Case 2

By Abby Ives, 2006

Ellen is a 43 year old divorced mother of 2 and grandmother, who came to me because "I'm annoying colleagues and friends and I would like to live out my life in relative peace." She is first and foremost a survivor of sexual abuse as a child. She became pregnant at a young age and went on to raise 2 children while getting her GED, graduating from college and continuing on to get her Master's in Education. She now works for a large trade organization and some story elements refer to her specific employment, although they are not so identified. Ellen has major issues of self esteem and one interesting problem that manifests itself in a self destructive way; she speaks without thinking so that these amazing bon mots fly out of her mouth that are often caustic, critical or intended to be funny, but which turn out to be hurtful or inappropriate. This habit has alienated her from others and created difficulties for her at work. Ellen sees these sudden outbursts as being out of her conscious control, and thus they cannot be anticipated or restrained, and while she knows they can be hurtful, they are somewhat ego-syntonic as they represent the "spontaneous" part of her personality. Some of her snappish remarks are indeed a response to a perceived threat, and we refer to her "Crusader Rabbit" or "Mighty Mouse" persona, who is quick to ride into battle and right the wrongs she sees. But at other times, Ellen simply responds in frustration, annoyance, thoughtlessness or pique. Ellen can be scattered, overwhelmed, disorganized and has no head for details. Her inner world is often chaotic. She is anxious, dysthymic, asocial, hyper-vigilant, has difficulty concentrating, feels stressed out and has mood swings, but she is also intelligent, articulate, funny, sharp, curious, independent, able to entertain herself, and excellent company. She minimizes her positive attributes, sees herself as without skills, and has no sense of all she has achieved or how to integrate those accomplishments into her life, but she is a rather remarkable, extremely determined woman who is creating a successful life for herself.

We have had a difficult time finding ways to stem the tide of Ellen’s spontaneous outbursts, which she feels are out of her conscious control, and thus cannot be anticipated or restrained. However, Ellen can slip into a trance simply by stepping onto her escalator and we were able to go into her own metaphor to do the work.

Ellen, when you’re ready, step onto your escalator and take it DOWN… DOWN… DOWN… to whatever level you FEEL MOST COMFORTABLE… where you can enter your tunnel… and emerge on your beach… and maybe you can feel what it is like to sit on the beach feeling CALM and RELAXED, see that unmistakable DEEP blue-green, green-blue color of the water… that can sparkle like diamonds when the sun bounces off it… smell the fresh salt air… feel the warmth of the sun on your skin and the gentle touch of a light breeze… hear the never ending sound of the surf in the background… and while you RELAX more and more DEEPLY I’I'm going to tell you a story… So you can let your conscious mind drift lazily like a raft on the water while your unconscious mind can hear what it needs to hear…

This is the story about a duck named Melanie Mallard. Melanie had been around the pond a few times, as they say, but she was in her prime… and was rated highly by the other members of her community, although Melanie never really believed this was true, and if it came to her attention, usually said people were just being polite, or that they didn't’t know any better. Sadly, Melanie had a rather low opinion of herself, one that was not shared by others. But Melanie also had a problem; Melanie quacked at the strangest times. She quacked before she thought, she quacked when she was anxious, she quacked when she was irritated, she quacked when she encountered something different or unusual, and of course, she quacked when she was scared or when she felt attacked, she quacked. Unfortunately she experienced many of these feelings much of the time so that it is fair to say she quacked a lot. Needless to say, this habit of inappropriate quirky quacking had gotten her into trouble on a number of occasions, but Melanie had no idea how to stop it. None at all, she said, and so she just quacked on and on, sounding like, well, some kind of nut cracker, or maybe that was quacker…It was not doing her business any good, nor was it helping her in social situations.

