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We all get clients 'suffering' from this condition in our consulting rooms, but it is rare indeed for it to be given as a presenting symptom. Put simply, it is a condition where the individual concerned holds an inner belief that s/he has to be totally on his/her guard every waking moment of every day, wherever they are and whatever they are doing.
It can lead to all sorts of obsessive behaviour patterns as well as producing difficulties with social interaction, relationship problems, and paranoid thought processes. It can cause problems 'on the couch', because there will be a tendency not to relax as much as we would like and almost certainly some difficulty in entering even a light state of trance. It is essential that we recognise and deal effectively with it, since trying to conduct a satisfactory session of either suggestive or analytic therapy without doing so is likely to be at best frustrating, at worst, a complete waste of time. Some therapists automatically diagnose it and conduct their session accordingly, almost without being aware that they are doing so but for those less experienced, a few pointers may help.
The Hypervigilant individual has learned, at some point, that it is desirable to be very wary at all times, so wary that absolutely nothing escapes their attention. It can be caused by a single repressed memory, especially if the individual swore at the time that s/he would never ever allow anything like it to happen to them again, but the most likely cause is some form of Cumulative Trauma.
Cumulative Trauma, in its simple form, arises out of a series of similar unpleasant or disastrous events (continual ridicule, rejection, dismissal of achievement, or perceived humiliation being some of the likely root causes) rather than a straightforward repression. Compound Cumulative Trauma, on the other hand, can arise where events of fate seem to confirm an idea, anxiety, or concept introduced into the psyche at an earlier time. Here, the early event may be repressed, but releasing the repression does not necessarily bring about the expected alleviation of symptoms, for a very powerful reason; the symptoms have been created not solely by the repression itself but by a series of following events, in the same way as the simple form. Sometimes, indeed, it is the anxiety brought about by an existent Cumulative Trauma syndrome that has caused a repression in the first place.
These events have conditioned the individual into an acquired behaviour pattern of expectation/belief - in other words they have created a conditioned response of their presenting symptoms, and those symptoms are likely to persist until the sufferer makes the discovery that their expectations and beliefs are totally without foundation.
Whatever the origins of the problem, the Hypervigilant individual will never drop his/her guard even for an instant in the normal way and views being relaxed as an extremely vulnerable situation. That feeling is only partly in the conscious mind, and at a subconscious level is certainly linked to the 'fight or flight' response and therefore to mortality and survival. What s/he is looking out for, of course, even though they are not consciously aware of the fact, is evidence that what they subconsciously fear is about to attack them, and it doesn't matter that we know they are safe in our consulting room - their subconscious doesn't understand that concept, so they don't.
Needless to say, we have to do something about that if our efforts are to be of any use. We'll come to that later on, but first, a few more symptoms and then some questions we can ask to reveal its presence.
Among the indicators of this syndrome are: a dislike of the suggestion to close their eyes; an uneasiness about being in front of the therapist in the first place; evasiveness when answering questions of a personal nature; poor sleep patterns; excessive justification of presenting symptoms; instant, categorical dismissal of the idea that their reasons for their symptoms may be an erroneous association; a tendency to answer questions indirectly - often with another question; a tendency to dispute the idea of an existent repression. Mostly, they tend to be predominantly Anal Paranoidal or Anal Retentive personalities but it is certainly not unknown in other personality groups and then its existence can easily lead you to a wrong assessment of type - although it is fair to say that there will always be a fair degree of Anal influence at work.
QUESTIONS TO ASK
Each 'Yes' response to the first five questions is an indicator of the Hypervigilant personality. Questions 6 - 10 will typically be answered with a 'No'.
- Do you always wake up more than once during the night?
- Do you always have trouble getting to sleep in the first place?
- Do you tend to feel uncomfortable in crowded places?
- Do you find yourself truly disliking people for no reason?
- Do you feel uncomfortable if there are people standing behind you - in a queue, perhaps?
- Could you easily fall asleep in public - in a crowded train carriage, for example?
- Is it possible for people to fool you, to 'pull the wool over your eyes'?
- Do you feel at ease with strangers?
- Do you find it easy to trust people once you know them?
- Can you 'let your hair down' easily at parties, or on occasions when other people are doing so?
Seven or more 'correct' answers out of those ten questions, along with a few of the other indicators, means it is pretty certain that your client has a degree of Hypervigilance that needs proper handling; more than that suggests that you will have great difficulty getting this individual through a satisfactory therapy, if at all.
METHOD
Getting him/her to relax is unlikely; the best we can manage is to get them focused, get the psyche turned inwards for once. The best form of induction is one that there can be no arguing with - if you suggest relaxation, they can argue back that they were NOT relaxed at all, so they clearly didn't 'go under'. Attempts at using imagery will often produce: 'But I just can't see that star (or stairs or whatever)...' or something similar. Any attempts at trance ratification, especially with any form of eyelock (just try telling someone who believes that he must be constantly on guard that his eyes are 'stuck tight, tight, shut'!), are almost certainly doomed to failure. So I always use a more permissive form, along the lines of:
'...now I want you to be aware of how your body is in the chair as you just lie there... being aware of the position of your arms, your legs... noticing, perhaps the weight of your head as it rests against the back of the chair... maybe feeling the texture of the arms of the chair against the palms of your hands, perhaps noticing whether there seems to be more weight in one arm than the other... or one leg or the other... or perhaps just being aware that your body is exactly as you want it to be... familiar, safe feelings... so that you can feel... just comfortable within yourself...' etc.
