This paper, the fourth in the present series, is based on a world-wide search of the
literature, and focuses on the use of hypnosis in the treatment of social phobia and
agoraphobia. Both disorders are complex and difficult to treat. Several explanations of
the aetiology of social phobia and agoraphobia have been suggested over the years, but
researchers are in agreement that, in both disorders, patients have frequently suffered
inadequate parenting and experienced a huge amount of anxiety in early life. It is
for this reason that therapists using psychodynamically orientated psychotherapy in
treatment, must take great care to provide patients with the space to come to terms with
these inner conflicts. Hypnosis is employed as an adjunct to therapy: It is used to help
patients to reduce cognitive and physical symptoms of anxiety and provides them with
more control in everyday situations. The author reviews a range of treatment procedures
which have been shown to be highly effective in the treatment of both social phobia and
agoraphobia. Some of these treatments are based on behavioural lines, but all of the
approaches, to a greater or lesser extent, explore the psychodynamics responsible for the
condition. Detailed accounts of the treatment procedures are given so that practitioners
may incorporate these techniques in clinical practice. Implications of treatment are
discussed.
Phobias, according to the DSM IV classification (American Psychiatric
Association, 1994), are contained within the category, “Anxiety Disorders.” In
this journal, Kraft and Kraft (2006) gave an account of the use of hypnosis in
the treatment of both anxiety disorders and sleeping disturbances. It is clear
that, from the classification above, phobic anxiety comes under the remit of

anxiety disorders; however, due to the complex nature of both agoraphobia
and social phobia, the author has decided to devote this paper to the subject.
The following study looks at the way in which hypnosis has been employed as
an adjunct to psychodynamic psychotherapy in the treatment of agoraphobia
and social phobia. These disorders will be elaborated now and the role of
hypnosis in their treatment considered.

AGORAPHOBIA
Agoraphobia is a very complex condition and varies from person to person.
The Shorter Oxford Dictionary (OUP, 1993) defines the term as “an irrational
fear of open spaces”; however, the Greek word “agora” literally means
“assembly” or “market place.” Individuals suffering from agoraphobia are
anxious about a range of places or situations outside the comfort and safety
of their home, although this can be extended to other places near or around
the local area. These places are known as “comfort zones” (Chambless, 1982).
Agoraphobics can indeed fear open spaces, but can also be afraid of being in a
crowd, standing or walking across a bridge, travelling in a car, on a train or bus,
being alone, standing in a field, meeting friends, climbing hills, going shopping,
walking amongst tall buildings, and some fear different types of weather. The
effects of agoraphobia vary considerably: some individuals are housebound
while others are able to venture into the outside world, albeit with varying
degrees of success (Buglass, Clarke, Henderson, Kreitman, & Presley, 1977;
Chambless, 1982); further, each person can experience fluctuations within
a week or month, and traumatic incidents in everyday life can often have a
deleterious effect on wellbeing. In many instances, agoraphobic patients feel
that they cannot escape a situation and most go at lengths to avoid difficult
situations which might potentially set off a phobic response: Agoraphobia
is often accompanied by panic attacks and these, according to DSM IV, can
produce a range of symptoms. These include: palpitations and accelerated
heart rate, hyperhidrosis, trembling or shaking, shortness of breath, choking
sensations, chest pain, nausea, abdominal pain, dizziness or light-headedness,
dissociation and/or feelings of depersonalization, feelings of losing control, fear
of dying and hot flushes.
More often than not, individuals with agoraphobia stop working or begin
to develop phobic attacks as a result of having stopped work (Ellis, 1980;
Katerndahl & Realini, 1997); furthermore, their reduced mobility outside
the house affects overall quality of life (Leon, Portera, & Weissman, 1995;

Milne, 1988). Others continue to work or expose themselves to their own
personal feared situation or place, but continue to be anxious, and this is often
associated with intermittent panic attacks. However, agoraphobia is selective
and in some cases, for instance, on special occasions, individuals are able to
cope with a feared situation with a companion or “safe partner.” However,
these associated panic attacks can be so traumatic that many sufferers avoid
any situation which might lead to a reaction and, as the condition worsens,
more complex avoidance patterns begin to emerge. Some individuals who
have been suffering from agoraphobia for a period of time complain that the
mere anticipation of having a panic attack is enough for them to avoid, or be
fearful of, a specific situation or place: Some authors refer to this as “the fear
of fear” (Goldstein & Chambless, 1978; Kraft & Kraft, 2004).
