Problems associated with people’s sense of their own body have increased over recent years and discussions about body image are much more commonly found in the media, alongside those within health and social care. Orbach (2009: 1) suggests that ‘millions struggle on a daily basis against troubled and shaming feelings about the way their bodies appear’. Societal obsession with the perfect body, which includes being beautiful, fit, and slim and remaining youthful; all exert unrealistic pressures on individuals. The images of perfection are everywhere and our bodies are being shaped by forces beyond our control (Orbach 2009). It is not hard to see therefore why society is beginning to acknowledge this as a growing problem.

Over recent years, an increasing amount of literature has emerged, with a number of authors attempting to define body image and develop models relating to practice. Grogan (1999) defined body image as a person’s perceptions, thoughts and feelings about his or her body, which incorporates appearance, body size, shape and attractiveness. Concern about our bodies is normal and allows us to have healthy body awareness. However, excessive bodily concern can lead on to an abnormal focus and can result in bodily obsession or body dysmorphic disorder (Webster’s Dictionary 2008).

A broader view of body image would include more than just the issues relating to appearance but would involve the psychological perception by the individual of their body as being intact, whole and properly functioning. There are many life-threatening and life-limiting illnesses which can cause body image changes, or which impact on how the body functions; these include strokes, multiple sclerosis, rheumatoid arthritis, diabetes and cancer, to name but a few. In addition, the result of life-changing events such as accidents, surgery including amputations and colostomies, leave many people with body image issues. Some of these changes are temporary, while many remain permanent and require the person to adjust to them.

Disfigurement is a particularly difficult body image problem relating to more than just the visual effect of the disfigurement, but linking with the patient’s thoughts and feelings about how it was acquired. Barraclough (1999) reminds us that people cope differently with disfigurement and suggests that some people can be very self-conscious to changes that are not immediately obvious to others. It is important therefore, to assess the patient’s perception of the problem, while suspending our own judgement. One way of doing this is to adopt an approach developed by Berne’s (1972) and ‘think Martian’. When asking the person to describe how they see the problem, we suspend our personal knowledge base and judgement, in an effort to see it through their eyes. This technique is very powerful because, in addition to being empathetic, the therapist also enters into the patient’s ‘frame of reference’ by listening to the language and metaphors they use to describe themselves.

Body image is closely aligned with a person’s sexuality and as such, the authors recommend a broader working definition in order that all aspects of the patient’s persona are acknowledged. White (2006) takes a holistic view in relation to this area of practice suggesting that:

Sexuality embraces the associated concepts of sexual identity, sexual expression or behaviour and intimacy. It is also closely allied with concepts such as body image or self concept, gender identity, gender roles and relationships

White (2006: 676)

Freud (1936) also recommended a similarly broad approach, reminding therapists that sex is something we do but sexuality is something we are and as such incorporates many facets of the individual. It is important therefore, that when assessing patients, prior to offering hypnotherapy techniques, we need to ascertain how their body image concerns relate to the broader view they have of themselves, and whether this affects their roles and relationships with others.

ASSESSMENT MODELS

Assessment of body image and sexual concerns is dependent on the therapist’s attitude, knowledge base and skills in eliciting the patient’s perception of their problems. Three models which provide a framework to assist this process will be considered.

DIRECT/NEGOTIATION MODEL

The DIRECT/Negotiation Model (Box 9.1) utilizes a staged approach to assessing body image and sexual concerns which allows the therapist and patient to proceed at a mutually agreed level. It is a 6-stage approach which is particularly useful when negotiating with the patient as to whether they wish to discuss and work with particularly sensitive areas. Negotiation is used to elicit what the patient is comfortable working with and is used throughout the assessment, enabling the therapist to proceed at the patient’s pace. This can relate to either the depth of communication they are comfortable with, or when negotiating which hypnotherapy approaches they are happy to engage in. (For further explanation of this model, see Chapter 5, and a full version, which also includes Annon’s (1976) P.LI.SS.IT (1976) Assessment Model, can be found at: www://learnzone.macmillan.org.uk.)

