Hypnosis and Ego State Therapy: Carolusson & Sandemose
Hypnosis, Ego State Therapy, therapeutic relation, transference and countertransference; case and reflections
Hypnosis, Ego State Therapy, therapeutic relation, transference and countertransference; case and reflections
Authors: Susanna Carolusson and Hedda Sandemose
In the training and supervision of hypnosis, imagery, gestalt, ego state and other creative therapies, methodological competence are always a part of the curriculum. When I (SC) studied Gestalt therapy in the 1970's, a popular opinion was that you can focus on the expressed, projected imagined problems, together with the client, without having to deal with aspects of transference. However, in Ego state training we teach not only theory and method but also the value of dealing with transference and countertransference. Thus we appreciate Watkins’ inclusion of transference and countertransference into Ego State Therapy (Watkins, 1997 ). Even more explicit was this relational issue elaborated by Claire Frederick (Frederick, 2005) and myself (Carolusson, 1998). My experience with creative variations of Ego state therapy and body focus, with Kathatymes Bilderleben (Guided Imagery) and hypnosis, has convinced me that some clients unconsciously need to, also unconsciously, repair their past relational traumatic or obstructive relations. As a therapist and supervisor of hypnosis and ego state training, I repeatedly realize that the therapeutic management of clients’ fear of abandonment and rejection, represent crucial opportunities for the client’s future trust in the therapist and the therapy (Carolusson, 1998). Kairos is a relevant concept regarding how to be attentive to the client’s need of attunement. The relational presence has been regarded as important from the starting era, in the psychodynamic roots of egostate therapy since Helen Watkins’ founding work. (Peter, B et al, 1996).
If I put my diagnostic glasses on, my conclusion is that the more violated the attachment and trust has been in early life, the more the relational trust/distrust will be part or cause of the presented problem in therapy. So, beyond the symptoms from which clients suffer on a conscious level, they also bring their relational past to the therapeutic relation. They project their unconscious fears and expectations on the therapist-client relation, sometimes metaphorically in the creative work, sometimes as resistance to suggested imagery, ego-state work and hypnosis, in verbal language or as subtle nonverbal phenomena.
In this paper my Danish colleague Hedda Sandemose presents a case that illustrates how the client’s need is perceived and met by the therapist and how the speed and intensity of the therapy is governed with care and respect for the client’s needs, sometimes deviating from the therapist’s expectation and plan. During this therapy Hedda was in her final EST training, and I was her supervisor.
The case is a short seven sessions intensive therapy with a woman, who had been traumatized and sexually abused as a child. Hedda describes each session, followed by her own reflections. At the time of therapy, and directly after sessions, Hedda had made a drawing to make explicit to herself how she had experienced Ewe in the session. The drawings are inserted in the case illustration.
Finally, I (SC) give my theoretical reflections with relevance to relational aspects. Finally, in conclusion , I discuss in brief some perspectives on the effectiveness of relational safety in Ego State Therapy.
My client, we can call her Ewe, is a Danish woman about 50 years old. She tells that she’s married and has three grown up kids. She is very fond of her husband. Their sexual life is historical and she regards him as a friend. That’s ok for Ewe since she has never been keen on physical intimacy. Ewe is a woman with middle-range education and has a full-time employment. In her spare time, she likes being with her family, travelling and to be in her little workshop, creating pottery.
Ewe grew up in a provincial town in a home marked by alcohol abuse and unemployment. The father was violent and hit Ewe if she was angry, noisy or in other way disturbing him. She has no siblings. As an adult Ewe has always been sad, tearful and very depressed and has therefore often consulted doctors and psychotherapists. She feels worthless and has often made plans to commit suicide, but thinking about her children kept her from doing so. Ewe feels as if there is a little girl inside of her, feeling very guilty. She wants to get in contact with that part of her, but hasn’t succeeded.
Ewe has a kind of childhood image, in which she is hiding a coin somewhere and this image is associated to feelings of guilt and discomfort. She hasn’t got the strength to explore it, but a part of her needs to get the work done. She cannot stand being that depressed anymore and thinks, that hypnosis might help her.
Ewe has had many physical complaints, especially in the abdomen. She is very tense and almost always has a headache.
