Recently I stayed at a friend’s house. “You snored all
night long. It woke me up and I couldn’t get back to sleep for over an hour,”
she told me the following morning. “Wake me up if it happens again tonight,” I
said. “Did I snore last night?” I asked the morning after, although I had slept
all night without being woken. “No, not at all. I don’t understand why,” she
answered. “I told myself not to lie on my back at any point during the night,
and instead only to move from my left side to my right side.”
The story “Alarm Clock with a Snooze Button” represents a basic intervention for handing over control of sleep from the conscious to the unconscious, and for suggesting that it is safe to do so because the unconscious knows that it can easily handle the task. The alarm clock story can be used for patients who find it difficult to fall asleep or stay asleep, for patients who repeatedly oversleep and for patients who are worried about waking up too early from an anaesthetic or not waking up at all. It can also be used for all sleep disorders which can be prevented by waking up in time, such as bedwetting, sleep apnoea and snoring, as well as for nightmares. The story embodies the basic suggestion that control is retained even during sleep, and can therefore be used to make it clear to patients with a compulsive and controlling personality that they can stay relaxed while remaining fully in control.
“My body has an internal alarm clock,” one friend said
to another. “Before going to sleep, I tell myself; ‘Tomorrow morning I’ll wake
up at ten past six.’ And then the next morning I’ll wake up at exactly ten past
six. Yet recently I woke up at ten past six and did not get straight out of
bed. I went back to sleep again and overslept.” “That could never happen to me,”
answered his friend. “My internal alarm clock has a snooze button. Before going
to sleep, I tell myself; ‘Tomorrow morning I’ll wake up at ten past six, and
then I’ll wake up every five minutes after that.’”
The case study “Soiled Underwear Again” demonstrates a symptom prescription in the form of homework to carry out a ritual. This paradoxical intervention follows the Milan tradition of systemic family therapy.
Paul was six years old. Almost every day he waited
until he was alone, found a quiet spot in the house where he could hide in
peace and take his time, and then soiled his underwear. His excuses were many
and varied, and often he had none at all. He only used the toilet reluctantly
and under protest. None of the doctors who had examined him had found any
problems. His mother had tried both being patient and being strict.
When I met Paul and his mother, I asked him whether he
thought he could deliberately soil himself on a particular day. He responded in
the affirmative, both to this question and to the question of whether he could
deliberately not soil himself on a particular day.
So I came to an
agreement with Paul and his mother that he should deliberately soil himself,
today if possible, and that his mother should allow him to do so. Tomorrow
could then be the day when he deliberately did the opposite. Or he could soil
himself today and tomorrow, with his mother’s express permission; what mattered
was that he had soiled himself at least once before our next meeting. He could
tell his mother beforehand or afterwards, or simply let her work it out for
herself. And I discussed the details with Paul; on how many days of the
following week he would soil himself, and on how many he would not. His mother
offered to note down every time when he soiled himself on the calendar so that
I could see whether he had done his job properly. The young boy protested that
he would never soil himself again. I made a point of telling him that it was
much too early to be thinking about that. I implored him to try and soil
himself at least one more time
The case study “Continent Eyes” highlights the widespread phenomenon of conversion disorders. Simply alerting clients to the possible existence of a conversion disorder may cure it; alternatively, speculation that the incontinence might be a conversion symptom can also cure disorders which can be influenced through suggestion, presumably through a type of placebo effect.
A man once came to see me because he was still suffering
from continence problems after undergoing prostate surgery, even though his
doctors had told him that there was no longer any organic cause for his
incontinence. During his third therapy session, he told me that he had recently
cried for the first time in years when a doctor told him that all of his
symptoms were perfectly normal, and that he would in all likelihood become
continent again.
“Have you ever heard of a conversion symptom?” I asked
him. “Maybe your excretion organs are incontinent because your eyes are
continent. Your bladder has taken on the role of your eyes or vice versa,
depending on your point of view. I wouldn’t be at all surprised if you became
incontinent in an unexpected way in the near future.”
When I next saw the man, he said: “I don’t know whether
it’s because of what we discussed, but now I only need to use one third as many
incontinence pads to stay dry.”
