INTRODUCTION

Working hypnotherapeutically with children can be a richly rewarding experience. It offers the opportunity to help the child utilize their own capacity to make beneficial changes and to tap into their limitless creative ability. The underpinning philosophy within this chapter is a belief that each individual child has, within themselves, all the resources they need. It offers suggestions for both therapists and child care practitioners to adopt a child-centred, flexible, responsive approach, whereby the therapist/clinician uses whatever the child brings to the therapeutic encounter to enable the child to achieve their goals.

The term ‘practitioner’ will be used throughout this chapter to be inclusive of both therapists (psychologists, counsellors, etc.) and clinicians (doctors, nurses, etc.). As Sugarman (2007) points out, hypnotherapy is a skill-set and strategy that bridges both physiological and psychological in both intent and outcome.

Research into hypnosis with children suggests that they are generally very good subjects for hypnotherapeutic intervention. It also suggests that they are often more hypnotically responsive than adults. They respond well to creative visualization, metaphor and pretending. In general, children have active imaginations and come along to sessions without many of the preconceived notions about hypnosis. They also tend not to analyse themselves or the process to the extent that adults do. Hilliard (1979) suggests that most of the variables suggestive of hypnotic responsiveness in adults have their precursors in the creative, affective and play experience of childhood.

There are several distinctions between working with children and adults. While adults commonly close their eyes during hypnosis, children, particularly those under the age of 10, seldom do. They often associate instructions for eye closure with being told to go to sleep and may equate it to loss of control. They are curious and do not want to miss anything. This can be somewhat disconcerting for therapists who often regard eye closure as validation of the trance experience and a sign of intensity of the hypnotic experience. This can be initially uncomfortable for the practitioner, as it moves them out of their comfort zone of eye closure and requires modification of their usual practice. Children also have a tendency to fidget and move around more than adults in hypnosis and this can be misinterpreted as a sign that the child is not in trance. Children generally learn hypnosis more easily than adults because they are frequently in and out of altered states of awareness as part of their normal development (Kohen 1990).

There is a well-documented link between hypnotic ability and stages of child development. Children aged between 4 and 6 years tend to be more responsive to a kind of ‘protohypnosis’ which is an absorption in fantasy games related to the external world rather than detached internal fantasy. Between the ages of 7–14 hypnotic ability is thought to be at its peak and decreases during adolescence (Hilliard & Morgan 1978). However, it is important to note that individual children vary greatly in their speed of development. Success in working with children requires the practitioner to be aware of development issues and therefore to adapt inductions and suggestions to not only the age of the child but also to be consistent with the individual child’s level of intelligence, understanding of language and their cognitive and perceptual skills.

CREATIVE FLEXIBILITY

There has been a general shift over the past few decades from the authoritarian, direct approach in the field of hypnotherapy to more indirect permissive approaches pioneered by the work of psychiatrist Dr Milton Erickson. He developed an indirect style of induction, characterized by words such as ‘allow yourself’ and ‘imagine, if you will’, using ambiguous and cooperative, rather than directional language, to guide the unconscious mind into trance. Erickson used a non-directive approach, using stories and metaphors in order to distract the conscious mind, making indirect suggestions to the unconscious mind. He believed that the unconscious responds to metaphor, symbols, images and artfully vague language. His work influenced many practitioners in the field, including Dr Karen Olness, Professor of Paediatrics (foremost authority on the application of hypnosis with children). She is the co-author of the classic text: Hypnosis and Hypnotherapy with Children (Olness & Kohen 1996). The recipe for a successful hypnotherapeutic intervention with children, according to Olness, is using induction techniques which are permissive in nature, emphasizing the child’s involvement and control and encouraging their active participation in the process of experiencing and utilizing the hypnotic state.

Hypnotherapy training courses commonly teach hypnotherapeutic techniques as a series of ordered steps: introduction, induction, deepener, therapeutic suggestion, reorientation, ratification and reflection. This process has been likened to a ‘vessel’ approach to hypnosis, whereby the subject is dipped into a vessel full of hypnotic trance and some subconscious change occurs during immersion. The subject then floats back to the surface, is removed from the vessel and wiped down (Teleska & Roffman 2004). This vessel approach is a useful protocol to use with adults, but less useful with children, as successful hypnotherapeutic intervention with children relies on the practitioner being creative, flexible and going with the flow. Children often arrive for consultation in their own everyday trances, drifting between fantasy and reality. This provides the opportunity to tap into their natural state of being. It can be highly effective to go with the flow of their fertile imaginations and allow the child’s tenacious and self-protected autonomy to dictate the order and flow of the therapeutic outcome (Sugarman 2007).

