Det förefaller som om intresset för hypnos ligger i tiden, men de föreställningar många har av hypnos bygger på den som förekommer i underhållningsbranschen och som går under benämningen scen- eller estradhypnos. Samtidigt gör forskare och kliniskt verksamma psykologer sitt bästa för att skingra den aura av mystik som fortfarande omgärdar hypnosen, mycket på grund av hur den framställs i underhållningssyfte.
Det är angeläget att framhålla att det finns olika typer av hypnotiska metoder. Dessa är olika eftersom de mål man vill uppnå är olika. Syftet med klinisk hypnos är att hjälpa människor må och fungera bättre. Med hjälp av experimentell hypnos undersöker man hjärnans olika delar och deras sätt att fungera. I estradhypnos är målet att underhålla en publik.
I denna artikel vill vi ta upp en speciell aspekt av hypnosens tillämpning i klinisk verksamhet, närmare bestämt dess användning i traumabearbetning.
Diskussionen om å ena sidan kognitivt orienterade, å andra sidan psykodynamiska terapiformer har varit till den grad polariserad att andra former som kombinerar element från olika håll hamnat i skuggan. Detta gäller t.ex. modern hypnoterapi som erfarenhetsmässigt visat sig effektiv vid mer genomgripande traumabearbetning. Gäller det bearbetning av icke-traumatiska upplevelser kan det räcka med jagstärkande hypnos med inslag av positiva suggestioner och målbilder.
Begreppet trauma förefaller sakna en entydig definition. Inom medicinen betecknar det en skada som uppstått genom yttre våld. I vårt vardagsspråk och även inom psykologin varierar den betydelse man lägger i begreppet. Det kan beteckna
– en speciell typ av händelse som antingen är begränsad i tid eller äger rum vid upprepade tillfällen
– en upplevelse av en eller flera händelser av speciell karaktär
– den påfrestning en individ utsätts för genom sådana händelser
– den skada som drabbar individen på grund av dessa händelser.
Den första definitionen är klart missvisande eftersom det inte finns några händelser som i sig är traumatiska. Däremot finns det traumatiska upplevelser vilka som regel har sitt ursprung i en eller flera yttre händelser som ger eller gett upphov till stark rädsla och där man upplever eller har upplevt att man är hjälplös och befinner sig i ett underläge. Rädslan kan vara så stark att man tränger bort allt eller delar av det man upplevt. Det hamnar i en inre del av oss, traditionellt kallat vårt omedvetna/undermedvetna, otillgängligt i ett vanligt vaket medvetandetillstånd. Indirekt kan det ta sig uttryck i drömmar och olika typer av symptom.
Inom psykoanalysen talar man om sådana upplevelser som bortträngda minnen som behöver medvetandegöras. Båda begreppen är egentligen missvisande i det här sammanhanget.
1/ Upplevelserna kan inte medvetandegöras eftersom de redan befinner sig i en djupare del av vårt medvetande.
2/ Upplevelser vi inte förmår återkalla i vanligt vaket medvetandetillstånd kan inte heller kallas minnen eftersom minne uttryckligen definieras som återkallad föreställning eller förmågan att återkalla.
I förändrade medvetandetillstånd som hypnos kommer vi i kontakt med dessa upplevelser men inte i form av minnen utan som reella här och nu-upplevelser. Det är först då de bortträngda upplevelserna bearbetats i terapi som de kan omvandlas till minnen som därefter läggs på hyllan och inte längre spelar någon aktiv roll i vårt liv.
Bättre än att tala om traumatiska minnen är beteckningen posttraumatiskt stressyndrom (PTSS) som tar sikte på att beskriva de konsekvenser upplevelserna får i och med att man upplever och reagerar på de händelser som gav upphov till dem som om de var lika verkliga i dag som när de inträffade. Denna verklighetskänsla upplever vi med full styrka under hypnos, där den hypnotiserade har en intensiv här och nu-upplevelse som om hon befann sig mitt i händelsernas centrum.
Peter Levine har i Waking the tiger: Healing trauma: The innate capacity to transform overwhelming experiences (Berkeley, CA: North Atlantic Books 1997) gett ett värdefullt bidrag till förståelsen av människors och djurs reaktion på händelser som skapar traumatiska upplevelser. Om t.ex. en antilop blir anfallen av en gepard reagerar den på detta livshotande angrepp genom att ”frysa” sin energi. Enligt Levine gör den så för att spela död inför sin angripare och göra sig okänslig för smärta. Djuret ”fryser” den energi det använder om det har en möjlighet att fly från den situation det hamnat i. Detsamma kan en människa göra som befinner sig under dödshot. Det är ett slags chocktillstånd och på samma gång en överlevnadsstrategi. Men i motsats till människan kan djuret – om det överlever – rent fysiskt skaka av sig den uppdämda energin. Därmed nollställs kroppen igen från onödig spänning och från minnet av det inträffade.
