Consultation Guidelines For Hypnotherapy
The initial consultation may well be the most crucial aspect of hypno-psychotherapy, if not all therapies. Everything from the interpersonal dynamic to the eventual success of the intervention has a basis in this first meeting between the client and the therapist. Indeed, the client's decision to remain engaged with the therapeutic process will be determined by factors from this early stage. Despite this, it is not possible, or even desirable, to proscribe the process. As a dynamic, evolving interaction, dependent on the individuals involved and the course the therapy is to take, until the consultation begins to take shape it is unhelpful to try to impose too much structure upon it. This view is expressed by the NCHP, as evidenced by the following;
It is, therefore, not possible, or even desirable, to suggest a blueprint which all should follow. (NCHPa)
With this in mind the following discussion will be concerned with one individual's approach and focus primarily on those features that this author believes are most decisive in fulfilling the aims of a consultation. If it is not wise or helpful to be prescriptive then we can perhaps understand Feltham's (1997) comment,
"the best we can aim for is practitioners who are honest, conscientious, flexible and experienced enough to offer each client suitably individualised counselling."
The goal of the consultation is to provide direction for informing therapeutic intervention. At the most basic level there are certain physical factors that are likely to play a role in a successful consultation. For example, a room that is suitably furnished and offers quiet, comfort and provides confidentiality. The exact details will be dependent on the therapist's style, budget etc and the desires of the client (e.g., temperature, lighting, distance between client and therapist etc).
However, obvious considerations are furniture that is adaptable to a range of positions and for a range of people, which offers a clear view of the client, a room that is welcoming and so forth. Ideally the consultation and treatment would be conducted in two different rooms so that the client associates one location specifically with the hypnotic process.
The next level for consideration is the initial contact between the therapist and client. Here the knowledge and use of basic counselling and communication skills are paramount. The client must feel that s/he is dealing with a professional who is genuinely interested in and accepting of their situation. Thus, greetings (including checking the client's name and any other identificatory information the therapist already has), timeliness and other aspects, which signal respect and focus, must be incorporated into the first moments when the clients make their initial appraisal.
Throughout the process it is important to maintain these high standards, not only because it facilitates open and honest exchanges with the client, but also good communication skills help to engender rapport. Communication skills are for the most part considered to be natural, however recent work within medicine and dentistry has begun to highlight the importance of developing an awareness of what makes communication work (see Lloyd, 1996; Fielding, 1995). The skills that are considered important for clinicians to develop and be flexible with for fruitful consultations are;
i) Clarity of language
ii) Audibility & enunciation
iii) Eye contact
iv) Non-verbal behaviour
vi) Methods of questioning
vii) Sensitivity of questions
viii) Greeting and identity check
ix) Introduction of self and role
x) Respect of patient's views
xi) Clarification and summarising
xii) Checking understanding and closing
During the hypno-therapeutic consultation the therapist would do well to have had practice in these skills and not rely on their belief that as they are a caring individual, that will naturally make them a good communicator. The NCHP suggest that it is necessary to 'like' the client (NCHPb). There are certain issues with this, for example, a therapist might be more likely to be seen to be collaborating with a client's unhelpful thoughts or behaviours, or there may be complex issues surrounding transference during therapy. Equally it might make certain aspects of therapy more difficult to undergo if one's relationship with a client is based on liking them, rather than respect for them.
It is certainly true that one can like a person without endorsing their beliefs and behaviour however it does make the therapeutic relationship potentially more complicated than necessary. Traux and Carkhuff (1967) suggest that rather than liking the client it is important to communicate empathic understanding, unconditional positive regard and to be 'with' the client.
Although the two previously described issues are important, they are basic to most successful human interaction, i.e., a suitable location and interpersonal skills. Without an awareness of these factors it is unlikely that a therapist will progress with a client to the consultation proper. It is the next step where the therapist's particular skills come to the fore.
The consultation process is concerned with two primary aims; knowing the person and informing the person. The latter is somewhat less involved and aims to ensure that the client has a clear understanding of the therapist, the nature of hypnosis, and the guidelines within which both are framed. Clients need to know that they are dealing with a trained individual, and how that person will work with them.
This means that they should know the therapist's qualifications (and perhaps even a method of checking them, such as a telephone number or web address) and their particular philosophy or approach to therapy. Some clients may have experience of preferred or disliked therapies. The client also needs to be clear about the nature of hypnosis, what it is and what it is not, issues regarding loss of control, revealing secrets, not coming out of a trance etc. It might be useful to send such information to clients when they make their consultation appointment and then review it during the first face-to-face meeting.
