Every now and again, we are presented with cases that require us to think out of the box, cases that push us to hone skills more in line with detective work than clinical technique.These cases, while complex and sometimes confusing, are also the cases that can lead us to the "ah-ha's" many of us originally signed up for.
The following case report describes a young patient who came into the office with her diagnosis already delivered on a silver platter: Tic Disorder NOS. She had been so diagnosed and subsequently medicated by a competent and respected neurologist and it did not occur to me at that early juncture to question it.
However, as the case evolved over time and I saw improvements with the use of hypnosis I began to wonder. What if this weren't a Tic Disorder, but a Conversion Disorder?
JJ was a pert, bright, athletic 18-year-old female. She expressed some urgency about seeing me when she called. Her recent breakup with a long-term boyfriend left her with an intolerable increase in anxiety and tic activity. JJ presented with a tic that manifested as massive and uncontrollable twitching on her right side only, affecting her right eye, head, neck, shoulder and arm.
When it occurred (approximately every 5-10 minutes), JJ was highly conscious of it and often became embarrassed and angry at herself for having it. She was put on Klonopin the previous summer and, while the tic was diminished, by September she'd become irritable and moody.
She herself found the changes disturbing and asked to be taken off the drug. Her family did not object. Her neurologist agreed, hoping for the best, but by December the tic had rebounded back with even greater intensity.
Patient and Family History
JJ came from an upper middle class family consisting of her father, who was a successful businessman, her mother, who worked as a secretary, her younger sister, who was a student in a neighborhood public school and her older brother, who had been in extensive treatment for multiple drug addictions. When speaking of him, she became irritated.
She felt he had taken up most of the family's attention for the last several years and had been almost pleased at how her mood changes on the Klonopin had put her in the spotlight for a change.
"It was pretty amazing at how I could scare people. It was a new feeling for me," she'd said.
The tic began in 4th grade and developed gradually. By 5th grade, she had an MRI for eyelid flutter and some disturbing head movements. She remembered that at the time the tic disappeared when the focus was on her, e.g, when the doctors examined her. The tic only occurred on the right side. By 8th grade, however, she began to suffer from more flagrantly out-of-control head movements. She recalled having had fights with schoolmates and that there were a lot of cliques, making her feel unhappy and unwanted.
Around 12th grade, the tic manifested mostly during major events (e.g, SAT's, graduation) and was associated with stress and sleep loss. In college, the tic got worse and at one point was so violent, she felt like she dislocated her shoulder.
She said to herself, "I better stop or I'll get hurt." And as if on command, it stopped-though only until September of that year. She stated, "I know I said I wanted attention, but I don't want to injure myself."
She was more complex emotionally than she presented. She could express anger, but had more difficult with weeping, fear, tenderness, and sorrow. She had frequent nightmares, some numbing and dissociation. Interestingly, whenever she came into session, she "forgot" to close the door, a habit that continued for months.
Because of the centrality of the voluntary nervous system, the secondary gain of the tic (e.g., "it was pretty amazing how I could scare people"), and the presence of other symptoms suggestive of early trauma, I began early on to explore the possibility of a diagnosis of Conversion Disorder and PTSD even though her neurologist had already made the determination of tic disorder.
Description of Treatment
All treatment came from the modality of holistic psychotherapy. Initial sessions strongly utilized an object-relations model of psychotherapy with an emphasis on establishing a "frame" and offering support while information gathering. My emphasis on ego strengthening is supported a great deal by the work of Dr. M. Phillips (AJCH 2001) on the use of hypnosis and EMDR for ego strengthening. Dr. Phillips' research has also suggested that the healing relationship may in fact be the most significant aspect of all recovery from trauma, in whatever form that relationship takes, whether with a professional, a friend or a pet.
The importance of providing this patient with a safe environment becomes even more clear when we see JJ's vigilance and anxiety as she comes to session. Rarely did she close the door entirely. While from time to time I mentioned it, I did not move to close it. (In time, she did.) At the same time, because Verbal First Aid, clinical hypnotherapy and NLP would be utilized, special attention was always given to the patient's use of language as it expressed unconscious conflicts and needs.