Människan har inte som djuren förmågan att bara skaka av sig det som hänt. Därför fortsätter hon att gå omkring med ”frusen” eller uppdämd energi i kroppen som i sin tur ger sig tillkänna i form av olika psykosomatiska och andra typer av symptom. För att vi ska få utlopp för den uppdämda energin behöver enligt Levine den primitiva, mest ursprungliga delen av vår hjärna engageras i traumabearbetningen, den s.k. reptilhjärnan. Detta innebär att då vi går igenom en bearbetning av traumatiska upplevelser behöver vi gå igenom en fas där vi precis som ett djur rent fysiskt skakar av oss det som hänt.
Handlar det t.ex. om bearbetning av traumatiska upplevelser i barndomen är ett levinskt skakande utan överdrift ett måste. Det finns som ett inslag, som en helt avgörande del i hypnoterapin. Bildligt talat innefattar en fungerande traumaterapi ett slags upptining. Känslor och olika typer av fysiska reaktioner som varit infrusna börjar nu tina upp och energin i kroppen börjar återigen flöda fritt.
Anledningen till frysning är att man inte klarar av att reagera eller motreagera på ett adekvat sätt i den situation man befinner sig i när man har en traumatisk upplevelse. Instinktivt väntar vi – precis som antilopen som blivit överfallen av geparden och överlevt – tills vi befinner oss utom fara och har kapacitet att reagera på ett konstruktivt sätt genom att vi utvecklar adekvata motreaktioner på det som hänt. Motangrepp är i detta fall bästa försvar.
Att reagera fysiskt är en viktig och ofta bortglömd del av lösningen men uttryckligen bara en del. I och med att människan har en mer utvecklad hjärna än andra djur är det naturligt för henne att bearbeta situationer också på ett kognitivt och emotionellt plan, d.v.s. på ett reflekterande och kännande sätt. I modern kognitivt orienterad hypnoterapi arbetar man på och integrerar dessa olika plan.
En del författare/psykologer varnar för att det som sker i en terapi kan vara retraumatiserande, d.v.s. att klientens upplevelser i terapisituationen kan innebära en förnyad traumatisk upplevelse och därmed förstärka problemen i stället för att bota dem. Det är ett välkänt faktum att personer som haft traumatiska upplevelser löper större risk än andra att senare drabbas av sådana även i objektivt sett mindre belastande situationer.
Det kan vara motiverat att fråga sig hur det kommer sig att detta att bortträngda upplevelser under hypnos kommer upp till ytan kan ha en helande och inte en traumatiserande effekt. För att kunna belysa den frågan är det först och främst viktigt att göra en åtskillnad mellan att traumatisera och att bearbeta. Piaget, schweizisk psykolog och kunskapsteoretiker, liknade bearbetning vid vår matsmältning. Liksom kroppen inte kan tillgodogöra sig föda utan att först bearbeta den behöver vi bearbeta våra upplevelser för att kunna införliva dem och dra nytta av erfarenheten.
Levine har med sin s.k. SIBAM- modell gett en bra beskrivning av de olika ingredienser som karaktäriserar våra upplevelser (opublicerad, beskriven t.ex. i Babette Rothschild; The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment. W.W. Norton & Compay 2000) Normalt består våra upplevelser av fem olika element: förnimmelse (Sensation), föreställning (Image), beteende (Behaviour), känsla (Affect) och betydelse (Meaning). I en fullständig upplevelse integreras alla de fem elementen medan en traumatisk upplevelse kan innebära att något eller några element dissocieras, avskiljs från upplevelsen ifråga. En traumatiserad person kan t.ex. vara oförmögen att känna och uttrycka sina känslor inför det som inträffat.
Terapeutens rädsla för att skapa ett nytt trauma hos sin klient kan medföra att hon hindrar denna från att gå så djupt in i sina upplevelser som hon behöver för att kunna bearbeta dem. Bearbetning innebär nämligen att få tillgång till alla dessa element, att reagera fullt ut på det som hänt och därmed integrera, införliva det, få det att bli en del av en själv i stället för något som känns främmande och kan vara till skada. Bearbeta är något vi gör med automatik hela tiden men vi märker det bara om våra upplevelser är för komplexa eller av för negativ natur. I bägge fallen kan de ge symptom i form av spänningar, oro, ångest m.m.