Ewe was referred to me by a psychologist, who knew I work with hypnosis and EST.
Ewe has a remarkable reliance on me – from the first meeting. She has never tested hypnosis before, but relies on my ability to help her. Her initial trust in me is probably boosted by her psychologist’s appreciative attitude to me and my methods. So, Ewe trusts that the therapy will have a positive effect on her depression. In this first session, I get a feeling that she has experienced trauma.
Hedda is humble enough to realise that the client is trusting her even before their first encounter, thanks to the previous psychologist who had expressed a high appreciation of Hedda. Hedda thus had the advantage of receiving a highly motivated client, with a positive expectation to receive competent help. This also gives us a clue that the referring psychologist had been good enough not to cause disappointment, but to add to the trust in therapists, and that the referring psychologist just didn’t have the needed training, in this case, Ego State therapy. This may be true, or it may be a construct. At least it was constructive.
Ewe is relieved that she now has the courage to explore the origins of her depression. It is time for “all in”, she says. She is very hypnotizable and I guide her to find a safe and comfortable place. She chooses her little pottery workshop where she finds peace and quiet. She experiences her ability to get absorbed in imagery and get contact to resourceful ego states: Creative and strong parts of her, including pride, joy and safety.
Again I experience, that Ewe is sure, that I as a therapist have a certain skills that will help her. She is happy and lively when she leaves and I get a little worried that it might be a kind of agitated depression, a manic defense.
Hedda is open to the possibility of a manic escape, as a defense. She is resisting the temptation of a narcissistic countertransference, i.e. believing that one is the savior with the exceptional competence that other therapists are missing. The theory of EST is also a help to see beyond the apparent euphoria that Ewe expresses having found a therapy at last, that works! EST theory helps us to keep in mind that surface states sometimes have the function to protect violated states. So, Hedda is open to any truth here; the joy can be genuine from surface to basic true self, or it could be an idealizing defense against a distrusting and fearful part. At this early state of the therapy we could not know.
Ewe has several times during the last week been in contact with resourceful parts. She is amazed that these parts seem so real and that she is able to imagine them so clearly. I tell her that they are parts of herself and that it is normal to have such ego states. They can be more or less active, known or influential, like her depressive part or the part who feels guilty. After that I make a light trance induction and ask Ewe to get in contact with a part, who needs to be heard or seen today. Ewe immediately sees herself as a 7 years old girl. The girl plays in the street with some other children and they get the idea, to ask some adults if they can work for them and earn some money and then buy ice cream. Little Ewe knocks on a door in the neighborhood. She already knows the man who lives there. He offers her 5 crowns if she comes in. He pushes her into a room and rapes her. I ask who is there to help the little Ewe and spontaneously the adult Ewe experiences how she can rescue little Ewe and get her out in the street again. I ask if there is anything that she wants to say or do to the man and she returns, with all her strength, into the man’s house again. She ties him with a rope and puts him in the boot of the car and takes him to the wood. It surprises Ewe that he is so light. Weightless. In the wood, she puts him on an anthill where he is eaten to the bone by the big wood ants. Filled with pleasure she sees how he shrinks. Thereafter she wants to go home to her parents and tell them what happened to little Ewe. They ignore her and that makes her very sad and at the same time very angry on behalf of the little Ewe. I ask her if there is a way to make the parents understand what has happened but she finds no solution. She chooses to comfort the little girl herself and takes her to the workshop where she can play and have fun.
For Ewe it is much more painful that her parents did not listen to her than the rape itself. The pain of being rejected is the worst. She is able to react on the rapist in an appropriate way but in the relation to the rejection she is paralysed.
*** I think the term rejection is a simplification! Her parents are ignoring her complainte and not relating to her quandry. They have failed her here, and that certainly may be a greater pain than being raped!
Hedda wrote: “and ask Ewe to get in contact with a part, who needs to be heard or seen today”. This is a good example of mutual trust. Hedda chooses not to tell Ewe in detail, what to look for, because from session 2, she has proof that Ewe has deep genuine resources of her own, which is not always the case with traumatized patients. Hedda trusts that the resourceful states will easily come to surface, when needed.
