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- 변영돈박사는 2000년 10월 2일부터 7일까지 독일 뮨헨의 막시밀리안대학교에서 있었던 국제최면학회에서 만성정신병의 최면치료에 대한 강의를 하였습니다. 변영돈박사는 현재 이 분야의 세계 최첨단에 서 있습니다.
Hypnotherapeutic Methods in the Treatment of Chronic Psychosis: Analysis of Successful Factors in the Hypnotherapy of Schizophrenia and Bipolar Disorder.
Lecture, The 15th International Congress of Hypnosis
at the Ludwig Maximilians University of Munich, Germany
Oct. 6, 2000
Pyun, Young Don, M. D.
Pyun Neuropsychiatric Clinic
It is a great pleasure to present to you my experience with hypnothearpy in patients with chronic psychosis. I hope this will prove to be helpful and motivate all of you who attend.
Once upon a time, there was a misconception that hypnosis activated latent psychosis. Some clinicians considered chronic psychotics to be low hypnotizables and hence not good candidates for hypnotherapy. But today, there is no doubt that hypnosis can be used in chronic psychosis.
The issue here is the kind of hypnotic strategies and methods that are useful and effective. The field of hypnosis has no final answer yet. What we have are some anecdotal case vignette along with theories and practices from psychoanalytic perspective in acute psychosis. Indeed, we are still in the middle of a heavy mist. This became increasingly frustrating to me as a physician. I had no real answers to offer to chronic refractory psychotics who sought hypnosis. I needed more certain, reliable and trustworthy hypnotic strategies and methods.
Currently, I have been treating several chronic psychosis patients. They had not responded to psychopharmacological therapy. In fact, their symptom showed none to minimal improvements and some were even aggravated by medical therapy. I have yet to see a single case of chronic schizophrenia using psychotropic drugs who is completely free of symptoms. However, almost complete subjective and objective long-term improvements have been possible with the utilization of pharmacological therapy in conjunction with hypnosis. This combination was often necessary as some patients feared discontinuation. For them, I think the combined use of medication facilitate hypnotherapy.
I will present cases, discussing my hypnotherapeutic methods and about the factors for success later. I invite you to the discussion and hope this will be the pilot experience for the development of hypnotherapeutic method for chronic psychosis.
Case 1: Mrs. Han is a 32 year-old female who has been diagnosed with schizophrenia at 19 years of age because of paranoid delusion. She has been admitted several times and had been treated with psychopharmacotherapy, electroconvulsive therapy etc. She visited in 1996. At that time the current issue was a conflict with her 70 year-old mother. She had violently knocked her mother down and had slashed her cheek. The patient was angry because her mother tried to take her husband away from her. The patient's delusion was that her mother loved her husband. She also complained of anxiety, depression and other violent behaviors accompanied by suicidal ideations.
After the intake, hypnosis was begun with progressive relaxation. Her subjective measurement of the depth of comfort was 3/10(three over ten). Eye Roll Sign was grade 4. I administered tense and release for more relaxation. Her eye lids fluttered during hypnotic induction and she tried to concentrate on my words carefully. At the end of induction, she felt very comfortable. I gave simple direct suggestion for symptom disappearance and recovery. Three mg of haloperidol was combined. In the second visit, after two weeks later, she said anxiety was much relieved. Induction with tense and release resulted in the subjective depth of comfort 8/10(eight over ten). Visualization of comfortable place and simple form of ego-strengthening suggestion were done. She showed much improvement with only two session of hypnosis and she said that she felt happier. I also was surprised and suspected that she may not be a schizophrenic because of dramatic improvement. Haloperidol was decreased one point five mg per day.
I dealt current issues in the reality and suggested ego-strengthening and comfortable scenes. At the 10th session she showed no symptom subjectively other than worrying about sleeping without medication. After that period she was only infrequently depressed. I discounted 25% of the fee as long-term therapy was expected.
When I did not induce hypnosis for several sessions to talk about many issues, she asked to do hypnosis and suggested the words that she want to hear during hypnosis. I made childhood memory of sleeping on her father's lap; recommended several places where she could go only herself. I also dealt with feelings of left out; relationship with others including husband, daughter and neighbors; negative thinking; dependency; independence. She was afraid of that I would make fun of her and expressed suspicion that I was conducting therapy which would not be successful.