In other words, nothing that can be challenged or disputed, but everything that will lead to concentration upon self, with the 'natural' use of such words as familiar, safe, comfortable, and so on. You might find a hypnotic flush occurring and you might not; if you use a bio-feedback device, you may find the reading changing, but then again, you might not. So you will have to use your judgement as to when it is the right time to start whatever will pass for free association with this client. But whenever that is, you will need to weave into the end of that induction some item from the client's history as they have reported it to you during your information gathering, to get their mind and concentration where you need it to be. Yes, I know that's leading, but it's stuff they've told you before and therefore has a place in their psyche, and besides, if you don't do it they will simply flip back into guard mode and start analysing what's happening to and around them today, on your couch.
If you are working with any form of causal event therapy - hypnoanalysis or regression - there will almost always be one thing they tell you, at some point, that it is obvious should have more emotion attached than there seems to be or to have been; save this until the right moment. That moment is when they mention it again, during a session, usually with some sign of mild unease. Then... go for it! Hit them with every trick you know that will get them to release the emotion: repeating the image back to them, with feeling; ask them where they felt that event in the body; ask where they are feeling it now; if they deny it, ask them to imagine how it would feel and where they would feel it if they were feeling it right now; anything you can think of. You might be wrong, of course, this might be the wrong event... but the emotional work being suggested will often be enough to place them exactly where they should be. In any case, it's the best you are likely to be able to do with this sort of character and you are going to come a lot closer to success than you ever would with more 'standard' methods.
A CASE HISTORY
Philip was male, 40, unmarried and presenting with insomnia which he had had for as long as he could remember, although it had got a lot worse since his father had died some four years previously, after a year long illness through which Philip had nursed him. He was resentful about having to do all the nursing, though he admitted that the only other surviving relatives - two of his father's sisters - were elderly and living too far away to help. All his family, apart from these two aunts, were now dead; his brother had been the first, thirty years previously in a road accident; then his sister two years later through illness. He hesitated for the briefest of moments before telling me how, when he was thirteen, he had discovered his (maternal) grandfather slumped dead in an armchair on one of his weekly visits. He had run two miles home and banged frantically on the door for some time before realising that his mother was out; when she came home she at first refused to believe his tale and had punished him for saying wicked things, asking him how he would feel if his grandfather were to die now. It was another hour, he estimated, before she began to believe him and even then she insisted that he was probably only asleep , before she went to check for herself.
All this was told to me with no apparent emotion, though I drew no attention to that fact, nor to the fact that his mother had unwittingly given him a link between sleep and death - the idea that he was not able to tell the difference. His mother died three years or so later and it was about then that his insomnia had started, though he assured me it was unconnected. He commented that, for a while, he had begun to think that he was somehow responsible for all these deaths, but that he soon recognised that as being ridiculous, though he had always felt a vaguely guilty sensation every time another relative died, hastily assuring me that this was quite natural. In all there had been eleven deaths, culminating in his father's.
He was not too keen on the idea of hypnoanalysis and free association, saying that he knew that it was his father's death that was the problem, and requesting that I help him put that event out of his mind. Eventually, though, he grudgingly conceded that I possibly knew more about the way the mind works than he did, and decided to give it a try.
There is no need to go through the first five sessions - they were 'bog standard' apart from the induction as outlined above and the fact that he would keep his eyes open until about halfway through. He showed no signs of relaxation, and no hypnotic flush at any time, though he did admit that some of the things he remembered seemed very clear. Free association was adequate, though I had to interrupt his own analysis of his recalls from time to time.
He arrived for session six agitated and with the news that his sleeping was now worse than ever and this would be his last session - it wasn't working, he was running out of money, he'd never been hypnotised... and so on.
Into my recliner - induction - 'Now... tell me what you're thinking...'.
Frown. 'About my granddad, actually...'
There was a silence while I waited for something else, but nothing came. 'And what else is there about that memory...?' I asked, but he merely shook his head. 'That awful run all the way home?' I prompted, sensing he was about to get off the subject. He nodded. 'And that dreadful wait when there was only you that knew the awful thing that'd happened? Just waiting and waiting for mum to come home? And you were all on your own.' Another nod. 'And then not being able to make her believe you were telling the truth about poor granddad... how did that feel?'
He sniffed. 'Er... pretty awful... erm...'
'Pretty awful, hmm? And it was still something you had to deal with all by yourself...'
He sat up abruptly and opened his eyes, then an involuntary tear trickled down his cheek. I offered him a tissue, which he brushed violently away.
'I don't need all this!' he muttered. 'I didn't come here for all this!'
He stood up and stared at me for a few seconds, then announced that he'd better go - which he quickly did, ignoring my questions as to what he'd actually remembered, and my suggestions that he might like to sit down and compose himself a little. In fact, there was nothing to suggest that he was not already composed, but plenty to suggest that he was thoroughly irritated with his therapist! His look in my direction, as he left the room, would've set concrete...
I didn't see him again, but I did have this message on my answering machine a week or so later:
"I suppose I should have told you that I wasn't actually ever sure that my grandfather really was dead when I found him. I was just so scared that all I wanted to do was get home, and then I was afraid that he might've only died because it was so long before anybody got round there afterwards. The hospital said he'd been dead for two days, but I was never really sure, and every time anybody else died I thought it was supposed to have been me. So it made me feel really bad last week when you started having a go at me about it, because I realised you knew, so I'm definitely not coming back. Anyway, I don't think I need to because, for some reason, I seem to be sleeping better now, anyway...'
For some reason!
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