Such an approach also allows for more detail to be provided than might be suitable during the first consultation, for example some history of hypnotism, information regarding the therapist's background and training etc). Clients should be made aware of issues surrounding confidentiality, what the limits are, and how they will be protected. The order of presentation of this material is important as people tend to remember the things they have been presented with at the beginning and ends of a session, so the description of hypnosis might best be presented last so that the prospective client has good recall of the details of hypnosis whilst considering whether to come back. It is important to ensure that the client does fully understand this information and again good communication skills will facilitate the process of checking whether this is the case.
Regarding confidentiality, it is my opinion that no sources of information should be contacted (e.g., GPs) without the client's written consent, and no information passed on to others unless (a) the client gives written consent, (b) a court requires it, or (c) information divulged by the client suggests that s/he is planning to harm her/his self or another. At times this might mean that some clients will have to be referred on, or not accepted for treatment if they deny access to information that the therapist believes is necessary, or they cannot accept the guidelines for releasing information.
Assuming that the therapist is now in the company of a seated, comfortable, informed and engaged client it will be possible to begin to get to know the client. It is important that the therapist remembers that there is both a 'client' and a 'concern', and that the two cannot be separated, nor should they be confused. My preferred approach to this stage of a consultation could be termed "unstructured structure". In essence this means that there are certain key elements that must be covered in the consultation, but the exact order and manner in which this will be achieved is determined by the flow of the consultation. It also means that the specifics of the questions are for the purposes of this paper, by definition, vague because they must tie in stylistically and temporally with the client.
Most important is the client's reason for coming for therapy - and it must involve some description of
i) The concern
ii) The motivation for change
iii) Why now
The way in which the client describes these three factors provides much detail. For example, the description of a presenting concern, and the language used to describe it, gives an indication of how the person understands and relates to the issue. Epicetus, the stoic philosopher, stated that people are disturbed not by things but by the views they take of them and this view is embodied in cognitive approaches (e.g., Beck, 1964).
Although one might not wish to use cognitive therapies, or one may not be trained in them, all therapeutic philosophies share this central concept that at some level, whether conscious or unconscious, it is how we respond to our world that determines our control of ourselves within it. The concepts and terms the client uses may point toward a familiarity with certain therapies, including hypnosis, and these may suggest routes for the therapist so that s/he can use the client's familiarity with these concepts in therapy. That is, the therapist can use the client's already existing 'working model'.
The use of language is central to hypnotherapy because we must find methods that can be easily assimilated by clients, which they can understand and respond to. Communicating at the same 'level' as the client naturally works in will greatly assist this. Responses to motivation for change and 'why now' provide not only extra language information but also insight into how much responsibility the client is taking for change. A person who wants to cease smoking for their own health will be a qualitatively different experience to a client whose partner is badgering them to give up.
Language use and level of responsibility are important because they interact with my philosophical orientation, which is broadly Gestalt. It does not rule out or demand any particular tool, method or philosophical orientation, as these must be determined by the needs and experiences of the client. It does see the therapeutic process as collaborative so that the client appreciates the importance of their active involvement. By being collaborative, therapy will be a transparent, shared process, with a shared agenda and analysis of progress through feedback which the client gradually takes more and more responsibility for through learning self-hypnosis and the use of tapes (where appropriate), and by taking on certain homework tasks e.g., keeping a diary, experimenting with ideas etc.
Having covered these three primary areas it is important to develop a deeper understanding of the client and their concern. This is part of what Palmer and McMahon (1997) have outlined as being the common elements in all assessments.
i) what is the problem
ii) is therapy suitable
iii) is the client suitable (are there contraindications)
iv) what underlies the problem
v) transcultural and gender issues (e.g., differences in verbal and non-verbal behaviour and the recognition that one's own social/cultural biases (e.g., Ridley, 1995) may influence therapeutic decisions etc.).
In essence we are assessing the fit between a therapeutic framework and a client or presenting problem (e.g., Ruddell & Curwen, 1997). These questions cannot be addressed until the therapist understands the client, unless the presenting problem is one that the therapist does not feel competent or inclined to address.
Often people are not fully aware of the range of factors which can influence their desire to change and those which can be obstacles to change. These factors can be internal or external. It is also useful to contextualise the client, so that the therapist can begin to understand what boundaries there may be in the person's life that could assist or detract from therapy.
For example, it is important to be sensitive to any disclosures the client might make regarding previous experiences with therapy, early problems that may or may not be what the client sees as a central part of their current concern (e.g., being a victim of physical or sexual abuse, time with mental health issues etc.). Further this extends the exploration of how the person thinks of themselves and their world. Partly it is important to uncover aspects of the client's personality as there is evidence that compatibility on a variety of personality characteristics is important for the therapeutic relation (e.g., Parloff et al., 1978).
