Critical Illness as a Magnifying Glass on Hypnosis: From Helplessness toward Agency

1. Introduction

Critical illness creates a distinctive setting for psychological intervention. Survival depends largely on other people and technical systems, while the patient’s usual means of orientation, communication, and control may be severely restricted. Yet this is also when social and suggestive influences from the environment may become especially consequential. The question is therefore not only whether psychological communication can help a critically ill, even sedated and mechanically ventilated patient, but why it can become clinically significant and under what relational conditions it may be adaptive.

This article develops a theoretical model from empirical and clinical observations within an iterative ICU research program (K. Szilágyi et al., 2007, 2014; Kelemen-Szilágyi et al., 2026). Differences between two ICU centers first drew attention to relational continuity, followed by the reorganization of cognitive and social functioning under stress and the evolutionary significance of group belonging. From this emerged the Superorganismic Connection State (SCS) hypothesis: under critical stress, temporary permeability of previously stable social and meaning systems may create not only vulnerability but also an opportunity for rapid adaptive connection to a new survival-supporting social system. The SCS framework was previously introduced in a clinically oriented form (Kelemen-Szilágyi, 2024); the present paper develops it into a more explicit process model of relational regulation, contextualization, and agency.

Through work with critically ill patients, this article examines why familiar hypnotic communication techniques may be especially useful when delivered within a maternal relational quality of bodily-affective attunement. Such connection may make context accessible while events unfold, supporting the bodily, temporal, causal, social, and agentic organization of experience. The maternal function, understood here as relational-regulatory rather than biologically female, may support participation and agency while autonomous functions remain restricted. Repeated spiral alternation between maternal-mode pacing and paternal-mode leading may then transform attunement into orientation, meaning, action, and gradually renewed autonomy. By shaping the organization of experience while it is still unfolding, these processes may also offer a possible preventive pathway against the later development of PTSD.

Although the model developed from observations in intensive care, its intended relevance is not limited to critical illness. Critical illness is treated here as a magnifying condition in which basic human regulatory needs and relational processes become unusually visible: what we need for safety, orientation, connection, and agency when our usual means of maintaining psychological equilibrium are compromised. Viewed through this lens, processes observed in the ICU may also help make psychotherapeutic settings more intelligible at a deeper level and may clarify how hypnosis can support adaptive reorganization within them.

2. The Clinical Starting Point and the First Empirical Puzzle

Critically ill patients are exposed not only to severe physiological strain but also to pain, uncertainty, loss of control, inability to communicate, unfamiliar interventions, and dependence on strangers. These experiences may add substantial psychological and physiological stress to an organism whose regulatory resources are already severely constrained (Divani et al., 2022; K. Szilágyi et al., 2007; Selye, 1956).

Positive Suggestion-Based Psychological Support (PSBPS) was developed to reduce this avoidable additional burden. It requires no formal hypnotic induction but uses the altered and suggestion-sensitive state often accompanying critical illness. Through state-adapted information, realistic reassurance, and opportunities for participation, PSBPS aims to make the ICU more comprehensible, controllable, and safe (Varga et al., 2007). Clinical experience suggested that such communication could reach patients during mechanical ventilation, sedation, or severely restricted responsiveness (Diószeghy & Varga, 2002; Varga et al., 2007), leading to a prospective randomized study of daily PSBPS.

The study included 60 patients mechanically ventilated for more than 48 h in two Budapest ICUs. Patients received standard care alone or approximately 20 min of daily semi-standardized, individually adapted PSBPS in addition to standard care. Outcomes differed strikingly between centers. At the Semmelweis ICU, PSBPS was associated with significantly lower use of benzodiazepines, opioids, and an α2-agonist (Schlanger et al., 2013). At Jahn Ferenc Hospital, it was associated with 78.74 fewer hours of mechanical ventilation and 94.88 fewer hours of ICU treatment—about 3.3 and 4 days, respectively (both p < 0.02; K. Szilágyi et al., 2007).

Thus, the same psychological intervention was associated with clinical effects of different kinds and magnitudes in the two centers. Why?