Agoraphobia is very difficult to treat and its aetiology often centres around
complex and irregular family dynamics: It is for this reason that treatment
tends to be long-term (Milne, 1988). A number of case studies has shown that
agoraphobia can be treated using behavioural procedures, and successful results
have been reported using systematic desensitization (Kraft, 1967; Wolpe, 1958),
group exposure (Teasdale, Walsh, Lancashire, & Matthews, 1977), flooding
(Matthews et al., 1976), in vivo exposure (Emmelkamp, 1980), and hypnosis
(Mellinger, 1992; Gruenewald, 1971). Agoraphobia has also been treated
using antidepressants (Mavissakalian & Michelson, 1986), psychotherapy (e.g.,
Shilkret, 2002) and CBT (Beck & Emery, 1985). However, whether hypnosis is
used as an adjunct to therapy or not, due to the complexity of this condition, it
is extremely important for clinicians to provide clients with the opportunity to
come to terms with the psychodynamics responsible for their condition. The
following looks at how hypnosis can be employed to accelerate and enhance
treatment in clinical practice.
An extensive search of the literature has uncovered seven studies which
have used hypnosis in the treatment of agoraphobia: The first two studies
(Gruenewald, 1971; Jackson & Elton, 1985) use a hypnoanalytic approach
with age regression, the third and fourth studies (Hobbs, 1982; Schmidt, 1985)
both use audiotapes, the fifth study (Mellinger, 1992) employs a hypnotically
augmented multidimensional approach, while the sixth study (Roddick, 1992)
uses a fantasy technique to encourage cognitive re-structuring. Finally, the
seventh paper (Milne, 1988), is useful in that the therapist employs a number
of approaches in treatment including group therapy, ego strengthening and
the gradual introduction of hypnosis from a process similar to meditation. In
all of these studies, with perhaps the exception of the final study (Roddick, 1992), the treatment hinges on an exploration of the family context in order
to uncover the sources of the agoraphobia.
Hypnoanalysis and Age Regression
Often in treatment, agoraphobic patients are highly resistant, and therapists
need to make some important decisions about the treatment program and
how to utilize these actions in order to effect change. In addition, the source
of the phobia may lie in the distant past and focus on traumatic events in
childhood involving one or both of the parents. When using age regression
and/or hypnoanalysis in hypnosis, it is important to encourage the patient to
explore safely their recollections of these traumatic events, but this must be
done with care, and, at all times, exposure to these events should be combined
with positive enhancement and ego strengthening. It is also recommended,
when using age regression, to employ a dissociative technique during the
process: This might include, for example, the patient watching a younger
version of herself, watching a film or seeing a reflection. It is essential that
the therapist should provide the patient with the opportunity to integrate
the present with this past, traumatic experience and that the purpose of the
regression should be to help her to learn from this event and to become
stronger as a result.
Gruenewald (1971) described in detail the successful treatment of a 58-yearold woman who had had a 43-year history of agoraphobia with concomitant
vertigo and anxiety attacks. She had an overwhelming fear of crossing the road,
and she was petrified that she would fall over and hurt herself. In addition, she
felt helpless, insignificant and small in comparison with tall buildings; these
buildings seemed to close in on her and “crush her to death.” In the past, her
over-protective husband would accompany her for short distances around the
neighbourhood, and would fulfil daily tasks for her, thus self-perpetuating
her condition; however, her husband’s failing health caused him to be less
protective. As a result, she derived fewer secondary gains from her condition,
and this, in turn, provided her with a rejuvenated motivation for therapy.
Born in Russia, the patient recounted early in treatment the fact that
she had lost her only sister at the age of five, and as a result of her father’s
underground activities had had to leave the country shortly after this event.
The patient described her mother as “hostile towards men,” and she passed
this hatred on to her daughter. She described the move to the U.S.A. as a
frightening one: Both she and her mother, with some justification, felt that they would be attacked or sexually assaulted by the soldiers on the train. But
her main fear was one of abandonment: She feared that she would be left
behind. This feeling was exaggerated when she arrived in the U.S.A. because
she was retained on Ellis Island in order to recover from residual trachoma.
Later in treatment, the patient described her fear and trepidation when
going to high school, and it was essentially at this time, aged 15, and at the time
of menarche, that she developed agoraphobia and depression. She was unable
to go to school, and were it not for her two brothers, who later took her to
and from school, she would not have had a high school education at all. At the
age of 20, the patient described having a complete breakdown and said that she
had become “totally immobilized,” and consequently spent most of her time
in bed with severe headaches. With her father’s help, aided by his optimism and
humour, she was able to work locally; at 24, she married, and at 30 gave birth
to a daughter. Twelve years later, after a phantom pregnancy which turned out
to be a hydatidiform cyst, she suffered from a second depression which centred
around the fact that she had a disappointing marriage and, consistently, sexual
intercourse was a frustrating experience for her.
