The essential of psychotherapy is to promote positive changes. This allows the patient to move on in his life instead of staying frozen, unable to advance sufficiently, or blocked in repetitious behaviour, failing in life and suffering. Today, there is a large palette of approaches in psychotherapy. For several years we have been looking at what makes treatments work.
The four squares technique is at the cross roads between hypnosis, EMDR, and drawing.
It uses the safe place, the affect bridge, an evaluation of the intensity of difficulty, and the focalisation of attention on a repeated bilateral alternating stimulus. The stimulation is accompanied by indirect verbal suggestions of change. The therapist is focused on his patient and observes his evolution. When properly applied this therapy permits a pathological behaviour to be replaced by a behaviour which is better adapted to the patient’s life by using new resources.
This technique can be applied in adult and in child therapy. It is compatible with a large number of psychotherapeutic and psychosomatic approaches. The patients known to benefit from this approach are those suffering from the following pathologies: PTSD, phobias (including social phobia), anxiety related problems, psychological pain, conversion states, school difficulties with fear, social stress, repetitive dreams, nightmares, low self-esteem and negative cognitions etc. It is possible to work on past, present or future oriented problems.
We started using the original method known as “la technique des quatres compartiments”, which was presented to us as a method of stabilization during a workshop in psycho-traumatology. However, after working with the original method, we realized that it had a greater realm of therapeutic applications and could even be used in those cases where a strong emotional charge hindered other techniques. Therefore, we decided to adapt and to integrate the method into our clinical practice of hypnosis.
This method is the result of a combination of experiences by therapists dealing with trauma intervention. It begins in 1997 with Jarero et al. in Mexico after a hurricane. It continues in 1999 during an earthquake in Turkey. Lucina Artigas is rewarded by EMDRIA for her creative innovation the “butterfly technique” in 2000 (bilateral alternative auto-stimulations by light taps on the upper arms). In 2006 D.Lanch adapts the protocol to individual therapy sessions: the “Vierfeldertechnik”. L. Burkhardt and K. Schmidt-Riese present the “technique des quatres compartiments” en Suisse (Lausanne) during a general psycho-traumatology workshop (formation en psychotrauma-therapie DeGPT: techniques de stabilisation niveau II par Dr.Karla Schmidt-Riese et Dr. Lucien Burkhardt 08.05.2009)
Since then we are constantly adapting and integrating this technique in our daily consultations. We have modified the name of this technique to the four squares technique finding that the form of the square delimits better the problems and also the resources drawn within.
The four squares technique step by step
In order to illustrate the technique, we present the following case.
C is a single woman of 35 years of age, who suffers from feelings of rejection and abandon in certain life situations. The therapist proposes that she remembers one of those very difficult situations (target). While she is imagining that moment, he asks her to describe any disturbing feelings in her body, emotions and eventually a negative cognition about herself that she is still living here and now. While involved in this re-experiencing, he asks her to evaluate the degree of distress, which she feels in relation to her body feelings and her emotions, and in this example her negative cognition. The scale used is the SUD (Subjective Units of Disturbance (Wolpe); from 0 (there is no disturbance) to 10, (maximum disturbance that she can live). In our example the SUD is 6.
C draws a red broken heart on a sheet of paper, which the therapist has previously folded into four squares. The heart in the right upper square represents her feelings of pain. She describes this pain as “a heavy burning and acid ball located in my belly”. Emotionally she feels “sadness, but also anger. When asked for a negative cognition, she answers: “I don’t love myself, because I am not interesting nor capable”.
The therapist asks her to define a resource, which is within her already, linked to a moment in her life, which could help her in this situation. She is asked to draw a picture to represent this resource. C draws in the upper left square a picture of nature, which inspires in her simplicity, animals, which bring her “consolation”. She recognizes that while imagining this she experiences calmness. This feeling of calmness is the patient’s resource, which is to be amplified.
We wish to indicate that the drawings are usually in colour. This one is as follows: yellow sun, green-stemmed flowers with red buds, and a red butterfly.
The therapist proposes to C to focalise her attention on the drawing of the resource (calmness). He undertakes bilateral alternate stimulations. The creation of trance by focalisation on a repetitive movement is well known in hypnosis. The movements can be seen as the motor, which accompanies the suggestions towards positive change. The resource is thus anchored and becomes part of the patient’s experiences.