3. The First Clue: Relational Continuity

The difference between centers shifted attention from what was communicated to how and by whom. At Jahn Ferenc Hospital, continuity with the ICU-embedded psychologist was greater; at Semmelweis, patients more often met different providers from day to day. Exploratory analyses suggested that favorable outcomes were strongest among patients supported by the same psychologist on at least half of their ICU days: compared with controls, ICU stay was 88.42 h shorter (p = 0.009) and mechanical ventilation 81.95 h shorter (p = 0.007) (K. Szilágyi et al., 2007).

This raised the possibility that relationship may not be merely a nonspecific accompaniment to suggestion but may potentiate its effects. Although the same PSBPS method was used in both centers, the pattern of outcomes nevertheless differed strikingly. The question therefore expanded beyond whether positive suggestions work: what does relationship add to suggestion, and how could it amplify its effect so substantially?

A more fundamental question is what relationship can mean for a sedated, mechanically ventilated patient who may neither communicate normally nor retain explicit memory of previous encounters. A patient I saw after an epileptic seizure illustrates this. He asked me at least thirty times where he was and what had happened. Eventually he smiled: “I know I’ve already asked where I am and what happened, but could you tell me again?” Although he could not retain the factual answer, his behavior suggested that some implicit knowledge of the reassuring, safe quality of our interaction had nevertheless formed.

Relational continuity in such a situation need not depend on explicit recognition of the person or recall of previous encounters. What may persist is an implicit appraisal of the source—benevolent, reliable—and the psychological meaning attached to the relationship—providing safety and a dependable point of connection—even when the episodic history of the relationship itself is not retained.

Although intensive care primarily supports, maintains, and when necessary, temporarily replaces threatened vital functions, classic deprivation and attachment research showed that physiological maintenance alone does not exhaust basic human needs (Harlow & Harlow, 1962; Spitz, 1945). Benczúr’s analysis of early ICU data also found that earlier intervention after ICU admission was associated with better outcomes (Benczúr, 2012). In my work as the ICU-embedded psychologist at Jahn Ferenc Hospital, I began to view the ICU as a magnifying glass: what becomes vitally important here also matters under ordinary conditions. If a psychological, relational need is magnified here and has substantial consequences, its meaning and significance deserve examination.

4. From Stress to the Social Survival Environment

4.1. The Stress-Reorganized Cognitive and Social State

Before asking why relationship may become especially significant in critical illness, we first need to understand the state of the patient with whom we are trying to connect. Severe physiological threat, pain, uncertainty, sleep disruption, medication, altered bodily functioning, restricted communication, and fear do not simply “impair” cognitive performance: under stress, the organization of psychological processing may be reorganized.

Drawing on then-available neurocognitive evidence, Kulcsár (2005) integrated this reconfiguration into a cognitive, bodily, and social model in which processing may rely more on nondeclarative strategies. Suggestibility, emotional sensitivity, and social drive may increase, and psychological boundaries between self and Other may become more permeable. Kulcsár linked self–Other differentiation to Georgieff and Jeannerod’s (1998) “who” system, which helps identify the acting agent. Under stress, episodic and autobiographical memory and spatiotemporal context may become more vulnerable, complicating the encoding of self-referential experience. Absorption may also increase, with focused attention and relative loss of broader context.

In Kulcsár’s theory, these cognitive changes are inseparable from social changes. Partly overlapping neural systems for social and visceral processing may allow emotional influences from the Other to operate at the level of bodily-affective regulation, not merely as information. Greater self–Other permeability can work in both directions: we may take on others’ fear, pain, and negative affect, while appropriate attunement may support positive experiential qualities and integrative processes linked to posttraumatic growth. Effects therefore depend on attunement and the social environment; permeability is neither pathogenic nor growth-promoting in itself. Kulcsár’s model proposes that it may bridge bodily and psychological, and individual and social, regulation.

In the approach of Varga’s research group, stress-related reorganization can also be described as a relative foregrounding of more immediate, bodily-affective and associative, primary-process-like functioning compared with more reflective, rule-governed secondary processes (Varga & Diószeghy, 2004).

Research over the past two decades has further strengthened several central elements of Kulcsár’s model. Acute stress is indeed associated with large-scale network reconfiguration: connectivity may increase among systems involved in autonomic-neuroendocrine regulation and rapid, vigilant attentional reorientation (Hermans et al., 2011). Particularly important for the present argument, a 2026 human experiment found that acute stress reduced hippocampal reactivation of earlier memory elements while participants learned new, overlapping events, and related events remained represented more separately, impairing flexible inference (Schüren et al., 2026).