After several weeks of psychotherapy, a treatment strategy was formulated
which would consist of three to six months of systematic desensitization,
some hypnoanalysis, together with further psychodynamically orientated
psychotherapy. It was clear that during the first hypnotherapy session, there
was a huge amount of resistance to treatment: This manifested itself in the
patient’s ambivalence towards the therapist. However, the therapist overcame
this using an authoritative invitation to lie down and experience “a new
kind of relaxation.” After the induction and deepener, she spontaneously
abreacted and, after this subsided, she was encouraged to feel sensations of
soothing and was given direct suggestions of reintegration. The therapist used
the first hypnotherapy session to establish herself as a figure of authority and
control, and she felt that this would encourage the patient to have a positive
transference.
However, after several weeks it became clear that, every time the patient
was asked to be active in the hypnosis, she resisted: She refused to give
ideomotor signals, she was unable to simulate any sensory changes given
by the therapist, and she refrained from carrying out the progressive muscle
relaxation exercises at home. Later on in the treatment, the therapist employed
scene visualization and sensory imagery and this started to reduce her anxiety;
however, she began to develop a second psychosomatic symptom—sciatic
pain. The therapist cleverly suggested that her unconscious mind “didn’t have to acquire a secondary symptom” if she wanted to get rid of the old one, but,
if she wanted, she could consult a medical doctor on the subject about her
“symptom substitution.” This suggestion had the desired effect, as the mere
prospect of having to pay extortionate private medical fees was enough to
eliminate this secondary manifestation.
The psychodynamic psychotherapy at the beginning of each session was
used to encourage the recall of stimuli in the hypnoanalysis. In the following
weeks, the patient recalled three memories in her past which illustrated the
roots of her agoraphobia. One recurring image was at the age of four or five.
The patient described nearly drowning, and looking at nude men and women
bathing in a lake; although the mother was there to revive the patient, she was
absent in the fantasy image. This reinforced the therapist’s opinion that one of
the sources of her problem was her fear of being abandoned; the therapist gave
the patient space to come to terms with her infantile erotic fantasies, her fear
of abandonment and death.
The second memory was when the patient was aged seven, and it was
here that she recalled various children taunting a psychotic woman. After
some time, she realized that the significance of this visualization was that she
identified with this lady, and it was connected with her fear of failure. The
third memory dated back to her ninth or tenth year. The memory consisted
of her riding on her bike only to have her mother reprimand her when she
got home. Her mother told her that there were many dangers outside: She
realized at this point that she was made to feel that the outside world was a
place that was associated with fear and trepidation. The patient also said that
she enjoyed lying in the meadow, and the therapist utilized this memory to
encourage feelings of strength and renewed hope. The age regression, in all
cases, was used to set the patient on a new path, where she was in charge of
her destiny. After these hypnotherapy sessions, the therapist then encouraged
the patient to address this material and work through it, and she also set a time
limit for the end of treatment. At the follow-up, a year later, she said that she
was coping well, she had improved control of her anxiety and was coming to
terms with her husband’s increasing lack of mobility.
Jackson and Elton (1985), treated four females all of whom met the criteria
for agoraphobia. In two of the cases reported, hypnosis was used as an adjunct
to treatment. In the first case, the authors described the treatment of a 41-yearold lady, Mrs B, who had had a long history of suffering from agoraphobia.
When she was considered for treatment, she reported that she was unable to
travel on public transport and could not cope with crowded places on her own. At the time, she was still taking amitriptyline (75-100 mg daily), and
clorazepate (15 mg at night), and this was gradually stopped before treatment
began. Over the next six months, Mrs B went to the senior author (Jackson)
for treatment, and she experienced significant gains in the initial stages using
in vivo exposure therapy alone. However, these gains stopped in their tracks
and the patient complained that she had experienced anticipatory anxiety.
Further, she pointed out that, although she was able to travel on a train, she
had had a number of panic attacks, especially when visiting her mother or
when she was the only woman in the carriage.
Using hypnosis with age regression, Mrs B described a traumatic party scene
at the age of eight in which her mother encouraged strange men to undress
and fondle the petrified girl. At this point, Mrs B abreacted and screamed that
she hated her mother. Her ambivalent feelings toward her mother engendered
guilt because she was now old and frail, but the acknowledgement of this was
extremely empowering for the patient. She also pointed out that she projected
the molesters’ faces onto the men on the train and felt that they were going
to harm her or undress her in a similar way. The therapist made sure that,
during the age regression, she was connected with the present, and that she
should use this past event to make her stronger in the future. Following this
important session, Mrs B was able to tell other people—including her friends
and family—about this experience, and this had a huge relieving effect on
her anxiety. As a result, Mrs B was able to travel freely on public transport.
