[Paper presented to the 1997 Annual Conference of the American Psychological Association]

My goal in this presentation is to describe an exciting development in the field of addictions counseling, and to then convince you all in retrospect that the development was inevitable. Because in the final analysis, addictions counseling, clinical hypnosis, and counseling psychology have a great deal in common. In my own work, in the work of the counselors and therapists I have trained and supervised, and in the work of many others, it has become clear that all three endeavors share a common paradigm.

First I want to note an irony I hope we all seek to correct. In my training as a counseling psychologist, addiction received rather minor mention (there was not a single course specifically devoted to addiction and addiction counseling) and hypnosis was completely omitted. Almost everything I learned about addiction, and all that I learned about clinical hypnosis, has been the result of postgraduate training. I know from my conversations with dozens of other counseling psychologists that my experience is not unique. I will be very clear and perhaps somewhat dramatic in stating: training counseling psychologists without a grounding in addictive behavior is in my opinion gross negligence that greatly potentiates the likelihood of malpractice. And teaching graduate students how to counsel people and do psychotherapy without providing even the basics on hypnotic communication is like teaching oil painting without teaching anything about color mixing.

I am going to provide a Reader's Digest version of what we know about recovery from addiction. First, we know that recovery is best predicted by the addict's strengths rather than by his or her weaknesses (e.g., seriousness of addiction). Second, we know that most addicts will relapse. Many will relapse multiple times. Many of those who relapse will recover. Third, we know that there is no single "best" way for an addict to recover. Many recover using therapy, many do not. Many use twelve-step programs, many do not. It may be helpful, but it is not necessary to admit you are an addict to recover.

The fourth fact is something that is not only true of addiction recovery, but of all of therapy as well. Client factors and external factors (including things like outside support and just plain luck) are far more important than therapist factors in the overall change equation. The primary role of the counseling psychologist is to assist the addict to utilize his or her own internal resources, and to reach out and utilize extra-session resources.

To now provide a Reader's Digest version of a Reader's Digest version of what we know about recovery from addiction, let me be even briefer and more to the point. What we know is that it takes motivation and inner strength to recover from addiction, and that people arrive at recovery from a multitude of paths.

And that is where hypnosis enters the picture. Clinical hypnosis, when skillfully and thoughtfully applied by a well-trained counseling psychologist, can impact on all three factors. It can help increase motivation to change. It can help the addict contact strengths he or she may have forgotten, and it can enhance learning new skills. And it can help the addict discover his or her own unique path to recovery.

I view hypnosis, because it is ultimately a collaboration between client and therapist, as fitting perfectly the Alcoholics Anonymous tradition of "attraction, not promotion." Contemporary hypnosis does not "put the patient under hypnosis," but rather invites the client to join with the therapist in a journey of discovery (Dubrow-Eichel, 1985; 1996).

These words would have been a bit too poetic for the scientific psychologist of the 1940s and 1950s. Traditionally, and especially prior to the immense growth and proliferation of professional psychologists during the 1960s, clinical psychologists were more prone to consider the statistical significance of a correlation than the significance of arresting addictive behavior by relying on spirituality. This, after all, was more in the realm of faith healing than psychology, and although it may be interesting to study the process of faith healing, it certainly was not considered within the purview of clinical psychology to engage in faith healing. Please do not misunderstand: Clinical psychologists certainly did not have a better track record with addicts. They shared psychiatry's general inability to heal addiction; psychoanalytic psychotherapy has long since been abandoned as a first-line treatment strategy for this problem.

Counseling psychology, however, has a different history with addiction. With deinstitutionalization in the 1960s, the community mental health movement swept the nation and more and more counseling psychologists found themselves uniquely suited for community mental health centers. The community mental health movement was followed by the increased demand for psychological and addiction services in the VA hospitals, as more and more Vietnam veterans returned--traumatized and often addicted--to a contemptuous homecoming. As a result, there was increased contact between counseling psychologists, addicts and addiction treatment programs. Counseling psychology, long associated with humanistic psychology and the human potential movement, was more amenable to viewing addiction as a spiritual problem. Counseling psychologists--many of whom were training (and, to be quite honest, being trained by) the first wave of modern addictions counselors--were also among the first psychologists open to working with the only known, successful outpatient "treatment" for addicts: Alcoholics Anonymous.