When Hedda asks Ewe to get in contact with a part, who needs to be heard or seen today, that is also a suggestion and an implication: If Ewe needs more of safety and stability to work with trauma, she will. And if Ewe is ready for trauma work, she will take that choice.
A rape was presented, and worked with. Hedda notices a very important insight: that the parents’ rejection was more painful than the rape itself. This is an indication to Hedda that she must be very reliable and that this client is sensitive to anything that could be interpreted as rejection.
Ewe has had many thoughts of her childhood. She has been crying and she has been very tired. And she feels more vulnerable than ever before. At the same time she feels a strange restlessness in her arms. For the first time it is possible for Ewe to talk about the sexual abuse. She also recalls that she as early as five years old was raped from behind by a member of the family. After both episodes Ewe suffered from enuresis and encopresis. She felt guilty and shameful for what had happened. Mostly because she had been rewarded with a coin. She buried it under a bush. At that time Ewe did not tell anybody about her painful experiences. But now she wonders why her parents didn’t realize that something wrong. Why didn’t they react to her messing her pants?
During the hypnosis in the fourth session I ask Ewe to examine if there are any experiences, sensations or tensions in her body. She feels again the restlessness in her arms and I ask her to let the sensation be as a bridge to the original situation. Ewe experiences that she in her adult ego state, is back in the childhood home. She tells the parents that little Ewe longs for their support and attention after the abuses and how they have forsaken her by not sensing that something was wrong. I ask Ewe to find the courage to do what she needs and I promise to go with her all the way. She shouts and screams at her parents and knocks them down. She feels a kind of release in her arms as she manages to give way to her anger.
Afterwards she is exhausted, relieved, but still sad that the parents are so unsympathetic and indifferent.
In this session Ewe was more active and seemed more self-confident. This new confidence made me believe, that she was able to handle, as well as benefit from the abreaction.
In the 4th session Ewe feels more vulnerable than ever before. Hedda still trusts Ewes capacity to deal with vulnerable parts, probably because Hedda is confident there are resourceful parts available. So, she does not offer a boosting session of safe place experiences. She trusts that Ewes body language: “a strange restlessness in her arms” is sign of a readiness to explore further. Another rape comes to surface, at an earlier age, and the rapist is a relative. I can’t but associate here to the “false memory” advocates. In this case, as often in similar therapies with repressed sexual trauma, clients tell us about corroborating evidence, like enuresis and encopresis. Those symptoms are kept in conscious memory because they are odd, collectively avoided, bewildering, but dissociated from the unfathomable cause. Ewe now asks what she never dared to ask when it happened: Why didn’t the parents react?
Guilt and shame are a result of absent parental support, a rejection the child associates to the abuse. Children are self-centered and believe in causing others’ reactions. The fact that she had accepted the coin caused guilt and she had buried it. Until this therapy, she had dissociated the sexual abuse, but kept in conscious memory the odd image of hiding a coin, feeling guilty.
Hedda chooses a body focus on the restlessness, and that feeling bridges back to the childhood home. Ewe demonstrates here, a common perseverance in children; in this imagery she gave the parents a second chance, and there were probably several more, in real time. A safe ego state technique is spontaneously used by Ewe: she lets the adult part explain to her parents, the child’s longing for support. This way the child is not left alone to be exposed to parental neglect, if so. Hedda offers herself as another adult support (“I promise to go with her all the way”) and encourages Ewe to let herself do what she needs to. Ewe abreacts anger, and typically, after the release of anger, if the parental support is absent, reflecting how it was at the time of the original traumata, sadness, sorrow and grief comes up. The silent abreaction, as Watkins labeled this technique, is never re-traumatizing, given that the therapist is actively supporting the release of anger, and actively boosting the client’s self-esteem after abreaction, thus strengthning self-value and a harmonising relaxation. How to guide the client in silent abreaction and after, in a rewarding ego-strengthening atmosphere, is described by Sara Krakauer, who created some variations of Helen Watkins’ original technique (Krakauer, 2009).
Ewe finds herself more joyful and energetic, but has diffuse pains in her private parts and around the anus. The pains remind her of both the abuse to the five years old Ewe and of giving birth to her son. It was a painful delivery and most of the time, due to staff shortage, she was left to her own. After that she had felt even more sad and helpless.