ETHICAL CONSIDERATIONS

Working with children requires care and consideration, as children are still in the process of developing their own construction of reality. Fordyce (1988) suggests that two questions should be at the forefront of the therapist’s mind when working with children. First, ‘What am I teaching my client by what I say and do?’ Second, ‘What is my client learning?’ These questions arise from the need to maintain a self-supervisory capacity and reflect sensitivity to the ongoing process of the therapeutic session.

Working with children requires the practitioner to have either formal training in paediatrics, child psychology or have taken sufficient postgraduate training and supervision with children in their respective discipline and area of expertise before using hypnosis. It also assumes appropriate training and certification in the use of hypnosis in general and its application to children (Wall 2007).

The practitioner working with children must stay within their own professional remit and know when to refer on to another appropriate professional (see Ch. 3). Children, who present with problems such as pain or enuresis, should always, without exception, be medically evaluated before commencing with hypnotherapy sessions. This is also applicable when dealing with issues such as psychological trauma, whereby the child should be referred for assessment of a child psychologist.

Contraindications to using hypnosis with children are: risking physical endangerment, risking aggravation of emotional problems, hypnosis for entertainment outside the therapeutic relationship and when more effective treatment is available (Olness & Kohen 1996).

PARENTAL INVOLVEMENT

A consideration when working with children is having parents as a contributing factor. The role of parents is significant in the overall process. Their words and actions can support or undermine the hypnotherapeutic work. The child’s problem may even be due to the parent’s behaviour or exacerbated by them. Kohen et al (1984) in a study of over 500 hypnotherapy sessions with children found that negative outcomes were correlated to parental over-involvement. Autonomy is required for children to effectively develop self-mastery techniques and parents ‘nagging’ appeared to negate the autonomy necessary for the child to take ownership of their own self-hypnosis.

The role of the parent is central to the work the practitioner does with the child. From the onset, the practitioner is dealing not only with the child but also with the parent, therefore it is vital to establish rapport with both the child and the parent. There is a fine balancing act between keeping the parents feeling they are part of the process, while also respecting the child’s right to be able to speak to the practitioner about their concerns in confidence. It is important to establish open challenges of communication with parents from the beginning to ensure all concerned are working towards a common goal.

Although there are numerous benefits to using hypnotherapeutic approaches with children, there can be reluctance on the part of some parents to seek out hypnotherapy due to widespread misconceptions about hypnosis. This often comes from the perceived connotations relating to lack of control associated with stage hypnotism. This fear can be allayed by spending time to explore the myths with the parents and offer them reassurances that hypnosis is a very safe and effective therapy and the client is always in control. They may even wish to experience hypnosis themselves so they can feel comfortable with the process.

THE INITIAL CONSULTATION

As the initial point of contact comes from the parent, this provides an opportunity for basic information gathering such as the nature of the problem, family dynamics, child’s health history, etc. This initial discussion also gives the practitioner the opportunity to establish the ground rules in terms of how the therapy sessions will be conducted. In practice, the author finds it useful to conduct this initial consultation with the parent via the telephone or in person prior to meeting the child. This allows for the initial contact with the child to focus upon directly addressing them individually; giving the child the opportunity to express their perception of what is happening to them. It also gives the practitioner the opportunity to establish the child’s level of motivation to change.

The initial consultation with the child enables the practitioner to gather information about the child’s interests, hobbies and experiences. This information can be used later in the hypnotherapeutic process. The language used when addressing the child should be pitched at their level and should avoid being too simple, and therefore patronising, or too complex for the child to understand. The practitioner can enhance rapport by taking into account the child’s perceptual and conceptual skills with regard to both the problem and the possible solutions.

It is important within any initial hypnotherapy session with either an adult or a child, that they can define or perceive a desired therapeutic outcome. While working with children, it is useful to remember that the desired outcome of the parent or indeed the practitioner may be different from the desired outcome of the child. This can be addressed by directly asking the child: ‘Am I right in understanding that what you want is …?’ (e.g. to stop biting your nails). Alternatively, the practitioner can set up an ideomotor response during the hypnotic induction and after asking a series of general yes/no questions, can pose the question about the desired outcome.

