Comments on The Case of Anna: Headache and Heartache
Max P. Shapiro, PhD is the Director of Education & Research for the New England Society of Clinical Hypnosis. Dr. Shapiro practices and teaches in Newton, MA. A Past-President of NESCH, he was formerly the Chief Psychologist at Newton-Wellesley Hospital, where he maintained a practice in behavioral medicine. He has practiced and taught psychotherapy, clinical hypnosis, and hypnotherapy on the Faculty of the Harvard Medical School and The Tufts University School of Medicine. Dr. Shapiro has a special interest in the use of hypnosis in enhancing outcomes in healthcare, academics, athletics, and the performing arts.
The Case of Anna: Headache and Heartache by Dr. Daniel Kohen presents the significant gains achievable when hypnosis is an integrated part of a comprehensive healthcare intervention. Several aspects of the case are noteworthy:
First, Dr. Kohen saw his patient only after a full diagnostic evaluation by her pediatrician and a consulting neurologist, both of whom found no underlying pathophysiology (neurological disease, tumor, etc.) This sequence of evaluations is important because attempts to modify physiological symptoms through hypnosis are generally fruitless unless the patient can be assured that the symptom is not serving a valid physiological function. No individual will give up a “useful signal”: eg., pain sensations that protect the individual, or that serve to alert her to an unrecognized problem.
Second, Dr. Kohen assessed the possible psychological/developmental functions of the headache symptom. It is believed that some symptoms are “empty symptoms”: phenomena that originally served a purpose for the person, but are no longer useful. However, learning is powerful and symptoms can easily become habits. Obsolete “empty habits” can often be ameliorated with hypnosis, but such was not the case here. Rather, the history suggested a link between this patient’s difficulty managing important family losses and her symptom course.
Third, Dr. Kohen’s focus was teaching Anna how to achieve active mastery. While important for all hypnotic work, it is essential for work with adolescents for whom mastery is a key developmental issue. By presenting hypnosis as a way for Anna to “be the boss of herself”, Dr. Kohen was able to build a therapeutic alliance of considerable power. As he continued to help Anna develop her hypnotic skills in managing the symptom, she could feel her increased strength and the symptom loosened its grip. As this strengthened her self-control, the protection afforded by the therapeutic alliance with Dr. Kohen could then encourage Anna to bear the vulnerability and pain of the grief work. It is quite common to find that hypnosis alters a symptom which has been blocking normal development. The symptom amelioration then allows growth to resume, often paving the way for gains in other areas.
Finally, Dr. Kohen’s technical use of hypnosis is exemplary:
Quite sensitive to his patient’s subtle alterations in state of consciousness, he utilized the occurrence of spontaneous trance states to offer therapeutic suggestions: “you can send me all your past, present, and future headaches...” The use of "trance-logic" here is elegant: Anna was invited to dissociate the headache pain in the future and also to develop amnesia for previous pain. Highly useful since the memory of previous pain serves as a trigger for stress and anxiety which inevitably increases the patient's suffering.
He taught Anna how to symbolize the headache pain ( i.e., color, circle, numeral), and then manipulate the symptom by strengthening the mind-body connection. This is, of course, one of the most intriguing applications of hypnotic process.
In addition, he helped her control her symptoms by skillfully using appropriate therapeutic tools in addition to hypnosis ( self-monitoring, biofeedback, etc.)
Later in the treatment, Dr. Kohen reinforced and suggested continued gains in the healing process, increased proficiency in self-hypnosis, and Anna's ongoing creativity in further developing her skills after the formal office visits ceased.
To her request for additional suggestions, he responded that she “might want to do her self-hypnosis as a “stress immunization…” Empowering the patient to continue to strengthen her coping skills is another hallmark of an excellent course of treatment. He also normalized her continued use of trance, making it more of a "life skill".
In summary, this case report is an excellent presentation of technical proficiency in hypnosis. It presents an outstanding clinician who demonstrated great skill and compassion in helping his patient.