Ewe tells me that she wants to work with the parts of her who have suffered from the abuses. For this session, I had actually planned to use hypnosis and affect bridge to explore and treat Ewes pains, but she refuses. She needs to talk. She is more distinct in her body language and eye contact than before. We talk about her pain and then we agree on booking a prolonged session next time, so she will get all the time she needs for intensive EST work.
At first I was a little annoyed to cancel my treatment plans, but realized that it was my need and surely not hers. She wanted to find words for all the stuff she had been hiding until now.
The idea to have all the time the client needs in one session is inspired from Barabasz, Helen Watkins and others who work with EST. They find it important that there is time enough to let all ego states relating to a problem appear and get a chance to talk and express themselves.
This session is a good illustration of a common observation I have made: When we work with such intense techniques as EST, with such dissociative defenses as complex early trauma cause, after some intensive sessions, clients need a cognitive overview to help them see and understand the structure and the process from a distance. In this phase, it helps to use a whiteboard or a paper to map the ego states, their needs, their functions and their relation to each other. Hedda, however, had a plan to continue the experiential EST work and focus on the pain. Skillfully, she skips her plan when the client rather wants to talk about, not explore and repair, trauma. Hedda uses introspection, and a kind of “inner supervisor” and realized that her plan was about her own needs as a therapist, not the client’s need.
Then they agree to intensify the therapy next session. Ewe offers Hedda three clues here, that assist Hedda in this plan. The delivery pain reminding of traumatic abuse pain, the staff shortage reminding of parental neglect and sadness-helplessness as a result. Thus, a strong relational need will be expected in the near future therapy. The rationale in EST is to accept all feelings; anger, sadness, helplessness, needs, to understand them and embrace them. Hopelessness is thus changed to hope. Hedda demonstrates hope, she offers more intensity for the next session, secured by the open ending of the session’s time frame.
Ewe has felt a little anxious and she is looking forward to continuing the process. After a light trance induction Ewe finds her safe place, the workshop. From that place I invite her, together with me, to walk down a staircase and into a room furnished with table and chairs. I ask Ewe to invite all ESs who are related to the abuse. The following six appears and I ask, with Ewes approval, how old they are, how they feel and what their functions are in Ewes life.
- “The creative” – an Ewe who always finds out something to do. Considerate and strong (child)
- “The wounded” – crying and stooping, holding hands on her stomach which hurts (child)
- “The hard-working” – wants to learn (child)
- “The helpful” – takes care of others (child)
- “The obedient” – does what she thinks people expect from her. Avoids anger (child)
- “The pensive” – withdrawn, alone and serious. Tries to understand (almost grown up)
All six are refusing to commit themselves to each other. “The wounded” is the most isolated of them all. The adult Ewe takes care of her. I ask how she can do it in the best possible way and together they go to the house of the rapist. He opens the door and they hit him with a big heavy stone. They bind him with a rope and take him to the woods, where they (once again) put him on an ant hill. This time he is very heavy and they are very exhausted. They find two more shovels of ants from other ant hills so that they can be sure that he will be eaten. They return to the table and the other ESs with whom they have a long conversation. “The wounded” is now much more upright and looks into the others’ eyes with more self-confidence. “The creative” is now more rebellious and asks “the obedient” why she always does what others want her to do. The obedient feels a bit stupid and realizes, that she doesn’t have to obey others in the same way anymore. They all agree that they don’t have to be that conscientious anymore. They don’t have to work so hard anymore. They want an adult to take the responsibility for them. I tell each of them that they now are safe and that they will be taken care of. Adult Ewe promises to be there for them. They all go out in the woods together and find the man. He is now a white skeleton with big holes where the eyes once were. With great effort, they dig a deep grave in which they put the skeleton. They cover him with soil and stamp it with their bare feet. When the work is done, they clap their hands joyfully and fool around and sing and dance while they walk back through the wood to the room with the table. They find out that there is nothing more for them to do there and walk up the stairs to the workshop, released and happy. Ewe shuts the door to the meeting room and feels that she can breathe in a new way. That the oxygen gets into every corner of her body and that something is loosening up between her shoulder-blades. She gets a vision of floating over the streets of her childhood where the rapes once took place. The area shrinks, loses its significance and disappears.
