, it appears as a distinct dimension of animal existence, a domain rich in manifestations of consciousness. The state of hypnosis is an expressive space where can be observed elements of reality, dreams, the psyche and the mental and physical state, from the emotional to the limits of the imagination and hallucination. In the framework of analytical work, it is these qualities which make hypnosis both a crossroads for the study of the human sciences and an important space for observation and therapeutic action. As a space, as a site, it is only an open terrain for the application of "theories of treatment" and not a therapy in itself. It is for this reason that certain therapies have been born from hypnosis. Conversely, it is logical that the therapies derived in this manner should be applicable within that special space known as the "state of hypnosis." It is therefore easy to understand that hypnotherapy can by definition only be applied by combining the state of hypnosis with theoretical principles drawn from theories such as behaviourism, psychoanalysis, communication or neuro-linguistic programming. A certain number of ideas assumed to be known and accepted will not be discussed here, but simply mentioned: - Hypnosis is a state of consciousness, a relational mode, not a theory. - Hypnosis as conceived in the 19th century was a simple and direct technique, reductionism both on the level of its application and the obtained effect. - Numerous theoretical models building on the descriptions of Pierre Janet permit hypnosis to be viewed today as a specific state of consciousness, as a particular mode of mental and psychological activity originating from a "disassociation" of consciousness. - The clinical approach falls within the fields of medicine and psychology. For example, the words "consciousness" and "primal" will be used here as they are defined by ordinary language and standard dictionaries. - We view psychoanalysis as a theoretical tool describing in its own manner the operation of the psychological apparatus on one hand, and as psychotherapy on the other hand. Numerous concepts described by psychoanalysis have been confirmed by other, completely different approaches. This can allow us to assert the universality of such concepts as descriptions of psychological functioning (the Oedipus complex is one example). - The theoretical tool of reflection used to analyse the results of a hypnotherapy of a given type will be identical to that used in the theoretical frame of reference, although certain distinctive features will appear. It is in this sense that there exists a post-analytical hypnotherapy, which we will call hypnoanalysis, in which the widening of the frame of reference allows the introduction of psychoanalytic practice and references and their association with the hypnotic state. - According to the most recent data drawn from the evaluation of various psychotherapies (the World Congress of Psychotherapists in Phoenix), there is no basis to conclude that any particular model of psychotherapy provides superior results. Rather, the congress concluded that results varied according to clinical indications, as well as the personalities of, and the dynamic relational structure between, the patients and the therapists. It is in this spirit of openness and research that our work is done, the different varieties of hypnotherapy being only a few possibilities among many others to permit a patient to open himself towards the world, first through a process of treatment and then through a process of personal development. THE METHOD The following study originates from the hypnopsychotherapeutic method, a technique described here in broad outline. Hypnopsychotherapy, which I will refer to as "hypnoanalysis," can be defined as a psychoanalytic therapy which is carried out under hypnosis at certain moments. In practice, after a period of initiation, the use of the technique of free association is proposed to the patient. The state of hypnosis discussed here can be defined as a state of modified consciousness in the sense that the subject displays a vague state of awareness, principally characterized by the phenomenon of disassociation. The originality of this technique lies in the subject's increased ability to explore the layers of consciousness which are usually accessible in classic analysis only after much longer periods. In addition, the accompanying emotional manifestations appear to be simultaneously facilitated and rendered more profound. In the large majority of cases, the hypnotic trance of a subject evolves in the course of the sessions: the light state of hypnosis in the first sessions deepens as the therapy continues, without any modification in the technique applied at the outset. This phenomenon often reverses itself at the end of the psychotherapy; the subject emerges progressively and spontaneously from hypnosis. In our experience, such developments are associated with the positive results of the treatment; the subject enters the state of hypnosis more easily when he feels less threatened by his problems. This evolution continues in the most successful cases until the subject masters the state of hypnosis and becomes autonomous, meaning that he feels free to explore by himself the different states of consciousness, perhaps for his pleasure. I would add that the factors which hinder the entry