The story “Shifting Interests” makes it clear that people often have hidden skills which remain unknown to their nearest and dearest, sometimes for decades. It is impossible for us to tell what another person cannot do or does not know, and we are only aware of a small fragment of what he can do and does know. This is particularly true when working with children with behavioural problems or persons with mental health problems or disabilities.
After spending a long time in a coma, Dennis returned
to the land of the living with reduced mental functions. He had forgotten many
things, and was apathetic about most of the rest. Yet he often pointed to the
sky and said, “Look, an F-14 Tomcat plane!” or “Wow, an Apache helicopter!” and
described the engine types, performance, carrying capacity, cockpit equipment,
crew and weapons of the aircraft he saw flying past. “He fought in the Korean
War,” said his wife. “But I had no idea he still remembered all of this. We’ve
been married for 30 years, and he’s never shown any interest in aircraft.”
The case study “Memory” illustrates a procedure for learning to remember things again. Single associative connections are useless if they are disrupted; instead, a larger network of links is communicated so that individual functioning associative connections within this network can help to reactivate others or reconstruct the context.
“After my stroke,” he said, “people knew me but I no longer knew them. ‘I’m
Peter!’ one of them said. ‘Which Peter?’ I replied. ‘Don’t you remember me? We
went to school together, we did our apprenticeships together, we worked side by
side…’, ‘I’m sorry, I don’t remember you,’ I said. ‘But we went on holiday
together,’ he continued, ‘and you gave my daughter Julia this funny teapot.’ ‘Are
you Julia’s father?’ I asked with surprise. ‘He was called Peter and went to
school with me. Is that you?’”
The story “After the Storm”, like the following three stories, is an intervention which can help a patient to recover missing words and skills if he or she has the necessary level of understanding. The stories refer implicitly to the fact that the relevant information is not lost in the brain but merely inaccessible, and can therefore be found again.
The storm has wrought havoc. Fallen trees are strewn
throughout the forest. Their trunks are blocking the paths and roads. No
traveller can pass. Yet the time after the storm is the time when the
lumberjacks start work. They use their saws to open up the paths, move the blockages
and clear the roads, starting at the outer edge of the forest and moving right
to its very interior.
Time and time again we try to take sides, to support the victims against their perpetrators. But who are they, who are the perpetrators? My wife Karine shared this video with me…
The case study “Pantomime” shows what communication of this kind might look like and the effects it can have. Interventions of this kind can also be used to utilise the behaviour of a person suffering from mutism for the purpose of establishing
“Hello. My name is….” he began. “She can’t talk,”
the nurse told him. “She’s had a stroke…” The young patient’s helpless
gestures told him that she could not even understand what he was saying, with
the exception of a few words to which she replied with a nod or a shake of the
head. How can one communicate in such a situation? He used gestures to outline
a steep staircase with high steps in the air in front of him. He sighed; too
steep, too high! He shook his head in disappointment. Then he gestured with his
hands to indicate a staircase with shallow steps, and he walked up the entire
staircase with his fingers. The woman watched attentively and nodded. He used
hand gestures to outline a high mountain in the air. A climber (represented by
two fingers) wanted to reach the top, but kept falling back down. Then he found
a less steep route which zigzagged upwards with many twists and turns, and he
followed this path to the top. The woman’s eyes began to light up, and the pantomime
continued. “Never losing sight of your goal” and “strength” were the next ideas
to be expressed. The movements of a long-distance runner and a raised fist
encouraged her to persevere and develop a fighting spirit. A clock with a
ticking hand told her that it would take time. He continued the game of
charades by placing his hands to the side of his head and pretending to fall
asleep and wake up, fall asleep and wake up, over and over again until she had
reached her goal, which he demonstrated by shading his eyes with his hand, peering
out and pointing into the distance. He used his hands, his feet and his whole
body to demonstrate how her children would support her on the left and her
parents on the right, and how they would all complete the long journey
together. He stretched his fist up to the sky once again; she would have to put
all her strength into the fight. Three days later he came back to visit the
patient again, and the patient in the neighbouring bed spoke in her place. “She’s
been here for four weeks now, and before you came she wasn’t improving at all.
But over the past three days she’s made enormous progress.” He spoke to the
patient, and this time she understood every word. Then he said goodbye. “Goodbye,”
she said. That was the first word she learned to say again.