However, this caused further problems in the family context: It seemed that
the husband had a vested interest in keeping Mrs B immobile and, now that
she was able to travel more freely, he became increasingly more introspective,
increased his alcohol intake and underplayed her treatment gains. In the
psychotherapy, Mrs B revealed that she had not had sexual intercourse with
her husband for some time, and that he was impotent. It was clear that her
phobia camouflaged her husband’s condition and the therapy focused on
accepting her ambivalence and feelings of guilt. At the follow-up, the patient
was completely asymptomatic.
The second patient described by these authors was a 42-year-old lady who
feared leaving the house, shopping and using public transport. The patient
had sessions once a week for 11 weeks. Early on in the treatment, the patient
complained that she would be unable to practise the in vivo desensitization
work because of her uncontrollable fear that she would be attacked by her
ex-husband. This fear was eliminated in a single two-hour hypnosis session
in which she was exposed to scenes in which she was being attacked by her ex-husband. She then began to carry out various in vivo exercises on public
transport.
After several weeks, the patient reported that, although her children upset
her, she was unable to voice her opinions because of her uncontrollable fear
of losing them, and this caused her to carry around with her a huge amount
of repressed anger towards her children. Over a number of sessions, the patient
was encouraged to express these feelings to her family. She also continued to
practise her in vivo exposure tasks and made significant improvement.
Use of Audiotapes
In some cases, particularly in the early stages of treatment, agoraphobic patients
are unable to get out of the house and go for treatment. It is, therefore, helpful
to provide telephonic sessions or to arrange home visits in order to help
patients overcome the immense fear associated with leaving the “safe zone.”
Schmidt (1985) used a unique approach in the treatment of a 28-year-old
female with agoraphobia. To begin with, she explained that she had developed
agoraphobic symptoms after a prolonged trauma at work. In the first instance,
she was unable to go shopping, and this caused a huge amount of anxiety;
but this developed, and after a while she was unable to go further than her
neighbour’s house across the street. The therapist arranged for a house call, at
which the patient insisted that her neighbour be present at least somewhere in
the house. The treatment strategy was designed to start with autogenic training
(Luthe & Schultz, 2001), and then moving on to goal-centred hypnotherapy:
This was combined with the use of specifically designed audiotapes. The
rationale behind this was that the initial training in hypnosis would give the
patient immediate success and feelings of empowerment, and that a carefully
designed imagery program on audiotape, if practised regularly and consistently,
would desensitize the patient to public places.
In the first session, after initial history taking, the therapist demonstrated
the six steps of autogenic training as described by Schultz (Jencks, 1973; Luthe
& Schultz, 2001): During this part of the therapy, the patient was encouraged
to attain relaxation by imagining changes through progressive muscle
relaxation, temperature, feelings of heaviness or lightness, and reducing heart
and respiration rates. Following this, the therapist discussed with the patient
the treatment program which consisted of (a) audiotapes, which helped her
to experience different levels of relaxation, using all the sensory modalities,
and (b) a graded imagery program. The first scenario in the graded imagery program was to practise, in hypnosis, going on a trip with her husband near
to the house, and gradually these distances were increased. As the therapy
progressed, the patient negotiated with the therapist that one of the final goals
would be to be able to go to the shopping mall.
It is important in treatment that the patient begins to exercise control not
only in the consulting room but also in everyday situations. The therapist
recognized this and, when the patient stressed the importance of moving
slowly towards each goal, he responded appropriately and to the benefit of the
patient. Each new scenario, which gradually moved closer and closer to the
shopping mall, was incorporated into a new audiotape, and subsequently mailed
to the patient; further, on completion of each task, the therapist arranged for a
telephone session. These sessions were essential for the following reasons: They
provided her with the support and encouragement that she needed, but they
also gave her the opportunity to discuss her progress, and also to make any
necessary changes to treatment strategy. She also felt that she had involvement
in the process, and her somewhat obsessive nature and motivation were utilized
by the therapist: Indeed, she consistently practised the autogenic training on a
day-to-day basis and reported back a huge amount of material relating to her
personal associations and thought intrusions each stage of the treatment. Her
therapist also gave her direct suggestions to meet friends during the week, and
these suggestions were accompanied by feelings of lightness. He pointed out
that these lighter steps would build her self-confidence and provide her with a
new sense of optimism. The treatment lasted six months and, in a letter to her
therapist, she commented that her progress had been maintained.
