Hypnotherapy for Traumatic Grief: Janetian and Modern Approaches Integrated

Onno van der Hart, Paul Brown, Ronald N. Turco 1 Hypnotherapy for Traumatic Grief: Janetian and Modern Approaches Integrated Onno van der Hart Utrecht, Netherlands Paul Brown Melbourne, Victoria, Australia Ronald N. Turco Portland, Oregon Received November 11, 1988; revised September 12, 1989; accepted for publication October 18, 1989. Traumatic grief occurs when psychological trauma obstructs mourning. Nosologically, it is related to pathological grief and posttraumatic stress disorder (PTSD). Therapeutic advances from both fields make it clear that the trauma per se must be accessed before mourning can proceed. The gamut of psychotherapies has been employed, but hypnosis appears to be the most specific. Pierre Janet provided a remarkably modern conceptual basis for diagnosis and treatment based on a dissociation model. His approach is combined with contemporary innovations to present a systematic and integrated account of hypnotherapy for traumatic grief. Hypnosis is widely used in the treatment of beginning of the current century Pierre Janet pathological grief but is much underreported. It systematized the hypnotic treatment of posttraumatic speeds and facilitates mourning and makes stress disorder (PTSD), including traumatic grief possible a personal reorientation to the future (Janet, 1889, 1898a, 1898b, 1904, 1911, 1919/25). (Fromm & Eisen, 1982; Yager, 1988). Hypnosis is Recently, the hypnotic treatment of traumatic grief specifically indicated in the resolution of has been taken up again, especially within the con- traumatic grief. Grief is traumatic when it follows text of advances in hypnotherapy of PTSD. objective and severe subjective trauma and when However, further development has been hampered posttraumatic reactions inhibit mourning. by the absence of an adequate conceptual basis for In recent years, reports of traumatic grief in diagnosis and treatment. both children and adults have begun to appear, describing the reactions of survivors of those lost Pathological Grief and PTSD as a result of lethal accidents (Lundin, 1984; Traumatic grief straddles two diagnostic fields: Lehman, Wortman, & Williams, 1987); disasters pathological grief and PTSD. Neither one describes (Raphael, 1986); homicide (Rynearson, 1984; the symptomatology completely, and because neglect Amick-McMullan, Kilpatrick, Veronen, & Smith, to accommodate both aspects may lead to therapeutic 1989); and battle combat (Spiegel, 1981). failure, the clinical focus must include both (cf. Traumatic grief reactions do not occur only when Amick et al., 1989; Burgess, 1974; Eth & Pynoos, the event is witnessed directly. Death of loved 1985; Furman, 1974; Lehman et al., 1987; Lindy, ones can also be seen on television, read in news Green, Grace, & Tichener, 1983). reports, reconstructed in fantasy from court According to Horowitz, Wilner, Marmar, and proceedings, or even experienced in cells adjacent to Krupnick (1980), pathological grief involves torture chambers (0. Brozky, personal intensification of mourning without progression to communication). completion. Parkes and Weiss (1983) subdivided As yet, there have been few reports on pathological grief into three distinct syndromes: treatment of traumatic grief. Singh and Raphael chronic grief occurring from the onset in dependent (1981) describe marked neglect of psychological relationships, ambivalent grief where relationships trauma in bereavement counseling. The earliest are conflicted, and unexpected grief. Parkes (1985) reports of successful use of hypnosis for traumatic recognized that sudden and untimely grief was also grief were from the early and middle nineteenth often horrifying, painful, and mismanaged. 1n fact, century (Bakker, Wolthers, & Hendriksz, 1814; the symptoms of traumatic loss center on recurrent Hoek, 1868). At the end of the nineteenth and terrifying images of the victim's death (Eth & American Journal of Clinical Hypnosis, Volume 32, Number 4, April 1998 Onno van der Hart, Paul Brown, Ronald N. Turco 2 Pynoos, 1985; Rivers, 1918; Rynearson, 1981, reduced; patients became even less able to 1987). These "traumatic memories" intrude into transform their traumatic imagery into narrative waking life as flashbacks and disturb sleep with memory and to perform their grief work, that is, nightmares. They are accompanied by fears of death to accomplish the necessary adaptation to the and dying and by feelings of helplessness and shame loss of their beloved one (cf. van der Hart, (Lindy et al., 1983). Survivors generally avoid re- 1988a). minders of the loss and of death in general (Terr, 1984). They become withdrawn, hypervigilant, and Hypnotic Approaches to Traumatic Grief given to startle reactions. Survivors of the victims of Hypnosis played a key role in