During therapy mother passed away. The patient was able to remain in a controlled and serene state.
At present she has no anxiety; no depression; no persecutory delusion; no idea of reference and sleeps well. Her husband sees much improvement in her and says she is almost normal. She now visits me once a month for hypnosis.
There are two more cases of involving successfully improved female schizophrenics using hypnotherapy of similar strategy and methods.
Case 2: Ms. Kim is a 24 years old known Bipolar Disorder patient(severe with psychotic features). She is in a hypomanic episode with mixed depressive mood. She visited at December 8 1995. She became ill when during her first year student in high school. She had been admitted to a closed ward twice and had taken medication for 7 years. She relapsed, however, after discontinuing her medication for an year. Again she was admitted and treated with psychotropic drugs including lithum, valporic acid and haloperidol. But this time she showed little improvement. She visited me for hypnosis by the recommendation of her nephew. She had already been diagnosed with borderline personality disorder with marked dissociative features when she sought hypnosis from my office. She ultimately recovered to normal state. Ms. Kim's subjective measurement of the depth of comfort was 9.5/10(nine point five over ten) after two sessions. Eye Roll Sign was grade 3-4. Visualization of comfortable place and simple form of ego-strengthening suggestion were done and there was marked improvement.
After three months of hypnotherapy similar to Mrs. Chang, I discontinued medications and had one booster session per month. She didn't keep her appointment and her symptom aggravated after two month. I restarted hypnosis and pharmacotherapy but discontinued after six months. Two more episodes of aggravation was resolved by hypnosis. During this period she entered and graduated from college. Medication was combined briefly at the onset of an episode and discontinued shortly thereafter. The first words she said at her first visit was "I want to discontinue drugs". She is currently in a good state. Long-term careful follow-up supportive hypnotherapy will be necessary.
My reasoning for the success common to the above mentioned cases are as follows:
First, the subjective experience of hypnotic induction and the induced state of comfort.
Second, initial improvement response was experienced after one or two sessions of hypnotherapy composed of reframing, direct and indirect suggestion for symptom disappearance and psycho-strengthening.
Third, visualization. Vivid imagery enhance the quality of one's subjective experience and potentiate the response to hypnotherapeutic strategy and methods.
Fourth, the unexpressed love. Subjective experience of hypnotic induction and induced state of comfort enhanced the love for the therapist. That is, she loves me but in reality she expresses only respect and trust. This is analogous to a love for a teacher or for parents. Here, unexpressed love means erotic transference which is not interpreted and not recognized in real life situation. She probably couldn't continue therapy if her love was recognized explicitly by her family members or myself. This kind of love maintained the necessary long-term therapeutic relationship, made it stronger and increased compliance to therapy. All the cases are females who have interests in love with a man. Hypnotic induction and hypnothearpeutic procedures make erotic transference unfolding rapidly and strongly. I, of course, worked on it not to be expressed.
Fifth, dealing with the current issues in real life situations and suggesting appropriate resolution.
Sixth, neutralize affect such as anxiety and depression with the comfort of doing hypnosis with a doctor.
Seventh, psycho-strengthening procedures; imagination of the filling of whole body with the feeling generated from the visualization of the comfortable places and happy scenes; direct and indirect suggestions for the disappearance of the symptoms and ego-strengthening; making psychological connection between the doctor and the patient with suggestion and imagery; intentionally suggested sleep to allow the unconscious feeling of sleep together with the one who is object and also have the healing power in the subject's imagination. This unconscious feeling of sleeping together symbolizes the union physically and mentally.
Eighth, I did not targeted delusion and hallucination directly.
Ninth, I did not force the patient to accept the diagnosis of psychosis if they insist that they are not psychosis patients.
Tenth, I followed the basic frame of supportive psychotherapy.
Eleventh, combined use of low dose of antipsychotic medications, Although the patients know their improvements were not due to medication, they tended to be afraid of the discontinuation of medication. I also have no confidence about complete discontinuation at this time.
In conclusion, three schizophrenia and one bipolar disorder with psychotic feature patients were almost completely improved with the use of hypnotherapy combined with the minimal use of psychotropic medications. I used similar strategy and methods in all cases and they displayed similar characteristics common to all. I hope my experience could be the cornerstone for the development of hypnotherapy for chronic psychosis.