BOX 9.1 The DIRECT/Negotiation model: a 6-stage approach to assessment

1. Develop the relationship/Negotiate before moving on

2. Invite the person to tell you about themselves and inquire how any body image concerns impact on them as an individual/Negotiate

3. Reflect back your willingness to hear their concerns/Negotiate

4. Elicit and Explore their concerns/Negotiate

5. Communicate your understanding of their problem/Negotiate how these might be resolved

6. Treatment/Therapy can be negotiated and suggestions made to how hypnotherapy techniques can help in resolving their concerns.

BODY IMAGE MODEL (PRICE)

Price (1990) developed a 3-stage model which enables the therapist or healthcare professional (HCP) to identify and explore different aspects of a patient’s body image:

1. The first aspect is ‘body reality’. This is the ‘warts and all’ of our body image which we may or may not choose to share with others. Under normal circumstances, the ‘body reality’ may not be problematic. However, when people are unable to keep these aspects hidden, either due to illness or lack of privacy, problems may begin to emerge. Our body reality changes throughout our lives, with a number of changes occurring at times of transition, such as puberty and menopause. Most people adjust to these changes without any support. However, for some, this can be the time when body image concerns begin to develop. The changes and challenges which occur throughout puberty can be the catalyst for problems such as anorexia and bulimia. Also the losses which occur around and following the menopause, may for some people be more difficult to adjust to.

2. The second aspect of the model is the ‘body ideal’. This is the picture in our heads of how we would like to be and may well be unachievable for most people. The media presents the ‘ideal look’ encouraging us to aim for perfection by promoting youthfulness and vitality. Most people, even the young and beautiful struggle with this ideal and those with body image changes due to illness or injury are often moving further away from the original ideal image they had of themselves. Orbach (2009) questions why bodily contentment is so hard to find and it would appear that the answer might lie in the constant striving for the ‘body ideal’.

3. The third aspect of the model is ‘body presentation’. This is how we present ourselves to the world and links with the term ‘being presentable’. Even this can be greatly compromised when people are ill or taking medication whose side-effects impact on their body image. In these situations, what is often presented to the world, is their body reality (and perhaps a new even less positive body reality), which for some patients is very distressing. Examples might include: hair loss or weight gain from steroids, or where a disfigurement is impossible to hide.

BODY IMAGE MODEL (CASH & PRUZINSKY)

Cash & Pruzinsky (2002) have developed a useful framework for assessing body image concerns. Their book offers a variety of tools which patients can use individually or can be used to form part of their therapy. A body image diary is used as a way of reflecting on their body image concerns. Patients are encouraged to notice:

• Activators – triggering events/situations which raise body image concerns

• Beliefs – what thoughts and interpretations they deduct from this

• Consequences – the emotional tide occurring as a result of the body image concerns being activated.

They are asked to name and record the types of emotions they feel, their intensity (scoring them from 1–10), their duration and any effects they have on their behaviour. This may include avoidance behaviour, which is common in this group. This information can then be used to form the basis of any work undertaken using hypnotherapy.

Applying hypnotherapy

When looking at using hypnotherapy in this area of practice, the following examples may be of use to practitioners.

The American Society for Clinical Hypnosis (2009) suggests three main ways of practicing hypnotherapy:

1. The first is to encourage the use of imagination. Patients are asked to imagine what they see and the therapist may go on to work in a way that helps them to change a negative image. This will be further explored when looking at Cunningham’s (2000) model below.

2. The second way is to present ideas or suggestions to the patient, which in the case of body image will help them to use positive suggestions in order to reframe their perception of the problem.

3. The third way is to use hypnotherapy for unconscious exploration and is used to explore motivation or links with past events. Hypnosis avoids the critical censor of the conscious mind, allowing the interface between the conscious and unconscious, which results in the client having the information they need to make the changes.

IMAGERY

Imagery is an important aspect of working with body image issues. Two modes of imagery, which are useful in facilitating this process, are: ‘diagnostic’ and ‘therapeutic’ (Cunningham 2000).

