Treating insomnia through hypnosis and the strategic approach

Hypnosis as a compliance strategy

In their work In Search of the Palo Alto School (Wittezaele, Garcia-Rivera, 1992, p.356), the authors open the chapter Unconscious and psychotherapy as follows: 

“It would be absurd to deny the fact that most of the information processed by our body does not reach consciousness; the way we construct our mental images as well as most of our learning and the lessons we draw from it remain unconscious. »  

The fundamental influence that must be attributed to the unconscious in the construction of a behavioral or emotional response no longer needs to be demonstrated, both with regard to voluntary behavior (what the patient tries to do involuntary reactions spontaneous or solutions ) ( Nardone , 2000, Preface by Jean-Jacques Wittezaele)

The teaching of the great systemicists teaches us that it is useful to understand the structure of a disorder in order to use it in the resolution strategy; to use, in prescription, the same logic as persistent pathology by reorienting its meaning (Nardone, 2000).  

Thus, if the disorder advances masked, covert, involuntary and uncontrollable, we can assume that it persists with and through the unconscious. Attempts at solutions that fuel and maintain it are sometimes involuntary reactions . Using the tools of strategic communication and hypnosis without trance is part of the logic previously laid down as a strategy in itself, namely: reinvesting the strategy of the disorder in its resolution.

The use of hypnosis is a navigational tool to navigate the sea unbeknownst to the sky. 

The hypnotic strategy 

Traveling the sea without the sky knowing : hypnosis without trance

In the Methods and techniques attributed to Erickson (Wittezaele, Garcia-Rivera, 1992, p.249), the authors warn. No question “[... of magic, mad genius and the captivating powers of hypnosis. [... Its main usefulness probably lies more in the qualities it develops in the therapist than in its use itself. [...Hypnosis is therefore not the key to change; the important thing is how you can get someone to behave differently through interpersonal influence. »

Using hypnosis means learning to observe others, to embrace their vision of the world by collecting their images, to decipher the structure of their thoughts through the structure of their

language, to rely on its analog communication by exploiting non-verbal and paraverbal data. This is based on a central principle of learning to use the patient's language (Nardone and Watzlawick, 1990).

Milton Erickson used processes such as: imitation of the patient's style of perception and communication, mimicry technique, imitation of non-verbal forms of communication, which are all persuasion techniques intended to remove the patient's resistance subject to operating. “as naturally as possible” so as not to fall into a caricature that would suddenly increase resistance.

Erickson increasingly used, in the second half of his professional life, behavioral prescriptions without recourse to the trance state to induce therapeutic change.

Strategic communication 

Among the fundamentals of hypnosis without trance we can highlight:

• Cropping 

Which is one of the main techniques of brief therapy based on the rhetorical and hypnotic use of communication. We understand it according to the definition of Watzlawick, Weakland and Fisch (1974, p.116) as the modification of the conceptual and/or emotional context of a situation, or the point of view from which it is experienced, "by placing it in another framework, which corresponds as well or even better to the “facts” of this concrete situation, the meaning of which therefore changes completely. »

Carried out verbally or nonverbally, "Reframing can vary in complexity, and range from a simple cognitive redefinition of an idea or behavioral pattern to the use of metaphors and evocative suggestions, and even reframings complicated paradoxes” (Nardone, Watzlawick, 1990, p.95).

Through reframing, it is a question of modifying the patient's perceptual structure rather than reality to soften his perceptive-reactive system by giving rise to doubt which we will call therapeutic doubt. 

The work of Cialdini (1984) also shows that reframing can take place without relying on logical or rational elements. As if the semantic structure could free itself from meaning to alter it. In this sense, reframing is a privileged tool of hypnosis.  

• The use of metaphors

“These strategies allow the therapist to communicate messages even indirectly, using the identifications and projection that people often make of characters and situations in fiction. This technique reduces resistance because we do not ask patients to do anything nor do we criticize their opinions or behaviors. The message gets through “slowly”, so to speak. » (Nardone, Watzlawick, 1990, p.107)

Here the message, through poetic evocation, is addressed to the subject's unconscious and its projections.