Another approach which utilized the use of audiotapes is one by Hobbs
(1982). She outlines a treatment program emphasizing the fact that the
agoraphobic patients become introspective and self-analytical and that the
therapist should interrupt this pattern of behaviour in order to effect change.
In addition, agoraphobic patients are often overwhelmed by external and
internal stimuli—for example, sound, heat and cold, light, climate, crowds—
and this hyper-suggestibility to all the sensory modalities can be utilized by
the therapist in the hypnosis in order to provide them with the opportunity
to effect change in their own environments.
Hobbs emphasized that the first consultation is critically important for
agoraphobic patients—and all patients for that matter. When a patient comes
for the first session, (s)he has made a conscious decision to comes to terms
with the fact that (s)he has a problem that needs to be resolved; and, for some,
the wait in the consulting room can be enough to provoke a panic attack of some kind (Kraft, 2011). Hobbs points out that it is important not to keep the
patient waiting for too long, and it is important to build good rapport—one
that is based on trust and continued support— as quickly as possible.
Quite rightly, the author points out that the first two or three sessions vary
from individual to individual, but suggests that all patients should be educated
about the condition, and be provided with audiotapes and explanatory
diagrams which explain the physiological changes which occur during panic
attacks. Patients were also given questionnaires to complete in which they
were asked to construct a hierarchy of difficult, potentially anxiety-provoking
scenarios. Hobbs recorded the audiotapes in order for the patient to become
used to her voice, and, although the tapes were educative, she included a large
number of positive terms which, working as indirect suggestions, encouraged
patients to become more confident. She also gave patients relaxation tapes
to use at home. The first tapes used progressive muscle relaxation, and
gradually hypnosis was introduced with guided imagery. As the treatment
continued, Hobbs introduced patients to their hierarchy and worked through
each scenario through the use of cue cards on which self-coping statements
were written. As the patients became more desensitized to their own feared
situations (Wolpe, 1958) they developed the ability to cope with their anxiety
and eliminated the possibility of having a panic attack.
Multi-Dimensional Approach
An interesting approach to the treatment of agoraphobia is one presented
by Mellinger (1992). This report stresses the importance of the therapist
being adaptable in his treatment approach; indeed, Mellinger had to change
his strategy after the initial stages of treatment. The patient, Mrs G, suffered
from agoraphobia with panic attacks, and had a number of associated phobias
including a fear of flying, driving and shopping. In the first eight weeks of
treatment, Mrs G was given the opportunity to talk about her situation and her
fears. She was then briefed on cognitive restructuring techniques that would
help her in the future, and on the basic principles of exposure therapy—that
is to say, in vivo desensitization. She was also given a thorough explanation
of her disorder and was taught progressive muscle relaxation. Further, she was
given alprazolam which was gradually reduced to a maintenance dose of 1.5
mg three times a day.
In the next stage of treatment, Mrs G was prepared to begin her exposure
therapy which consisted of gradually exposing herself to more difficult anxiety-provoking situations. She planned to go to an all-night convenience
store in order to buy some food; however, despite her preparation, applying
both cognitive–behavioural strategies and using relaxation exercises prior to
the expedition, she had a small panic attack in the shop. Mrs G reported that
she had had a near escape in this situation, and as a result it was decided that
they would use hypnosis and guided imagery in order to enhance her ability to
cope in difficult situations before returning to the in vivo work. In this process,
Mellinger also provided Mrs G with a powerful anchor which consisted of her
touching her fingertips on her solar plexus, whispering the word “relax,” and
this method provided her with a sense of calm and even respiration. Mellinger
also encouraged her to visualize herself watching herself on a television screen
where she was able to adjust the volume, brightness and focus controls (Clarke
& Jackson, 1983). She was able to adjust the volume in order to reduce the
intensity of affect and, when working through the scenario of going to the
shops, she was able to cope using this strategy. Further, she was encouraged
to practise auto-suggestion by herself at home. After six weeks of this work,
she started the in vivo desensitization again, using anchoring whenever she
became anxious, and she practised this four to six times a week. A further
five weeks of this work meant that she was able to go shopping regularly
without panic and reduce her alprazolam intake. Mellinger commented that
the hypnotherapy acted as a “flexible vehicle for fortifying [her] coping skills”
and helped her to be more equipped to tackle real life situations, even after
an initial relapse.