Diagnostic imagery

Diagnostic imagery can be used just to elicit information, or in addition can form the basis from which the therapist works using hypnotherapy techniques. During the imagery, ideas/information from the unconscious become available, which is not always accessible from the rational mind. The wealth of information that the unconscious holds, allows patients to gain new information in order to bring about healing. The therapist is the privileged facilitator of this.

Therapeutic imagery

Therapeutic imagery entails working in a positive way with the images the patient presents, based on the principle that images affect body function. The therapist encourages the patient to imagine beneficial changes in the images they see. The patient gets in touch with both their conscious and unconscious, to consult with their ‘Inner Healer’ in the imagination, to bring about healing from within (Cunningham 2000). From practical experience, patients work well using this approach. They are usually very inventive and can fill up empty spaces with ‘magic healing fluid’, making it the colour and consistency which is just right for them. They can change parts of the body which look dark and diseased by flushing out all the dark colours and replacing them with bright healing colours. Often the healing comes about in the patient’s unconscious through seeing themselves whole again; even though the physical reality may be different.

CLEAN LANGUAGE MODEL

Finally, another useful framework worth consideration is that developed by Grove and Panzer (1991) to resolve traumatic memories. The basis of the model is the use of what they refer to as clean language (using the patient’s words). They assert that this ensures that the patient’s meaning and resonance remains wholly intact, and is uncontaminated by the therapist’s words. Working in this way opens the door to change through developing a much more naturalistic trance which avoids evoking resistance. The therapy begins by inviting the patient to tell their narrative, paying attention to the language they use. This is done by examining the auditory, visual and kinaesthetic channels used, in addition to noting how they use language in order to describe their experiences and inner realities.

The model suggests that a patient may express their internal reality in one of four languages. These are expressed as: memories, symbols, metaphors and semantics, and the therapist’s role is to discover which of these appears to be predominant.

Grove and Panzer (1991) link this way of working with neuro-linguistic programming (NLP) and Ericksonian therapy, in that the therapist matches and paces the patient’s language and mirrors their body language. They assert that their model goes further as the adoption of clean language and the structuring of questions, facilitates the patient to naturally go into trance. They describe this as conversational trance, and feel that the benefits arise because patients can go inside to get the information they need, and then give feedback to the therapist in relation to what they see and how they want to work. It also allows the patient to give feedback when they have completed their task.

HYPNOTHERAPY FOR WEIGHT CONTROL

Hypnotherapy can be a very useful tool dealing with weight control issues. It can be used to help clients to re-programme their unconscious attitude to food and also to place less importance to food in relation to their feelings of well-being. Hypnotherapeutic suggestions can be used to increase the appeal of healthy foods and enhance the sensory experience of eating. It is also a useful tool to help to reduce negative self-image and boost positive body image.

During the initial consultation, it is useful to help the client to set a well-formed outcome. A key factor for clients in reaching their desired weight is to have a clear and realistic goal in mind. Focus on what they want, not what they don’t want. ‘I want to be slim, fit and healthy’, rather than ‘I don’t want to be fat’. This should be specific, e.g. ‘I want to lose 1 stone in 2 months’ or ‘I want to feel comfortable in size 12 clothes’. Visualizing is also key here, and it is useful to help the client develop a clear picture of themselves the way they want themselves to be, ‘see yourself looking fit, slim and healthy, make the picture as bright and you can.’ This point is reinforced frequently during the hypnotherapy session, as it is important for the client to focus upon how they want to be; to send messages to their unconscious mind to explore every opportunity possible to move towards their goal. Visualization techniques can be a very useful tool in helping the client to develop a positive body image. During hypnosis, the client bypasses critical consciousness and therefore is often able to create a very vivid picture of themselves looking and feeling slim and healthy.