Ewe returns from the trance in a very relieved state with deep feelings of devotion and gratitude.
The ESs seemed very prepared to appear, as if they had been waiting for an invitation for a long time. For me it was interesting, that Ewe was so considerate about “the wounded” child, which we can understand as “the most wounded and vulnerable self”. And that she chose to take this wounded child to the rapist, where the child could express and abreact her feelings, protected and supported by a helpful grown up.
This is an illustration of an EST intervention that is debated, and warned against in some therapy schools. Although John Watkins, my mentor in EST theory (Helen was my mentor in practice), was a psychoanalyst, he did not espouse the theory that all objects are self-objects, or that bad objects are projected denied parts of self. If they are, they must never be hurt, killed or extinguished. In EST work, we are prepared for aggressive abreactions in the service of integrity. The rationale for abreactive aggressive extinction of an introjected perpetrator, is that trauma caused by someone who was trusted (family member, neighbor) and who inflicted shame and guilt, needs a technique that validates signs of aggression. Aggression is utilized to create a distance to the perpetrator, and to create boundaries towards that object. The theory behind this, that I espouse as well grounded in clinical experience, is that the perpetrator was introjected as a defense against an even worse condition of constant paranoia, i.e. an older person, whom the client trusted, can rape, damage and punish, with no apparent cause, no reason in the client’s appearance and behavior, no fault of the child, and therefore no chance to prevent it from happening again …
In EST, to engage an adult ego state will be the best preventive protection. ES therapists are also aware that the wounded child part needs help to realize that an adult part actually exists, which the child part as a consequence of dissociation, often do not know! In therapies that do not acknowledge dissociation and states/parts theory, therapists communicate as if talking to an integrated adult who has access to all aspects of trauma. This is probably the reason why some are not helped in traditional talking, cognitive, behavior or analytical approaches, but get what they need in hypnosis-based parts therapies, like EST.
Ewe tells me that in the previous session, it helped her that I explained why she could be like two or more persons, of whom one suddenly could become sad. She had not had the urge of crying after the last session. It was a relief that her inner parts had met and talked and were so helpful and kind to each other.
Ewe had had the experience that she suddenly got oxygen to all her cells. The symptoms, the pains in her private parts had disappeared.
Since apparently only one of the raping episodes was handled in the therapy and only one of the rapists had been punished I ask whether there is a need for therapeutic intervention in relation to the rape she remembered from when she was five years old. Ewe responds she doesn’t need that. There is no reason for wasting one’s breath for that, she says. It is done and she wants to go other ways in life now.
I ask Ewe what made it possible to come to terms with the rape and three things are important:
- The hypnosis was good because it made her feel that she could help herself and because after the hypnotic work, the need to talk about the sexual abuses was gone. It was as if she could close a door behind her.
- It had been a safe and considerate experience to know that she had all the time needed in one of the sessions.
- She had had a great reliance, completely sure that she could trust me.
For me it was surprising that Ewe was able to go through this process in only six sessions. One reason could be, that there was not much resistance during the therapy. And I think that the explanation is, that Ewe was very well prepared. The previous therapy had led her to a point of really wanting to get rid of depression and lack of self-confidence. Another reason could be that the previous therapist had given me and my way of working a seal of approval. Anyway, Ewe trusted me from the first day.
And the other way around I felt myself capable of handling the therapeutic process. As my supervisor, Susanna Carolusson, often pinpoints, the therapist has at least three needs when we are talking about countertransference: a narcissistic need, a need of repairing and a need of doing – doing one’s best. And most of the time in this therapy with Ewe, I felt that these needs were met. I had a little problem in the fifth session, because Ewe wanted to talk things over, while I wanted to make a hypnotic session. I don’t think she ever found out, but I had this little feeling of not being allowed to help her in the most appropriate way, frustrated in my needs of repairing. It was no big deal. It was a matter of something technical and I was aware of it. It is a problem, when unconscious countertransference processes are not made conscious. This is why it is important to be supervised and to examine one’s own reactions and feelings as a therapist. This can be done in a nonverbal creative way, by using hypnosis in supervision or by drawing or painting elements of a therapy. Like I have done here.
