Hypnosis

HYPNOSIS: THEORIES, RESEARCH AND APPLICATIONS No part of this digital document may be reproduced, stored in a retrieval system or transmitted in any form or by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in rendering legal, medical or any other professional services.

HYPNOSIS: THEORIES, RESEARCH AND APPLICATIONS

GAEL D. KOESTER AND

PABLO R. DELISLE EDITORS

Nova Science Publishers, Inc. New York

Copyright © 2009 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA Hypnosis : theories, research, and applications / [edited by] Gael D. Koester and Pablo R. Delisle. p. ; cm. Includes bibliographical references and index. ISBN 978-1-61668-216-3 (E-Book) 1. Hypnotism--Therapeutic use. I. Koester, Gael D. II. Delisle, Pablo R. [DNLM: 1. Hypnosis. 2. Psychotherapy--methods. WM 415 H99833 2009] RC495.H985 2009 615.8'512--dc22 2009029340

Published by Nova Science Publishers, Inc.  New York

CONTENTS Preface Chapter 1

Chapter 2

vii A New Theory for Understanding and Appreciating the Power of Hypnosis: Comparing this Theory to Previous Theories and Noting its Many Benefits Alfred Barrios Patterns of Interactional Harmony: The Phenomenology of Hypnosis Interaction Katalin Varga, Emese Józsa, Éva I. Bányai and Anna C. Gősi-Greguss

Chapter 3

Applications of Waking Hypnosis to Difficult Cases and Emergencies Carlos Lopes-Pires, M. Elena Mendoza and Antonio Capafons

Chapter 4

Language, Metaphor and Neuroscience: Scientific Explanation and Pragmatic Rules for Effective Communication in Hypnosis Renzo Balugani, and Giuseppe Ducci

1

53 99

131

Chapter 5

The Relational (Intersubjective) Approach to Hypnosis Udi Bonshtein

145

Chapter 6

Hypnosis, Absorption and the Neurobiology of Self-Regulation Graham A. Jamieson

161

Chapter 7

The Neurophysiology of Hypnosis in Mass Psychogenic Illness Felipe A. Tallabs G

175

Chapter 8

Relaxation, Meditation, and Hypnosis for Skin Disorders and Procedures Philip D. Shenefelt

187

Chapter 9

Hypnosis and Cancer: A Dead-End Story? Fabrice Kwiatkowski, Nancy Uhrhammer, Yves-Jean Bignon and Alain Blanchet

Chapter 10

The Valencia Model of Waking Hypnosis and its Clinical Applications 237 Antonio Capafons and M. Elena Mendoza

207

vi Chapter 11

Index

Contents Hypnosis in the Management of Chronic Pain Conditions, and the Acute Pain Accompanying their Treatment John F. Chaves

271 293

PREFACE This book presents new research on hypnosis, including a clinical review comparing the effectiveness of hypnotherapy to psychoanalysis and behavior therapy. Some of the recent clinical evidence contradicting the common criticisms and misconceptions surrounding hypnotherapy are presented, providing a good indication of how to make the best use of this tool, and to provide a rational explanation for its hard-to-believe therapeutic effects. This book also describes and illustrates the use of waking hypnosis based on the Valencia Model and applied to clinical cases considered difficult and/or emergencies. Furthermore, the relationship between hypnosis and psychoanalysis is extensively reviewed. The main assumptions of the intersubjective approach and how it is used in hypnosis, through case stories, is presented as well. Finally, this book presents evidence that the neural mechanisms of hypnosis is a fundamental prerequisite for the environmental context to provide the onset of MPI (Mass Psychogenic Illness). Other topics examined in this book include the effects of hypnosis on cancer patients and its use on people with skins disorders and procedures, as well as its effect on people with chronic pain. Chapter 1 - This chapter will first present a clinical review comparing the effectiveness of hypnotherapy to psychoanalysis and behavior therapy. This review indicated that the average number of sessions needed and success rates were: 600 and 38% for psychoanalysis; 22 and 72% for behavior therapy; and 6 and 93% for hypnotherapy. This is followed by an overview of a comprehensive theory of hypnosis based on principals of conditioning and inhibition explaining hypnosis including why hypnotherapy is so much more effective. The theory is then compared to three other current hypnosis theories, the Sociocognitive, the Dissociation / Neo-Disassociation, and the Response-Expectancy perspectives as well as with Erickson’s strategic approach to therapy. Research in support of the theory is next presented, including an experiment done by the author on the effectiveness of post-hypnotic suggestion which presents ways of eliminating many of the methodological shortcomings of previous hypnosis experiments. Finally, additional benefits of the theory are discussed. This includes its providing: (1) a further understanding of the hallucinogens, schizophrenia, bi-polar disorder, biofeedback, higher-order conditioning, placebos and religion; (2) development of more effective methods of hypnotic induction; (3) development of more effective methods of giving post-hypnotic suggestions; (4) and development of Self-Programmed Control (SPC), a positive-oriented behavioral improvement program aimed at achieving self-actualization, greater self-efficacy, and higher emotional intelligence. The dramatic positive results of

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SPC’s application in the areas of: education, welfare, industry, medicine and drug rehabilitation are presented. Chapter 2 - In this chapter the authors review the process of the formulation of our interactional approach to hypnosis together with the development of a new methodology through various experiments. The first interactional method developed to detect interactional synchrony between hypnotist and subject on the subjective level is the Parallel Experiential Analysis Technique (PEAT). PEAT is suitable for eliciting and simultaneously gathering free reports on the subjective experiences from both interactants that later can be parallelly processed. On the basis of four experimental series, characteristic data are shown as examples of the phenomenology of the subjective experiences of hypnotists and subjects. The free reports of hypnotists about their subjective experiences were analysed separately as well and yielded three common topics that are illustrated by verbatim quotations from the original reports. Another possibility of the interactional analysis is the use of the same paper/pencil tests for the hypnotist and subject. First we used the Phenomenology of Consciousness Inventory (PCI) for this purpose, and in several of our experiments the authors compared their subjective experiences along their scores on the PCI factors. Later they developed a new paper/pencil test, the Dyadic Interactional Harmony (DIH) questionnaire, for directly measuring the synchrony of an interaction. DIH was validated in a series of experiments and it is a promising measure for tapping the interactional aspects of a hypnotic relationship. They used PCI and DIH from hypnotist and subject as means of interactional analysis of subjective data along with the concept of hypnosis styles (maternal/paternal scores) in a real-simulator design. They exemplify the special possibilities of the interactional approach of phenomenological data by a recent empirical result: they demonstrate the very different pattern of heritability in the case of subjective data as opposed to the behavioral score of hypnosis. In their experiments, in which standardised hypnosis interactions of subjects of various kinship had been analyzed, results showed that the phenomenological experience of hypnosis is not based on genetic determination, but the way interactants evaluate the session (the interaction itself) seems to be closely related to the degree of kinship. All of these empirical results seem to add special new possibilities to the understanding of hypnosis and the authors encourage every researcher to follow this interactional approach and methodology. Chapter 3 - In this chapter, the authors describe the use of this approach for difficult cases and/or emergencies based on the Valencia Model, albeit introducing substantial modifications to adapt it to the specific characteristics of the intervention in these cases. Difficult cases and/or emergencies are defined as follows: 1) people who have gone through a number of treatments without receiving significant benefits, and, consequently, they have fewer therapeutic options; 2) people in despair (for several reasons); 3) people whose problem needs to be solved or improved immediately; 4) people in shock; 5) people who, due to their poor clinical condition, are not amenable to starting a treatment using the choice techniques for their problem, such as exposure, behavioral activation, etc. As a result, their approach puts forth three intervention models for difficult cases and/or emergencies, which correspond to the different types of cases that have been considered the most relevant according to our clinical experience. Chapter 4 - Neuroscience, in particular thanks to imaging techniques, now makes it possible to express the embodied, sensorimotor nature of many cognitive domains including