A particularly detrimental aspect of dieting is the obsessive behaviour which is created. When a certain food is ‘forbidden’ we tend to want to eat it all the more. The restriction of certain foods sets up obsessive behaviour patterns. Strict dieting regimes are antisocial, impossible to maintain long term and lead to yo-yo dieting and low self-esteem. It is important to emphasize that if they want to gain control of their eating patterns, they should not deny themselves any types of food. The aim is to move away from relying on the willpower it takes to follow other people’s rules and to move towards listening to their own body. Hypnosis can be used in a way which puts the client in control of their own eating patterns. The following technique is a method of helping the client to tune in to their body’s needs.

A significant step to becoming permanently slimmer is to tune into your own personal hunger gauge. This is a highly effective tool to help you become aware of your own body’s needs. Imagine a horizontal scale in your stomach marked incrementally with 1 at the bottom up to 10 at the top. One representing a feeling of starvation and physically faint and 10 representing feeling stuffed and nauseous. The points in between range from 2 – very hungry; 3 and 4 – averagely hungry; 5 – neutral; 6 and 7 – nicely satisfied and 8 – quite full. Picture and tune into this gauge whenever you go to eat something, if it registers 5 or above you soon become aware that your body does not need the food. You are always in control with this method, there is no should or shouldn’t, just you making your own choices.

Stephenson (2005)

The above technique is often unconsciously used by naturally slim people who also check how their stomach feels when they approach meal times. They often imagine how the food would feel in their stomach over time if they ate it. The thought of sickly sweet fattening food slowly digesting may not be very appealing. Hypnotherapeutic suggestions can be used to reinforce this point and enables the client to recognize foods that help to make them feel good inside. As the client becomes more and more in tune with their own body, they move towards gaining a strong sense of inner security and confidence.

Many people gain weight due to a series of bad habits they develop over the years. This may include reaching for biscuits with a cup of tea, driving short distances instead of walking or eating heavy meals late at night. Clients will find it easier to change habits when they become consciously aware that they are not a part of themselves, but simply bits of behaviour that they have learnt and can be unlearnt. Hypnotherapeutic suggestions can help clients break old habits on an unconscious level. Suggestions can be made during the hypnotherapy session to incorporate new patterns of behaviour with regard to times, places and reasons for eating. Post-hypnotic suggestions can be incorporated into the hypnotherapy session for: symptom substitution, trading one eating habit for another healthier option; symptom amelioration, to directly reduce overeating and symptom utilization, to encourage the client to accept and re-define eating habits (Alman 1992).

There are some people for whom being overweight is a symptom of something deeper and the therapist may use analytical tools such as regression or dissociation. However, the vast majority of people who seek hypnotherapy for weight control, respond very well to suggestion therapy combined with goal-setting visualizations and techniques to listen and respond to their own specific and unique body. This combination can help the client to gain control over their eating patterns and develop a more positive body image.

BODY IMAGE AND SEXUAL ISSUES RELATING TO ILLNESS OR DISABILITY

Changes arising due to illness or disability can leave patients and their partners requiring support to adjust to the body image and sexual issues which may arise. Any support offered should aim to facilitate adjustment to the resulting changes and the losses which these may bring. Each patient’s response to his or her illness is unique, and helping them through the anxiety of adjustment requires an individualized holistic approach. People use different coping mechanisms in an effort to adjust and an initial reaction of denial has an important role in protecting against unbearable anxiety (Wells 2000). Before using any hypnotherapy techniques, the therapist needs to assess if this is the case and decide whether hypnotherapy at this time would have a positive effect. In many cases, denial operates as a healthy mechanism and protects the person against the immediate shock of reality (Cawthorn 2006). Davidhizar and Giger (1998: 44) remind us that ‘normally denial diminishes and the person begins to face and accept the harsh reality of what has been blocked’. However, when denial appears to be causing a problem or is longstanding, often the solution lies in identifying and working through what is causing the blockage. The patient’s own critical sensor will protect them if they are not ready to make any changes during trance work.

CANCER DIAGNOSIS

Being diagnosed with cancer can have a major impact on body image and can include a total body effect, as patients come to terms with their own mortality (see Ch. 14). The psychological impact of an altered appearance relating to cancer can be far-reaching and varied (Harcourt & Ramsey 2006). This is because problems occur not only in relation to the disease, but also as a result of the side-effects of treatments, which include surgery, chemotherapy and radiotherapy and hormone therapy. For these reasons, people may be attempting to recover from one body image change, only to be faced with one after another, which makes adjustment even more difficult.