Fantasy Technique
Roddick (1992) briefly described a case of agoraphobia in which he employed
a fantasy technique in hypnosis. The patient he described was a lady who was
unable even to be driven by her husband for more than a mile from her home.
She had a number of associated symptoms which included dry mouth and
nausea and had had to give up a successful career because of her condition.
Roddick must have had problems of resistance during the initial stages because
he pointed out that it took four sessions for her to get used to his approach
and to be able to relax in his presence. He pointed out that, once she had
got used to her therapist, he was able to use hypnotherapy successfully in the
consulting room, and she began to make more rapid progress.
After the induction and deepener, Roddick addressed her unconscious
mind and focused on the following: 1. The importance of practising self-hypnosis and general relaxation,
2. Being able to sit and travel in a car, and
3. Being able to eat and drink.
The therapist then suggested that the three parts should be combined
in order to come up with a strategy that would enable her to cope with
her agoraphobia without any problems whatsoever: This was confirmed as
being an acceptable approach by the patient by way of an ideomotor signal.
The strategy consisted of a “secret place fantasy” in which the patient was
encouraged to throw out all her negative feelings and aspects of her life. After
only two sessions, she reported that she was able to travel 200 km away to visit
her family and, after a further eight sessions, she was able to drive herself to
the consulting room. At the time of writing the paper, Roddick said that she
continued to make progress, and had secured a full time job in the local area.
Use of Group Therapy and Hypnosis
Gordon Milne (1988) reported the treatment of three women with complex
agoraphobia, the most successful of which is reported below. At the start
of treatment, the patient was still able to drive her car but only when
accompanied by her husband. Her panic attacks were severe: She suffered from
hyperhidrosis, dizziness, weakness of the legs, tingling of the hands of the feet,
and, more alarmingly, depersonalization. On journeys, when she lost sight of
her “safe partner(s)”—namely, her husband or her sister—she would suffer
from constant thought intrusions which centred around the following fears: (a)
worrying about collapsing in public, (b) going mad or (c) dying.
During the initial case history taking, she pointed out that she suffered
from periods of depersonalization at school at the age of 12, and that she
experienced a great deal of frustration due to the fact that no one understood
her condition. She managed to control her panic attacks and feelings of
depersonalization with psychotropic medication, and these attacks lessened as
she grew older; however, two sudden deaths of close members of her family
had reactivated her condition.
The patient was delighted to find that there were other individuals who
were suffering from the same condition, and she became a regular member
of the support group at the community centre. She pointed out her life was
made a misery because her husband couldn’t understand why she was unable
to socialize, and he consequently spent more time drinking with his colleagues
after work, which in turn caused a number of arguments late at night. Essentially, the first part of the treatment was to get the husband on board, and
to brief him about the nature of agoraphobia and the treatment strategy. The
therapist arranged a joint counselling session to this end.
The next stage of treatment focused on reducing the panic attacks without
the use of medication: A treatment strategy was put in place so that she would
gain more control of her panic attacks and gradually reduce her psychotropic
medication. Hypnosis was introduced as an extension to meditation, and she
was gradually able to respond adequately well to the therapist’s suggestions.
Later in the treatment, in the hypnosis, she was given ego strengthening to
provide her with the ability to function outside the comfort of her home, and,
using guided imagery, she began by sitting in the car on her own and worked
towards driving to the supermarket. This process of systematic desensitization
was slow. Whenever she became anxious, she raised her finger and was able to
reduce her anxiety by taking five deep breaths. This exercise was taped and she
practised this religiously at home twice a day.
As a result of her work in the consulting room, at home with her practice
tapes, and with the continued support which she gained from being able to
share and listen to other people’s experiences in the support group, she made
a significant recovery. Indeed, the support group was extremely helpful in this
process: Not only were they able to support each other during group sessions,
but they were also able to help by giving each other lifts to and from the
therapy sessions. By the end of treatment, the patient was able to drive herself
without support from anybody else, and was regularly going out on social
events with her husband. At the follow-up, a year later, her improvement had
been maintained.
SOCIAL PHOBIA
According to DSM IV, Social Phobia is characterized by a noticeable fear
response to social or performance situations, and this is connected with a
fear of embarrassment, or being judged by other people. When social phobics
experience a difficult social situation, they invariably become intolerably
anxious, and this can lead to a panic attack. Often, they will go at lengths to
avoid these threats and, in many cases, this can lead to a significant reduction
in mobility and contact with other people. Avoidance in social phobia takes
on many forms: Some patients will even avoid eating, drinking or talking in
public because they fear that others will notice their behaviour or concomitant
symptoms (Milne, 1988). Individuals with social phobia may suffer from the following—shaking hands, palpitations, blushing, hyperhidrosis, muscle
tension, stuttering, gastrointestinal discomfort, persistent feelings of wanting
to urinate and nausea.