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action perception, simulation and imagery. There is also growing neurophysiological evidence regarding the sensorimotor basis of language and concept formation, as previously theorized by cognitive linguistics. The role of metaphor posited by Lakoff and Johnson in the construction of the thought and abstract thinking is described. Conceptual metaphors and their use in everyday language are discussed, emphasizing both their universality and their variations in specific pathological populations. Arguments about the close link between hypnosis and metaphor are given; the opportunity of a finely graded assessment of the particular use of metaphors in any particular patient is suggested in order to build up a more effective intervention in the practice of Ericksonian psychotherapy. Chapter 5 - The main aim of this chapter is to discuss how intersubjectivity can be applied to hypnosis. Intersubjectivity is the sharing of subjective states by two or more individuals. This is a major perspective in psychoanalysis. Adopting an intersubjective perspective in psychoanalysis means, above all, abandons the myth of the isolated mind. First, the chapter reviews the relationship between hypnosis and psychoanalysis. Three splits are described: a) psychoanalysis splits off from brain science; b) psychoanalysis splits off from hypnosis and c) splits occur within psychoanalysis. I discuss how these splits can be healed, so that hypnosis can be considered a two-person rather than a one person process. Next, the chapter presents the main assumptions of the intersubjective approach and how it is used in hypnosis, through case stories. The assumptions are based on theoretical and empirical from neuroscience. Chapter 6 - In hypnosis, suggested behaviours are characteristically accompanied by a diminished sense of effort and personal agency while suggested experiences, which strongly contradict objective reality, appear to be accepted without conflict. Dissociated control theory is a cognitive neuroscience account of hypnosis that emphasises functional disconnections (dissociations) within the predominantly anterior brain networks, which implement cognitive control. Profound alterations in the ongoing experience of the self outside the hypnotic context (labelled by Tellegen as absorption) are a key predictor of a person’s ability to experience suggested distortions of reality. Tellegen (1981) defined the trait of absorption as arising from the interplay of two mutually inhibitory mental sets, the instrumental and the experiential mental sets. The capacity to set aside an instrumental set finds a clear counterpart in current neuroimaging and EEG studies of dissociated control in hypnosis. The consequent ability to adopt an experiential set has a clear counterpart in the recent discovery of a characteristic brain network during quiescent mental activity. Neuroimaging studies of suggestions used to induce hypnotic analgesia show strongly overlapping activations with the loci of this network which generates core aspects of internally focused self experience. Tellegen pointed to distinctive roles for the instrumental and experiential mental sets in psychophysiological self-regulation in order to explain the importance of the trait absorption in mediating the mixed pattern of results in earlier biofeedback studies. This account finds further support in recent studies on the roles of these mutually inhibitory neural networks in differing patterns of regulation of peripheral physiology. These findings provide an important foundation from which to understand the unique contributions of absorption and hypnosis in effective practices of self-regulation. Chapter 7 - Mass Psychogenic Illness (MPI) is typically defined as the collective occurrence of a constellation of similar physical symptoms and related beliefs, for which there is no plausible pathogenic explanation, and which can be divided in two possible conditions, Mass Anxiety Hysteria and Mass Motor Hysteria. Evidence has emerged that the

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cultural context is of utmost importance in the mechanism of both variants of Mass Psychogenic Illness. However, there is an underestimated variable that relates both conditions even in a more meaningful manner, and this is the neurophysiology of hypnosis. This study presents evidence that the neural mechanism of hypnosis is a fundamental prerequisite for the environmental context to exert pressure and provoke the onset of MPI; the role of empathy is assessed as a part of the mechanism of suggestibility during MPI, as well as a possible mirror neuron system that could be the cornerstone of symptomatology transmission. Fundamental differences are presented from the two variants of MPI, Mass Anxiety Hysteria and Mass Motor Hysteria. Chapter 8 - Relaxation, meditation, and hypnosis can help calm and rebalance the inflammatory immune response, which in turn can ameliorate inflammatory skin disorders. The relaxation response has been shown to help rebalance immune functioning. Mindfulness meditation has been shown to enhance the response of psoriasis to ultraviolet light treatments. Hypnosis has been shown to decrease inflammation and discomfort in a number of skin disorders and to improve the patient's attitude about having the condition. Hypnosis has also been shown to be more effective than relaxation alone in alleviating inflammatory skin disorders. Psychocutaneous hypnoanalysis permits diagnostic evaluation as to whether psychosomatic issues are initiating or exacerbating specific skin disorders. If psychosomatic issues are present, hypnoanalysis also permits treatment by reframing the initiating event in a way that defuses the negative emotional charge associated with it. Rapid induction hypnosis followed by deepening and then self-guided imagery has also been effective in alleviating anxiety and discomfort associated with dermatologic procedures. Chapter 9 - Oncology is a domain where hypnosis has a role to play, since medical treatments are still not sufficient. Although the impact of many types of psychosocial intervention have been tested in cancer patients with disappointing results on survival, hypnosis has not yet been assessed using appropriate methodology. Surveys testing hypnosis that include survival as an end-point need still to be performed. On the other hand, the impact of hypnosis on patients’ well-being has been well studied, and appears to be very useful against depression, pain, treatment side-effects and other symptoms. It can now be proposed to children or adults, and has proven to be a great help to terminally ill cancer patients. It can also prevent distress during invasive medical procedures. In most trials, hypnosis appears to be superior to standard educational and/or cognitive-behavioral interventions. Sometimes sessions can be performed by nurses and physicians having followed a short course in the technique, although for prospective trials testing wider end-points, we suggest that welltrained hypnotists participate, preferably practitioners trained in psychology. These trials should explore various dimensions of the patient’s psyche, examine the impact of the alleviating past trauma, promote behaviors known to reduce the risk of relapse, including physical activity, diet, and biological rhythms. The effect of hypnosis on immunity should also be evaluated since some authors have shown a positive impact on natural killer cell count and activity. For research purposes, measures concerning susceptibility to hypnosis should be collected and new indicators developed in order to facilitate future progress. Oncology is only just beginning to take advantage of the diverse possibilities of hypnotism. Chapter 10 - In this chapter, authors describe in detail the Valencia Model of Waking Hypnosis. The concept of waking hypnosis, originally introduced by Wells in 1924, was developed in Spain, and several standardized methods were generated shaping this Model. It is based on the socio-cognitive or cognitive-behavioral paradigm of hypnosis, and represents

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the first approach to waking hypnosis that disregards the concept of trance. Rather it advocates the continuity between hypnotic and everyday life behaviors, and is focused on variables such as expectations, motivation, attitudes, beliefs, etc. The model consists of a number of efficient methods intending to be straightforward and pleasant for the patient as well as quick to learn and to apply. The procedures implemented as part of the model in order to achieve good rapport with clients are the following: a cognitivebehavioral introduction to hypnosis, a clinical assessment of hypnotic suggestibility, and a metaphor for hypnosis. Furthermore, two induction methods of waking hypnosis are added to these procedures, namely, Rapid Self-Hypnosis and Waking-Alert Hypnosis, the latter also known as Alert-Hand Hypnosis. During the intervention, hypnosis is used in combination with motivational questions to help clients understand the relevance of their thoughts in the maintenance of their problems and the usefulness of hypnosis in changing them. The sequence is structured while flexible to be adapted to the intervention. Thus, the ultimate aim is to enable patients to activate therapeutic suggestions in those everyday situations in which they need them. Some of the advantages of waking hypnosis are the following: clients show less fear of losing control; it usually takes less time to obtain results; clients can remain self-hypnotized with eyes open while engaged in other activities, which enables them to give themselves therapeutic self-suggestions that can go unnoticed when the problem occurs in public situations; it is easy to generalize to everyday life; it is versatile and efficient; and it is easily convertible into a general coping and self-control set of skills. Therefore, due to its versatility, the Valencia Model of Waking Hypnosis presents many clinical applications. An illustrative case of the clinical application of this model is described in this chapter. Chapter 11 - The effective management of chronic pain continues to present a serious challenge to the health professions. Even though we now have a wide array of medical therapies that are relatively safe and largely effective in managing many forms of chronic and acute pain, these therapies have significant limitations, especially in the management of chronic pain. The pain relief achieved with traditional biomedical and surgical therapies is often incomplete and sometimes ineffective. Moreover, relief too often comes at a high cost in terms of the patient’s quality of life. Adding to these considerations has been our growing awareness of the limitations of a narrow biomedical perspective on health and well-being and a recognition of the need to embrace a broader biopsychosocial perspective that encourages our examination of alternative approaches to pain management. This chapter describes and evaluates the ways in which one such alternative, clinical hypnosis, has been used in the management of chronic pain, including the management of acute pain associated with the treatment of underlying medical conditions producing chronic pain. It describes the nature of hypnotic interventions and the manner in which they have been used in chronic pain management. It also considers the spectrum of application of hypnosis in chronic pain management and reviews systematically collected data as well as case studies pertaining to several chronic pain problems. The emphasis is placed on finding reported since recent critical reviews by Spanos and Chaves. My goal is to provide a framework for clinicians who may be unfamiliar with this modality to understand better the nature of hypnotic treatment, help them appreciate the empirical evidence supporting its use, and introduce some of the practical issues involved in its effective use in chronic pain management.