In this sense, it is likely to influence his behavioral patterns, which, the authors add, “in turn, can bring about a change in his perceptual and cognitive pattern. » (Nardone, Watzlawick, 1990, p.107)

• The language of injunction and suggestion 

“I am convinced that the language of the injunction is called upon to occupy a central place in the range of modern therapeutic techniques. Of course this has always been the case in hypnotherapy, because what is making a hypnotic suggestion if not ordering one to behave as if... and getting this hypothetical as if to become reality because the order has been executed? This amounts to saying that injunctions have the virtue of constructing realities […] . (Nardone, Watzlawick, 1990, p.107)

In addition to this ability to construct different realities – which indicates to the patient that the reality that he brings or proposes to describe in consultation is also the fruit of a construction – the language of the injunction is also essential to respecting the prescriptions (Watzlawick, 1978): “[... the use of the language of injunction or hypnosis is essential for their effectiveness in psychotherapy; otherwise, patients rarely carry out the prescriptions given to them, particularly those that are indirect or paradoxical ” (Nardone, Watzlawick, 1990, p.114).

The unconscious: this other who does not sleep 

The formulation of the problem linked to insomnia during a hypnosis consultation does not deviate from the formulation of other types of problems. “I would like to sleep but I can’t. » . Poses like a barrier between the individual and sleep, maintained by another inside me. This other is stronger and more determined than me, so that my will cannot be exercised.

This then operates as an interpretational aspiration; from behavior to capacity; from capacity to identity.  

Since I cannot sleep, who is this other who does not sleep and what can he want? 

The client of a hypnosis consultation therefore postulates the existence inside him of a contrary will and, generally, the request consists of silencing it. 

This forms the basis for the search for positive intention and allows us to move towards: 

• the discovery of a secondary benefit 
• the making sense of a disorder which turns out to be mine, this allowing engagement in the therapeutic process

In all cases and against his evidence, the client must be willing to reveal something of which he was not aware. 

Admit the idea of ​​a positive intention 

It may be that the client often wrongly believes he understands the reasons for his disorder (“ I know where it comes from but I can't get rid of it ”) or ignores them completely (“ It's incomprehensible, it's nonsense, I don't understand anything about it") .

In this second case in particular, bringing the idea of ​​a positive intention is a perilous exercise which cannot do without strategic communication. 

Robert Dilts (2009) defines positive intention as follows: 

“ This principle states that at some level all behavior holds or has held a positive intention. In other words, all behavior serves or has already served a positive purpose. »

The client whose condition or quality of life is significantly degraded is not inclined to admit or seek gain from this deterioration. The springs of strategic communication are all levers for accepting the presence of this other that it is futile to deny. Like the dog who entertains guests and comes back even stronger when pushed away; like the child who cries more and more to be heard; there is a time, that of consultation, when it is appropriate to stop, greet him and listen to him. The use of metaphor is essential.

To admit through rational arguments the possibility of gain when a disorder occurs defies understanding and the laws of emotional gravity. 

For the therapist who sets out in search of positive intention, the mise en abyss of “how does this happen?” » or “what happens then?” » is of great help.

But even more valuable is the search for secondary benefit as formulated in 1982 by Fisch, Weakland and Segal. 

Look for the secondary benefit 

In Tactics of Change (1982, pp. 201), the authors invite us to seek positive intention in a roundabout way.

It is not a question of questioning the client about what the disorder allows him to gain or what he would lose by seeing it disappear but to confirm the idea of ​​a real and not potential danger linked to the disappearance of the disorder. . 

We do not find the timid possibility of gain in the manifestation of the disorder but the affirmation of a danger in its disappearance.