The solution-focused ‘miracle’ question can be beneficial in ensuring that the child is engaged in the process and it also enables them to see beyond their condition and set positive outcomes for the future. This helps to give them motivation to change and this is an important variable in the success of the hypnotherapeutic intervention. For example:

The feedback can later be woven into any future orientation suggestions in hypnosis using the language the child uses. Also the absence of symptoms can be translated into beginnings of new future behaviours (Berg 2003).

The child will benefit from the knowledge that hypnosis is not something done to them. It is something that the child does for themselves. As the child progresses throughout the sessions, it is useful to focus on the fact that they have made the changes themselves. Therefore the symptoms do not just go away; something the child did made it better. So for example if the child who bites his/her nails does not do this for a few days the practitioner may say, ‘I wonder what you did to make it better.’ A central theme of the hypnotherapeutic inductions and suggestions is the focus on the child’s own involvement and control in the overall process. Directing questions to the child allows them to answer directly for themselves. If the parent persistently answers for the child, refocus on the child by saying, ‘OK so that is how your Mum would answer my question and what do you think?’

Children are not always as forthcoming as adults when describing their conditions and often need gentle prompting such as ‘What can you tell me about xxx?’; ‘How does having xxx make you feel?’; ‘Is this a problem for anyone else?’ Once the practitioner has elicited the symptoms in the child’s own words, it is useful to use these words when feeding back to the child. This helps to establish rapport and allows the child to feel understood.

SPECIFIC CONDITIONS

Hypnotherapy has been used as an effective tool to help children overcome a wide range of conditions. It has been used to overcome phobias (Hatzenbuehler & Schroder 1978), in the control of pain (Olness & Kohen 1996), with sleep disturbances and nightmares (King et al 1989). It has also been used successfully in paediatric oncology to alleviate chemotherapy-related nausea and vomiting (Hawkins et al 1995).

There are many techniques which can be employed when working with children, notably dissociation, re-framing, anchoring, suggestion, creative visualization and metaphors. A practical application of these techniques and case study examples will be explored in the following section. The intention is to illustrate examples of interactive co-creative processes, as opposed to prescriptive imagery and scripts.

MEDICAL PROCEDURES

An effective technique to use with children undergoing medical procedures is the trance phenomenon disassociation, whereby the child experiences their body, mind or feelings as separate from themselves. This enables the child to put a barrier or some distance between themselves and any discomfort. This technique is very useful in dental treatment, for example, suggesting to the child that they can imagine going to their own special place (Box 12.2). The child is asked to imagine a place where they would feel safe and comfortable; this can perhaps be a place familiar to them or created in their imagination.

Dissociation is a very useful tool to use to help a child feel more comfortable and in control when undergoing a variety of medical procedures such as lumbar punctures, bone marrow biopsies and chemotherapy. Liossi’s (1999) review of a range of research studies indicted the usefulness of hypnosis as an effective intervention for the control of pain and anxiety associated with medical procedures.

The use of hypnosis with children undergoing medical procedures has many advantages. It is safe and does not produce unpleasant side-effects. There is no reduction of mental capacity and no development of tolerance to the hypnotic effect. It can help the child to develop a sense of control and personal sense of mastery.

REDUCING ANXIETY AND BUILDING SELF-ESTEEM

Hypnotherapeutic suggestions can help to build self-esteem and reduce anxiety (Box 12.3). Children can often get caught up in a cycle of worry about a whole variety of things from concern about friendship groups, anxiety about performing well at school and adapting to changes at home. Just in the same way as adults often do, children can make themselves quite anxious about many things and this can lead to developing some of the physical symptoms of stress such as upset digestion, insomnia and lack of concentration. Hypnosis can help children to break the cycle of worry and learn to accept that sometimes life is a challenge, and that they are more than capable to rise above any challenges and deal with things in a calm and positive manner. Children are often very receptive to learning new ways to regain a sense of control. Relaxation techniques, role play and creative imagery can help them to feel empowered. Cognitive-behavioural approaches and positive hypnotherapeutic suggestions can help the child to feel good within themselves and about themselves, increase their levels of self-confidence and bring about a calmness of mind. It can also help them to be free of anxious stressful thoughts.