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To put this topic in context, it is important to note that contemporary approaches to chronic pain management have increasingly coming to reflect an awareness of the significant contribution of psychosocial factors in the etiology, diagnosis, and treatment of many painful medical conditions. That fact is due, in part, to the reconceptualization of pain perception provided by the gate control theory of pain that offered new ways of understanding the neurophysiological mechanisms by which psychosocial factors could amplify or attenuate the pain experience. Although the basic observation that pain could be profoundly modulated by various psychological interventions was already well known, the articulation of a formal theory that provided explicit mechanisms by which this modulation of pain could be produced had an enormous impact on research and clinical practice and helped to encourage the development of multidisciplinary approaches to pain management. Soon, systematic efforts were underway to refine older therapeutic strategies and to develop new strategies for exploiting psychological resources that were already available to patients as well as assisting them in developing new skills that could be beneficially applied to reducing their symptoms. Although substantial gains in the clinical practice of pain management have been made since the Gate Control Theory was promulgated, the biomedical perspective has continued to dominate contemporary medical practice, even as more sophisticated psychological interventions for pain management were developed. In recent years, however, there has been substantial growth in the amount of research, including randomized clinical trials, being conducted on psychological interventions for chronic pain management. Favorable results have contributed to a growing acceptance of the notion that interventions like hypnosis, that can augment more traditional medical or pharmacological approaches, or reduce reliance on them, have the potential to play an important role in contemporary pain management.

In: Hypnosis: Theories, Research and Applications Editors: G. D. Koester and P. R. Delisle

ISBN 978-1-60456© 2009 Nova Science Publishers, Inc.

Chapter 1

A NEW THEORY FOR UNDERSTANDING AND APPRECIATING THE POWER OF HYPNOSIS: COMPARING THIS THEORY TO PREVIOUS THEORIES AND NOTING ITS MANY BENEFITS Alfred Barrios SPC Center, Culver City, CA, USA

ABSTRACT This chapter will first present a clinical review comparing the effectiveness of hypnotherapy to psychoanalysis and behavior therapy. This review indicated that the average number of sessions needed and success rates were: 600 and 38% for psychoanalysis; 22 and 72% for behavior therapy; and 6 and 93% for hypnotherapy. This is followed by an overview of a comprehensive theory of hypnosis based on principals of conditioning and inhibition explaining hypnosis including why hypnotherapy is so much more effective. The theory is then compared to three other current hypnosis theories, the Sociocognitive, the Dissociation / Neo-Disassociation, and the Response-Expectancy perspectives as well as with Erickson’s strategic approach to therapy. Research in support of the theory is next presented, including an experiment done by the author on the effectiveness of post-hypnotic suggestion which presents ways of eliminating many of the methodological shortcomings of previous hypnosis experiments. Finally, additional benefits of the theory are discussed. This includes its providing: (1) a further understanding of the hallucinogens, schizophrenia, bi-polar disorder, biofeedback, higher-order conditioning, placebos and religion; (2) development of more effective methods of hypnotic induction; (3) development of more effective methods of giving post-hypnotic suggestions; (4) and development of Self-Programmed Control (SPC), a positive-oriented behavioral improvement program aimed at achieving self-actualization, greater self-efficacy, and higher emotional intelligence. The dramatic positive results of SPC’s application in the areas of: education, welfare, industry, medicine and drug rehabilitation are presented.

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INTRODUCTION The work and ideas presented herein evolved from my 1969 Ph.D. dissertation in psychology at UCLA entitled “Toward Understanding the Effectiveness of Hypnotherapy: A Combined Clinical, Theoretical & Experimental Approach” and which I am proud to say was nominated that year for the national Creative Talent Award. The presentation will start with a review of the clinical literature of the time comparing the effectiveness of hypnotherapy to psychoanalytic therapy and behavior therapy. This review – which comprised the first third of my Ph.D. dissertation – was published as an article entitled “Hypnotherapy: A Reappraisal” in the APA journal Psychotherapy: Theory, Research and Practice (1970). One important point to keep in mind when assessing this review is that although the studies referred to took place over forty years ago, the results and conclusions still hold true today.

HYPNOTHERAPY: A REAPPRAISAL Introduction Throughout the years there have been periodic surges of great interest in hypnosis. Many extraordinary phenomena have been attributed to its effects and great claims made as to its effectiveness in therapy. Yet, in spite of such claims, there still appear to be relatively few therapists using hypnosis as a major tool. Why? Is it because the criticisms usually leveled at hypnosis are true? That it is overrated, actually limited to a small range of problems, unable to produce lasting changes? Will removal of symptoms by hypnosis lead to new symptoms? Is it dangerous? No, there is far too much clinical evidence contradicting these statements. Such evidence can no longer be ignored. It is felt that the major reason behind the rejection of hypnosis has been that for most people it is still virtually an unknown. It seems to be human nature to stay clear of or reject anything that doesn’t seem to fit in or be explained rationally, especially when it seems to be something potentially powerful. It is mainly its unknown nature that has led to the many misconceptions surrounding hypnosis and has kept us from making the best use of it. The purpose of the present paper is to present some of the recent clinical evidence contradicting the common criticisms and misconceptions surrounding hypnotherapy, to provide a good indication of how to make the best use of this tool, and to provide a rational explanation for its hard-to-believe therapeutic effects.

Overview of Recent Literature There have been 1,018 articles dealing with hypnosis in the past three years (1966 through 1968), approximately forty per cent of which dealt with its use in therapy. In the same period we find 899 articles on psychoanalytic therapy and 355 on behavior therapy. Contrary to popular opinion that hypnosis is only effective in certain specific symptomremoval cases, a wide range of diagnostic categories have been successfully treated by hypnotherapy. This includes anxiety reaction, obsessive-compulsive neurosis, hysterical

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reactions and sociopathic disorders (Hussain, 1964), as well as epilepsy (Stein, 1963), alcoholism (Chong Tong Mun, 1966), frigidity (Richardson, 1963), stammering and homosexuality (Alexander, 1965), various psychosomatic disorders including asthma, spontaneous abortions, dysmenorrhea, allergic rhinitis, ulcers, dermatitis, infertility and essential hypertension (Chong Tong Mun, 1964, 1966). Also in the past few years an increasing number of reports indicate that the psychoses are quite amenable to hypnotherapy (Abrams, 1963, 1964; Biddle, 1967).

Three Large Scale Studies Three large scale studies in the past five years contain basic findings. Richardson’s (1963) study dealt with seventy-six cases of frigidity. He reports 94.7% of the patients improved. The average number of sessions needed was 1.53. The criterion for judging improvement was increase in percentage of orgasms. The percentage of orgasms rose from a pre-treatment average of 24% to a post-treatment average of 84%. Follow-ups (exact length not given) showed that only two patients were unable to continue realizing climaxes at the same percentages as when treatment terminated. Richardson’s method of treatment was a combination of direct symptom removal, uncovering, and removal of underlying causes, since he had found that direct symptom removal alone was not always sufficient. He reports no hypnotic induction failures. Chong Tong Mun’s (1964, 1966) study covered 108 patients suffering from asthma, insomnia, alcoholism, dysmenorrhea, dermatitis, anxiety state, and impotence. The percentage of patients reported improved was 90%. The average number of sessions was five. The criteria for judging improvement were removal or improvement of symptoms. The average follow-up period was nine months. Chong Tong Mun’s method of treatment was a three-fold approach. With some patients he would work on reeducating the patient with regard to the behavior patterns immediately underlying the symptoms. With others he would first regress the patient back to the original onset of the symptom. Once regressed, he would reeducate the patient to the fact that the original cause was no longer operative. In addition, he usually used supplementary suggestions of direct symptom removal. Hussain’s (1964) study reports on 105 patients suffering from alcoholism, sexual promiscuity, impotence and frigidity, sociopathic personality disturbance, hysterical reactions, behavior disorders of school children, speech disorders, and a number of different psychosomatic illnesses. The percentage of patients reported improved was 95.2%. The number of sessions needed ranged from four to sixteen. The criteria for judging improvement were complete or almost complete removal of symptoms. In follow-ups ranging from six months to two years no instance of relapse or symptom substitution was noted. Hussain’s approach is illustrated by the case of a 35 year old woman exhibiting the following symptoms: anxiety, alcoholism, depression with suicidal tendencies, sexual promiscuity, insomnia, and inability to make decisions and future plans. Prior to treatment, Hussain pinpointed the various fears and negative attitudes which he felt were underlying the symptoms – e.g., the patient feeling unloved and unwanted in regards to her marriage, feelings of inadequacy at being a mother, fear of her own mother, fear of responsibility and making decisions, and guilt over her sexual promiscuity.