Areas that should be covered here are family and work life, any past, present or continuing problems or difficulties (other than the presenting problem), contacts with other forms of services, and evidence of successes. The issue of contact with previous services contains medical and mental health information so that the therapist is aware of either contraindications for hypnotherapy (e.g., psychotic episodes) or issues that might make certain inductions inadvisable (e.g., asthma). It also includes hypnosis, in case the client has previous experience of hypnosis, whether successful or not. The therapist may be able to discover induction methods that the client is comfortable with, or prefers to avoid, their visualisation capability, IMR etc. If the client has no previous experience then the therapist knows to include specific questions (e.g., favourite 'safe place' etc) and even visualisation exercises.
The final area, successes, is important because the therapist may need access to positive material if the client has issues with self-esteem or if s/he plans to link success with the presenting problem with previous successes. It is also useful for the client to know that that are seen as a person with a range of qualities, rather than with a list of defeats, ailments and issues.
Having covered the specific material related to the presenting problem and hypnosis, and the more general areas relating to the individual's other relevant life experience (and having paid close attention to non-verbal behaviour, language etc) the next step is to focus back to the presenting problem. The therapist needs to know what the precipitating factors are for the thoughts/behaviour that the client wishes to change. Armed with the biographical knowledge, the therapist can supplement the client's descriptions with specific questions relating to events and situations that the client has previously described (e.g., family, work, past failures, past experiences). This provides useful target areas for change. Additionally the therapist needs to explore the consequences that the client sees as coming from their thoughts/behaviour, both positive and negative as this can inform issues related to a client's barriers to change, or extra motivations to succeed.
This approach, precipitating factors, behaviours and consequences is found in many therapeutic approaches and is known as ABC (Activating event, Belief (Behaviour), Consequence, e.g., Ellis, 1977).
Part of ABC is looking at underlying beliefs and thinking errors (e.g., catastrophic thinking, dichotomous thinking) which, as the quote from Epicetus suggested, is believed to be the central area for developing problems that a client might wish to change. The reason why these two themes are important is that they identify where hypnotherapy might be useful and how it would be best targeted. For example, if a client comes in claiming to be shy, and they have the underlying belief that they are unlovable that would suggest one course of action, whereas a similar client with a similar issue, but with the thinking error that to overcome their shyness they needed to be assertive and superior at all times would suggest another. The manifestation of the issue under concern cannot be the depth at which the therapist ceases their exploration.
Once the therapist has to their satisfaction gained enough information so that they can form a picture of the client, albeit at a later date, it might be advisable, time permitting, to give the client the opportunity to experience relaxation or mild hypnosis. Particularly in prospective clients who have a fear of the process this might be the aspect that decides if they will engage in therapy.
With the knowledge gained during the consultation the therapist will know whether imagery can be used, and if so what images should be used or avoided. No therapy should be attempted at this stage. It is important for the client to get a 'feel' for the therapist and to know if they are comfortable with the methods used, the voice etc. On completion of this (if undergone) the issue of the contact should be raised. Initially the contract should offer a 48-hour period during which the client needs to decide if they want to continue with therapy, with the current therapist, under the framework that the therapist works within.
Also, the client will know the costs and recommended number of visits and can make an informed choice regarding financial commitment, payments, failure to attend etc. The contract should re-iterate the confidentiality clauses, and detail what the client is agreeing to, and cancellation policies etc and provide the client with contact details.
The above description makes it very clear that a detailed consultation will be both time consuming and result in the exchange of much information. Sometimes it is not the explicit information alone which is important but reactions, comments, etc and these tiny details do need to be remembered. How should the therapist do this? There are a number of approaches.
Firstly the therapist might decide to rely on memory, and with practice it is possible to develop the ability to use specific points in a consultation to 'hang' other information from, so one remembers a narrative which can later be written down. The alternative is to either take notes or to record the consultation. In the former case there is the issue of attentiveness - is it possible to fully attend to a client and accurately note down all the detail and nuances of a consultation? In the latter there are issues of privacy - how comfortable are clients with the idea that their words are being recorded, even with the knowledge that these recordings will be erased later?
Possibly of all the issues within consultation this is the thorniest. As with other aspects it is probably best to be flexible, and know when one cannot rely on memory alone, and know when one must attend absolutely to the client and thus some mechanical means of recording is required. Although clients might be uncomfortable with being recorded it is likely that they will be less upset with that than with a therapist whose head is constantly in a note pad, or who has remembered some important detail of the life story that the client presented at consultation.
Consultation is neither a science nor an art, but a mixture which must be performed on a social tightrope, where the demands of balance co-exist with the cognitive demands of accuracy in an evolving dynamic. In some sense we know what it is, but essentially we need to know how to do it. However, the complexity, which makes it so engaging, also makes it difficult to define. Perhaps a paraphrased and adopted version of Heisenberg's Uncertainty Principle is at work here; if you can do a good consultation then you can't know how to describe it, if you know how to describe it you probably can't do it.
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Simon Duff, Hypnotherapist