The bilateral alternate stimulations are accomplished by asking the patient to follow the therapist’s fingers with his eyes or by alternate light tapping on the backs of the patient’s hands.
The therapist can see the positive effects on the patient by observing the patients body changes: a slower, deeper breathing pattern. In this way and others, he can realise that the patient has acquired this resource. After verifying the successful acquisition of the resource, the patient is asked to use a technique of auto-stimulation. While focalising on the resource and its drawing, he is asked to use the butterfly technique of auto-stimulation. This successfully acquired resource can then be evoked and used at a later date.
This procedure can already bring about a lessening of disturbance.
This manner reminds us that in other techniques, the research and enhancement of resources is recommended before the confrontation with the problem situation: positive age regression before negative age regression.
The desensitisation can begin. This procedure is well known in hypnosis and other therapies. In the desensitisation of phobia, the patient is asked to focus his attention alternately on his hands (one hand contains the problem, the other hand the resource) but also in more complex techniques like age regression.
In the four squares technique, the patient is asked to focus his attention on the drawing of his problem, which represents his target situation. In order to immerse the patient in his problem, the therapist uses a hypnotic voice enouncing the body feelings in detail, the accompanying emotions and the eventual negative cognition. The therapist starts the bilateral alternative rapid movements, which are accompanied by suggestions of positive change, for example: “even if the disturbances get greater at first they will finally give way to positive change”. Thus the therapist’s belief in the treatment and in positive changes is transmitted to the patient. Also, the therapist’s belief that the patient is capable of positive change is included.
The specific use of rapid movements for desensitisation and slow movements for resources allows unconscious anchoring and communication between the patient and the therapist, which assures the progression during the stimulations.
In our example, the patient focuses on the heart picture and the therapist stimulates alternatively rapidly, while suggesting to the patient “simply let all that continue to evolve and just be there to receive the changes in the picture, in the thoughts, in the body sensations, and the emotions “. When something changes, the patient is asked to speak out loud or signal STOP, to take a deep breath and to come back to the therapist’s office, therein bringing the patient out from his dissociated state between the periods of stimulation. Then the patient is asked to draw a picture representative of the changes that he has just lived.
Our patient has seen and felt “the end of an important rainfall”. She adds that “after the rain, all seems clean and the colours more intense” (clouds and rain in blue, bright rainbow colours, yellow sun). The therapist suggests to C that she takes “all of this” and allows the changes to continue and to signal again when change occurs in the image, in the body, in the emotions. Rapid bilateral stimulations are repeated.
The stimulation time varies. We think that the rapidity of change is linked to the individual’s capacity to dissociate at a sufficient level, and also to the importance of the trauma for the person (vulnerability) and the acquired resilience. The change can occur immediately or after several minutes. When the patient signals stop again, the therapist acknowledges this by saying “fine” and suggests that the patient take a deep breath to come out of the trance state. The patient can profit from this moment of reprieve. The phenomena of fragmentation of the experience will have a positive effect by intensifying and facilitating the next dissociative state during the stimulations. The changes recognized by the patient are drawn in the following free space (bottom right).
C explains her drawing. She says that it represents “liberty, when she does bicycling in the Country side…”
This is the first drawing with truly positive undertones of a new resource (drawn in green, colour equally found in the originally established resource in the countryside, the calm).
It is important that the therapist simply receives the information without getting tangled up by giving his interpretations of the drawings to the patient or asking too much additional information. This will cut short the on going procedure. The therapist receives all that the patient brings and encourages him to continue.
In the same way, the therapist continues to stimulate and the patient to draw in the following square while carefully noting the changes. This procedure continues until the patient has dropped his SUD to 0.
Here are the following drawings of patient C and her evolution.
C explains that she has cycled to a large area of water, the sky reflects in the water, lots of colours.
An empty row- boat approaches
She wonders if she will go on board
She climbs on board and advances along the coast with pleasure.
The changes in the drawing represent the important changes produced simultaneously within her mind and body. The scale SUD is now at 0,5. In our experience the desensitisation is not yet complete as long as the SUD is above 0.