Janet's homicide also report feelings of rage and treatment of traumatic grief and related vengefulness (Amick-McMullan et al., 1989; posttraumatic syndromes (Janet, 1889, 1898a & Rynearson, 1984). b, 1904, 1911, 1919/25). His view of the These posttraumatic reactions, which can be relationship between hypnosis and posttraumatic subsumed under the diagnostic category of PTSD stress is remarkably similar to modern thinking (American Psychiatric Association, 1987), prevent as exemplified by Kingsbury (1988): ". grief work; they mask, inhibit, and delay the mourn- hypnosis may be an isomorphic intervention for ing process (Burgess, 1974; Eth & Pynoos, 1985; PTSD because both involve related dissociative Furman, 1974; Rivers, 1918; Rynearson, 1986; shifts in the state of consciousness" (p. 84). Wolfenstein, 1969). Hypnosis was incorporated into a three-stage Thus, traumatic grief is not only a subset of treatment model (van der Hart, Brown, & van der pathological grief but also of PTSD and exhibits the Kolk, 1989). Initially hypnosis was employed to same biphasic symptom-swings from symptoms of induce relaxation, relieve life-threatening arousal, intrusive traumatic imagery, and anxiety to symptoms such as anorexia, mobilize energy, defensive numbing and avoidance (cf. Horowitz, and focus attention on the therapeutic task. In 1986; Brom, Kleber, & Defares, 1989). As with stage two, it was required to access and modify PTSD, there are many formes frustes (cf. Brown & dissociated mental states. Janet called this Fromm, 1986). Not all cases of traumatic grief process "liquidation" and employed three overtly present with posttraumatic symptomatology. hypnotic approaches: uncovering, neutralization, Survivors are frequently silent about their traumatic and substitution. The former was often loss. In some this is a conscious suppression, but in incorporated in the latter two. Neutralization others it reflects psychogenic amnesia. Diagnosis is consisted of progressive uncovering and further complicated by disorders which overlap, dissolution of traumatic memories. It enabled the mimic, or mask the posttraumatic grief response. patient to move from experiential (symptomatic) Cases sometimes present with antisocial recall to neutral, verbal recollection. Substitution behavior and substance abuse, as has particularly was a method of therapeutic revision in which been noted in Vietnam veterans (Jellinek & traumatic memories were substituted by positive Williams, 1987). Traumatic imagery presenting or emotionally inert images. Liquidation of in the form of pseudo-hallucinations may even traumatic memories enabled mourning to be managed as functional psychoses. Kardiner proceed, often with the aid of hypnosis in stage and Spiegel (1947) recognized that the adaptive three. In general, this stage consisted of failure in posttraumatic states, including prevention of the tendency to dissociate and traumatic grief, can actually give rise to the relapse, consolidation of therapeutic gains, and symptom picture of any known mental illness. rehabilitation. It was Pierre Janet who first presented many Uncovering and liquidation of traumatic cases of traumatic grief and emphasized its memories also form the basis of modern dissociative nature (Janet, 1889, 1898, 1904, hypnotherapy for traumatic grief. Methods are 1911). Janet observed that many persons exposed drawn from contemporary treatment approaches to the sudden or violent death of a loved one to PTSD. They are usually not grounded in were completely unable to adjust to it. Instead, theoretical models of psychological dissociation. they were overwhelmed by vehement emotions, We have tried to restore this conceptual basis, which exerted a disintegrative effect on the and below we attempt to systematically describe mind. The traumatic experience became the hypnotic techniques of both Janet and dissociated from ordinary consciousness and modern authors. continued as "traumatic memories," described by Janet as subconscious fixed ideas (cf. van der Hypnotic Approach 1: Uncovering Traumatic Hart & Friedman, 1989). Ordinary consciousness Memories in Traumatic Grief became restricted, and affect and interest also Patients with complicated traumatic grief became restricted. Traumatic memories, evoked are amnestic for the traumatic memories of the by associations and reminders, manifested as death of their loved ones. Instead, traumatic vivid and terrifying flashbacks, nightmares, and imagery emerges in dissociative symptomatology behavioral reenactments in the form of or is disguised and replaced by conversion "somnambulistic crises." The vehement emotions symptoms, antisocial behavior, or psychotic which accompanied these traumatic man- phenomena. Traumatic memories can be ifestations, and the related

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