Counseling psychologists, addictions counselors, and clinical hypnotherapists all share a belief in some higher power that governs human growth and development. Our labels may be different--some refer to this power as God (or Buddha, or Allah, etc.), some prefer to think of it as a "life-force," and Ericksonians talk mystically of the "unconscious" that contains creative resources and the drive to actualize (Yapko, 1990)--but I think it is safe to say that the belief in some higher process is a vital part of our theoretical foundation.

How can clinical hypnosis be utilized in addictions counseling? I plan hypnotic interventions by assessing my client's position along three axes.

The Use-Abuse-Dependence (Disease) Model

The first axis is the traditional addiction progression model as described by Jellinek (1960). Adolescents referred by anxious schools and parents constitute the vast majority of clients I have treated at the "use" (Experimental and Social) stage of substance use. Adults generally do not see the use of substances, even illegal ones, as a problem for themselves. At this stage, I generally use hypnosis for ego-strengthening, improved coping skills, decision-making skills enhancement, and assertiveness. My clinical experience matches the research that shows that enhanced skills and good rapport are the best strategies for adolescents who have or are experimenting with drugs. Scare tactics do not work (remember how, when we were teenagers, we all laughed at these efforts?) and obviously "Just Say No" approaches are no longer relevant. I also liberally pepper hypnotic metaphors with suggestions that encourage teens to "take your time and think...". Encouragement of future-taking perspectives and (e.g., "if...then" reasoning) and age progression and goals clarification are also fairly standard for me. Finally, I often utilize hypnotic strategies for mood regulation at this stage, and I encourage the teen to develop an "Inner Advisor" and strengthen his or her "Observer" ego-state.

I am frequently referred clients who are clearly at the "abuse" (Instrumental and Habitual) stage. Hypnotic strategies at this stage are focused on ego-strengthening and self-soothing, but may often involve conflict-provoking age progressions (cautiously). Clients at this stage more frequently than not have post-traumatic stress disorder and/or unresolved trauma, for which hypnosis (and other strategies, including EMDR) are highly appropriate. At the habitual stage, I will attempt trauma or abuse containment and ego-state or "parts" therapy. My primary goals typically include increasing motivation and encouraging (hopefully productive) conflict between the "healthy" self and the "using" or self-destructive self. I will address the client who is using habitually but does not see it as a problem later.

Working with clients at the dependence (Compulsive and Addiction) stage can be the largest challenge a therapist may ever face. The compulsive drug user must use more of the substance to maintain emotional equilibrium; the "high" may be secondary at this point. The Addiction Stage is marked by required use of the substance/behavior to maintain both emotional and (perceived or real) physical equilibrium; the "high" is definitely secondary at this point. The addict feels s/he must use in order to physically survive. Psychological and/or physical dependence is present.

To the extent that the compulsive user is capable of maintaining therapeutic contacts (without being high), the therapist should continue to focus on the user's "internal war" between ego-states. Directly assuring the addict ego-state that s/he will not be annihilated may be appropriate. Reminding the non-Addict ego-state that the parts of the Addict want him/her dead may also be appropriate.

Generally speaking, the active addict will not be amenable to direct hypnotic strategies; the therapist (assuming the addict is seen) should probably focus on indirect suggestions predicting bottoming-out and hope for recovery. To the extent that non-Addict ego-state(s) can be contacted, the therapist should address communication in that direction.

I can not recall ever hearing psychologists address how hypnosis can be used with the client who is hitting bottom. Yet this may be exactly where hypnosis can be most effective. If the client is panicked or highly agitated, it may be necessary to utilize forms of "walking hypnosis" (if you have used hypnosis with young children, you may already be familiar with a few of these strategies). If intensive treatment (i.e., rehab) is an option for your client, talking directly to the "wounded child" ego state can be extremely effective.

