EXAMPLE ANSWERS: VIGNETTES 2

VIGNETTES

Case Study one: You have an appointment with a new client, Mark, who has booked in for smoking cessation. Your client, Mark, enters the practice and you engage in small talk about how he travelled there and you notice there is no eye contact as he continues to look down most of the time. The conversation then turns to the reason for his visit and what you may be able to help them with and the reply comes back, “I don’t really see the point anymore, I am too tired to carry on”, or “everyone would be better off if I was not here”. When asked how long the client has been feeling this way, it transpires that his wife recently left him and she has begun divorce proceedings. It is likely to be a prolonged battle over assets and child access. He volunteers that he feels he has not slept well for weeks and is alternating between being tearful and irrationally angry. Discuss how would you deal with this client and any associated issues.

(Student answer here) Ideas how you would proceed i.e. suitable intervention, ethical complexity, referral etc. I would ask if he has talked to a professional about the way he is feeling, a GP, or some other professional, or sought any help from a crisis team, give him the number for the Samaritans if he needs to have contact urgently at an out of hours time. Include that he would be able to go to A & E if they are feeling severely suicidal. If I felt that it was him reaching out rather than a genuine threat of suicide I would consider treating him, if I felt his threats were serious and imminent then I would make the call myself to his GP or hospital. If I decided to treat him rather than referring back to his GP, this is an example of how I would work with him. I would build rapport by matching his low energy, matching his body language somewhat not being too cheerful so he feels that he is being met at his level. I would ask Mark if he felt that there were other issues superseding the issues of smoking at the present time. I would maybe share my observations of his body language with him and ask him to describe his feelings in his own words, making a note of what we are talking about. I would ask him if he felt that (as an embedded command -EC) “you being a non-smoker” was in fact the…(EC)”most important thing” or if (EC) “sleeping soundly at night” would be another important thing to work on…. Thus allowing him to have the energy to deal with the pressing matter of the divorce proceedings and child access battle that he is expecting. I would tell him (EC) “you already have all the resources you need to feel good and positive and to deal with difficult situations I can help you access those now” I would ask Mark to identify what feelings he would prefer to feel, if he is currently feeling the way he does, then if we could have him feeling a different way by the time he leaves how would that be? Encouraging him to use positive terminology, maybe giving him a few examples such as ‘if I was feeling tired, I would want to feel energised, if I was feeling sad I might want to feel happy’ to encourage him to access in his own language a set of feelings that are more positive and productive. I would ask him to identify a time in his life or access a memory before he was a smoker, and maybe before he met his wife when (EC) “you feel really good” and was (EC) “breathing clean healthy air” I would ask him what was happening in that period of his life that caused him to remember that he used to (EC) “feel positive and productive and healthy” and suggest that “we can use that memory and the way you feel so good in that memory now, to give you the healthy body and sound mind that I know you know how to have”. Talk about the positives and the idea of having a positive future. I would suggest that we work on the presenting issues, the fear of the divorce, the access issues with his child, how he is feeling now. Then after the session suggest that he see his GP in the meantime then come for another appointment to deal specifically with the smoking issue that he originally booked the session for. An intervention may include talking about recognising the support and the positive relationships that he has in his life now. I might also be tempted to use metaphor in an intervention, maybe talking about the life of a tree and how the tree continues to grow and be useful even though it experiences many events in his life time, branches may break off, seasons change, children come along and climb him, then as they get older the climbing stops happening, and still the tree stands strong, knowing that the roots in the ground are strong and far reaching, that his trunk is strong and that his leaves provide a canopy of shade to nurture and protect those who come into his space. That the tree has a very important job in providing life giving oxygen to the surrounding people and animals, touching the lives of many people and essential for those people whose lives it touches. That a tree lives a complete and healthy life for a long time and rolls with the seasons and the weather, recognising that it can take a battering from a storm and still remain steadfastly strong and resolute in his existence, and gets all that it needs from the environment around him. He knows when to sleep and recover and knows when to wake and gain energy. Most of all he knows how to be strong and live a long and healthy life independently. I would do a lot of future pacing, encouraging Mark to see himself in a few months after the initial stress that he is experiencing now and feeling calm and resolved and content and sure that he has all the resources he needs just like the tree. I would call to mind the experience that he told me about during the metaquestioning from before he was a smoker and before he had met his wife and remind him of those feelings and experiences. After the hypnosis part of the session I would recommend that Mark make another appointment for the following week and go and see his GP or a mental health professional in the meantime if his feelings do not improve.

Tutor feedback (DO NOT delete/edit feedback. Write amendments, additional information & thoughts underneath this table) Whilst there really is no wrong or right in this scenario, this is an excellent answer in dealing with a highly complex client situation. The strategies that you suggest are interesting and comprehensively creative and as long as you have client engagement throughout will serve to lift your client from the immediacy of present trauma into a more far reaching life view. I hope you use this approach with someone who really needs it and report back its effectiveness. Thank you. Interestingly I did get a chance to use this intervention with a client two days after I submitted this answer (as with the pain control client mentioned above), with a major anxiety issue and a lack of internal strength, a sense of just ‘giving up’, which was leaving him feeling depleted and like there was no reason to carry on in the capacity of work and as a father as he was feeling right now. I asked him if he was feeling suicidal and his answer was ‘not actively, I feel like there is no point in carrying on if nothing changes but something has to change, I don’t feel like life should be like this, I hate my job, my family have no idea I feel like this though’ I worked with him almost exactly how I talked about with this answer, calling to mind an experience that he had had when he felt good and able to cope and he told me about a time in his childhood when he was very young and living in South Africa, where he was born. He said that he felt very ill equipped to deal with life stressors, that as a university professor he felt that if he dealt with a student who challenged his mark on a paper that he wouldn’t be able to ‘hold his own’ and stick to what he thought was appropriate for the work submitted, instead just giving in to the pressure that the student was putting on him. After further metaquestioning and an induction I worked using the tree metaphor, emphasising the ability of the tree to be strong and sturdy and not easily swayed. That his roots were far reaching and that he draws all that is needed for his mental and physical survival from the environment around him. It was an extremely successful session, as when he ‘woke up’ I asked him how he felt and he said ‘yeah, really enthusiastic, like “bring it on!” ‘. I have him booked in for a follow up session in 2 weeks’ time. Great to hear this Lucy, I hope you share your experiences on the forum and elsewhere as this is a powerful and insightful, and as you have proved, productive approach.