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Hussain then used a therapeutic technique somewhat similar to Wolpe’s (1958) desensitization technique to eliminate these fears and negative attitudes. For example, he would have the patient think of a particular fear-producing situation and recondition her by suggesting she would find herself calm and relaxed in the situation. This particular approach is very often used now in one form or another. Abrams (1963) refers to it as an “artificial situation” technique. Through hypnosis the patient is able to experience his new attitudes in an “artificial situation,” an imagined situation. This artificial situation technique was incorporated into the SPC program discussed below and is referred to as the “Projection Method” for self-programming of positive suggestions (Barrios, 1985, pp. 43-51). It differs from Wolpe’s approach in two respects. First of all, Wolpe does not often use hypnosis. Secondly, Wolpe has the patient go through a hierarchy of “imagined situations,” going from easiest to deal with to most difficult. (There is no reason, however, why this hierarchy approach cannot be incorporated into hypnotherapy.) With the above patient Hussain also used direct symptom-removal suggestions. For example, “aversion to the thought and sight of alcohol was also built up by direct suggestion.” This patient was discharged from the hospital after twelve sessions. “No relevant symptoms were left behind and there was no relapse during the six-month follow-up period.”

Current Method of Using Hypnosis As one can see in the above studies, and this probably comes as a surprise to most therapists, the main use of hypnosis is not as a means of direct symptom removal. Nor is its main use as an uncovering device. The current trend is to use hypnosis to remove the negative attitudes, fears, maladaptive behavior patterns, and negative self-images underlying the symptoms. Uncovering and direct symptom removal are still used to a certain extent, but usually in conjunction with this new main function. In the past, so much emphasis was directed towards symptoms and disease processes that some of us were guilty of forgetting the person in the body. It is incumbent upon us [hypnotherapists] to concentrate on treating the particular patient who presents the symptom rather than the symptom presented by the patient (Mann, 1963). Psychiatric hypnotherapy, as practiced today by the leading practitioners in the field, has in common with all other forms of modern psychiatric treatment that it concerns itself not only with the presenting symptoms but chiefly with the dynamic impasse in which the patient finds himself and with his character structure (Alexander, 1965). The objection that the results of symptom removal will seldom be permanent is certainly not valid. This may have been so in the past, when direct symptom removal alone was practiced and nothing was done to strengthen the patients’ ability to cope with his difficulty or to encourage him to stand on his own two feet (Hartland, 1965). This change is being stressed in the present paper because it is part of its purpose to fit hypnotherapy into “the scheme of things.” Many therapists have rejected hypnosis because its direct symptom approach of the past clashed violently with their dynamic approach. Now we see that such a clash need no longer exist.

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The Ahistorical vs. the Historical Approach in Therapy Some hypnotherapists use, in part, a historical approach, going back into the patient’s childhood and changing his attitudes regarding the causes of these patterns (Fromm, 1965; Abrams, 1963; Chong Tong Mun, 1964, 1966). However, most hypnotherapy is ahistorical and, it would seem, faster. If we wanted to change the direction of a river it might be much easier to work on the main current directly (once it had been located) rather than going back upstream, locating all the tributaries, and pointing each one in a new direction.

A Comment on the Dangers Ascribed to Hypnosis In the past there have been certain dangers ascribed to the use of hypnosis – for example, the danger of a psychotic break, or the substitution of more damaging symptoms. According to a number of investigators (Kroger, 1963; Abrams, 1964) these dangers have been grossly exaggerated. However, whatever dangers there were have been virtually eliminated by this new approach. The few mishaps that have occurred in the past resulted either from (1) the misuse of hypnosis as an uncovering agent, or (2) its misuse as a direct symptom remover. The first type of mishap was produced by a therapist, who would allow, or force, the patient to become aware of repressed information which he was not strong enough to face. The second type of mishap occurred when the therapist wrested away a symptom which the patient was using as a crutch before he was strong enough to stand on his own.

Hypnotizability of Patients Freud abandoned hypnosis because of “the small number of people who could be put into a deep state of hypnosis” at that time and because in the cathartic approach, symptoms would disappear at first, but reappear later if the patient-therapist relationship were disturbed (Freud, 1955, p. 237). In the above studies the only hypnotic induction failures were reported by Chong Tong Mun (eight failures out of 108 patients.) This can mean one of two things: the hypnotic induction procedures have improved since Freud’s day, or that the reconditioning approach used in these studies (as opposed to Freud’s cathartic approach) does not require very deep levels of hypnosis. There is evidence that both factors may be involved. Although many have thought that hypnotic susceptibility was a set character trait, there are a number of studies which now seem to indicate that this is not the case, and that responsiveness can be increased by certain changes in the hypnotic induction procedure (Pascal and Salzberg, 1959; Sachs and Anderson, 1967; Baykushev, 1969), as well as by means of a pre-induction talk aimed at insuring a positive attitude, an appropriate expectancy and a high motivation toward hypnosis (Dorcus, 1963; Barber, 1969; Barrios, 1969). With regard to the depth of hypnosis required for the reconditioning approach to work, there are a number of therapists who feel that only a light state of hypnosis is necessary (Van Pelt, 1958; Kline, 1958; Kroger, 1963) A study by Barrios (1969) gives this contention some support; it was found that an increase in the conditioning of the salivary response could be produced almost as effectively by lighter levels of hypnosis as by deeper levels.

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The latter point brings us to the question of whether hypnotic induction is necessary at all for the re-conditioning approach to work. Judging from the work of Wolpe (1958) it would appear that hypnosis is not an absolutely necessary requirement. This would also be supported by the work of Barber (1961, 1965) who found that hypnotic phenomena could be produced without a prior hypnotic induction. However, the real question to be answered is not whether hypnotic induction is absolutely necessary, but whether it can further facilitate the conditioning process. Wolpe, himself, concedes the hypnosis apparently does facilitate the conditioning: “Patients who cannot relax will not make progress with this method. Those who cannot or will not be hypnotized but who can relax will make progress, although apparently more slowly than when hypnosis is used.” (Wolpe, 1958, p. 141; italics added). Also, although Barrios’ (1969) study indicated that conditioning could be increased during lighter levels of hypnosis, it was also found that there was no increase in conditioning with those subjects indicating no response to the hypnotic induction. As pointed out in the theory (Barrios, 1969), hypnotic and waking suggestion are on the same continuum and hypnotic induction should be looked upon as a procedure whereby we can increase the probability of getting a more positive response to suggestion. The next question to be decided now is not so much whether hypnotic induction procedures increase responsiveness (this is fairly well accepted – e.g., Barber, 1969) but what variables in the hypnotic induction are playing the key roles and what can be done to strengthen the effectiveness of these factors.

Comparison with Psychoanalysis and Behavior Therapy In Wolpe’s comparison of his and the psychoanalytic approaches (Wolpe, Salter, and Reyna, 1964), we find the following: Based on all psychoneurotic patients seen, the number of patients cured or much improved by psychoanalysis was 45% in one study involving 534 patients and 31% in the other study involving 595 patients (the only two large scale studies in the literature on psychoanalysis). The average duration of treatment for the improved patients (given only for the first study) was three to four years at an average of three to four sessions per week, or an average of approximately 600 sessions per patient. For Wolpe’s approach we find that, based on all patients seen, the recovery rate was 65% in his own study involving 295 patients (usually [misleadingly] reported as 90% of 210 patients) and 78% in a study by Lazarus involving 408 patients. The duration of treatment for the improved patients was an average of thirty sessions in the former and fourteen in the latter. Averaging the above figures, we find that for psychoanalysis we can expect a recovery rate of 38% after approximately 600 sessions. For Wolpian therapy, we can expect a recovery rate of 72% after an average of 22 sessions, and for hypnotherapy we can expect a recovery rate of 93% after an average of 6 sessions. It is interesting to note the negative correlation between number of sessions and percentage recovery rate. At first sight this seems paradoxical. However, if a form of therapy is truly effective, it should not only increase recovery rate, but also shorten the number of sessions necessary (as well as widen the range of cases treatable).

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The Need for a Rational Explanation In spite of all the encouraging reports, there continues to be considerable hesitation on the part of psychotherapists to use hypnosis. Hypnosis is still looked upon as an “unknown” by most therapists. They are as yet not aware of any reasonable rational explanation for hypnotic phenomena that would satisfy them, one that would tie these phenomena down to observable facts and laws. As long as hypnosis continues to exude an air of mysticism and charlatanism, it will continue to be rejected by many, no matter how great the claims on its behalf.

An Explanation Based on Principles of Conditioning The experienced therapist really should not be so surprised at the effectiveness of hypnosis in facilitating therapy. Hypnotic induction can be looked upon as a technique for establishing a very strong rapport, for establishing a greater confidence, a greater belief in the therapist, whereby the latter’s words will be much more effective. As Sundberg and Tyler (1962) point out, one of the common features among all methods of psychotherapy is the attempt to “create a strong personal relationship that can be used as a vehicle for constructive change… It is a significant fact that many theoretical writers, as their experience increases, come to place much more emphasis on this variable” (pp.293-294). The question still remains, however – what exactly is the process whereby “mere words” can produce such great changes in personality. As pointed out in Barrios’ (1969) theory of hypnosis, the ability of words to produce behavior changes is really not so difficult to understand if we are familiar with the principles of higher-order conditioning. First of all, we know that words can act as conditioned stimuli. Pavlov recognized this fact: Obviously for man speech provides conditioned stimuli which are just as real as any other stimuli… Speech, on account of the whole preceding life of the adult, is connected up with all the internal and external stimuli which can reach the cortex, signaling all of them and replacing all of them, and therefore it can call forth all those reactions of the organism which are normally determined by the actual stimuli themselves (Pavlov, 1960, p. 407).