Like agoraphobia, social phobia is extremely difficult to treat. In many cases,
the source of the phobia is inextricably interconnected with the quality of
their attachment with their mother from birth until the age of five (Bowlby,
1999). This attachment is essential for individuals to develop. If adequate love,
attunement and comfort are provided at this stage, infants are able to begin
to explore the world around them and this, in turn, leads to individuation,
separation, the ability later to engage in meaningful personal relationships
and to pursue a professional career (Frankel & Macfie, 2010; Kohut, 1984;
Winnicott, 1984). Inadequate attachment at this stage leads to a poor sense of
identity and lack of both confidence and personal autonomy in adolescence
and childhood (Winnicott, 1984): This can cause a constant fear of losing
significant partners and friends. Some use self-sacrificing techniques in order
to maintain relationships (McWilliams, 1994), while others are unable to assert
themselves or display independence in their everyday lives.
The literature search revealed only a small number of case reports that
used hypnosis to treat social phobia. The treatments of choice had tended
to be psychotherapy (Leichsenring, Beutal, & Leibing, 2007), CBT (Taylor,
1996), pharmacotherapy (Versiani et al., 1992) or systematic desensitization
(Marzillier, Lambert, & Kellert, 1976). However, there are two studies that
used hypnosis in treatment: Lipsett (1998) who combined cognitive therapy
with systematic desensitization (both in hypnosis and in vivo), and Frankel
and Macfie (2010) who reported a case in which the therapist used insightoriented psychodynamic psychotherapy and hypnosis. It was clear that, in
both cases, to a greater of lesser extent, it was important that the hypnosis
was combined with a thorough psychodynamic investigation of patients’
dependency and separation, avoidance behaviour, feelings of guilt, and fears of
rejection in both present-day relationships and as an infant.
Lipsett (1998) used a multi-modal approach in the treatment of a 26-yearold man with social phobia. In the first session, the patient, Eric, described
how uncomfortable he felt in what he called “unstructured” social situations:
He complained that he was unable to relate to people and, although he
had some good friends, felt that he was handicapped in social situations,
particularly with new people. Eric was asked for a goal to work towards, and
he said that he wanted to be able to approach strangers with ease and to make
new friends; the first goal, however, was to be able to walk into a hotel and have a conversation with a stranger. Eric was then given direct suggestions
of wellbeing and how the hypnosis would provide him with more control
of his life, his control being enhanced with ideomotor signalling. In the
second session, a cognitive approach was used in order to help Eric fulfil his
potential with his communication skills. He was also taught self-hypnosis and
was asked to practise this twice daily: It was explained to him that this would
condition his sense of relaxation when it was required. He was also asked to
read Matthews’ (1990) Making Friends.
In the third session, these “unstructured” social situations were reframed
so that Eric would be able to define the parameters of the interactions—for
example, he would be able to engage in conversation, talking about the topic
of his choice. During the hypnosis, and using the principles of systematic
desensitization, Eric was then encouraged to buy a drink and to have a
conversation with a stranger in a hotel. The therapist also gave Eric ego
strengthening and asked him to imagine in detail a mental representation of a
confident Eric engaging comfortably in social situations in the future. This was
combined with self-image work (Langton & Langton, 1983), tracing back all
the steps that helped him achieve this goal. Finally, as a homework task, Eric
was asked to go into a hotel and to make conversation with a stranger, and
that this should be done between now and the next session.
In the fourth and final session, Eric reported that he had had a successful
conversation in a hotel and had been bought a drink. Eric did, however, point
out that he dreaded walking in and that he felt chest pains. Lipsett asked Eric
to move from chair to chair. First, he asked him to say what he saw when he
wanted to be able to enter the hotel; secondly, in the next chair, he asked him
what he heard when about to enter the hotel, and at this point he said that
he heard his father’s voice tell him that he “could not go in there.” Using a
somatic bridge, Lipsett instructed Eric to follow his paralysed feelings back
in time: He identified that the source of his problem was at the age of three
when he was terrified of his father’s anger, and he said that he wanted to ‘be
safe’. The therapist then instructed the older, wiser Eric to comfort this little
boy, telling him that he would “be safe.” As a result, Eric said that he was able
to enter a hotel with feelings of being in control and that he no longer froze
or had the unpleasant chest pains.