VIGNETTES

Case Study two: Mary arrives at your practice for help losing weight. In your pre-talk she comments angrily about the behaviour of her nine year old son, Josh, who never does anything she asks. She has been a lone parent for over a year since the breakup of her relationship which she blamed on Josh’s bad behaviour. She says she is at her wits’ end and does not understand why he is so badly behaved. She admitted that he angered her so much one night that she even threw an empty bottle in Josh’s direction when he particularly upset her. As you ask about her eating habits etc she volunteers that she and her son live on a diet of fast foods which are delivered to the home as she never has time to shop or cook properly because her job involves long hours, where she is not home until late, and it is very stressful. She then tells you that she cannot sleep unless she drinks at least a whole bottle of wine every night. Discuss how would you deal with this client and any associated issues.

(Student answer here) Ideas how you would proceed i.e. suitable intervention, ethical complexity, referral etc. I would take a lot of notes whilst talking to her, making sure that I got all the details that are necessary for a referral to social services or her GP later. If I was concerned enough about the woman and the welfare of her son in particular, asking lots of questions about her child and his safety and whether anyone is looking after him when she is working late, or whether he is on her own, I would inform her that I felt that her risk to herself and her child was high and that I would need to refer her to the appropriate authorities as I am not sufficiently capable of dealing with her issues around the needs of her child. I would say that as a hypnotherapist I am not qualified to deal with risks to her health and family to this degree. Alternatively I would ask questions to determine the risks to her child, if I felt that the risks to her health and the child’s safety then I would tell her that with respect to the risks to her and her child I would need to contact her GP so that they can access some support. If I decided to treat her I would build up a strong rapport with the client. I would ask her if she felt she has any choices regarding her food and drink consumption, then use metaquestioning to help her realise her choices and the fact that things don’t have to be this way and that there are other ways. Would find out if the client feels that the drinking and food situation is actually a problem? Does she feel that her behaviour with food is causing her to have a weight problem? Mention that wine is very high in calories, maybe she could choose different foods and drinks that are healthier. I would mention that at least a bottle of wine every night is a lot of alcohol and suggest that she seek some help. I would ask if there was anyone available to look after her son when she has drunk her bottle or more of wine each night? I would suggest that we could remove the need to drink In order to sleep using hypnosis, is this something that she would want to do? If she still wanted to drink despite being offered the choice not to I would do further questioning to establish whether she actually wanted to address the drinking at all, and whether without addressing the drinking would she be able to control her weight at all. I would use the logical levels technique to assess what it was that was lacking in her life or where the blocks were that would be stopping her to committing to making significant changes to her lifestyle. If there was a lack in motivation, I would tell her that during this session I would work on motivating her to find ways to make changes and during the intervention part of the hypnosis I might do a control panel to increase her motivation to change and then a NBG to work on different ways of behaving when needing to de-stress with her child causing her anxiety and anger. I might do a bit of guided imagery and metaphor using a waterfall as a metaphor for abundance, abundance of energy, abundance of patience, an abundance of time etc. Stating that a waterfall would continue to be filled with water no matter how many buckets of water a person removed from it. I would maybe suggest in her intervention that she would feel the urge and then find herself desiring new types of food and find the time to start cooking and eating foods that are healthy and nutritious and enjoy preparing and eating these foods. I would do a lot of future pacing, seeing herself in the future being calm and being able to sleep well and feel refreshed, that she as laid back and deals easily with issues that might arise in her life. That she is moving into the place she wants to be emotionally and giving herself and her son the time and energy and attention that they both need. After her session would suggest that maybe bringing her son in for a session to help him control his temper and to feel calmer might be a good idea, and that I would like to see her again soon for a follow up session.

Tutor feedback (DO NOT delete/edit feedback. Write amendments, additional information & thoughts underneath this table) A good answer again to this one and again it is highly complex. The recognition that the anger which is displayed at the son has its root elsewhere and is coming out inappropriately within the trance experience is helpful too. The information given is privileged and can be delivered to you either because you have created a rapport of yourself and environment to such an extent that she feels safe to deliver it (and therefore betrayed if you announce too early on your decision to report to authorities). Or it can be delivered to you as you are just someone who is standing still long enough as she volunteers her problems to all and sundry. It is a judgment call on your part as to which of these is more likely. It is a very tricky one. I say these things to you because I think you have the level of maturity of client interactions to measure this and the skills necessary to help those that might be turned away by other therapists. The simplest and most highly effective intervention to do at the initial stage is perhaps to do what hypnosis is most appropriate for, to promote sleep. A fork in the road technique for sleeping with copious amounts of alcohol in the system, versus sleeping without alcohol will be enough for the unconscious to actively discourage waking up with hot sweats, dryness and dehydration, headaches, tossing and turning and perhaps even vomiting as recognition of the body’s ability to rid itself of excess alcohol is recognised and a preferable technique to relax is chosen to experiment with then the appropriate fork will be chosen. These are just my additional thoughts to help you with possible future scenarios and encouragement for you to use the abilities you have clearly demonstrated during this course.