Melanie was not a Mallard for nothing. She was a strong… and proud… and very smart duck who had been very successful in her chosen line of work and she had worked too hard to get where she was to risk losing it all by quacking at the wrong time, quacking back, snap quacking or even quacking out of turn. She needed to FIND A NEW WAY OF COMMUNICATING. Melanie had no idea how to do this and so after waddling through Borders to no avail and then searching unsuccessfully on Google, Melanie decided to put on her best orange twin set, a duck in orange which made her look just delicious, and go ask some people she respected how she might go about CHANGING HER STYLE. Melanie didn't want to change who she was. Not at all. She just wanted to change how she came across so she wasn't so cross, and so she sounded a little nicer and more thoughtful.

Melanie decided to approach Esmerelda who was a sleek, smart and savvy feline of impeccable credentials. Esmerelda was a cat of consequence and Melanie had much respect for her opinion. Melanie put her question to Esmerelda and the cat stared thoughtfully at her paws while she PAUSED BEFORE RESPONDING. The cat purred,” A PAUSE SHOWS CONFIDENCE AND PURR-POSE You must pause for the cause,” and then as an afterthought she added, “do not bark like an uncivilized dog,” and here she shuddered at the very thought “rising to every challenge. Instead, save your snarls and snaps and growls for those rare situations which really call for howls. Or, in simpler terms, PICK YOUR BATTLES. You do not have to be Crusader Rabbit, after all.” And then she smiled her sly smile and was gone with a swish of her tail. Well, that was interesting, thought Melanie, and how did she know about that Crusader Rabbit thing anyway…? But Melanie wasn't entirely convinced.

So Melanie decided to seek out Svetlana Swan as she sailed serenely by. Svetlana was svelte and soigné and Melanie felt just a little bit jealous, but she also wanted to hear what Svetlana had to say, because the swan was very popular and was not plagued by the problems Melanie faced. Svetlana was very gracious and suggested that Melanie pretend to be like a serene swan and LET THINGS SAIL BY HER,… LET THEM GO… Said Svetlana, “a WAIT gives weight to my words so I sound smart… and sophisticated… and savvy.” Sure, thought Melanie, as Svetlana swam off, easy for you to say, you’re a beautiful swan… But she filed the words away for future reference…

Melanie next consulted Aretha Owl, who was renowned for her wisdom, and who stared at her with those big eyes before saying, ”Remember who who who you are, child. Just be yourself. That is good enough. All you want is a little R-E-S-P-E-C-T, RESPECT, just a little bit… and humming loudly, she flew off. Odder and odder thought Melanie, as she paddled onward. What did pausing or waiting have to do with not quacking? And where did being herself or respect fit into this picture?

This was a very diverse neighborhood, you must remember, and fair housing laws were in full effect here, so there were all types hanging around. Hank Hyena burst out laughing when Melanie explained her problem and as he trotted off, he was heard to say, “ if it walks like a duck, and talks like a duck…” and then he chuckled some more. He was no help. Karen Kangaroo, a very happy, one might even say hoppy, sort, told Melanie; “DON’T JUMP TO CONCLUSIONS” which seemed strange advice coming from her, but Melanie had to agree it was probably a good thought , although she still didn’t see what that had to do with her quacking problem. Melanie was puzzled. She was probably getting a lot of GOOD IDEAS, but none of them seemed relevant to the problem at hand, or rather, at mouth. What was she supposed to do about her quacking? Melanie’s feathers were beginning to get ruffled and she could feel a quack coming on. It was hard work to be a quack addict.