The second study, provided by Frankel and Macfie (2010), consisted of a
single case study of a lady in her twenties who, although described as having
social and performance anxiety, displayed all the features of social phobia. She
avoided confronting friends and family when she was angry; she experienced  accelerated heart rate and impaired attention; she had extreme difficulty in
forming meaningful relationships with friends and potential romantic partners;
and was obsessed with time management and meeting deadlines at work.
The treatment consisted of 13 months of insight-orientated psychodynamic
psychotherapy on a weekly basis, which amounted to 58 sessions in total, and
this was combined with hypnosis.
In the psychotherapy, the therapist revealed that, as a result of inadequate
attachment experiences as a child, the patient, Ms A, had struggled to develop
into an independent and autonomous adult and was left feeling insecure
and fearful of social situations. Her mother had developed cancer when Ms
A was very young, and her fear of losing her mother was reactivated when
the mother’s cancer returned when Ms A was an adolescent. Importantly, the
therapist provided the patient with a “safe space” and she was given support
and encouragement in the consulting room: This secure environment made
it possible for the patient to experiment with possible new interpersonal
behaviours and explore the view of herself and others in her everyday life.
The therapist provided an adequate attachment bond which, unlike her
childhood experience, encouraged her to practise autonomous behaviours.
The psychotherapy also focused on her avoidance of intimacy during
adolescence and in adulthood; she explored the effect that her consistently
unavailable mother had on her interdependence and began to shape a sense
of identity.
Hypnosis was used in order specifically to focus on reducing anxiety in
social situations. The therapist devoted several sessions to teaching Ms A selfhypnosis. During the hypnosis, the patient was encouraged to bring her mind
to a “soothing and peaceful place,” allowing the physiological manifestations
of her anxiety—namely, the irritability, loss of concentration, accelerated
heart rate, confusion and impaired attention—to disappear, and her mind to
“refocus.” Unfortunately, the patient used hypnosis inconsistently during the
course of treatment; however, Ms A did used hypnotherapy successfully during
difficult social situations, and she regarded it as an “on the spot intervention
tool.”
At the beginning of therapy, the mother’s illness became rapidly worse and
this had an effect on progress. The treatment significantly reduced her worries
about time management but did not reduce the peak level of daily anxiety.
The patient did, however, report that she had less rumination with regard
to time management, while the daily self-reports indicated that there was a
definite cognitive shift away from her anxious fears and worries. Ms A also said that she had begun to place her own needs before other people’s needs
and felt that her behaviour was “less distressing”: In the past, she felt unable
to be forward with other people about her needs and preferences, but she was
now able to communicate more successfully with others and to be consistently
more “open.” This resulted in a shift in her ability to trust others and, with the
addition of hypnotic intervention, provided her with increased confidence in
social situations.
COMMENT
In the case studies reported in this paper, the main focus of the treatment was
to establish the source of the phobia through the process of psychotherapy
and, in both social phobia and agoraphobia cases, this source was associated
with early trauma or inadequate parenting. It was also necessary to consider
the role that marital and/or parental figures played in effectively maintaining
or perpetuating the condition (Hand & Lamontague, 1976). The efficacy of
in vivo exposure therapy has been established (e.g., Jansson & Ost, 1982), and
it is recommended that clinicians incorporate in vivo desensitization into the
treatment program using a hierarchy of anxiety-provoking situations—this
work can be done between sessions.
The Milne study (1988) showed how helpful it was for patients to receive
help from other people: Indeed, the patient in this study benefited significantly
from the encouragement of her colleagues in the support group. Unfortunately,
few support groups of this type exist; however, if group therapy is not available, it
is important for patients to feel that they are not alone (Clarke & Jackson, 1983),
and, as was the case in the Hobbs (1982) study, to be given education so that they
can understand the physiological changes that take place during a panic attack.
Hypnosis is a powerful adjunct to therapy. The case studies presented
here demonstrate that it has been highly effective in helping patients (a)
to explore feared situations in a safe environment; (b) to reduce anxiety
using desensitization; (c) to gain more control using anchoring, fantasy
techniques and autogenic training; (d) to enhance coping strategies using
ego strengthening and breathing techniques; and (e) to reduce affect using
television screen imagery. Age regression (f) was also employed effectively to
help a patient to address, and come to terms with, inner conflicts and traumatic
events in early childhood. Finally, carefully designed audiotapes were employed
to encourage two patients to practise self-hypnosis at home, and this had the
effect of enhancing treatment outcome. The use of hypnotherapy in clinical practice offers are more rapid and cost
effective treatment for social phobia and agoraphobia, and it is recommended
that it be used in conjunction with psychodynamic psychotherapy and/or in
vivo exposure therapy.
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