When adjusting to body image changes, the reactions of others are very important. This is particularly relevant if the changes arise as a result of rapid disease, surgery, accidents and cancer treatments, as the person is still struggling to come to terms with their own thoughts and feelings surrounding this. John Diamond (1998) wrote extensively about the ongoing problems he experienced in relation to his oral cancer and subsequent surgery, chemotherapy and radiotherapy. He reminds us that the negative reactions of others can inadvertently add to the problems.

Diamond (1998) writes about his responses to individual treatments. He recalls his surprise at his reaction to the loss of body hair during chemotherapy and the psychological effect this had on his manhood. He goes on to say how he was unprepared for the anger which erupted from nowhere when receiving radiotherapy and the sadness and regret that this was often directed at the ones closest to him, who were his wife and children.

Body image problems (including sexual problems) can occur in relation to any form of cancer, affecting both males and females. Many women report feeling less sexually attractive following breast surgery, as breasts are often seen as a symbol of femininity and sexual attractiveness (Burwell et al 2006). Chemotherapy can add to the problem due to hair loss and increased weight. Breast Cancer Care (2008) sums up the difficulties experienced by this client group in a quote by a patient who was undergoing chemotherapy, who when asked about her sexuality said:

She didn’t feel too sexually attractive as a sweating, bald-headed one breasted woman with mouth ulcers and sore gums!

Men also have body image and sexual problems relating to effects of surgery and hormone therapy for prostate cancer. Reduced fertility, and altered sexual identity or masculinity being just a few of the problems which can arise. There are many issues relating to this client group, which are covered in more detail by White et al (2006).

For some people, the whole experience of any disabling illness can have a profound effect on their sense of self. They effectively become defined by the disease which can potentially take on a life of its own. These thoughts may be out of their conscious awareness, which can lead on to very limiting beliefs about themselves, and translate into changes in behaviour. One common behaviour is avoidance. It is useful to use hypnotherapy techniques when working with patients, as often in trance they elicit a strong image of the disease. It is useful to gain their permission to elicit the image and what this feels like. Some people describe its shape, colour and texture very easily before a trance state is induced, while others only become aware of what it looks like during trance. Negotiation is the key to working in this way, as the person may not want to change the image or bring it into their current awareness through the use of hypnotherapy.

An example of how this approach was effective is with a young woman who learned to adjust and accommodate a tumour situated too near her spine to safely remove it (see Case study 2, Box 9.3).

BOX 9.3 Case study 2

Kirsty, aged 24, came for hypnotherapy to help her to adjust psychologically and physically to a tumour within her abdomen. During imagery she saw the tumour as black and impacting on her femininity (see Fig. 9.1). She sat awkwardly and because of this complained of low back pain. In trance she was able to clear the black away and pack the area around the tumour with white feathers, making it much softer and accommodating. This resulted in her being able to sit in a more relaxed way, reducing her back pain. Hypnotherapy was used to work on an abusive relationship, and she was happy to send the abuser off in a hot air balloon. Kirsty went on to draw this work in collaboration with her art therapist. The internal changes can be seen in Figures 9.1 and 9.2 and her personal growth and healing can be seen in Figures 9.3 and 9.4. She still has the tumour in situ (currently dormant) but has adjusted to the disability it brings.

FIG 9.1 Imagery. Kirsty, Case study 2 (see Box 9.3 for details).

FIG 9.2 Imagery. Kirsty, Case study 2 (see Box 9.3 for details).

FIG 9.3 Imagery. Kirsty, Case study 2 (see Box 9.3 for details).

FIG 9.4 Imagery. Kirsty, Case study 2 (see Box 9.3 for details).