I viss mening är traumatisering och bearbetning varandras motsatser: traumatisering splittrar medan bearbetning helar, integrerar. Då vi traumatiserar befinner vi oss i ett ekorrhjul där vi hela tiden upprepar det vi egentligen vill komma ifrån. Kanske är det vårt sätt att tvinga oss att hela de upplevelser som står och stampar. Bearbetning gör däremot att vi kommer vidare. För att kunna lära av erfarenhet behöver vi ha förmågan att bevara minnet av det traumatiska utan att vi för den skull fortsätter att traumatisera, d.v.s. utan att vi fortsätter att reagera som om den situation som från början fick oss att uppleva något som traumatiskt fortfarande vore en realitet här och nu.
Men låt oss komma tillbaka till den fråga vi ställde: Om en klient befinner sig i ett hypnotiskt tillstånd och det hon upplever känns lika reellt som det som ursprungligen gav upphov till traumatiska upplevelser, varför leder detta inte till retraumatisering utan till bearbetning och i förlängningen till helande?
Modern hypnoterapi som bedrivs på ett professionellt sätt inleds alltid av en period av jagstärkande träning av kortare eller längre varaktighet beroende på klientens behov. Syftet med denna är att klienten blir stark nog att kunna konfronteras med sina icke-färdigbearbetade upplevelser på sätt som leder fram till bearbetning, d.v.s. till införlivande av en upplevelses alla aspekter. Detta jagstärkande arbete fortgår och löper som en röd tråd genom hela terapin, d.v.s. inte bara under den inledande träningen utan även under bearbetningen. Det äger rum både i samtalsform och under hypnos, där klienten hela tiden ökar sin förmåga att skapa lugn och välbefinnande. Förenklat skulle man kunna säga att man behöver må tillräckligt bra för att kunna ta itu med det som gör att man inte mår så bra som man har kapacitet att göra.
Den mest centrala delen av modern hypnoterapi bygger på observationsträning. Förmågan att observera är kungsvägen in till de djupare hypnotiska tillstånden där vi efterhand upplever allt större välbefinnande. Att göra detta är en förutsättning för att bli stark nog att möta svåra upplevelser utan att uppslukas av dessa. I de hypnotiska tillstånd där vi möter dessa är vi då inte bara upplevande utan samtidigt observerande. Den del av oss som vi kan kalla ”det observerande jaget” är en klarvaken iakttagare av det som händer här och nu. Med hjälp av denna skapar vi distans till det som sker. Från ett utifrånperspektiv kan vi då betrakta en annan del av oss, den delen som befinner sig mitt i händelsernas centrum. Är det t.ex. fråga om traumatiska barndomsupplevelser finns alltid den vuxna observatören med som vittne och stöd till vårt inre barn som kommer i kontakt med upplevelser det inte orkat och inte klarat av att sätta sig i kontakt med tidigare. Dessutom finns terapeuten med som ytterligare stöd och som en garant för trygghet och vägledning.
Sammanfattningsvis kan vi säga att då vi i hypnotiska tillstånd kommer i kontakt med traumatiska upplevelser är situationen inte identisk med den eller de situationer som gav upphov till dessa. Men den är tillräckligt lik den eller de ursprungliga för att möjliggöra en framgångsrik bearbetning och leda till helande.
Vi vill särskilt poängtera att det viktiga inte är att komma i kontakt med traumatiska upplevelser utan framför allt hur man gör det. Ren katharsis kan med all säkerhet vara retraumatiserande. Det finns därför all anledning att ifrågasätta s.k. utlevelseterapier där bl.a. det observerande jaget lyser med sin frånvaro.
Slutligen bör också nämnas att vi i motsats till Freud betraktar vårt s.k. omedvetna/undermedvetna som en rationellt fungerande medveten del av oss själva. Arbetar man med hypnoterapi på ett modernt sätt, vilket bl.a. innebär det jagstärkande sätt vi förordar, visar vår långvariga erfarenhet att denna inre del av oss delger oss icke-färdigbearbetade upplevelser i den takt och i den omfattning vi klarar av. Bearbetningen tar pauser vid behov och varvas med jagstärkande arbete. Bit för bit konfronteras vi med upplevelsefragment som slutligen integreras till en helhetsbild och successivt lär vi oss att reagera adekvat på det som händer.
Under de nya och betryggande förhållanden som råder i en fungerande terapisituation bygger vi under bearbetningen successivt upp en ny positiv värld vid sidan av den gamla traumatiserade. Under en period lever vi i två parallella världar innan den positiva världen helt tar över. Detta manifesterar sig i ett fenomen som klienter i hypnoterapi brukar lägga märke till: Ju mer man efterhand vågar släppa fram och reagera i hypnosen desto större blir förmågan att mellan varven och efteråt komma till ro och uppnå ett djupt välbefinnande. Eller som en klient uttryckte det: Hur är det möjligt att samtidigt kunna befinna sig i himmel och helvete?
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