Melanie ploughed onward, a discouraged but determined duck if ever you saw one. Melanie was not one to quit. She was a survivor and this was important to her. After all she had been through, surely this was something she could do. How true, how true. Melanie was surprised when she looked down and saw a cricket. Not Jimminey, of course, but actually his cousin Gerard. Gerard looked up at her and rubbed his little legs together making that really annoying sound that made her want to eat him, or quack, neither one of which was an appropriate response, so she moved hurriedly on. There was NO SENSE IN BEING PROVOKED, now was there? She was so busy trying not to quack that she did not even hear the little mouse come up beside her, so silently did he move. Marvin Mouse looked expectantly at her and waited for her to acknowledge him. He seemed to have something he wanted to say and so Melanie stopped and waited for him to speak. Marvin seemed to PAUSE, WAITED a moment as if to MARSHAL HIS THOUGHTS, cleared his throat and then began to speak. “Melanie, I have seen you wandering about looking for answers and I’d like to help you PUT IT ALL TOGETHER. Why don’t you try this? Listen and reflect, repeat, add respect, refrain and restrain and then do it all again. Unfortunately, Marvin thought he was a poet, which really didn’t help matters at all. Melanie looked confused. Marvin tried again. “Delay the way the words you say play out.” Melanie did not feel much further enlightened and so Marvin tried once more: “A stitch in time, a nip a tuck, and there you have a happy duck, which is indeed a stroke of luck.” Melanie thought about all this for a few moments and decided that all the animals in the forest had gone stark raving mad. If that was a metaphor, she didn’t know what it was for. But she was intrigued, and more,… importantly, she didn’t quack because she was listening to what Marvin said, if only to figure out what was in his head. What was he actually trying to tell her? Was it something he was going to sell her? And should she INVEST THE TIME and effort it took to make this work? She could re-do a lot of things, she knew, but this was something entirely new. She paused… and waited… and listened… Are you ready? Well, I guess. Victory, victory, yes, yes, yes! (an old high school cheer had suddenly come to mind). Marvin continued in his poetic vein, “Attitude is rude. If you are near where you can hear a rude or crude interlude, be bold but don’t scold. Withhold, hold back, hold onto your words so you can refrain from regret and remorse while you still have recourse” which was clearly a pithy truism if you knew what he was talking about. Finally Marvin blurted out, “Melanie, just THINK BEFORE YOU SPEAK,” and with that it suddenly all fell into place and she swam off into the sunset, one very lucky duck because now she knew, and you can, too, can’t you?

And now, take a minute or two, it can seem much longer to you, and do what you need to do. Then when you are ready, you can return to the room knowing that you can remember not to forget to remember whatever it is you might want to take with you and you can remember to keep forgetting those things you no longer need to remember. And after a brief pause for thought, you will return to the room feeling thoughtfully refreshed and relaxed…

Jennifer, a twelve-year-old girl I am treating, came to see me for help with intrusive thoughts, anger and depression. When Jennifer was five, her mother suffered an initial breakdown and her parents divorced. Since then, Jennifer has lived with her father and her older sister. For years, Jennifer had little contact with her mother, but one year ago her mother, who by then had a diagnosis of schizophrenia with major depression and several suicide attempts, tentatively initiated visits with Jennifer and her sister. During these visits, Jennifer noticed the scars on her mother's wrists. Jennifer continues to think about her mother cutting herself and is preoccupied with fear of her mother killing herself. She alternates between longing for emotional connection with her mother and feeling angry and distant from her. Her mother is unable to be empathic or emotionally available. Recently, Jennifer sang a solo with the school chorus. She was hoping that her mother would attend the performance. Her mother did come but left before it was over and Jennifer did not see her in the audience. During our session, Jennifer sat in my seat and suggested that she be the therapist and I be her. She began to ask me questions about my life in a very good imitation of me. Then, she decided to put me in trance (as we had previously done in our work) and asked me to see her mother in the audience during her performance. She asked me to describe her mother. I described her as smiling and clapping for Jennifer. She then asked me to see her mother cutting herself and asked me to describe what I saw . . . which I did. Next Jennifer wanted me to see the two images of her mother side by side on a double screen and to imagine the smiling mother tell the cutting mother to go away. She had me describe the cutting mother refusing to go away or stop cutting. Then she asked me to have the smiling mother tell the cutting mother to smile and be happy for her daughter. When the cutting mother wouldn't, Jennifer wanted me to make the cutting mother go away and leave her alone. But when I described the cutting mother's departure, Jennifer told me that she could not see it. All she could see was the cutting mother pushing both her and the smiling mother away.