Human findings on social processing also accord with aspects of Kulcsár’s proposal. Acute psychosocial stress can increase sensitivity to emotional facial expressions (Domes & Zimmer, 2019), while another experiment found increased trust, trustworthiness, and sharing—forms of social approach behavior (von Dawans et al., 2012). These findings do not prove Kulcsár’s theory as a whole, but they support its core proposal that stress may simultaneously reorganize contextual cognition and increase the adaptive significance of social information.

This takes on particular significance in critical illness. To build a coherent model of the situation, the patient would need to retain facts, organize them temporally and causally, interpret rapidly changing bodily experiences, and at the same time assess the intentions of unfamiliar people. These complex contextual operations may be precisely the ones that become more vulnerable, while the relative organizing power of bodily-affective and social information may increase.

The patient may receive information from two sources. One is direct self-experience: bodily sensations, pain, pressure, breathing, tension, affect, and sensory fragments. The second source is input from the Other: tone, rhythm, emotional quality, and other socially meaningful signals. Patients may derive social meaning from these cues even when complex semantic content or the overall situation is difficult to process. They may therefore experience the person present as threatening, indifferent, or safe.

The first task of psychological communication is therefore not to pull the patient immediately into the clinician’s ready-made, organized model of the situation, but to enter the patient’s model of the world through the part that remains accessible to and through the patient. We can begin with the patient’s own directly accessible bodily-affective experience and the social signals still available to them, and progressively connect these with what the patient is not yet able to organize alone.

4.2. The Social Survival Environment

At this point, however, Kulcsár’s model leaves an evolutionary question open. Why would a stress state be adaptive if reflective and contextual organization may become more vulnerable while influences from the Other acquire greater regulatory power? At first sight, this seems like a dangerous design.

A major source of human evolutionary success is our extreme sociality. Humans can achieve far more in groups than the same number of people acting independently. Together they can form a superorganism in which, in some respects, the individual relates to the group as cells or organs relate to the whole organism. Physical structures hold the body together; in human communities the “connective tissue” is the human behavior complex: strong group attachment, behavioral and emotional synchronization, and jointly constructed rules, roles, and actions (Csányi, 2000).

For humans, therefore, the adaptive survival environment consists not only of physical objects and events. A fundamental part of it is made up of other people’s states, intentions, reliability, and actions, together with the shared rules and beliefs, roles, tasks, group attachments, and coordinated functioning that provide human communities with their survival capacity (Csányi, 2000).

If I am a member of a superorganism, I do not need to control every danger and every subprocess alone. It is enough to know my own “cell-level” role: my place and my task. At the same time, I can trust that the other members of the community are carrying out theirs. If I can trust that the others follow shared rules and do their part, it is enough for me to attend to what is mine to do.

Stable socialization therefore has enormous adaptive value. Yet this immediately creates a new problem: what happens when a previously adaptive world model, group organization, and role system are no longer sufficient in a radically changed situation? In such circumstances, survival is not served by holding even more rigidly to the old organization. The organism must be able to connect with new people, rapidly adopt new rules and roles, and temporarily resocialize into a new social system.

When I began to view the ICU patient in this way, the patient’s situation and needs became more intelligible. The patient is suddenly torn from their familiar social world; previous competencies and rules offer little guidance, and they find themselves alone and vulnerable in the face of an organized group of strangers, contact with whom may feel unpredictable, incomprehensible, and painful.

Adaptive switching, however, does not mean that the patient simply submits to the unfamiliar group. The ICU system needs to become recognizable as a temporary community organized around the patient’s survival and recovery; within it, the patient is not merely a member but the center of the shared work.

5. The Superorganismic Connection State: An Adaptation Window for Resocialization

Viewed from an evolutionary perspective, Kulcsár’s model raises the possibility that it would be difficult to make sense of evolution simply having “designed” stress to pull the ground out from under us. One possible adaptive function of the stress-related cognitive, bodily, and social reorganization she described may be precisely to “permit” stable socialization to become temporarily more permeable when circumstances require it.

A system cannot be prepared in advance for every possible situation. We may become more vulnerable to influences from the Other, but at the same time it may become possible, under radically changed circumstances, to connect rapidly with a new Other, adopt new rules and roles, and resocialize into a new social system that supports survival. I call this temporarily flexible state, particularly open to connection and resocialization and potentially available for adaptive evolutionary use, the Superorganismic Connection State (SCS).