 Through semantic footwork, the customer's perceptual position is shaken up: 

“This involves asking the patient if he is aware of the existence of dangers inherent in resolving his problem. (We don't ask him if there might be danger.) » 

The authors invite us to legitimize the therapist's position by evoking to the patient a disadvantage which would be credible and which would consist of “insisting on the real dangers that there are for the patient in getting better. »

This statement can be easily supported by a brief explanation of the primary and primitive functions of the unconscious (reptilian brain, functioning of the limbic, survival instinct, etc.) and this has several virtues: 

• the possibility of a scientific, rational and therefore acceptable explanation for the presence of the disorder 
• the acceptance of this other which exerts its contrary force inside the subject
• the possibility of perceiving this other as not harmful
• the consequent cessation of a frequent and commonly shared attempt at a solution: the tension around the idea of ​​resolving the problem 

The authors add, on this last point: 

“From the moment he manages to understand that an improvement will not only include pleasant aspects, the client will be less likely to torture himself to return to normal behavior and will therefore be more relaxed. By ceasing to try too hard to change, he will have thereby changed his "solution", which, we can almost certainly predict, will either have the effect of reducing the intensity of the problem which was at the origin of his complaint, or even to resolve it completely. » p 205

The use of paradoxical logic is required here.

The authors include the use of paradoxical logic even in the formulation of the consequences of therapy: advising not to change too quickly, considering the risks of change, what the patient could lose by changing (Wittezaele, Garcia, 1992). 

In addition to this, we can also anticipate another possible consequence: that of seeing another problem emerge in place of the initial complaint.

To what extent is it virtuous to replace one problem with another we might ask? 

It seems that the emerging problem is more digestible for several reasons: 

• First of all, the arrival in the discourse of the second problem effectively cracks the armor of the first. As it is part of a dialogic exchange, it seems to proceed from reasoning and acts as an explanation to the initial problem, instantly removing the fear of not being able to resolve it.  
• Then, as it takes the form of a discovery made by the client, it infuses 

the hope to the customer of his own ability to solve his problem. 

• Last but not least, as it is new or at least seems so, it is not the subject 

of a rigidification unsuitable for resolving it. 

Through these last maneuvers resulting from strategies relating to hypnosis as they consider, influence or address the unconscious, we witness a making sense of the problem and a shift in the client's perception which necessarily induces a relaxation. 

The use of strategic dialogue also creates a therapeutic alliance capable of undermining the client's resistance and promoting compliance.

The deployment of systemic and strategic intervention tools can then take place.

The deployment of systemic and strategic intervention tools

To exemplify their strategic actions, systemicists regularly draw on the great Chinese strategists and Zen masters, and in particular, on the 36 Stratagems , a Chinese treatise written between the 14th and 17th centuries, detailing the methods for winning over an adversary. .

The Chinese tradition of stratagems expressed in the form of aphorisms, often paradoxical, was already established since Antiquity. 

Thus, Giorgio Nardone (1998, p.154) borrows this maxim from Lao Tzu: “If you want to obtain something that is perfectly straight, start by trying to curve it even more. ". In other words, to straighten a stick you have to twist it more.

Indeed, anyone who has ever observed a blacksmith understands that it is by twisting the metal that we soften it in order to straighten it. To straighten a stick without twisting it is to break it; Adding too much wood to a fire will suffocate it. To avoid a battle is to get hurt. Preparing for war means ensuring peace.  

In the field of force, it is not force that wins and the Chinese strategist knows how to escape the standoff. So he doesn't give himself any chance of losing.  

These aphorisms and maxims, by their number, their formal similarity and the common intention of their authors tell us something: defeating an adversary requires a strategy and this strategy generally obeys a paradoxical logic. 

In the context of psychotherapy, the type of intervention that we undertake is intended to be systemic (a disorder, even self-referring, is expressed as a relationship to ) and strategic (the client consults because the solutions he has provided do not allow him to defeat his opponent.) We must adopt a strategy to offer him the possibility of escaping the standoff.

Using paradoxical logic: turning the logic of control against itself 

The imperative You will sleep is to biology what the categorical imperative is to Kantian morality: sleeping is an elementary physiological need, the condition of possibility for the survival of living beings.

Sleep disorders contradict this injunction according to the formulation of Marie Darrieussecq (2021, p.11): “But insomnia, “the real one”, has no need for objective conditions and crosses all social classes [...] . This arbitrary insomnia runs through human life with the indifference of a despot. His sentence has fallen: You will not sleep. »

The subject targeted by the sentence generally aims to counter it through behavioral patterns aimed at reestablishing conformity with the desired biological pattern, and likely to restore sleep in its most basic functional dimension: allowing the individual to ensure sleep. state of wakefulness from which it is inseparable. 