Now, according to principles of high-order conditioning we know that by paring word B with word A we should transfer the response produced by word B to word A and consequently anything that would evoke word A. Thus, for example, if we wanted to condition a person to be more relaxed in the presence of people, we would pair the words “people” (A) and “relaxed” (B), using a sentence or suggestion such as, “From now on you will find yourself more relaxed in the presence of people.” Mower’s theoretical formulations on the sentence as a conditioning device (Mowrer, 1960) tend to support this contention. Of course, we know that under ordinary circumstances suggestions are not always accepted (and thus conditioning doesn’t always result when an appropriate suggestion is given). Why is this? Osgood (1963) holds that a suggestion will tend to be rejected if it is incongruent with the subject’s previously held beliefs and attitudes or his present perceptions. It would seem that if there were some means of eliminating the latter we should be able to

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have a suggestion more readily accepted and thus facilitate the higher-order conditioning. Hypnosis is such a means. Thus we come to the reason hypnosis is so effective in facilitating therapy: the incongruent perceptions, beliefs, and attitudes are kept from interfering with the suggestion (and thus with the conditioning). As put by Pavlov: The command of the hypnotist, in correspondence with the general law, concentrates the excitation in the cortex of the subject (which is in a condition of partial inhibition) in some definite narrow region, at the same time intensifying (by negative induction) the inhibition of the rest of the cortex and so abolishing all competing effects of contemporary stimuli [present perceptions] and traces left by previously received ones [previously held beliefs and attitudes]. This accounts for the large and practically insurmountable influence of suggestions as a stimulus during hypnosis as well as shortly after it (Pavlov, 1960, p. 407; italics added).

As an illustration, let us say we wanted to change a patient’s self-image from that of an inadequate person to a more self-confident one. If under ordinary circumstances we suggested that he would no longer feel inadequate, it would most likely accomplish little. This is because the patient’s negative self-image, usually ever-present and quite dominant, would quickly suppress any positive image suggested, or at least keep it from being too vivid or real. But in the hypersuggestible hypnotic state conditions are different. The patient’s negative self-image is now more easily inhibited and should therefore be less likely to interfere when we attempt to evoke the positive self-image through suggestion. As a result, the conditioning can take place and new associations can be made. The person can truly picture himself feeling self-confident in various situations and these new conditioned associations in turn can lead to new behavior. This new attitude can now become permanent by means of self-reinforcement, just as his old negative attitude had been kept permanent by self-reinforcement. As long as the patient has negative attitudes, these are self-reinforcing. They lead to his tensing up, acting awkward and making numerous mistakes. Also, he is unlikely to believe any praise or any positive occurrences should they chance his way. But if this negative self-image has been replaced by a positive one, the opposite cycle can result. Being more confident and relaxed he will naturally be more likely to be accepted. Also, he will now be more open to believing and accepting praise and positive outcomes.

OVERVIEW OF MY THEORY OF HYPNOSIS* In the theory (Barrios,1969,2001) a hypnotic induction is defined as the giving of a series of suggestions so that a positive response to a previous suggestion predisposes the subject to respond more strongly to the next suggestion. Hypnosis is defined then as the state of heightened suggestibility, also referred to as a state of heightened belief, produced by a hypnotic induction. What occurs during a hypnotic induction to increase suggestibility is a process of conditioning of an inhibitory set. The latter increases responsiveness to suggestion

*

Much of the remainder of this chapter is taken verbatim from my commentary articles, Part I & II, in Contemporary Hypnosis (Barrios, 2007 a & b)

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by inhibiting thoughts and stimuli which would contradict the suggested response. The more effective the hypnotic induction, the greater this inhibitory set. It is postulated that at any point in time there are any number of stimuli (both cognitive and sensory) that one can be responsive to, some more strongly than others. This is referred to as the stimulus dominance hierarchy. The various hypnotic and post-hypnotic phenomena can be explained in terms of how the inhibitory set can rearrange the dominant position of a particular stimulus (cognitive or sensory) focused on by the suggestion. Post-hypnotic behavior changes are explained as produced through a process of higher order conditioning where the inhibitory set facilitates such conditioning by suppressing any dominant stimuli present (cognitive or sensory) that would interfere with the intended conditioning. From the theory, a number of ways can be deduced for increasing responsiveness to suggestion and thereby increasing the effectiveness of hypnotic induction. These include: the amplification of minute responses to suggestion such as with the use of biofeedback devices; the minimization or inhibition of competing stimuli such as in sensory deprivation or under the influence of inhibitory drugs; and the subtle introduction of stimuli that would naturally evoke the suggested response. Since the theory defines hypnosis as a state of heightened belief, one can see that hypnosis can be a natural everyday occurrence. Salesmen, lawyers and politicians are constantly benefiting from a variation of hypnosis (the powers of persuasion). So too are doctors (the power of the placebo) and ministers (the power of faith).

COMPARISON WITH OTHER THEORIES Comparison with Sociocognitive Theories Similarities Both perspectives discuss the importance of the part played by individual differences in affecting initial responsiveness to suggestion. The following are included as individual influencing factors in both perspectives: subjects' expectations and beliefs about hypnosis; motivation and imagination (or fantasy proneness). Two areas of individual differences mentioned in the theory which apparently are not mentioned in the literature on sociocognitive theories are age of the subject and prestige of the hypnotist in the eyes of the subject. It is expected that sociocognitive theorists would agree that these are also important individual difference factors. However, the explanation for how these factors play a part according to the theory might differ from the sociocognitive perspective. With regards to age, for instance, the theory states that the reason initial suggestibility varies with age, may be traced to certain factors that vary with age. One of these is language ability. Since [according to the theory] hypnosis is dependent to a great extent on the conditioned response evoked by words, we can understand why very young children whose language ability is not yet well-developed would make very poor subjects for hypnosis, and thus why we would expect an initial gradual increase in suggestibility with increasing age ...

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An explanation for the gradual decline in suggestibility after the age of eight is that with continued increasing age the number of cognitive stimuli competing with a suggestion increases (that is, knowledge increases with age) and a corollary to the 'reciprocal inhibition' or 'stimulus dominance hierarchy' postulate is that the more stimuli in the hierarchy, the lower the probability of a reaction to any one of them ... with increasing age there will be a greater number of possible contradictory stimuli [competing with] a suggestion; that is, subjects have more information available with which to verify or contradict the suggestion. (Barrios, 2001: 185) With regards to prestige, It is fairly well accepted that the more 'prestige' a hypnotist has in the eyes of subjects, the better his chances of success. It is felt this is so because the statements, commands or suggestions of a person with prestige tend to be questioned less, that is, such a person evokes a greater inhibitory set to begin with. In general, people have previously been conditioned to accept at face value the statements of someone who is an authority in his field. That is, an inhibitory set which inhibits contradictory stimuli [in the stimulus dominance hierarchy] has been previously conditioned (in much the same way as in the hypnotic induction process). This is so because what the authority says has usually turned out to be true! (Barrios, 2001: 181)

It will be recalled that in the theory a positive response to a series of suggestions (the hypnotic induction) conditions in an inhibitory set to automatically inhibit any stimuli (cognitive or sensory) in the stimulus dominance hierarchy that would contradict the suggestion. Another similarity between the sociocognitive and the theory's perspective revolves around the use of what the sociocognitives refer to as 'goal directed fantasies' (GDFs). GDFs are defined as 'imagined situations which, if they were to occur, would be expected to lead to the involuntary occurrence of the motor response called for by the suggestion' (Spanos, Rivers and Ross, 1977: 211). In other words, the more cognitive stimuli used associated with the suggested response, the more likely the response. In the theory, Hypothesis IV states: 'A suggestion produces the desired response by first evoking a cognitive stimulus which is associated with that response.' And a corollary to this hypothesis, Corollary 8, states: 'The more (compatible) cognitive stimuli associated with the response evoked by the suggestion, the stronger the response to the suggestion’. For example, to increase the probability of producing the involuntary response of salivation and/or the secretion of pepsin, you might want to suggest that the subject was eating a delicious steak or, better yet, a thick juicy steak smothered in onions. A third similarity between the two perspectives is how they apparently both seem to fit in with Milton Erickson's strategic approach to therapy. How Erickson's approach fits in with the sociocognitive perspective is discussed in a very extensive article by Lynn and Sherman (2000). The following includes some examples of how Erickson's ideas parallel those presented in the theory:

Scripts In the section of Lynn and Sherman's article where they are discussing Erickson's strategy of using scripts, they point out that

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Erickson found this technique useful in engendering a 'yea saying' response pattern. He would start with questions with an obvious 'yes' answer; to establish a pattern or response set, he would keep asking such questions. Patients would [then] apparently agree to things that they would not have agreed to in the absence of such a response set. (Lynn and Sherman, 2000: 306)

This also explains the effectiveness of persuasive salesmen who 'prep' a person to buy by getting the person to respond with 'yeses' to a series of questions. If we can look upon these 'questions' as a variation of suggestions, then in both cases the individual is being put through a form of hypnotic induction according to the theory. As stated by Hypothesis III of the theory: 'a positive response to a suggestion will induce within the responding person a more or less generalized increase in the normally existent tendency to respond to succeeding suggestions' (Barrios, 2001: 178). Also related to this 'yea saying' technique of Erickson is another he often used to get positive responses to his suggestions: 'He often tied suggestions to naturally or frequently occurring responses, or more broadly to whatever response the patient made (Erickson, Rossi and Rossi: 1976). Certain naturally occurring responses, such as lowering of an outstretched arm, provide immediate positive propioceptive feedback' (Lynn and Sherman, 2000: 307). To see the similarity of this to what is said in the theory, see Corollary 6 following Hypothesis III of the theory: 'The response could be "artificially" induced in a number of ways. For instance, the suggestions that the eyes are going to get tired may be helped if a slight eye strain is placed on them by having the subjects look at an object at a difficult angle' (Barrios, 2001: 180).

Erickson's Altering Accessibility According to Lynn and Sherman (2000: 306), 'Response sets can be established and reinforced by altering the accessibility of facts or events in memory ... For example, imagining negative outcomes of smoking and overeating and positive outcomes of not doing so can make it easier to resist these urges.' This very same procedure is referred to as the 'Punishment-Reward' technique, one of several visualization techniques for facilitating reprogramming, in the self-programmed control (SPC) program for improving behavior (see Barrios, 1973b and Barrios, 1985: 49 and 50). These techniques and others for facilitating suggestion and post-hypnotic suggestion are derived from Corollary 8 of the theory (see above) and will be discussed further in Part II of the Commentary. (Barrios, 2007b) Reframing Reframing was a technique of Erickson's to make general positive suggestions or treatment goals more attainable. For example, one of his approaches to break a patient out of depression over certain deficits was to 'turn the patient's deficits into assets'. This is very similar to one of the positive attitudes, Positive Attitude 4, 'Learn to look for the good in even the worst of situations,' in the chapter on positive attitudes in the SPC program (see Chapter IV of Barrios, 1985). If the goal of therapy is to help the patient break free of a depression caused by some negative life occurrence, for instance, instead of the hypnotherapist giving only the general suggestion that the patient will no longer be depressed, it would be more effective if the patient is also given the suggestion that he will learn to look for the good in even the worst of situations, in this way turning the patient's deficits into assets.

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In essence, this is saying that general suggestions alone (regarding treatment goals) without guidance to substantiate the suggestions are not as effective as the combination of the general suggestion plus guidance. This basic premise will be explored again later in Part II in the section on faith healing when pointing out that belief alone (e.g. a placebo) is not as effective as belief plus guidance. In so many words, this is similar to what Lynn and Sherman (2000: 307) mean when they state that 'As implied by these examples, Erickson's approach involves considerable reframing of behaviors [so] as [to be] consistent with treatment objectives.' Another area where Erickson's ideas fit in with the theory is where he talks about how it is that hypnosis plays a part in facilitating change in behavior. According to Lynn and Sherman (2000: 305): Erickson's appreciation of the crucial role of response sets is further revealed by his (Erickson, et al. 1976) observation that, 'much initial effort in every trance induction is to evoke a set or framework of associations that will facilitate the work that is to be accomplished' (p. 58). In fact, the authors define the 'therapeutic aspects of trance' as occurring when 'the limitations of one's usual conscious sets and belief system are temporarily altered so that one can be receptive to an experience of other patterns of association and modes of mental functioning ... that are usually experienced as involuntary by the patient (p. 20). All of these comments concur with the general thrust of response set theory [except for the concept of trance]. This is very similar to what is said following Hypothesis VII of the theory (in the section on posthypnotic suggestion) about how the inhibitory set aspect of hypnosis facilitates cognitive-cognitive conditioning and thereby facilitates positive behavioral change by eliminating any stimuli present that would interfere with the conditioning: 'Hypnosis, it is felt, provides an especially effective means (the inhibitory set) whereby interfering stimuli can be readily inhibited' (Barrios, 2001: 194-5). What Erickson refers to as 'the limitations of one's usual conscious sets and belief systems' the theory refers to as interfering stimuli, cognitive stimuli whose presence would ordinarily preclude the establishment of the desired new cognitive patterns and need to be 'temporarily altered' or as the theory puts it, 'inhibited,' in order for the new patterns to be made; or as Erickson puts it, 'so that one can be receptive to an experience of other patterns of association and modes of mental functioning' (Erickson, Rossi and Rossi, 1976: 20).

Differences Relative Importance of Hypnotic Inductions One major difference between the theory's perspective and the sociocognitive one revolves around the perceived importance of hypnotic inductions. The sociocognitive perspective seems to feel that hypnotic inductions increase suggestibility only to a minor degree whereas the theory does not agree with this. As Lynn and Sherman (2000: 298) put it, 'Suggestions can be responded to with or without hypnosis, and the function of a formal induction is primarily to increase suggestibility to a minor degree (see Barber, 1969; Hilgard, 1965).'

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The problem with this perspective is that it implies that all hypnotic inductions are able to increase suggestibility only to a minor degree, and thus it is implied that hypnotic inductions are really not that necessary. Yes, it may be true that the standard hypnotic induction emphasizing relaxation used in many of Barber's studies, for instance, is capable of increasing suggestibility only to a minor degree, but as indicated by Corollaries 5 and 6, following Hypothesis III of the theory, there are ways of increasing the effectiveness of hypnotic inductions even more (see: Wilson, 1967; Wickless and Kirsch, 1989; Kirsh, Wickless and Moffit, 1999 and Wickramasekera, 1973).

State vs Non-state Another significant difference between the sociocognitive and the theory's perspective revolves around the state vs non-state issue. According to Lynn and Sherman, because researchers like Barber and his colleagues (Barber, 1969; Barber and Calverley, 1964, 1969; Barber, Spanos and Chavez, 1974) in demonstrating the importance of individual differenced in hypnotic responding showed that non-hypnotized subjects exhibited increments in responsiveness to suggestions that were as large as the increments produced by hypnotic procedures. This research supported the idea that despite external appearances, hypnotic responses were not particularly unusual, and therefore did not require the positing of unusual states of consciousness. Accordingly, there is no need for clinicians to insure that their patients are in a 'trance' before meaningful therapeutic suggestions are provided. (Lynn and Sherman, 2000: 298)

There is some truth to this last statement. Some meaningful therapeutic changes can be produced with suggestions even without a formal hypnotic induction for some individuals. This would be true especially amongst those subjects who were highly suggestible even without a hypnotic induction. And even those who might not initially be highly suggestible could have their initial responsiveness to suggestion increased by manipulating certain individual difference factors such as attitude, motivation and fears, as pointed out on pages 183 and 184 of the theory (see Weitzenhoffer, 1953; Dorcus, 1963; and Barber and Calverley, 1965 as cited in Barrios, 2001: 183 and 184). However, by following such recommendations as those presented by corollaries 5 and 6 following Hypothesis III of the theory, the effectiveness of hypnotic inductions can be increased considerably more and responsiveness to suggestion (and therapeutic success) as a result raised significantly more than after a standard hypnotic induction (see: Wilson, 1967; Wickless and Kirsch, 1989; Kirsch et al., 1999; and Wickramasekera, 1993). If it is true that certain hypnotic inductions can produce significantly higher levels of suggestibility (even in already highly suggestible individuals), then I feel we can talk in terms of a hypnotic and nonhypnotic state. A hypnotic state could be defined simply as the heightened state of suggestibility (or as Skinner would put it, a heightened state of belief; see Barrios, 2001: 171) produced by the hypnotic induction. Yes, it is true that on an inter-individual basis, i.e. comparing one individual to another individual, some people can respond to suggestions without a hypnotic induction at the same level as another person who has gone through a hypnotic induction. In this sense there is no difference between states. But if we go on an intra-individual basis, i.e. comparing the same

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individual before and after a hypnotic induction, the hypnotic state for a given individual can be different than the waking state, especially after an effective hypnotic induction. Just one more thing: I would not recommend using the term 'trance' to designate a hypnotic state as it has 'zombie-like' connotations and we know a person can be in a hypersuggestible hypnotic state and still appear perfectly normal.