The SCS, then, is not an opening specifically to beneficial influences, but to influences in general. The direction of increased social permeability depends on attunement and the social environment. This is precisely why awareness of the opportunities and dangers carried by this state has practical importance. In the presence of a poorly regulated, threatening, or hostile Other, the same openness may intensify fear and vulnerability. A stable, comprehensible, and safe Other, however, may use the same adaptation window to offer the patient a new, usable social and situational model.

ICU staff themselves function under substantial stress, which may influence how they perceive the patient and the interaction. This can initiate reciprocal amplification: staff stress may lead to more threatening interpretations of the patient and more controlling communication, which in turn may increase patient distress. Regulation can therefore be reciprocal while responsibility remains asymmetrical: the participant who is more stable and has greater knowledge and power bears greater responsibility for shaping the shared interpersonal field. Psychological support for ICU staff may therefore indirectly influence the quality of the regulatory environment available to the patient.

The same perspective also helped me understand why communication from a psychologist may become particularly important even though, according to Bejenke’s suggestive hierarchy (Bejenke, 1996), the psychologist would hardly occupy the highest-authority position in the ICU. The ICU-embedded psychologist may serve a distinctive orienting function. In this role, the psychologist can make the social environment intelligible to the patient: who these people are, what they want, why they do what they do, and whether their actions represent threat or protection. The psychologist can also help the patient clarify where they are in this system—what their role is and what their own cell-level function is.

The patient does not automatically become a member of this temporary group: they can be invited into it. Initially, even a single reliable person may help the patient experience that “these people are my people now”; in this way, what had been a threatening outgroup may gradually become a temporary ingroup.

The SCS is therefore a possible adaptive state for connection and resocialization. In the ICU, it may allow a temporary new superorganism to assume, for the period of recovery, part of the survival and regulatory functions previously provided by the patient’s stable connection to their own community.

The SCS thus describes both the unusual vulnerability of critical illness and its adaptive potential. Dangerous openness without an adequate relational frame may, with an appropriate Other, become an opportunity for rapid connection and resocialization. The SCS can therefore be regarded as the field in which psychological intervention operates. The next question is how to enter that field through experience still accessible to the patient, create a sufficiently safe shared reality, and build from it meaning, roles, rules, and possibilities for action. Audio-Recorded Positive Suggestions (ARPS) incorporated several of these functions into the intervention itself.

6. From the Group Hypothesis to ARPS

The emerging evolutionary and group-based understanding provided the conceptual background for Audio-Recorded Positive Suggestions (ARPS), through which the initial bedside intervention developed further into an iterative research program.

ARPS did not begin with a new set of clinical contents. It incorporated the earlier semi-standardized PSBPS framework developed by Varga and colleagues. The six-page ICU-specific protocol specified how to make comprehensible the need for mechanical ventilation and other interventions, the function and safety role of machines, the expected treatment course, and the patient’s remaining options for choice, communication, and active participation (Varga et al., 2007). Interventionists were trained in this approach. Live PSBPS therefore shared a clinical-content framework while allowing wording, timing, and emphasis to be adapted to the individual patient.

The further development represented by ARPS therefore did not consist in each therapeutic element being newly introduced. The increasingly novel element was the organizing principle: orientation, provision of safety, reframing, choice, and participation—already present in the earlier intervention—were organized into a functional system along an evolutionary group perspective.

This becomes explicit from the beginning of the recording. The unfamiliar sounds of machines and staff are transformed into signs that “many things and many people here are working together… for you”; separate sounds are organized as signals of a shared healing effort. The voice of the recording itself enters this system, and the patient is not a passive object of the process: they are invited “into this teamwork for your recovery” (K. Szilágyi et al., 2014).

Later, the same group logic appears in the distribution of roles and responsibility: “everyone is doing their part, and everyone is focusing on their own task. The unit is focusing on your healing, and you on your own recovery.” The patient need not control the opaque ICU system. Tasks within others’ competence can be entrusted to them, while the patient’s own restricted but real domain of action becomes visible: “at every moment, there is something you can do for yourself,” even through very small actions.