JJ discussed a persistent need for control, a desire for attention, and alluded to underlying shame, a sense of not being "right." We established rapport and acquired an understanding of her general metaphorical framework: She used numerous allusions to trains, circuit boards, energy, "kicking the rail into position", "knowing where you're going", surefootedness, the "right track."
Her language suggested a blockage or a short circuit. Retrospectively, I can see that it may have also been the unconscious clues that led me to thinking of EMDR as a tool for disentangling the psychological trauma from the physiological response. Although NLP technique, formal trance induction and hypnotic interventions were used throughout as indicated, for the ease of review I have labeled those sessions discussed herein as #1, #2, #3, etc...
Hypnosis Session #1/ Week #3
*To begin the practice of hypnotic trance, deep relaxation.
*To increase somatic awareness and encourage comfort in being in her own body.
*To assess the metaphorical import of the right sidedness of the tic. Script for Somatic Awareness and
Metaphoric Import: "And everyone knows how to look into rooms and closets with a flashlight-so you can see what you need to see, see the separate items-the boxes, the clothes, the furniture, the places you want to go, the places you want to avoid, the places to step into, the places to leave alone...looking far and deep without having to actually go in, until you know you've got your flashlight on your side and any side is your right side...looking down deep and far in...Looking into body to see what you can see...starting way at the top of your head or way at the bottom of your feet, wherever you'd like to shine the light..."
JJ revealed a blocked area on her right side. She said she felt horribly trapped and proceeded to reveal a long history of trauma primarily on her right side. In exploring her history further, she made the connection that her tic started approximately 6 months after a serious arm break when she was a young girl. She had been playing in a backyard jungle gym and fell from a height of approximately 5 feet, landing square on her right hand and rigidly positioned arm.
At the moment preceding impact she could recall having said to herself: "I better do something if I don't stop this."
Interestingly, she consciously meant to say, "I better do something TO stop this," but it came out with a twist. To compound the traumatic injury, which resulted in a shattered arm, an adult relative came out when she was in mid-fall and proceeded to yell at her angrily. "I didn't even get a chance to scream," she said.
Subsequent exams revealed no concussions or brain damage and her injuries eventually healed, although she has had some residual rheumatic pains in her right hand.
At age 2 JJ also broke her right collarbone when she went down a flight of steps on a toy. At age 4, she got a hanger caught in her right eye and went to the hospital. After the session, it seemed to this therapist that JJ's tic was "a scream waiting to happen," and that she had held not only the trauma, blocked and short-circuited, inside her right side, but had repressed her own fear, vulnerability, and pain.
Hypnotic Session #2/Week # 7
*To more deeply explore the tic's meaning.
*To begin delivering therapeutic suggestion for release, smoothing out, rewinding and taping over.
*To reinforce somatic integration and depotentiate traumatic experience using Verbal First Aid.
At this point, we began to embed indirect and direct suggestions, utilizing metaphors of channels/tracks. "And you can see yourself, feel yourself now in a safe and comfortable boat, feeling the water licking up against the sides of the hull, smoothly gliding, effortlessly leading you through a series of canals with signs posted to guide you...so you can choose where you want to go...and on each channel you can see your way to those experiences in your life that hold the key to your current problem. And any channel you choose is the right one and the curious thing is how smooth your boat is..."
In order to lead her to the site of the tic activity, we said, "Whichever canal you take, whichever channel you float way down into, way down comfortably floating, you can take the right one, and you choose the right side, making the right choice. That's right. Because there is something waiting to happen."
During the trance, we spoke in highly descriptive and sensory-rich language and encouraged JJ to go into each scene she chose. She could experience each one, then depotentiate it by using various hypnotic techniques, such as the "dimmer switch" and "control room". We also explored the thoughts, statements, and sensations she has held onto and repeated from each experience. I asked her, "How have you learned from them so you can let them go and move on."
We exaggerated each somatic movement, repeating the statements and thoughts out loud.
JJ reported a marked decrease in tic behavior within 1 week, with only "a few" incidents all week. She was very hopeful, though still scared of being "too" hopeful.