of the subject into the state of modified consciousness fall into two main categories. Some are associated with the patient, such as his perception of hypnosis and his unconscious problems, but others are linked to the attitude of the therapist and can spring from an excessively peremptory initiation or the problem of the power associated with the therapist's role. During this evolution, there exist two fairly common phases as regards communication. TWO SPECIFIC STATES OF COMMUNICATION Before examining these different levels of communication, it must be specified that they could not serve as subjects for study outside of the transferential context which gives them their meaning. Furthermore, although the didactic approach requires us to separate them, these two levels of communication necessarily overlap and interact. It is important to consider that the transferential (and counter-transferential) relationship follows (or proceeds) this movement in the regression of the subject. This transfer, described as narcissistic [1] in that it is believed to activate the primary process of mental operation, is thought to provoke a cleavage of the self leading to a fusional relationship, a precocious object relationship. We are close to a relation of the type which exists between the mother and the unweaned infant (cf. the work of Bowlby), with as a consequence the appearance of phenomena of prelinguistic communication. As we will see later, these phenomena are only controllable and interpretable "through" and "by" transfer, in the sense that the state of being of the patient requires that the therapist assume a state which is at once equivalent (being on the same level of communication) and distinct (another level of communication which provides the necessary perspective for the "logical" processing of the information by the therapist). The first of these levels of communication is the most common and is present as soon as we use language. Although the quality of the material remains identical to what it would have been in a classic analytical framework, a particular characteristic which accompanies the hypnotic trance is the increased implication of the patient in the process of communication. When the subject's defences are confronted by the threat of the emergence of suppressed material, they may adapt to this new situation and reinforce themselves. As a result, resistances are created which prevent the patient from entering the state of hypnosis. For this reason, allowing the patient to achieve hypnosis through the analysis of his own resistance to the transfer represents a first therapeutic step in itself. The increased implication of the subject can emerge either from the outset or else progressively. Among its consequences is an increased ability on the part of the subject to describe his experience; the evocation becomes more accurate, more effortless, bringing with it a great wealth of information relative to the subject's personality, his dynamic of exchange and his problems. The recollection facilitated by the double movement of explicit and implicit regression allows the subject to discover, through a mechanism of unconscious associations, the most important biographical elements regarding his problems. At this level, there is no modification of the process of elaboration and interpretation. In the second level, the subject communicates through an imaginary mode which is much more regressive. The signified as well as the affect are expressed more directly, often through physical expression. The subject's statements may take a distinctive turn, characterized by imaginary evocations which resemble dreams in their content and their structure. On the surface, there is no link between these statements on the one hand and the personality and problems of the subject on the other. These imaginary statements are expressed in more or less primal fashion, varying across a spectrum from the most concrete to the most abstract, extending to the point where the mode of expression becomes physical and emotional. We would like now to deal in particular with this second level of communication. It appears doubly worthy of attention since it is specific to hypnosis and modified states of consciousness, and since it has never been explored in relation to post-analytical clinical hypnosis. THE METAPHOR AND THE ANALYSIS We will need to make a detour by way of reality and duplicate reality, taking inspiration from the essay "Le reel et son double" by Clement Rosset. Our capacities of observation and our faculties of discernment, being selective, imperfect and complacent, present us with an impression of reality which is often illusory. This becomes increasingly true the more we allow ourselves to deny the perception of a reality as soon as it becomes unpleasant. We know how to protect ourselves from a reality which is too insistent (and which will re-emerge in another form): temporary distancing in the case of repression as described by Freud and concealment in the case of repudiation described by Lacan. Simply put, no one is blinder than he who does not want to see, who accepts the perceived object but rejects the consequences which should follow. In such a case, there is a "useless perception," with as its consequence a denial which appears to be one of the remarkable characteristics of the illusion. The subject suffering from