The procedure continues.
She now enjoys the actual moment (going again towards the resource and positive changes).
“I swim and I do well for myself” (she draws herself in brown)
“I alight on an island between the reeds, in the sun” (she draws herself in the green colour of the resource)
Now the patient signals that the SUD is at 0. However, the therapeutic exercise is not finished. We must verify if the new resource is fully acquired.
The therapist asks C to confirm her confidence in her belief that she has really acquired the change. We use the VOC scale. (Validity of Cognition) This scale goes from 1 (I don’t believe at all in the change) to 7, (I totally believe that the change has taken place). The patient should get to 7 to insure that the new behaviour is fully acquired. It is very important to take sufficient time for this phase of the treatment.
Our patient is at VOC 7.
In order to be really sure, the patient is asked to look again at the original drawing of her problem and to evaluate the VOC. Thus, patient and therapist can be assured that this treatment is finished. If some disturbance is still felt, they can continue the technique at the next meeting. Here the patient confirms that the changes are acquired and that she no longer has any negative ideas, feelings, or emotions in front of the targeted difficulty.
During the exercise, it is important that the therapist accompany the patient by positive verbal suggestions to change and be open to discovery. The therapist, focused on the patient, observes the visible changes in the patient’s body and emotions, as well as his breathing.
Thus the therapist is often in a light trance accompanying his partner, the patient, in this “dance a deux”(accordage relationnel, Stern). The therapist must be able to respect all signals or demands of the patient concerning the therapeutic procedure. The verbal dialogue and signalling help this requirement.
If the patient’s emotions become too strong, it is possible to return to the acquired resource
drawn in the beginning of the procedure (anchored already to slow stimulations and the butterfly technique). It is of course possible to use other procedures of stabilisation in the therapist’s toolbox, like the safe place, previously acquired by the patient.
The consultation should end with a patient in a stable state with positive feelings. In order to be sure to achieve this, the therapist proposes to the patient to look again at the drawing of the resource while using the butterfly auto-stimulation. During this stimulation post hypnotic suggestions concerning continued positive changes can be voiced. These help to reinforce changes during the session intervals. (“Without any particular effort, you can just be open to receive the new and interesting changes.”) The patient should be reminded that he may reutilize this acquired resource at all times when needed.
As in many psychotherapeutic methods, more than one session is necessary to achieve success and health. Therefore there are “guidelines” to interrupt a session, to begin the next one, or to introduce another psychotherapeutic approach momentarily, etc.
The Four Squares Method permits the patient to be a partner during the therapy. The session unrolls in a step-by-step manner going from conscious state to a dissociated state to a conscious “here and now” state. This fractioning of the painful physical and emotional states allows the patient to continue his therapeutic work with more comfort. There is a better chance to help patients who dissociate too quickly into a state of anesthetized emotions and body feelings. The patient’s realization that he has the control of the unfolding of the sequences permits the therapist to avoid being the “torturer” who requires the patient to stay focalized on his suffering for a long time. This in and out possibility is also found in other hypnotic technics as well as in Narrative Exposure Therapy, but the control is more likely to be in the hands and the sole responsibility of the therapist.
The use of the body feelings and the emotions through the associated memory path links the patient to the origins of his difficult situation (Affect bridge Watkins). The manner favours Age regression.
The use of coloured felt tipped pens often brings a smile to the patient’s face by connecting to the patient’s childhood and creativity Realizing that he has been able to express himself, in what was seemingly impossible for him at the beginning of the four squares adventure. The positive changes in the drawings are tangible evidence of the important changes that have occurred. These successes contribute to the recognition of his capabilities and contribute to gain confidence.
The Four squares technique combines in a favourable way with other hypnotic techniques such as Age regression, Re-parenting, Affect bridge, indirect suggestions, posthypnotic suggestions and the use of metaphors.
We highly recommend that those practitioners who wish to practice this technique acquire sufficient training in this protocol, which at first sight appears rather simple. The four squares technique can awaken strong emotional reactions in the patients. The proper knowledge of stabilization is required of the practitioner when using this technique.
Our experiences and the patient’s testimonies are evidence that changes brought about during the four square sessions are definitively acquired and allow substantial improvement of the patient’s lives.