Hypnotic Session #3/ Week #6
* Explain and explore the nature of imprinting;
* Correct and "re-wire" JJ's response pattern;
* Anchor JJ to an internal "safe place."
I explained imprinting to JJ in the following manner:
"Before and during each twitch, each tic, there is an internal feeling reminiscent of your body-state just prior to your injuries. The body remembers what it needs to know. Once you've been in a fire, you never smell it the same way. You smell it faster. But it doesn't tell you its size-whether it's a wastepaper basket or a house that's burning. It's the law of negative interpretation-the physiology of fright. If we're afraid, anything that can be interpreted in more than one way will be interpreted negatively. It exists to protect us. The processing is instant for fear. For pleasure it can take upwards of three seconds. We need to know about danger faster than we can think. You've had a series of traumas, all of which happened in seconds, and anything that reminds your body/mind of that state will initiate a reaction to that danger.
"It's the same with certain drugs. Benzodiazapenes can cause amnesia. Imagine that they're given to someone who takes a plane ride to another city and then goes to a business meeting, where he meets someone he doesn't like at all.
However, when he gets home, he doesn't remember much about the meeting or anyone he met there. Later on, he meets one of the people he disliked at that meeting and without knowing why instantly dislikes her. Some things stick in our minds until we learn how to slide them off..."
I anchored her to her adult self and had her express that in one part of her body (she chose her left hand) thus: "Now, your problem has some interesting, really revealing characteristics...ones that your unconscious mind is very familiar with...so that as your conscious mind floats now... your unconscious mind can begin to consider a safe, strong space in your solar plexus, a vessel for feelings your conscious mind may not be considering...and I'm going to suggest that you feel this safe space now....feeling it clearly...and letting me know by lifting your 'yes' arm...and it may surprise you how automatic that response is..."
Then we went back in time to before the incident and back up through time to the minute right before falling. We used ideomotor signaling and I used my hand to pick up each finger of "yes" and "no" with each one signaling the message to deepen trance. At that point, in trance, I spoke to her adult self and asked her adult self to come back with me to observe the incident on the jungle gym.
She was able to recall it in striking detail. "I couldn't scream. It was too fast. But it was so slow, too. I remember, oh, my God, I have to stop this or I'll die. Then, he came in, he screamed at me, didn't know how badly I was hurt."
I asked her: "Is there a body memory, a part that you feel is a match to the tic process?" She nodded and ran her left hand over her upper right side. The rest of the session was spent on "re-wiring" and smoothing out the right side.
By self-report within 2 weeks, JJ experienced a 70% reduction in symptoms. We used scaling questions to concertize her improvements.
On a scale of 1-10 (1 worst, 10 best), we determined where she was for her two major complaints-her inability to sleep and the persistence of the tic.
Sleep scaling: When began: 2 Current: 7
Tic scaling: When began: 1 Current: 8
JJ maintained her improvement until around the 5th month, when she experienced a reversal she attributed to a breakup with a boyfriend. We did a graph of her tic incidents, accounting for sleeplessness, emotional upset (on a scale of 1-10), and nutrition (3 meals). We found that behavior modification, with special attention to sleeping eight hours a night, ameliorated tic activity about 30%.
Revealing the Mental Chatter with Holistic Psychotherapy
For the next month, we used trances weekly, combining deep stress and somatic release with images of stillness, reconnection, and smoothing the communication between neurons. Numerous sessions were spent on her subtle "mental chatter" - "I'm not good. Not good enough hair. Not tall enough." I gave her regular assignments throughout: meditation on stillness for no more than 3 minutes twice a day (a.m. and p.m.) and automatic writing with her right hand.
Hypnotic Session #4/ Week #26
* To establish readiness to be tic-free;
* To continue exploring the tic's imprint(s) and correct for it;
* Explore dissociation process.
"Now you've said that you want to get rid of that tic, that you no longer have any use for it and, everyone knows that when something is of no use, it starts to diminish...until it disappears..."