I consider it my honor to work with addicts who are newly in recovery. They are often among the most open-minded, humble, and grateful clients a psychologist will ever engage. Hypnotically, I often utilize age progressions at this stage, especially for clients who have lost a great deal while actively addicted. Suggestions to facilitate 12-Step involvement may be highly appropriate for some. To encourage the gradual development of lifestyle changes, I use hypnosis for self-soothing, containment, and inner advisor work; I also hypnotically encourage clients to engage in journeys of spiritual awakening and continued exploration/discovery.

The Stages of Change Model

In my work with addicts I have found hypnosis to be an invaluable tool when utilized within the "stages of change" model developed by DiClemente and Prochaska (1985), and further explicated by Miller and Rollnick (1991). It is no surprise to those of us in addictions counseling that this model, initially based on work with nicotine addicts and alcoholics, has become widely accepted outside the field of addiction. What works with addicts will almost definitely work with any other problem.

The stages of change model views change as occurring in cycles, beginning with contemplation, and moving through determination, action and maintenance stages. Relapse is also a stage of change in this model. Some people may not be ready to change. Often, these clients are uncertain they have a problem, or that the problem is "important enough" to make a concerted effort to change. Or what they want is a different perspective. We can assign those clients (e.g., many substance abusers, such as the stereotyped client referred on a DUI/DWI charge) to the "precontemplative" stage.

At this stage, the psychologist can utilize hypnosis for general ego strengthening and strengthening of the observing ego (a precursor to "inner advisor"). I use hypnosis in an "as if" or "what if" manner that is essentially a form of experimentation with different perspectives. For example, I may overtly or covertly encourage role reversals in which the client tries to convince me (or some other significant person) s/he is an addict.

In the contemplative stage there is no question that the client wants to change, but he or she is not sure what needs to change. For these clients, insight about themselves, other people, and their problems seems most valuable, and may be enough. Hypnotic interventions can include age progressions to a non-using life style, first encounters with the "inner advisor," and experimentation (both within and outside hypnosis) with new behaviors.

In the action stage, the client feels ready and committed to take whatever steps are necessary to effect the change. Hypnosis can be used to rehearse new behaviors. Encounters with the "inner advisor" are very desirable, and the psychologist can begin more advanced "parts" or "ego-state" therapy.

At the maintenance stage, the client has already made the change, but may need help, guidance, or support in maintaining the change. Hypnotic interventions involve continued ego strengthening, and may include age regression to addictive life style followed by progression to the present (to reinforce progress but also to "keep it green" for the client). Addressing spiritual and lifestyle needs can be readily facilitated with hypnosis. It is also at this stage that the psychologist may address, on a deeper level, any underlying trauma.

It is important to state here that there is no "right" or "wrong" stage to be in. However, it is also important that the therapist and client know which change stage they are in. That way, treatment strategy can match the change stage. Many clients move from one stage to the next stage while remaining in therapy. But others benefit from, or seem to need, a "break" from formal therapy between stages. In a sense, after completing one change stage, they take a "sabbatical" before moving on to the next change stage. These sabbaticals can be extremely important, and valuable. They allow people to rest, to take stock, and to consolidate gains before moving on. So, although therapy may have "ended," growth continues. When a person is ready to move to the next change stage, he or she may come back for additional therapy or counseling.

The Trauma and Shame Model

Most counseling psychologists who work with addiction are aware of the extremely high comorbidity rate between trauma (and, by extension, trauma-related shame) and substance abuse. Clinical hypnosis is an extremely valuable tool when working with substance-abusing trauma survivors. Current research and standards of practice do not support using hypnosis to "recover" dissociated (a.k.a. "repressed") memories of abuse. In my experience, memories of abuse can harm as well as help clients. The mediating factor appears to be ego strength, general coping abilities, and degree of external support. Hypnosis can be of vital assistance in the first two areas. We know that substance-abusing trauma survivors typically lack affect modulation and self-soothing skills. Both hetero- and self-hypnosis--soothing in and of themselves--can enhance other soothing experiences, such as music, rocking, car rides, water, or soothing natural sounds. Hypnosis is an excellent mechanism for learning and practicing containment strategies. Hypnotic containers can involve slow trickling, and the ability to "turn on" and "turn off" (e.g., faucets, pressure valves). They can be impermeable or "filtering" containers. Naturally-occurring boundaries (e.g., lakes, pools, cocoons).