The essential shift is that the patient no longer remains an outsider to this unfamiliar system but acquires a recognizable place and role within it. The psychological significance of group membership lies not in being central or peripheral, but in being inside: the patient can rely on the group’s rules, the role-consistent functioning of other members, and their benevolent protection. In the ICU, there is an additional reassurance: the system that initially appears as a frightening group of strangers is actually organized around the patient’s survival and recovery. The recording makes this explicit by framing surrounding tubes, machines, and equipment as signs that “everything happening here is for you.”

The redistribution of monitoring responsibility illustrates the functional significance of this particularly well. In ARPS, the machines and monitors temporarily “tell” us what needs to be done for the patient’s safety, “so that later you can again be the one who tells us what you need.” The patient therefore does not have to monitor the incomprehensible danger situation alone: part of this function can temporarily be entrusted to the system to which they now belong.

The evolutionary group perspective therefore did not simply add new topics to the earlier PSBPS. It organized existing and new elements into a functional system in which the unfamiliar environment could become a coordinated group, interventions a shared healing effort, staff members reliable role-bearers, and the patient a participant with their own place and task within the system.

The next question was through what psychological mechanisms this frame could become genuinely receivable and usable for regulation by the patient. A further empirical clue led toward this question; later, we will also see how these mechanisms can be identified in the structure of ARPS itself.

7. The Maternal–Paternal Regulatory Spiral

A second conceptual strand comes from the familiar hypnotic logic of pacing and leading, closely aligned with Erickson’s utilization approach: beginning with the person’s current responses and available experience and using these as the basis for therapeutic movement (Erickson & Rossi, 1979b). Linking this principle with Bányai’s distinction, I use maternal-mode pacing to refer to meeting the patient’s current state primarily through bodily-affective attunement, recognition, and synchronization, and paternal-mode leading to refer to providing orientation, structure, meaning, and direction. These are integrative terms proposed here, not established terminology from either original model. The axes are distinct: not all pacing is maternal and not all leading paternal; I highlight the combination that appeared particularly relevant in critical illness.

The principle of meeting the patient within their current experiential world can acquire an additional social meaning here. According to the present hypothesis, precise matching to the patient’s experience does more than create communicative congruence: if the Other repeatedly perceives and organizes in the same way phenomena that I can verify from within, this may function as a signal of a shared experiential and socialized world—as if we belonged to the same social world.

The inner world of critically ill patients may be difficult for others to access, while coherent access to the external world may also be difficult for them. They may know little about what is happening, while bodily and affective fragments remain available: pressure, dryness, unusual breathing sensations, pain, fear, or simply a sense that something is seriously wrong. Maternal-mode pacing starts there. Naming, differentiating, and reflecting accessible experience may support two related recognitions: “This person knows what is happening to me,” and “At last, I too am beginning to know what is happening to me.”

This shows a limited functional similarity to Gergely and Watson’s model of contingent affect mirroring (1996). The caregiver’s contingent, “marked” mirroring makes an affective state that the child already experiences internally, but cannot yet clearly identify and organize, recognizable and representable as if from outside. No developmental regression is assumed in the ICU; the parallel is limited to function: the more organized reflection of an Other may make one’s own currently poorly differentiated experience more accessible.

Repeated experiential congruence may therefore not only support self-perception but also build up a kind of reliability credit for the Other. If a communicator repeatedly connects accurately with experiences the patient can verify from within, the patient may come to experience: this person knows my world. With the increased interpersonal permeability and primary-process-like thinking of critical stress, where translogical organization may operate more readily, a rapid experiential linkage may arise without conscious inference: “If the Other interprets what I can perceive accurately, then somehow they are here with me, in my world. If they are here and helping me, they have a legitimate place here. If they know what is happening to me, I can also trust what they say about what I cannot verify: what is happening around me.”

External stimuli were already entering the patient’s world as suggestions (Varga, 2013), but this validation may allow the patient to experience their influence as subjectively authorized and consistent with their own will—welcome rather than intrusive. “Something is affecting me” may partly become “I can let this in because it is for me.” The patient may thereby experience agency despite genuine restrictions. Agency need not mean controlling everything; it may also mean safely relinquishing some control to someone judged capable of holding it. This matters in the ICU, where autonomy cannot be restored simply by “offering more choices”: in many matters there is genuinely no choice. Yet there may be a psychological difference between control being taken from me and being able to entrust myself, to some degree, to people working for me.