Jennifer had difficulty retaining a positive image in her mind. My work with her focused on helping her use her creativity to envision other possibilities with her mother. I had Jennifer banish the cutting mother; I had her make the cutting mother become smaller and smaller. I also talked about how in my mind, I could make the mothers do anything I wanted them to do. For instance, one could be a caterpillar and the other the beautiful butterfly the first turned into. I demonstrated how I had my own internal video screen and could see any scenario I wanted. I could see myself getting a little bit bigger, for example, and as I grew older, my singing voice became stronger and more magnificent and I could smile with all of my friends, my sister, father, and grandparents. At the end of the session, Jennifer told me that she had a lot to think about.

Therapist: Suzanne Little, Ph.D.
Director, Mind/Body Program
Continuum Center for Health and Healing at Beth Israel Medical Center

Urinary incontinence is fairly rare in young women. Natalia, a tense, anxiously depressed woman of 27, reported urinary frequency (12-15 episodes daily) and urge incontinence worsening over 2 years. Even though genitourinary abnormality was ruled out and she believed her problem was anatomical, Natalia tried hard to comply with her urologist’s injunction to "resist the urge." No intervention – medication, homeopathy, acupuncture (for ‘quick bladder’) – completely helped. Natalia, who wore dark clothes to conceal the leaking, usually had the urge to void during stressful presentations. She would hold it in for the meeting’s duration, then "sprint" down a corridor to the office bathroom: "I can feel it dripping out in little spurts." Her "accidents" occurred mostly at work or on the subway. Our treatment was brief and symptom-focused (she had a therapist), but took into account exacerbating factors such as low self-esteem, performance anxiety, mood dysregulation, and a turbulent relationship with a domineering, older man whom she supported financially.

Hypnosis seemed an ideal approach, not only because it would help calm Natalia – she once told me, "I never ever feel completely relaxed" -- but because it could counteract the urologist’s recommendation to resist the urge, which, as a behavioral strategy, I felt, had undermined her confidence and efforts at self-control.

Confusional wordplay was used to induce a mildly dissociative state. The words – press/push (physical act associated with urination), pressure (emotional state), and impress/impressive (ideal state) – helped seed for successful transformation:

Th: I imagine you feel pressed at times to do things you don’t feel like doing.

Pt: I do resent it, especially last minute presentations . . . [irritably] They just expect me to drop everything! [Pause] It isn’t any pressure I don’t already put on myself.

Th: I wonder if you can consider feeling less pushed to press yourself, is that possible? ... You can even impress yourself about the ways you can function without pressure, can you not?... And if there were less pressure you might flow …more freely…more comfortably...and that would be impressive .

Pt: [Musingly] I used to run after work. It calmed me. Maybe I should get back into that.

I built on the jogging theme by telling a story about a long distance runner–a woman marathoner -- famed for running laps to build special qualities of endurance. Each lap represented a "milestone" (e.g., inner resource) to help her gain her stride: This is a lap for strength . . . this is a lap for stamina…(uttered in a monotone to which she responded with a slight rocking) . . this is a lap for patience . . . The running culminated in a "victory lap," where she, as winner, could enjoy the feeling of a "runner’s high" -- a pleasing kind of mind/body flow . .

Natalia’s tension and anxiety remained a stumbling block. One day she was very upset about a fight with her boyfriend, and wondered if fighting aggravated her urinary problem. She asked why she always felt "in crisis." Her urgency became a useful device to help reframe her inner state:

The hypnosis took about 8 sessions. By the 4^th visit, she noticed a difference – fewer urinary episodes, increased assertiveness with her boyfriend. She had responded to a previous posthypnotic suggestion: If you hold back less, you can let go more. She bought herself a cream-colored suit "to wear when I’m better," and sat through an entire movie going to bathroom only once. In the next visit she made a major presentation to her corporate group without experiencing strain, and maintained her composure when the projector malfunctioned and she had to ad lib without slides. Afterwards she went to the bathroom without rushing: She took her time. Shortly after that, she reported over 80% reduction in symptoms and, a few visits later, said her problem was almost completely resolved.