an illusion is attentive to his fantasies and desires. Such a subject is much more ill than the neurotic; he is incurable. This blind person is incurable not of blindness, but of seeing. Any effort to point out the problem or to reprimand him would be in vain. The neurotic subject could return to reality thanks to a re-emergence of repressed experiences if he is victim of repression or repudiation. But what is the fate of the illusioned subject (who, let us note, for it is important, may also be the victim of a neurosis)? He is led to develop the art of accurate perception but to misjudge the consequences resulting from this perception. In other words, he is incapable of understanding the essential link between "I think" and "I am" in "cogito ergo sum." The illusion finally creates a "duplicate" reality in the sense that there is a similarity of structure between the illusion and the duplicate. While the theme of duplicate reality is often associated with cases of psychotic split personalities, it does not concern only the limits of normality but also an infinitely more vast cultural space; the oracular illusion linked to Greek tragedy, the metaphysical illusion inherent in philosophies which take their inspiration from idealism, etc. It may be useful here to take the example of one of Aesop's fables evoking the problem of duplicate reality, just as we could have taken the example of Oedipus as recounted by Sophocles or any one of numerous Sufi tales, in order to define the meaning of the oracular structure. THE SON AND THE LION [3] "A timid old man had a courageous only son who had a passion for hunting. In a dream, he saw his son killed by a lion. Fearing that the dream was a prophecy which would be fulfilled, he built a magnificent apartment high above the ground to protect his son and kept him there. To amuse his son, the old man had had paintings made of all sorts of animals, including a lion. But the sight of these paintings only increased the young man's boredom. One day, approaching the painting of the lion, he shouted "You cursed animal, it is because of you and the lying dream of my father that I have been shut up in this woman's prison. How can I revenge myself on you?" With these words, he struck the wall with his hand so as to gouge out the lion's eye. But a nail pierced his flesh beneath his fingernail, causing him a sharp pain which developed into an inflammation and then into a tumor. He died of the resulting fever not long afterwards. The lion, although it was only a painted lion, nonetheless killed the young man in spite of his father's useless efforts." Two meanings can be drawn from the analysis of this fable. The most obvious is certainly that no one can escape his destiny, which can otherwise be defined as reality or as the totality of the events of existence. Confronted by a ruse, destiny responds by using the same deception as the very means by which it achieves its end. But the other meaning, the one which interests us, is that the very act of attempting to avoid destiny leads to its fulfilment. If destiny is reality, then it is the attempt to escape it which is deceit, as in the fable where the destiny is death. The oracular structure reveals the reality situated on the side of the illusion, of the duplicate. In another manner, the structure of reality according to Lacan refers to the inability of reality to be aware of it; the "signifier" is by its nature nothing more than a symbol of an absence.[4] In each case, the meaning is exactly what is provided not by itself but by the other. For Hegel, it is the sensitive other which explains sensitivity, for Lacan it is another penis, or phallus, which gives meaning to the penis. In Lacan's "Seminar on The Purloined Letter", reality is only significant because it is missing from its place, just as in the oracular event where the event is only anticipated to the degree that it represents something else. From this illusion originates the duplicate reality. The duplicate of the subject is another reality of the subject, often better than the reality itself. It can appear as a sort of immortal entity in relation to the mortality of the subject. What is important is that the reality is not on the side of the subject but on the side of the double, of the "ghost." It is for this reason that the mirror is deceptive and provides false information, because it only shows the opposite of reality. Uniqueness thus does not exist, whether it is a question of the self, of the here or of the now which is not only now. The illusion should therefore always provide a magical duplication of the subject, whether directly or indirectly. However, the "illusion of the senses" obviously has no link with the refusal of reality and its duplication. Is it necessary to follow Freud regarding the "future of an illusion" which links the illusion to desire rather than to error? THE ILLUSION, THE DUPLICATE AND THE METAPHOR Regarding personality changes during artificial sleepwalking, Pierre Janet writes "Sleepwalking is a second existence which has no other characteristic except that it is the second." Janet thus shows that there is nothing supernatural or inexplicable in artificial sleepwalking. Instead, there are two modes of existence in life resulting from a process of dissociation which is believed to regroup certain characteristics of the psychological functioning