Decreasing shame is vital, especially in the maintenance stage. Metaphors and stories in which a listener/advisor (or, for some clients, God or a Higher Power) hears and accepts even the deepest/darkest secret can be very useful here. "Inner advisor" techniques are also very helpful. Hypnosis can also be used directly to assist the client in addressing shameful and/or traumatic experiences from safe distances. Distancing techniques provide the client with a mechanism for controlling the intensity of the experience. I often encourage viewing the experience on videotape, and suggest that the client has the remote control (with fast-forward, reverse, stop, volume control buttons, etc.). Or the client can listen to it on the radio, watch it at the movies, or read about it in a book. Hypnosis can assist the client to "anchor" competent ego-states and "parts." Age regressions and progressions can also help. In general, having the client recall or project (into the future) any experience with self-observation or self-awareness has the effect of strengthening that ego-state.

Formal inductions are often unnecessary for many of these procedures. Hypnosis can enhance that reexperiencing, but is not necessary for it. The therapist can often be most effective when s/he correctly assesses that the client is in a spontaneous trance, and then uses hypnotic patter when asking the client to recall or project. This is a form of utilization, or informal hypnosis.

Conclusion

It has been my experience, long before managed care became preeminent, that the treatment of addicts often occurred in spurts over many years. Clients come in, work, leave for some time, then come in again, do more work, leave, and so on. I initially believed this phenomenon to be a fluke, or I interpreted as symptomatic resistance or counter-resistance. After some years, however, I noticed that clients who were treated intermittently did not generally do any worse than those who consistently kept their weekly therapy appointments for years and years. Some did better, some did worse. Consistency and length of treatment did not seem as important as other factors in overall therapy outcome.

Counseling psychology has historically been more comfortable with brief, solution-focused therapy approaches. We are trained to emphasize strengths, skills, and the conceptualization of human problems and change processes within a developmental context.

I have come to view my style of addictions counseling as "intermittent developmental psychotherapy." It is intermittent because it moves in spurts; it is developmental because it moves in a discernible sequence, with one stage forming the foundation of the stage that follows it. As a therapeutic tool, clinical hypnosis is exceptionally amenable to being utilized within this brief intermittent counseling approach. Counseling psychologists can be at ease with hypnosis' emphasis on tapping the individual's own resources, and its respect for the mysteries of growth and change.

The two processes that are necessary and primary components of hypnosis--absorption and involvement--are in and of themselves anathema to the addictive aspects of the client's personality. Not inconsequentially, these same two processes are typically associated with effective counseling and therapy (Gendlin, 1969; Gendlin and Tomlinson, 1967). Therefore, the hypnotic experience can be a metaphor for, and a microcosm of, the larger change process.

It is ironic that addiction treatment and clinical hypnosis both involve a paradoxical form of "surrender." It is clear to me that being in control means being able to give up control. The recovering addict accepts surrendering to a higher power, even if that higher power (for those in Rational Recovery) is "reason." I have often found my best hypnosis sessions to be those in which I go into trance along with my client. In these sessions, I often find myself deviating from my a priori agendas as I surrender to some higher process (clinical intuition? my own unconscious? "cosmic flow"?). In hypnosis, our clients surrender to an externally-guided process and to their own imaginations. They are often pleasantly surprised by the results, and they invariably feel more in control. Again, the hypnosis session can be both a metaphor for, and a small-scale practicing of, the surrender process often discussed among recovering addicts.

I find working with addicts and substance abusers to be singularly frustrating and inspiring. All decisions are choices between growth and destruction; clearly, addiction is also about choosing between life and death. Counseling psychology is at home with such weighty existential and spiritual concerns.

The use of clinical hypnosis in addictions treatment is perhaps the penultimate example of two therapy modalities housed comfortably under the roof of counseling psychology.

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