Ideomotor signals were established and regression was initiated to locate the imprint: "Way, way down, that's right...and now time moves differently, comfortably, smoothly, effortlessly...And it can go this way or that...forward or back...yesterday or tomorrow and who knows what time it is...when it's okay with your unconscious mind to go back in time and review the time that is most important in the birth and development of this tic problem...and your first review can be a little detached like watching a movie, an old tape you already know...and the birth of any thing is usually a small thing, a seed that takes root and later with time and fertilizer grows into something else..."
Suggestions were given for correction: "If it's a plant you want, then you want to tend it carefully, helping it to flower, to fruit. But if it's a weed and it's gone wild, we need to pull it out by its roots so what you don't want and don't need stays out and never comes back..."
Each imprinting scenario was reviewed by having JJ go into each scene, state to herself or to me (using all five senses) what she experienced (or, in some cases, watched herself experience), signal me to indicate that she'd finished her review, then return to it to review it not just somatically but emotionally.
Finally, we future-paced JJ to a time that she could see herself as tic-free: "You might begin to notice a parallel, now possible universe, a world, a life with no tic, with only smooth lines, clear lanes, easy transmission, and only the plants you truly love to have there with productive, beautiful fruits..." We closed the session with post-hypnotic suggestions for a deep, refreshing, natural sleep, a significant dream, and a tic free week.
After this session, she revealed that she was angry with herself for having the tic and scared to leave the office for fear it would come back.
I had her go back into a light trance and gave her two suggestions:
1. That she doesn't need the punishment (of the tic) to be a good person.
2. That if the symptoms return they can go to her right hand pinky. While in trance, she suggested that she needed to put a sling back on her arm, as if the injury had just happened. I answered, "Good idea, wear it at night and let the healing and dreaming happen together."
Her report one-week post-session was that she had slept well, recorded her dreams, and was tic-free for one night. Overall, her symptoms decreased but stayed in the same range, up 1 or 2 points, then down again.
Introduction of EMDR
At this point, we seemed to have reached a plateau, with hypnosis alone serving to ameliorate but not effect a resolution. Why would hypnosis produce these results, even if they were variable, in what was supposed to be a neurologic case?
Clearly, the diagnosis of a conversion disorder and PTSD was indicated, though the symptoms seemed quite intense for a fall from a stool. Perhaps there was another layer of trauma beyond those that had already emerged? Pacing a patient towards their treatment goals is always a delicate balancing act, but perhaps nowhere more so than in cases of traumatic injury in which trust and vulnerability issues play such central roles.
How do we move them towards disclosure without overwhelming them? How and when are we sure there even is a trauma in cases that strongly suggest repression and conversion but in which the client either has no conscious memory or is unwilling or unable to make the connection or reveal the full story?
In this case, I believe that it may have been the more open-ended, perhaps tentative and less-direct nature of the hypnotic sessions I created that postponed the resolution of JJ's problem. Of course, another way of interpreting the psychological "stall" is that the patient was simply not ready and that each step, every component in the process was a necessary one, contributing towards JJ's overall well-being in exactly the way she required. This would imply that JJ unconsciously set the pace for treatment, a notion neo-analysts have promoted for many years and which Erickson masterfully appreciated, understood and never failed to utilize.
Preparing the Patient for the Next Phase
With this in mind, we discussed the possibilities and promise of EMDR in the treatment of trauma. Due to the client's tendency to be analytic and anxious, we induced a light trance first, utilizing imagery that had proved successful in prior trances. Hypnosis, in that way, served as the safe room in which the tool of EMDR was utilized.
The Revelation at The Core
In our first EMDR session, while the client was in a light trance, when asked what presenting issue or memory she'd like to work on, she revealed for the first time that she had been molested as a young girl by an adolescent relative for approximately a year. She remembered it clearly and felt "disgust," "violated," and "responsible for it."
As she related her thoughts, she experienced a number of tics in her shoulder and neck. When asked what she'd like to believe about herself now instead, she said, "I'm in control of my body." She only rated the believability (validity of cognition) of that statement at a 2 on a scale of 1 to 7 where 1 is completely false and 7 is completely true.
She rated her "Subjective Unit of Disturbance" (SUDS) at a 7 on a scale of 1 to 10 (1 being no disturbance and 10 being highest disturbance) and located the disturbance in her right side and arm. We proceeded with the rest of the EMDR protocol using my fingers to initiate the saccades/bi-lateral eye movements.