The study of these behavioral responses is essential to the systemic and strategic approach to sleep disorders.

The structure of the disorder 

“When I dance, I dance; when I sleep, I sleep [...] Nature has maternally observed this, that the actions which she has enjoined us for our needs, were also voluptuous to us, and invites us to do so not only by reason, but also by appetite : it is injustice to corrupt its rules. »  

In the Essays, III, 13, Montaigne designates as “corruption” of the rules of nature that of seeking to control an autonomous function of the organism such as sleep called upon by both appetite and reason. 

We can relate the attempt to want to sleep to the corruption mentioned. Wanting to sleep is not sleeping and it is even an intention capable of corrupting sleep which is precisely a state devoid of intention.

The sleep disorder is systematically explained by the responses we provide and generally the category of responses provided obey a paradoxical logic. In Changes, Paradox and Psychotherapy (Watzlawick et al., 1974, p.53), the chapter entitled “More of the same” or: When the problem is the solution, reports the ineffective solution attempts of insomniacs :  

“Those who have difficulty falling asleep (a common, if irritating, disorder with which we are all familiar), usually take essentially similar, and equally fruitless, measures to resolve their difficulty. The most common mistake made by insomniacs is forcing themselves to sleep through an act of will – only to discover in the end that they remain completely awake. By its nature, sleep is a phenomenon that occurs spontaneously, but can no longer be spontaneous when desired. However, this is what the insomniac does, whose despair increases with the ticking of the alarm clock and the treatment he inflicts on himself ends up becoming his illness. For him, “more of the same” can mean changing his diet, going to bed earlier or later, taking sleeping pills that will create an addiction: each of these measures, far from solving his problem, exasperates him . » 

This type of response gives an idea of ​​the paradoxical structure of the disorder; a paradoxical diagnosis is therefore established. The framework of this structure is no less paradoxical: doing more of the same thing . These repeated attempts at paradoxical solutions reflect the “potentially paradoxical” of the human being caught in a permanent compromise between emotional, perceptual, cognitive, socio-cultural and reflexive patterns that are sometimes diametrically opposed. (Wittezaele, Nardone, 2016, p.123)

“To curb a sensation or a frightening thought ,” add the authors, “ the patient wants to exercise voluntary action on a phenomenon with which he can only come to terms through experience [...] It is the mind against the experience, one could say […].

We return to Montaigne. 

Corruption of experience by the intention to exercise a will towards it. 

This desire embodies the logic of control which is fundamentally a paradoxical logic: containing gives rise to overflows and to use the time-honored formula: The more I control the less I control .

This explains the construction of the “paradox trap” which engages a paradoxical reaction: that of wanting to control or anticipate a situation “fundamentally uncontrollable by the will. »

This exercise of self-control constitutes a self-paradox . : “Situation in which a person receives two contradictory and simultaneous messages addressed to themselves.”

“If it appears logical to anyone who wants to fall asleep to act in this way, just as it does to want to get up, this logic is nevertheless paradoxical because, by exercising one's desire for unilateral control, one finds oneself in the position of the centipede trying to think about how it moves its legs and in what order. »  

Of course, the centipede that would like to control each of its legs separately would no longer be able to move forward. 

It is therefore through the use of stratagems modeled on the logic in which these disorders are part (injunction made to oneself through a logic of control for example) that the therapist will succeed in opening access to the arsenal . 

Fight fire with fire 

In Going beyond the limits of fear (Nardone, 2019, p.96), the author invites us to: 

“Reproduce, in its intervention logic, the structure of the persistence of the disorder. »  

In other words, and in the context of insomnia falling within a paradoxical logic, he invites us to the therapeutic use of paradoxical techniques. 

By a fortunate combination of circumstances, Jean-Jacques Wittezaele and Teresa Garcia-Rivera (1992, p.310) describe: “[... the use of paradox as one of the most powerful techniques for bringing about change. »

Thirty years earlier, Haley (1963, p. 53) had formulated therapeutic intervention as follows: " [... take control of the patient's symptomatic behavior by encouraging it, thus creating a paradoxical situation, to then change direction. »

In the section entitled Interventions to stop paradoxical or control logic , the authors invite the use of counter-paradoxes to stop paradoxical logic.