The Best Way to Measure Hypnotizability Also related to the question of whether there is that much difference between waking and hypnotic suggestion is the question of how best to measure hypnotizability. Many in the field, especially those from the sociocognitive perspective, seem to feel that a measure of suggestibility after the hypnotic induction is more than sufficient to measure hypnotizability. They feel they need not use the difference between hypnotic and waking suggestion as the measure since they find the correlation between the two to be very high (see especially Kirsch, 1997b: 213). However, this high correlation could be due to the fact that the researchers are basing their results on studies where only the standard hypnotic induction has been used, which tends to increase suggestibility 'only to a minor degree'. As more effective hypnotic inductions are used, this correlation will be less and it will become more appropriate to use the difference between hypnotic and waking suggestibility as the more correct measure of hypnotizability or hypnotic depth as I prefer to refer to it (See also section below on preventing methodological shortcomings in hypnosis experiments taken from Barrios, 1973a)

A Comparison of the Theory with Hilgard's Neo-dissociation Theory There are a number of similarities as well as a number of key differences between the theory and Hilgard's neo-dissociation theory of hypnosis. In discussing ways that determine what actions a person will take at any one time, Hilgard talks about a hierarchy of subsystems (habits or cognitive structures) that would vie for dominant position to determine the final common path leading to action. This is very similar to the stimulus dominance hierarchy referred to in the theory except, as per the theory, sensory stimuli are also included along with cognitive stimuli in this stimulus dominance hierarchy. Hilgard proposes two possible means for determining which subsystem will be in the dominant position of the hierarchy determining which action will take place. One, which he considers the old way, is where the subsystems would fight for control of the final common path leading to action according to their relative strengths. The other possible way of determining dominant position, and the way he seems to have finally leaned towards, is by way of a central regulatory mechanism. As he puts it, the subsystems are actuated according to the demands and plans of the central system. This central regulatory mechanism is responsible for the facilitations and inhibitions that are required to actuate the subsystem selectively. A hierarchy of subsystems is implied, although it is a shifting hierarchy under the management of the central mechanism. Once a subsystem has been activated it continues with a measure of autonomy. (Hilgard, 1977: 217-18)

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He then states 'Suggestions from the hypnotist may influence the executive functions themselves and change the hierarchical arrangement of the subsystem' (p. 218). According to the original version (Barrios, 1969), the theory leaned more to the old way of looking at how the subsystems arranged themselves in the hierarchy according to their individual strengths, and the inhibitory set part of the hypnotic suggestion was seen as directly influencing the eventual positioning of the dominant subsystem by inhibiting the competing subsystems. But now I also see the possibility of a central function playing a part in certain situations. This central control function I would describe as the will of the hypnotic subject, which can be listed as another of the individual differences of hypnotic subjects which can influence a hypnotic induction, i.e. everyone has a different level of willpower or free will that they bring with them. As presented in the paper 'Science in support of religion' (Barrios, 2002), free will is defined as control over one's involuntary functions (one's subconscious) via the power of belief, belief in one's ability to control one's destiny (control one's involuntary functions). This free will factor can have developed over the years or in a short period of time by means of a series of reinforced self-suggestion much like a self-hypnotic induction where the subjects come to develop their power of controlling their involuntary behavior through the power of belief. In a hypnotic induction this free will factor could either add to the depth of hypnosis achieved (the amount of heightened belief) or work against it. If the individuals see the suggestions given as working to their benefit, it would work in favor of a deeper induction. If against their benefit, it would work against a deeper induction. It would more likely work in favor of a deeper induction if in the pre-induction talk the subject is assured that all suggestions given will be positive ones or to the benefit of the subject; or if the induction is presented along the lines of self-hypnosis, i.e. as a means of developing even greater self control over one's involuntary behaviour. Now with regards to how according to Hilgard, does the hypnotic induction rearrange the hierarchy of subsystems, Kirsch and Lynn (1998: 110) feel that Hilgard 'leaves many unanswered questions: How do the hypnotist's words produce this rearrangement? ... and how does this contribute to the production of suggested responses?' In fairness to Hilgard, I feel he does present at least a partial explanation or answer to these questions. He posits two ways that hypnosis facilitates this rearrangement of the hierarchy (Hilgard, 1977): (I) 'Looked at in other ways, we find that hypnotic procedures are designed to produce a readiness for dissaociative experiences by obstructing the ordinary continuities of memories and by distorting or concealing reality orientations through the power that words exert by direct suggestion, through selective attention and inattention, and through stimulating the imagination appropriately' (p. 226)

And (2) 'The stress on muscular relaxation, familiar in hypnotic inductions assists in disorientation ... The lack of appropriately aroused memories makes the hypnotically responsive person less critical. To be critical requires comparing a present observation with familiar ones to judge its veridicality. If the memory context recedes, criticism also recedes. Hence imagination more readily becomes hallucination ... These illustrations show how memory interference has

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Alfred Barrios helped produce the dissociations found in hypnosis ... Under such circumstances, response to stimulation provided by the hypnotist takes precedence over planned or self-initiated action [the central regulatory mechanism] and the voice of the hypnotist becomes unusually persuasive'. (p. 227)

In somewhat different wording, Hilgard is saying the same thing that the theory is saying as to how and why hypnotic phenomena occur. The theory states that the suggested response occurs because the stimulus focused on by the suggestion rises to the dominant position in the hierarchy because the inhibitory set produced by the hypnotic induction inhibits the competing cognitive stimuli in the hierarchy (what Hilgard refers to as 'critical memories') as well as any present 'critical' sensory stimuli - something Hilgard does not include in his explanation. Something else that Hilgard does not include, which the theory does, is how this inhibitory set referred to is built up during the hypnotic induction through a process of conditioning. Hilgard does talk about selective attention and inattention (both of which have inhibitory components) and stimulating the imagination appropriately (i.e. triggering a cognitive stimulus) as part of the power that words exert through direct suggestion, but he does not explain why or how the hypnotist's words have become even more powerful after a hypnotic induction - which the theory explains as the build-up of, or conditioning in, of a strong inhibitory set. With regards to the part suggestions of relaxation play in producing the state of hypnosis, it is pointed out in the theory that suggestions of relaxation or sleep may help since the relaxed or sleep-like state 'may provide for even greater inhibition of stimuli competing with the suggestion' (Barrios, 2001: 172). However, the theory makes clear that a hypnotic state can be produced without any suggestions of relaxation or sleep.

Involuntary Behavior and the Subconscious There is one more thing that I would like to point out regarding similarities and differences between my perspective and Hilgard’s (and the sociocognitive & response set perspectives as well). It has to do with the automaticity of most behavior. It appears that all current theories concur with this apparent fact. One difference is that I have gone on to label this behavior as subconscious behavior or “the subconscious”: “The subconscious, or subconscious behavior, can be defined as behavior (learned or innate) that is so deeply programmed as to occur automatically without the need for that much conscious attention, if any (i.e. below conscious awareness). Driving a car is an example of learned subconscious behavior. When first learning to drive, you had to be aware of (be conscious of) every little movement. Now all the movements have pretty much become automatic. The ‘subconscious’ is to be differentiated from the ‘unconscious’ which can be defined as engrams or memories below immediate conscious accessibility. Most adult human behavior falls under the heading of subconscious behavior. The advantage of subconscious behavior is that it allows us to do many things at once, and relatively quickly. The main disadvantage is that once programmed in, the behavior is so automatic that it becomes difficult to change.” (Barrios, 2002, p.7) It is the latter fact, i.e. that certain automatic behaviors are so hard to change, that makes hypnosis such a valuable tool. Hypnosis provides us a systematic means of controlling the subconscious, of being able to rearrange the hierarchies of automatic behavior. And the more

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deeply imbedded this automatic behavior that we wish to change is (i.e. the higher in the hierarchy it is), the more effective a hypnotic induction is needed. It is this ability of hypnosis to facilitate post-hypnotic behavior change that plays the biggest part in making hypnotherapy so much more effective than any other form of therapy. The biggest problem with most people is that it is very hard for them to change. So anything that can facilitate change or re-programming will play a major role in achieving therapeutic success. In a way one can say that all humans are automotons because most of their behavior is automatic. But one major difference between humans and robots is that humans have the potential (through the free will factor) to reprogram themselves when necessary. Keep in mind, however, I said humans have the potential for re-programming but this potential has to be brought out and it is with tools like hypnosis and self-hypnosis that this can be done. It should be realized that when hypnosis is used in a therapeutic setting there are two ways that a hypnotherapist can help: One is to help add to the suggestibility (belief) factor sufficiently with an effective hypnotic induction in order to transcend or overcome certain negative automatic habits or cognitions that the patients with their own level of free will have been unable to accomplish. The other way the therapist can help is by providing the patients with some good guidance, a good idea of what habits and cognitions need to be changed. Now sometimes the latter is all that is needed and together with a sufficient level of free will to begin with the patients can then bring about the needed restructuring of the hierarchy on their own even without a hypnotic induction. But if the negative behavior is too high in the hierarchy for the patients’ own level of free will (own willpower) to rearrange it, this is when an effective hypnotic induction can be especially beneficial.