of the subject at a particular moment, called a "state of hypnosis." [5] In another way, it is possible to link this "second existence" to the problem of the duplicate. Would the subject under hypnosis not be living somewhere between illusion and reality, with reality perhaps being closer to hypnosis in its psychological manifestations? Is the metaphor in hypnosis not the representation of the double? The double and the metaphor present a structural analogy originating in the illusion, which, as we have already seen, can originate from several sources. The first is the interpretation of reality by our senses and our beliefs which means that each of us suffers from illusions, with reality always being elsewhere. The second is our inability to accept reality on a neurotic or psychotic level. In the second case, the double or the metaphor can take on the characteristics of delirium, to such a point that it is sometimes difficult to tell the difference between a product of hallucination or delirium. The metaphor of the patient is the story of the patient in another semantic field, in an "elsewhere" constituted by illusion on the one hand and repression and repudiation on the other. It is a space of creation, of re-creation, but also of projections. The metaphor of the patient, that which is expressed spontaneously in a hypnotic state, is interesting in the degree to which it represents the signified reality of the patient, or his supra-reality. In the following clinical examples, I wish to show on the one hand how therapy carried out during the state of hypnosis allows the patient to have access with extraordinary speed to primal material through a mode of communication which is also primal. On the other hand, I wish to show how the patient's metaphor, for example of a "previous life", represents a level of reality into which the therapist can integrate himself and carry out his work, and in which he is eventually placed in transferential representation. CASE STUDY Account of the first meeting and of the first hypnosis session which followed. Background Session Veronique is a 28-year-old native of a large city in northern France. She came to Paris around the age of l9 to continue her studies. Her parents are both alive and have been separated for the past two and a half years. Her older brother, three years her senior, is married and has an infant child. In Paris, she shared a studio apartment with a male student whom she had met in high school. Their relationship ended shortly after she met her current husband. She has never lived alone and says that she feels completely incapable of doing so. After graduating from a business school, she entered the field of communications and marketing in the food sector. She is not content with her present employment and would prefer to work in human resources, training or recruitment. She has been married for three years to her husband, who she met five years ago when he was teaching in the business school where she was studying. Her husband, 42, worked at the time as the director of a clinic and is currently employed in management training. The couple's principal conflict centers around her desire to have a child, while he says he does not want one. She says that they had tried in the past but without success. Medical exams showed no physical problem preventing contraception, but she complains that their sexual relations are too infrequent, at the rate of one a month. She currently lives with another man, 35, who works in advisor training. He is in the process of a divorce and has a five year old son. Her husband is convinced that she will return, and she feels guilty for leaving him. She wishes to begin therapy because she feels disoriented between these two men. First hypnosis session, one week later. The session takes place on the couch, with the following introduction: "Become conscious of the space which surrounds you... Little by little the sounds around you move farther away... farther away... You feel comfortable... Your attention is concentrated more and more on the interior space of your body... You feel pleasant sensations... more and more comfortable... The outside draws away... You simply let the sensations wash over you... the images... the impressions." A pause of several minutes follows. Suddenly her entire body convulses, her face contracts, her skin turns a deep, dark red, her face becomes even more tense and turns almost blue. She begins to weep with the cries of a small girl, sobbing uncontrollably. I intervene for the first time to reassure her and help her to express what she seems to be experiencing. She can barely speak. "I'm pushing... I'm pushing... I can't breathe... I'm shut in... (Sobs) It's my mother... she doesn't want me." A long time passes, several minutes during which she suffers intensely, then she continues: "My father is next to me, I feel it, I can barely speak." I say "Your father loves you!" "Yes," she answers. She relaxes slightly and her symptoms of pain disappear. End of the hypnosis. Gradually, she returns to reality. Later, she explains that while she was under hypnosis it suddenly became dark around her. She said that she felt as if she was dying and experienced intense anguish. She had the sensation that she was pushing to stay alive and that her mother was all around her. She then associates her experience with the memory