Paradoxical injunctions, “tasks which prescribe to the patient the behavior which he wishes to stop or which prohibit him from the one which he tries in vain to produce” are used as an “operational means” to prescribe the behavior which the patient wishes to eliminate.

“By obeying the command, (the patient) automatically stops the control . » (Wittezaele, Nardone, 2016, p.245).

Prescribing the symptom (I'm prescribing insomnia), forbidding what is desired (don't sleep) are therefore strategies brought about by the formulation of paradoxical injunctions and supported by a specific formulation. 

Since the logic of control must be combatted by logic of control, it is up to the therapist to be “very directive in his prescriptions.” 

Working on your relationship and posture is also of paramount importance. 

However, and in a less direct way, the imperative mode can also be used in its suggestive dimension. We have fun with the syncretism on which Wittezaele and Garcia-Rivera (1992, p.310) capitalize: that of the formulation of cooking recipes.  

“The principle being of course that, if the user follows these instructions to the letter, he will obtain the expected result.” 

Placing our intervention in a perspective of change , we will ultimately focus on this desired change towards a higher logical level. This change revolves around a paradoxical therapeutic method sometimes induced "by an intervention comprising an illogical element from the patient's point of view" (Wittezaele, Garcia, 1992, pp.348-349) and which consists of placing the patient in a situation of double bind.

The double bind 

The formulation of a double bind naturally proceeds from the type of injunction that we have just seen, "in particular in cases where the patient tries to control autonomous functions of the organism" , such as sleep (Wittezaele, Garcia, 1992 , pp.348-349).

In the first half of the 20th century, the logotherapist Victor Frankl theorized the use of paradoxical intention, a therapeutic technique aimed mainly at “treating phobic anxiety disorders and obsessive-compulsive disorders. It can also be applied in the context of certain sleep disorders, sexual dysfunctions, conversion symptoms, etc. » (Bayle, 2020)  

In 1975, in Paradoxical Intention and Dereflection, Frankl described this original method which consists of “teaching the patient to face his fear by “wishing for what he fears”; it's about directing one's thoughts towards a paradoxical goal, wishing for one's fear, which seems illogical, but which, in reality, very effectively treats fear or obsession...  

Frankl's work, which introduced the use of the therapeutic paradox, will be reinvested and developed by MRI researchers.

Use of the therapeutic paradox 

Wittezaele and Garcia (1992, p.221) report an exchange with Paul Watzlawick. The role of the double bind, they relate, was preponderant both from a descriptive point of view and as a therapeutic tool: “Because not only does it show a pattern of communication, but it has therapeutic implications: if you use a prescription of the symptom, you are using a therapeutic double bind, since you are asking someone to do something outside of their control. »

In the case of insomnia , it is a reminder of turning the logic of control against itself. We postulate that the patient is therefore in a situation of pathogenic double bind at the time of the consultation. Double constraint which could be formulated as follows:

When I sleep, I don't sleep / When I want to sleep I don't sleep / It's impossible for me not to sleep or not to want to sleep. 

The conditions for the double constraint seem to be met (Wittezaele, Garcia-Rivera, 1992): we are in the presence of a primary negative injunction; of a secondary injunction which conflicts with the first but at a more abstract level and which, like the first, is sanctioned by punishments or signals which endanger its survival; a tertiary negative injunction which prohibits the victim from escaping the situation.  

The prescription of the symptom or the prohibition of attempts at solutions intended to relieve it reproduce this pattern but for therapeutic purposes. It is always a question of using the structure of the disorder to treat it or, as said previously, to fight fire with fire. Similia similibus curantur.

We cannot better reproduce this strategic reuse of the double constraint than Watzlawick et al. (1967, p.245): “If he refuses to obey the injunction, he can only achieve this by not behaving symptomatically, the goal of therapy. If in a pathogenic double bind, the patient is "condemned if he does it and condemned if he does not do it" in a therapeutic double constraint, the patient "changes if he does it and changes if he does not do it not. »

By using the therapeutic double bind, the patient is therefore condemned to change. 

Training in brief systemic and strategic therapy 

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