When I had finished the drawings and looked at them I had a feeling that I had not taken properly care of the six child ego states that appeared in the 6th session. I kind of missed finishing a therapeutic job. And I still wonder if Ewe is coming back some day…. But that is my need.
Susannas conclusive remarks; what made the difference?
A relevant, scientific type of question may be “what worked and why?” In a single case study like this, it is more relevant to discuss phenomenological evidence, than cause-effect probability (is EST more effective than no treatment?). In this case, a reliable conclusion is that EST had a positive effect, since the first talking therapy did not give the client enough relief from her symptoms. The discrimination between quantitative studies for evidence, and a phenomenological attempt to evaluate EST, is discussed in depth by Claire Frederick and Hageman, who wrote: “Phenomenology is particularly applicable to ego state research because humans can relate intentionally to objects of the world in which consciousness also manifests relationships to things in ways other than in cause – effect relationships.” (Hageman & Frederick, 2013).
In my attempt to understand what made the difference for the better (phenomenology), I will first put my psychodynamic therapy (PDT) glasses on and conclude that Ewe’s explicitly expressed gratitude is a sign of maturation and reduction of shame. According to the Object relations theory of Melanie Klein, the splitting of evil and good and the attempt to project shame onto others, causes an envy, a fear that the faults are inside oneself, and therefore one’s destiny is to be rejected again and again. When good and bad has become integrated, envy is less poignant and gratitude is possible (in Joseph et al., 2001).
If I put my behavioural therapy (BT) glasses on I will simply say: The symptoms of tension, and the guilt-ridden obsessive idea of hiding a coin disappeared. A simple measure indeed: Symptom relief. From bottom up, not only on the behavioral surface!
If I put my cognitive therapy (CT) glasses on, Ewe was re-educated to think about herself in an accepting way, thus reframing anxiety and symptoms to resources and clues to find her needs and obstacles to resolve.
And so we can go on …
However, who can assess the effectiveness and outcome better than the client herself?
Hedda asked for Ewes opinion and evaluation. Ewes answer was:
- It was good for her to get an explanation, and to understand dissociation. (An academic lense could conceptualise this as educational).
- It helped to have ESs accept each other. (Many schools today focus on acceptance, commitment, and integration, so your glasses will probably help you conceptualise those factors).
- Hypnosis as a state of mind made it possible to help herself. (The hypnotic state is a mind opener, making change possible. You can use glasses that focus on psycho-neurology: unwiring of trauma-induced associations. In this case, trauma-induced pain was released from the wiring) (Scaer, R.C., 2001).
- Ewe felt no need to talk about the sexual abuses anymore. (Symptom relief. When pathological dissociation has no function anymore, the patient is integrated and can enjoy the present and the future).
- It was safe to know that she had all the time needed in the 6th session (The therapist gave assistance and support. My glasses say, “corrective emotional experience”).
- Finally, Ewe said the crucial three words: trust in the therapist. (Yes !!! I can’t express it better than that. Why complicate elegant formulations with glasses?)
What I believe is more crucial and basic than any other agent is a safe repairing relation framed in a method that helps both therapist and client to structure their sessions professionally.
Last but not the least: Hedda was prepared to question her plans and prioritize the client’s actual needs in each session. Hedda also has a self-critical attitude, allowing herself to be well prepared, but open to let go of her planned interventions. In the end of the therapy, she even doubted that seven sessions were enough, and asked if the five-year-old child needed more help to handle that abuse.
Hedda trusted Ewes feeling, although she asked herself if she as the therapist had taken properly care of the six child states. Winnicott would translate that to: “Have I been a good enough parent?” The role of a therapist and the role of a parent has similarities, elaborated by Winnicott in several texts on transference and object relations (Winnicott, 1953, 1967).
I want to end this article with a quote from Donald Winnicott, who, in my opinion, had an Ego State perspective, long before that concept was coined by the Watkins. "In the cases on which my work is based there has been what I call a true self hidden, protected by a false self. This false self is no doubt an aspect of the true self. It hides and protects it, and it reacts to the adaptation failures and develops a pattern corresponding to the pattern of environmental failure. In this way the true self is not involved in the reacting, and so preserves a continuity of being." (Winnicott, 1955-6)
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Last edited: 12/07/2017