SELF-ESTEEM AND SELF-WORTH

Low self-esteem and/or self-worth can result from body image problems. However, these could be longstanding issues which the new problems further compound. Newell (1999) suggests that body image changes can affect the person’s quality of life, resulting in reduced self-confidence and low self-esteem, which in turn can cause difficult social interactions and, ultimately, social withdrawal. White (2006: 678) reminds us that ‘serious illness and disability remove a person from their accustomed personal, social and sexual relation, threatening self-esteem and attractiveness at a time when their need for intimacy and belonging may be greatest’.

When assessing patients, it is important to elicit their perception of the problem and also find out how significant others perceive it. Perceptions are important and patients often assume that their body image changes will be problematic for their partner, when in reality this is not usually the case. A Macmillan ‘super survey’ (2008) found that only 5% of partners found the patient’s body image change to be problematic (see: www.macmillan.org.uk/sex).

It is important to assess the patient’s mood, as a low mood can impact on their body image, self-esteem and self-worth. Common psychological problems include anxiety, depression and adjustment problems/disorders. People living with depression often have negative expectancy and Yapko (2001) suggests that the first task in treating a depressed client is to address any sense of hopelessness.

SECURITY

Personal security is something we do not consider when life is going well and it is only when our security is challenged by life-threatening or life-changing experiences that we become aware of it. At these times, our whole being is threatened and we begin to consider our own mortality. An example where both individual and collective security was threatened was following the 9/11 or 7/7 terrorist attacks. During this time, there was a sense of personal and collective insecurity, which took time for people to adjust and move on from. This same scenario is repeated following the diagnosis of a life-threatening or life-limiting illness and can impact on the personal security of both the patient and their family members. From an existential perspective, cancer is still (incorrectly) viewed by many to signify impending death. John Diamond (1998) wrote that when diagnosed with cancer, he saw a death sentence. For him this eventually became true, but for many, it merely raises existential concerns which need to be worked through (see Ch. 14). Illness may bring other issues which relate to security such as financial, social, role changes and the ability to maintain and develop relationships. It may also raise old insecurities which can be transformed through trance (see Case study 3, Box 9.4).

BOX 9.4 Case study 3

Sheila, a 50-year-old lady, was recovering from breast surgery and she was afraid to undress in front of her husband in case he said she was ‘ugly’. On inquiry, it transpired that her mother had called her ugly as a teenager and this is where her body image issues originated. In order to reduce the impact of this memory, an adapted NLP technique was used (Rushworth 1999). Sheila contained the image of her mother (saying she was ugly) in a television screen. Sheila had the control switch and she turned the colour down, making it black and white, then turned the sound down and finally shrunk the picture down until she was happy with it. At the following session, Sheila said that her mother (surprisingly) had made contact with her for the first time in 20 years. Sheila was able to meet her and saw that her unkind words no longer impacted on her. When Sheila realized she was projecting her mother’s behaviour on to her husband, she allowed him to see her naked without fear of rejection.

Maintaining security is important for a healthy body image, and hypnotherapy techniques which help patients regain their sense of security and regain control are of great benefit. Learning self-hypnosis, accessing a safe place and having a supply of positive good memories which can be anchored at times of insecurity can all be useful. Being able to change an insecure image can also help to increase security.

LOSS

It is important to identify and work with the losses which a change in body image may bring. These losses could be overt and may include loss of body part/s following surgery including amputation, mastectomy, or enucleation of an eye. Other less overt losses, but equally significant, may include hysterectomy, oophorectomy (ovaries), prostatectomy and total or hemi-colectomy. Losses which relate to bodily functions such as colostomy, ileostomy and urostomy, cause the loss of the person’s ability to function as a normal human being. All losses need to be grieved for and many people are able to do this for themselves, while others need psychological support in order to achieve this. However, some people will need additional support in the form of hypnotherapy in order to adjust to the changes which the loss has brought about.

SEXUAL ABUSE/TRAUMA

When assessing people with body image or sexual concerns, it is important to consider that some may have a history of sexual abuse or trauma. These patients may present with body image issues, low mood or anxiety disorders, low self-worth or poor self-esteem, or be treated for an illness which is directly or indirectly linked to the abuse. Personal clinical practice has involved working with people who have developed cervical, vulval, ovarian, uterine or anal cancer, some of which may be linked to earlier sexual experiences or abuse. Some patients do not overtly make the link, but for those who do, this can add to the distress they are already experiencing. Fortunately, there are hypnotherapy techniques which can prove useful with this client group if they are comfortable working in this way.