of two of her siblings who died shortly before she was born. The first died at the age of a year and a half while the second was still-born. She thinks that he was unable to breathe because he was deformed. Then she talks about her mother: "I could never stand having her touch me, even today. I have no memories with her." As she is leaving at the end of the session, she says with surprise "I can't understand it. All that has nothing to do with what I told you the last time." Comments The first question which comes to mind is whether the information which emerged during the session is a mere memory or can be described as a metaphor. There is no metaphor in the strict sense of the word, because no semantic change occurs: the patient recounts her experience. However, if we ask ourselves which experience is being recounted, we see that it is impossible to answer directly. There exists a metaphor because there is a representation of an indistinct set of memories, or even of an imaginary construction justifying the emotional manifestations, and which does not necessarily have any significance at the level of reality, but which finds its meaning at the level of the duplicate reality. The metaphor is expressed both linguistically and physically, and the immediate transfer which follows falls into this metaphorical space. This case perfectly illustrates how the state of hypnosis allows the patient to relive with emotion the subconscious system from which emerges a group of traumatic memories. This sentiment, this experience of having to fight for her life against smothering, could well be linked to the anguish felt by the mother following this third pregnancy and communicated to the patient from her earliest days. Perhaps, but not exclusively; rejection and a lack of affection are also present. It is in any case a process of transformation of a group of experiences into metaphors. It is usually remarked that such cases of emergence of past experiences concern not a single memory but a group of memories clustered together around a unified group of themes, reduced to a single general theme and attached to a memory which serves as a common point of reference. In contrast, the emotions associated with these memories do not seem to group together but rather to combine into a single emotional charge. This may explain the manifestation of a very strong emotion which is sometime§ observed without the presence of corresponding memories. The patient appears to use the immediate transfer as a motor to "propel" herself across this ocean of trauma. This transfer allows her to experience the situation with the presence of a father, who is present in the metaphor. The father feels the need to respond to the appeal, and by doing so intervenes directly (in this case without having been previously present). The level of representation is very primal, and a part of the anguish can only be represented through a physical experience. This is confirmed by the fact that the patient indicates during the session that she is incapable of speaking, because there is no way to put the experience into words. This strange characteristic of metaphorical communication is repeated in a counter-transfer experienced on the same level; the therapist feels the suffering in a way which can not be expressed. It is because this suffering is perceived on a very primal level that it triggers the answer to the un-asked question, first on the unconscious level and then on conscious level. This process may then permit the introjections, the incorporation of a "good" object. On the level of reality, one of the implicit questions during the first meeting with Veronica was that of sterility. As in the majority of psycho-somatic problems, the question is asked in physical terms and no link is made between the symptom and the role of affection. The non-recognition of this link can go so far as to cause iatrogenic secondary effects, due to the request for physical treatment from the patient on the one hand and the frequent non-recognition on the part of the medical profession of the link between the psychological condition and the physical state, on the other hand. In Veronica's case, if the father-therapist helps her to "emerge from the mother," she can finally be born, freeing herself at last from the fear of death. As regards her sentimental life, she will finally be able to seek a father for her children who will not play the role of her own father, but who will instead be her companion. Furthermore, her current psychologically-generated sterility could quite well be cured by itself without any other form of realization or interpretation. Hypnosis appears in this type of case and used in a therapeutic framework as a privileged space for the emergence of psycho-somatic links. NOTES 1- Jacques Palaci, "La suggestion; hypnose, influence, transe." Editions "Les empêcheurs de penser en ronde," Laboratoire Delagrange , 1991. 2 - Clément Rosset, "Le réel et son double," Gallimard, 1976, 1984. 3 - Aesop, "Fable 295," translated by E. Chambry, Editions Les Belles Lettres. Site, 4 - Jacques Lacan, "Ecrits," Editions Seuil, p. 25. 5 - Pierre Janet, "L'automatisme psychologique," p. 134. 6 - Stanislas Grof, "Royaumes de l'inconscient humain," Monaco, Editions du Rocher, 1983. 7 - Pierre Marty, "La psychologie de l'adulte," Editions P.U.F., "Que sais-je" collection, 1990.