MANAGING PAIN

Hypnosis is an effective method for controlling pain. This approach is based on the premise that the processes of the mind have a direct effect on the body. At the mind/brain level, many children are able to distort their own perception, so that they experience deep levels of anaesthesia using hypnosis. At brain/body level, increased endorphins, the body’s own natural pain killer, have been recorded in clients following hypnotherapy sessions (Rossi & Cheek 1988).

The history of hypnosis demonstrates the use of pain management from the amputations of surgeon James Esdaile through to the current use of hypno-sedation. There are numerous clinic research studies on the use of hypnosis in pain management (Olness 1987, Kuttner 1988).

It is important to remember that pain is in a sense a warning signal and therefore the practitioner must ensure that the child’s parent has sought medical advice before doing pain management work.

Children tend to respond very well to making changes to the size, shape, colour and temperature of their pain. While taking the case history, it is useful to ask the child to describe the sensory modalities of pain, e.g. the kinesthetic sensations of the pain such as sharp, pounding, heavy, dull, twisting, tingling, stabbing, etc. They may also describe thermal sensations such as hot, boiling or cold. As the child describes their pain, it is useful to take note of the metaphorical references, e.g. ‘The pain is like a hammer pounding away in my head.’ You can ask them to close their eyes and imagine what the pain looks like and to describe the imagery of pain such as shape, texture, size, colour and even sound. This information gathering serves two useful purposes. First, it helps the child to feel understood and therefore enhances rapport. Second, it gives you information to work with in hypnosis.

Hypnotherapy can also help to alter the child’s perception of pain by helping to alter the interpretation they put on pain. You can suggest in hypnosis that the child can substitute the painful sensation for a less unpleasant sensation such as a tingle or an itch. This is particularly useful for clients who need to continue to be aware of the stimulus of the pain. For example:

Displacement of the locus of pain is another very useful method of pain control using hypnosis. The pain can be displaced to another area of the body to a less vulnerable less painful area from the ear to the toe, for example. The practitioner can also continue this and suggest the client moves it outside the body. One poignant example of this type of pain control is the case of my own daughter (Box 12.4).

THE GIFT OF SELF-HYPNOSIS

A wonderful gift to give to children during the therapy sessions is to teach them self-hypnosis. This enables them to actively participate in the treatment process and to reinforce self-mastery. Karen Olness’s (Olness & Kohen 1996) research into school children using self-hypnosis to change immune response, including both humoral and cellular response suggests that all children with chronic conditions such as haemophilia, cancer, diabetes and sickle cell disease should have the opportunity to learn self-hypnosis as soon as possible after the diagnosis is established.

Australian paediatrician, Dr Hewson-Bower’s research into hypnotherapeutic intervention demonstrated that children who learnt to practice self-hypnosis have reduced numbers of respiratory infections and fewer days’ illness when they do contract a respiratory infection (Hewson-Bower & Drummond 1996). Hawkins and Polemikos (2002) found that school-aged children who were experiencing sleep disturbances following a trauma benefited from learning self-hypnosis. In a controlled trial conducted by Olness (1987), self-hypnosis was shown to be significantly more effective than either pain killers or placebo in reducing the frequency of migraine headaches in children between the ages of 6 and 12 years of age. Teaching children self-hypnosis helps them to cope with stressful and challenging events using these self-mastery techniques as transferable skills. Evidence suggests that many young people continue to transfer the skills learnt in one context to other challenges and to learn for example, to control habits, prevent migraine and control anxiety (Kohen et al 1984).

SUMMARY

Working hypnotherapeutically with children requires a responsive adaptable approach on the part of the practitioner. It allows the practitioner to be inventive, playful and spontaneous and to build a strong therapeutic relationship with the child while providing symptom relief (Liossi 1999). When working with children using hypnotherapeutic techniques, it is useful to remember that hypnosis with children is easy but not simple, it is fun but requires concentration and it should be conducted with respect for the child and their intrinsic abilities (Kohen 1990). Successful intervention is based on harnessing the power of the child’s rich imagination and working with the child in a flexible, creative and responsive way. If practitioners wish to successfully work with a child, then they must modify the inductions and suggestions so they are compatible with the age of the child. The case study examples offered all have a common theme of working without set scripts in a spontaneous way, taking what the child offers and incorporating it into various well-known techniques such as disassociation, anchoring and creative visualization. The techniques all involved pacing the child’s experience and leading the child into a more resourceful state to achieve a successful outcome.