Screening Before Induction
A 58-year-old woman seeks hypnosis for insomnia and "nerves." During intake she reports sleeping about three hours a night for two months, racing thoughts, and a 7 kg weight loss. She mentions episodes where her heart pounds and she feels she cannot breathe, lasting minutes, several times weekly. She discloses a history of bipolar II disorder managed by a psychiatrist, currently taking lamotrigine, and that she recently stopped her mood stabilizer for two weeks because she felt better. She asks you to "put her under" so she can finally sleep and says she does not want to bother her psychiatrist. She has no suicidal ideation today but describes feeling hopeless about sleep.
1. Identify the screening and contraindication issues and state whether you should proceed with hypnotic sleep work now.
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Several red flags converge. The recent self-discontinuation of lamotrigine in a person with bipolar II raises the risk of mood destabilization or a hypomanic switch. Two months of severe insomnia with 7 kg weight loss and hopelessness warrants medical and psychiatric evaluation before psychological treatment is layered on. The panic-like episodes (palpitations, breathlessness) need medical clearance to exclude cardiac or thyroid causes, and untreated panic can complicate relaxation-based work.
The defensible position is to defer hypnotic sleep work and prioritize safety and coordination of care. Hypnosis is not contraindicated in bipolar disorder per se, but active mood instability, unmanaged panic, and unexplained weight loss are relative contraindications that should be addressed first. Contact or encourage contact with her psychiatrist, with her written permission, and recommend medical review of the weight loss and panic symptoms.
Do not accept her request to bypass her psychiatrist. Frame the referral as a condition of good care, not rejection, and document the reasoning.
2. She becomes tearful and says the referral feels like being "dumped." How do you respond while maintaining boundaries?
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Validate the feeling without abandoning the clinical plan. Acknowledge that being sent elsewhere can feel like rejection, and clarify that the referral reflects the seriousness of her symptoms, not her worth or your unwillingness to help. Distinguish what you can safely offer now (support, psychoeducation about sleep, help making the call, brief stabilization) from what must wait (hypnotic sleep suggestion during active instability).
Maintain the boundary clearly: you are not replacing her psychiatrist, and you will not advise on medication changes. Offer a concrete bridge, such as helping her schedule the appointment or agreeing to a follow-up contact. If she remains hopeless, screen for suicidal ideation explicitly and document the result and any safety plan.
Set a review point: once her mood is stable and medical causes are excluded, hypnosis for insomnia can be reconsidered. Document the conversation, her response, and the agreed plan so the boundary is transparent and defensible.