When working with patients it is important to listen to how they tell the narrative relating to their concerns. The ‘clean language’ approach adopted by Grove and Panzer (1991) allows the meaning attached to the abuse/trauma to be the patient’s and not the therapist’s. If denial is evident and it is proving to be a useful coping mechanism, then this should be respected. However, if the memories are problematic, there are a number of techniques which can transform them into more positive ones where the patient regains control. Grove and Panzer (1991) suggest a variety of ways when working in this area, all of which should match up with the person’s memories, language, symbols and metaphors.

Negative images can be changed using hypnotherapy techniques. Patients can help to repair the damage by using imagery to heal the areas which they feel have been damaged. They can be supported to imagine themselves regaining control in a situation where this was not the case. If they want to change the image of a perpetrator, they can make them look silly, or shrink them down in size, or send them off in a hot air balloon. This can be achieved during trance (see Case studies 2 and 3, Boxes 9.3 and 9.4).

Where patients have unpleasant memories which they do not want to re-live, then an NLP technique adapted from Rushworth (1999) can safely wipe the memory without the patient needing to re-visit it or talk it through with the therapist. The technique currently used in practice is as follows:

1. The therapist talks through the process with the patient before inducing trance.

2. The patient will be invited to find a safe place, and in this place they will go into a cinema where they can play a film (backwards) of the traumatic event.

3. Before they do this they will have anchored good memories in which they felt safe and secure; one from before the trauma and one from after the trauma.

4. They will be invited to run a film/video of the traumatic event, backwards and forwards until it is wiped. In order to run the film they will be invited to float out of their body, so they will be watching themselves watching the film (disassociation).

5. If during this process they need any support, they will be able to use the adult part of their personality to comfort the distressed part.

Patients will only consent to this technique if they are comfortable with how it is set up with the therapist. It can have a very healing effect without the therapist needing to talk through (or indeed know) what the trauma entailed. They are merely a companion while the patient transforms their negative image.

Working with dreams

Another way of working with trauma is to work with the dreams or nightmares which patients recall. Mallon (2001, 2003) and Kearney and Richardson (2006) offer suggestions as to how to work with dreams, and these have been integrated into the authors’ clinical practice. They recommend avoiding over-interpretation, allowing the person to make their own sense of what the dream evokes and the symbols and feelings they contain. If the patient is comfortable recalling their dream, this can be undertaken within the therapy session or through keeping a dream diary. This involves drawing or giving a narrative of the dreams, noting the shapes, colours, whether any patterns emerge and whether the dreams are reoccurring.

Mallon (2001) suggests that a number of questions are asked in relation to the dream. These refer to who was in the dream and where was it set. If the patient was in it, were they active or passive? Was there anything which impressed them or disturbed them about the dream and what was the main feeling? Healing can sometimes come in sharing the dream. However, for many patients, if there are negative images, traumatic scenes or incomplete or difficult endings, then to transform these while in trance can be very healing. If the dream relates to an actual situation, then it is useful to inquire what the patient wants to change within the dream; whether this is images, symbols or feelings, or even having permission to say to another person what they feel is important for them to hear. If this is carefully set up, then the patient, while in trance, is usually able to achieve a positive outcome with the therapist as their companion. In practice, patients usually know how they would like the ending to be.

Many dreams do not relate to any particular event. However, they may be a metaphor for something else and in recalling the dream, the link may become clearer. One dream which patients commonly recall is one where they are in toilets, where there is no privacy, where cubicle doors are missing and when they report this to people who should be able to help, they are not believed. Sometimes this symbolizes how they feel about their treatment, that what should be personal and hidden is revealed to anyone and everyone, with little regard for how that impacts on their privacy. In addition, despite telling people who should have been able to help, they were not believed, which mirrored their actual experience.