One adaptive advantage of belonging to the new superorganism is precisely this: regulatory functions can be entrusted to others without agency being lost. If I can trust others to fulfill their roles, then deciding what I can entrust to them and what remains my own task may itself be part of adaptive agency.

Here the process connects directly with the SCS hypothesis. Through maternal-mode pacing, a communicator encoded as trustworthy may become a bridge person, as if guiding the patient from the familiar social world into the unfamiliar ICU system. Because this person understands the new world, can navigate it, and has already proved reliable, the patient may enter the social system they reveal with greater safety. Paternal-mode leading, operating through this relational channel, does more than provide new information: it places the patient within an intelligible social system.

It explains what is happening and why; what can be expected; which sensations are part of treatment and which may signal danger; who is present; what their intentions are; what rules guide their actions; what they are monitoring; and what remains the patient’s own task. The maternal function reaches and holds the floating fragment; the paternal function finds a place for it.

I call the joint work of these two functions in-event contextualization. The bodily and affective fragment does not receive its first place in a story only afterward, once the trauma has ended; rather, while the event is still unfolding, it begins to connect with causality, time, intention, roles, and opportunities for action. The patient can learn not only what is happening to them, but also where they are within the event and within the group.

One important consequence is a redistribution of vigilance. If the ICU system becomes interpretable not as a collection of unrelated, unpredictable strangers and machines but as a group functioning together with the patient, then the patient does not need to monitor every alarm, bodily change, intervention, and person separately. This may reduce the burden of information processing and regulation: others monitor what belongs to their role, while the patient can focus on what belongs to theirs.

This process can be understood as scaffolded co-regulation, but not in the soft sense that “someone supports the patient.” A scaffold (Wood et al., 1976) temporarily lends regulatory capacity. The Other and the group temporarily carry certain functions—interpreting the situation, holding part of the vigilance, identifying the next step, monitoring safety—until the patient can organize them more independently. The aim, however, is not to regulate in the patient’s place, but to enable them, within the supported situation, to increasingly experience their own functioning while also sensing the secure availability of help.

I would compare this to teaching a child to swim. At first, we hold the child gently in the water while they make their own movements. We help them recognize what is still being supported from outside and what they are already doing themselves, then gradually loosen the support so they can experience that they are increasingly able to keep themselves afloat. The amount of help is always adjusted to current need; it can be increased again when necessary and withdrawn when it is no longer needed.

Several elements of the model are visible within this single process. We repeatedly pace the person’s actual state, then identify the next achievable step. At the same time, we give meaning to experience: what is happening, why, what deserves attention, what we are holding, and what the patient can do. Context is provided during the event—in-event contextualization. Only as much regulatory support is lent as currently needed—scaffolded co-regulation. In parallel, the patient’s contribution is repeatedly made visible: you did this; you held this; that was your movement. Partial, supported agency is still real agency: help does not make the experience of one’s own effect less real. Awareness of help therefore need not diminish achievement, motivation, or self-confidence.

This matters especially in the ICU because having an opportunity to act is not the same as experiencing that one has such an opportunity. A patient may signal discomfort, cooperate, modify breathing, cough, choose, or persist through a difficult task while still experiencing the situation as things are being done to me and I am helpless. Communication therefore makes existing self-generated action psychologically visible: you signaled this; you are doing this; this is in your hands; what you do has consequences. I call this supported agentic experience.

Scaffolded co-regulation and supported agentic experience are therefore two sides of the same calibrated process: we lend only as much regulation as allows the patient to begin experiencing something as their own, and we adjust the scaffold to the patient’s current state.

For this reason, the process is not linear. Successful leading changes the patient’s experiential and action position. The new state is no longer the one from which the previous leading began; it must be found and paced again before the next step can be identified. The maternal–paternal regulatory spiral can therefore be represented as follows:

maternal-mode pacing → paternal-mode leading → contextualized, supported participation → changed current state → renewed pacing → the next leading adjusted to the new state.

The process is not a circle: the next turn begins not from an assumed starting point but from the patient’s actual state. That state may reflect progress, stagnation, exhaustion, or temporary setback. If an attempt leaves the patient frightened, exhausted, or feeling they have regressed, this new state must first be paced; only then can what happened and the next manageable step become intelligible. Pacing does not assert progress where none exists; it places the current state within a process that remains understandable and can continue.