During the process, which we repeated for about 30 minutes overall, she experienced pain in her arm, a little comfort, then anger, then confusion, religious angst ("please help"), need, disgust, fear, pain in the lower arm, uncomfortable, blank, worried, pain in elbow and hand, pain in leg, "afraid to move", and finally she said she felt tired as her SUDS level dropped to a 2.
When we installed the positive cognition, which links the desired positive cognition with the original memory or incident, she moved from rating it at a 2 to rating it at a 5, indicating that she was already feeling more in control.
After completing the first EMDR, she still experienced some somatic discomfort on her right side. Thus, we decided to repeat the process. The second and third EMDR sessions were conducted in the same way (using a light trance), but focused on two other incidents: In the second EMDR session, she revealed that a boyfriend had disclosed to her that he was gay. In the third session, she described how (being so deeply attached to him) she had gone with him to a club and watched as he picked up men.
Her negative cognitions for both memories were reminiscent of issues to which she had alluded in earlier sessions: "I'll never be able to trust people again," "I'm not right. There's something wrong with me," "I'll never satisfy a man."
Her desired positive cognitions were: "I've come so far and built so much up that he destroyed," and "I have the ability to please." She rated the believability of the positive cognition at a 4 (1-7) and her SUDS was a 9 (10 being the highest). She felt the disturbance all over her body. Interestingly, in these 2 sessions using EMDR within trance, she felt comforted by the diagonal saccades and responded very quickly to them, moving the SUDS from a 9 to a 7 to a 5 to finally a 1. When we installed the positive cognitions, she felt the statements still "fit" and rated them on a scale of 1 to 7 (7 being completely true, 1 completely false) at a "6+".
Outcome of Case Using Holistic Pyschotherapy
In reviewing my own notes, it is still quite startling to see the almost utter absence of tic behavior subsequent to the combined hypnosis/EMDR sessions. Subsequent sessions focused more on issues of control, anger management, negotiating long-term intimate relationships, and work. She has since become successful in business, has married, and has in every way demonstrated a full recovery. In the 10 years since the combined hypnosis/EMDR intervention, she has had almost no tic activity despite the stress of career changes, marriage, and moving (twice). Her progress continues and she comes in for a session once in a while to brainstorm on one issue or another. She always closes the door behind her.
When hypnosis is used for ego strengthening and EMDR for both continued ego strengthening and uncoupling, they can offer clinicians a formidable toolbox for both generating and therapeutically utilizing those "unexpected responses."
It occurred to me in preparing this case that JJ had made her subtle request for EMDR in the initial stages of her therapy if only I had been listening more attentively. Her unconscious references to "tracks," "channels," "blocking," were all terminology used to describe and metaphorically explain the EMDR process by Shapiro herself (1995).
Also of great interest, and perhaps worthy of further study, is how only in the EMDR sessions were the incidents involving early childhood sexual abuse and her later humiliation by her ex-boyfriend disclosed. This author wonders whether the more structured process of EMDR was what allowed for this revelation. While I had naturally assumed that the right-sided tic was a function of the physical trauma, it seemed to have been interlocked with more complex psychological and sexual trauma.
While hypnosis and NLP perhaps laid the foundation, JJ's symptoms only subsided after EMDR exposed, then released the deeper layers of trauma she had buried for so long. Clearly, there was "a scream waiting to happen," only not the scream I had assumed. To this writer, JJ's case reaffirms the value of therapeutic flexibility and an eclectic or holistic stance when dealing with the mystery-and poetry-of the mind/body connection.
c. Judith Acosta, 2009. All rights reserved.
Judith Acosta, LISW, is an author, licensed psychotherapist, crisis counselor and homeopath in private practice in New Mexico. Specializing in the treatment of trauma, she is the co-author of The Worst Is Over: What To Say When Every Moment Counts, hailed as the "bible of crisis communications." She lectures around the country on Verbal First Aid, trauma, stress, animal-assisted therapy, and intuition development. She may be reached at her website (http://www.wordsaremedicine.com).