A Comparison with the Response Set and Response Expectancy Theory of Hypnosis There are a number of similarities and differences between the theory and the response expectancy perspective (Kirsch, 1985, 1997a, 2000). The following will present both the similarities and the differences. First, a major difference between the two is that Kirsch believes, as do most sociocognitivists, that 'The induction of hypnosis, for example, has a relatively small effect on the degree to which people respond to typical hypnotic suggestion' (Kirsch, 2000: 276). As already pointed out, although this statement might be true for the standard relaxation-type induction, it is not for other more effective types of hypnotic induction (see: Wilson, 1967; Wickless and Kirsch, 1989; Kirsch et a1., 1999; and Wickramasekera, 1973). The second major difference (and similarity) between the two revolves around his use of the term 'response expectancy'. Kirsch seems to feel that the key to increasing hypnotic responding is by increasing the subject's response expectancy (see Kirsch 2000: 275). I would be more inclined to agree with Kirsch if he were to use the term 'belief' in place of 'response expectancy'. Kirsch prefers to use the latter to describe what is being manipulated by a hypnotic induction whereas I would prefer to use the term 'belief'. As Kirsch puts it: 'A path analysis supported the hypothesis that hypnotic inductions enhance responsiveness by altering response expectancies' (1985: 1195). In the original theory I do refer more to 'suggestibility' as to what is being manipulated by a hypnotic induction. However, I have come to see the term 'suggestibility' as having some negative connotations, with some people possibly relating it to the term 'gullibility'.

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Consequently I now prefer to follow Skinner's lead of using the term 'belief' in describing hypnosis. As Skinner put it: With respect to a particular speaker, the behavior of the listener is also a function of what is called belief (a term very similar to suggestibility) ... our belief in what someone tells us is similarly a function of, or identical with, our tendency to act upon the verbal stimuli which he provides. If we have always been successful when responding with respect to his verbal behavior, our belief will be strong ... Various devices used professionally to increase belief of a listener (for example by salesmen or therapists) can be analyzed in these terms. The therapist may begin with a number of statements which are so obviously true that the listener's behavior is strongly reinforced. Later a strong reaction is obtained to statements which would otherwise have led to little or no response. Hypnosis is not at the moment very well understood, but it seems to exemplify a heightened 'belief' in the present sense (Skinner, 1957, pp. 159-160). (See Barrios, 2001: 171)

Now getting back to 'response expectancy' and why I prefer the term 'belief': one problem with the former term is that it implies that there is a visible response connected to the expectancy. Yes, you can get someone to produce the visible response of 'arm rising' if he has a strong response expectancy of 'arm rising'. But where is the visible response when the response expectancy is that the subject will see the color red? Not all cognitions necessarily have a clearly visible response attached to them. Next comes the question of how response expectancy or belief produces responses. Kirsch himself poses the question thusly: 'To accept a suggestion is to believe or expect that these events will in fact happen. So the real problem is to understand the effects of response expectancy on experience, behavior and physiology. How does response expectancy produce these changes?' (Kirsch 2000: 279). (Note how Kirsch uses the terms 'believe' and 'expect' interchangeably here which would lead one to believe that he might also be willing to use 'belief' and 'expectancy' interchangeably.) Kirsch's answer to this question is to posit some underlying substrate or connection between actual responses and the expectancy of that response. As he puts it, 'if we assume that there is a physiological substrate for any experiential state, then a change in perception is always a change in physiology, as well. For that reason, expectancy induced changes in experience will always be accompanied by at least some physiological change' (Kirsch, 2000: 280). And, 'Just as the expectation of an experiential response tends to generate that response, so too the expectation of an overt automatic response promotes its occurrence' (p. 280). The main difference between mine and Kirsch's explanation for how belief/response expectancy leads to responses is that first of all I explain how there is a response connected to the suggestion (as a result of classical conditioning - see the Pavlov quote on page 167 of the theory, Barrios 2001); and second, I explain the heightened response to hypnotic suggestion as resulting because of the greater inhibitory set produced by the hypnotic induction which inhibits competing stimuli. A third major difference between our perspectives is how we explain how response expectancy/belief can be increased in hypnotic situations. According to Kirsch: There are three kinds of cognitions that ought to affect response expectancies in hypnotic situations: (a) perceptions of the situation as more or less appropriate for the occurrence of

A New Theory for Understanding and Appreciating the Power of Hypnosis

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hypnotic responses; (b) perceptions of the response as being appropriate to the role of a hypnotized subject ... and (c) judgments of one's hypnotizability. (Kirsch, 1985: 1194)

As for his first two ways (a and b) I agree. These are covered in the theory under the heading of 'Subjects' expectation' in the section on 'Individual differences factors influencing hypnotic induction' (see Barrios, 2001: 181-3). It is pointed out that (a) as a result of the expectancy of being hypnotized, subjects are more likely to ascribe correctly the occurrence of the 'strange' phenomena to the hypnotist than to some external cause' (p. 182); and (b) 'Subjects' expectations of what hypnosis is like can influence hypnotic induction in other ways. For example if the subjects are told that a catalepsy of the dominant hand occurs when they experience hypnosis (Orne, 1959), then as subjects feel themselves responding, they are also indirectly being given the suggestion of catalepsy of the dominant hand. This response can, in turn influence the hypnotic induction, as can any positive responses to previous suggestions' (p. 183). With regards to how Kirsch describes methods of affecting response expectancies by manipulating 'judgments of one's hypnotizability', I differ significantly with Kirsch. What he describes as one way of manipulating judgments of hypnotizability by surreptitiously provided experiential feedback simply as 'an expectancy modification procedure' (Wickless and Kirsch, 1989: 762), I would directly refer to as an actual hypnotic induction according to Corollary 6, following Hypothesis III of the theory, which states that surreptitiously provided feedback would facilitate a hypnotic induction (p. 180). As indicated on page 171 of the theory, hypnotic induction is defined as the giving of two or more suggestions in succession so that a positive response to one increases the probability of responding to the next one. And Hypothesis III states 'A positive response to a suggestion will induce within the responding person a more or less generalized increase in the normally existent tendency to respond to succeeding suggestions.' It is interesting that Kirsch states that: 'According to response expectancy theory, people's beliefs about their hypnotic ability are one of the determinants of the number of suggestions to which they are able to respond successfully' (Wickless and Kirsch, 1989: 762). Now if he would also say that the number of suggestions to which subjects are able to respond successfully is in turn a determinant of people's belief about their hypnotic ability, he would be coming very close to saying what is said in Hypothesis III of the theory.

Summary of the above Similarities and Differences There were a number of similarities and differences presented between the theory and three current theoretical perspectives. Among the similarities between the theory and the Sociocognitive and Response Expectancy theories is the emphasis on the importance of the part played by individual differences in affecting initial responsiveness to suggestion; how both the theory and the Sociocognitive theories seem to fit in with Milton Erickson's strategic approach to therapy; and how similar the theory is to the Response Expectancy theory if one can look upon the term 'response expectancy' as equivalent to the term 'belief'. The main similarity between the theory and Hilgard's theory is the use of a stimulus dominance hierarchy concept to explain what actions a person will take at anyone time and how hypnotic induction influences a rearrangement of the hierarchy. The main difference between the theory and the Sociocognitive and Response Expectancy theories is that the latter two perspectives seem to imply that all hypnotic inductions can

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increase suggestibility only to a minor degree whereas the theory predicts that there are ways of increasing the effectiveness of hypnotic induction beyond just a 'minor degree'. And related to this, the theory, as opposed to these other two perspectives, concludes that there can be such a thing as a 'hypnotic state' which is significantly different from the 'waking state'.

Support for the Theory Numerous studies and experiments in support of the theory were presented in the original publication of the theory (Barrios, 1969). This included the experiment done by the author to support Hypothesis VII of the theory – that hypnosis facilitates the higher-order conditioning produced via post-hypnotic suggestion (the explanation provided by the theory for how posthypnotic suggestion works). The results supported the three predictions made from the hypothesis: (a) The hypnosis group (N=43) showed greater conditioning (p