The success of the regulatory spiral therefore does not require linear improvement. Even at the end of a day with no objective clinical progress, the patient may have more organization, safety, hope, and experienced competence than at the beginning. The reverse is also true: genuine clinical progress may occur without the patient experiencing any of it as their own achievement, and they may still end the day feeling helpless, unsuccessful, or resigned. One function of supported agentic experience is precisely to make the patient’s actual contribution psychologically accessible as well.

Retrospectively, the ARPS script offers clear examples of this organization. The clinical content of suction—including the patient’s ability to help remove secretions by coughing—was already part of the earlier PSBPS protocol; what matters here is how ARPS organizes it dynamically. The patient may hear suction, recognize what is happening, and attend to the difficulty caused by secretions. At the same time, they may know this is a purposeful intervention for them and one in which they can help. A small achievable action—coughing—can then produce an immediately perceptible result: easier breathing. That new bodily state can become the next pacing point. If the patient has not yet experienced suction, the communication can provide context in advance, so that during the event they may already know what is happening and what their own role can be.

A similar principle appears in the passages about breathing: different states of machine-assisted and increasingly independent breathing become intelligible stages within the same treatment process, while the direction—the recovery of independent breathing and self-regulation—remains visible throughout.

The maternal–paternal spiral is a retrospective recognition and theoretical naming of a mode of functioning that was already discernible in ARPS. ARPS was not developed through explicit application of this model; its patient-attuned quality emerged intuitively from earlier clinical experience.

In live interaction, the clinician can directly pace each newly reached state. Erickson’s utilization approach and permissive formulations similarly emphasize working with the patient’s available responses and accommodating multiple possible current states rather than imposing a fixed path (Erickson & Rossi, 1979a). Recorded communication can therefore encompass multiple possible experiences instead of relying on moment-to-moment contingent pacing. Critically ill, mechanically ventilated patients also encounter many bodily and environmental cues that are highly likely to be present and salient. ARPS phrases such as “perhaps…,” “you may notice…,” and “it may be that…,” together with naming likely experiences, can offer repeated meeting points at which the patient recognizes: yes, I hear this; yes, I feel this; yes, this is happening. Each congruent match may strengthen the experience that the text is about and for the patient and helps them orient themselves.

Recorded communication can therefore realize several core functions of the regulatory spiral: regulation can be scaffolded so the patient is not left alone; their contribution and competence can be made visible, supporting agency; events can be contextualized while they unfold; and the patient can recognize a place, role, and task within the temporary group. The goal remains clear: this temporary superorganism exists to help the patient regain autonomy as soon as possible and return to their own social world.

8. Conclusions

The starting question was what relationship adds to suggestion when explicit memory, orientation, and autonomous control may be severely restricted. The model proposes that relationship may shape the world of which events are experienced as a part, who an influence is experienced as coming from, and what meaning it carries. Maternal-mode pacing creates contact and credibility within the still-accessible bodily-affective world; paternal-mode leading can provide time, causality, social order, task, and direction. Through the repeated spiral, in-event contextualization, scaffolded co-regulation, and supported agentic experience may help the patient become not a passive object within an unfamiliar system but a supported participant in a human system working for them.

The ICU may thus function as a magnifying glass, making visible in extreme form a basic psychological question: how do we adapt when our previous world model, control, or habitual responses are no longer sufficient? In the ICU, threat itself may open this adaptation window involuntarily and without consent. Certain forms of hypnosis, by contrast, may be understood as a therapeutically co-created adaptation window in which established meanings and responses become more flexible within a safe, bounded, consensual relational space, allowing new possibilities for regulation, connection, and action. This does not equate hypnosis with critical stress; rather, processes magnified in the ICU may illuminate hypnotic and psychotherapeutic relationships.

The present model should not yet be treated as established. The SCS, maternal–paternal regulatory spiral, in-event contextualization, and elements of supported agency are retrospective, integrative, hypothesis-generating constructions requiring prospective testing. Their value lies in specifying why, when, under what relational conditions, and through what mediating processes communication should matter. The final claim is simpler: in critical illness, relational communication may do more than comfort or convey information. It may help organize an overwhelming experience while it unfolds, so the patient can be not only a helpless object of treatment but a supported participant in a protective human system.