The Oxford Handbook of Hypnosis Theory, Research and Practice

OXFORD LIBRARY OF PSYCHOLOGY

The Oxford Handbook of

HYPNOSIS

Barnier

Contributors Elgan L Baker, Arreed F Barabasz, Marianne Barabasz, Joseph Barber, Amanda J Barnier, Dominic Beaulieu-Prévost, Grant Benham, Jeffrey J Borckardt, Richard A Bryant, Nicholas A Covino, Rochelle E Cox, Zoltan Dienes, Thibault du Chéné, Gary Elkins, Michael N Hallquist, Michael Heap, Mark P Jensen, John F Kihlstrom, Irving Kirsch, Linn LaClave, Ann Lagges, Stephen Lankton, Jean-Roch Laurence, Steven Jay Lynn, Kevin M McConkey, Chris J Mitchell, Franny C Moene, Mark Moore, William P Morgan, Michael R Nash, David A Oakley, David R Patterson, Mary-Jo Peebles, Nicole A Pérez, Michelle Perfect, Karin Roelofs, Pamela Sadler, Eric L Scott, David Spiegel, Aaron J Stegner, Anthony F Tasso, Eric Z Woody, Michael D Yapko, Jarred Younger

The Oxford Handbook of

• An exhaustive review of the science and practice of hypnosis • A successor to the classic text by Fromm and Nash • Features contributions from leading figures in the field

MICHAEL R. AMANDA J.

BARNIER

The Oxford Handbook of

Cover image: © iStockphoto.com/Ugur Evirgen

ISBN 978-0-19-964580-0

9 780199 645800

NASH

HYPNOSIS

The Oxford Handbook of Hypnosis is the successor to Fromm and Nash’s Contemporary Hypnosis Research (Guilford Press), which has long been regarded as the field’s authoritative scholarly reference for practitioners and researchers alike. With 31 original chapters this new book is a comprehensive treatment of where the field has been, where it stands today and its future directions. The world’s leading scholars masterfully track the latest developments in theory and research. These chapters are thoughtful, lucid, and provocative. Clinical chapters then comprehensively describe how hypnosis is best used with patients across a broad spectrum of disorders and applied settings. Authored by internationally renowned practitioners these contributions are richly illustrated with case examples and session transcripts. Unparalleled in breadth and quality, this book is the definitive reference for students, researchers, clinicians, and anyone wanting to understand the science and practice of hypnosis. The only reference you’ll need for years to come.

EDITED BY

2

HYPNOSIS Theory, Research, and Practice

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The Oxford Handbook of

Hypnosis Theory, Research and Practice

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The Oxford Handbooks series is a major initiative in academic publishing. Each volume offers an authoritative and state-of-the-art survey of current thinking and research in a particular subject area. Specially commissioned essays from leading international figures in the discipline give critical examinations of the progress and direction of debates. Oxford Handbooks provide scholars and graduate students with compelling new perspectives upon a wide range of subjects in psychology. Mike Nash is one the world’s leading experts on hypnosis. He is a prolific researcher and clinical educator, who also maintains an active clinical practice. He is Professor of Psychology at the University of Tennessee, and is Editor Emeritus of The International Journal of Clinical and Experimental Hypnosis, the world’s premiere venue for scientific and applied hypnosis. He received his Ph.D. from Ohio University in 1983 and completed his clinical internship at Yale University School of Medicine Department of Psychiatry in the same year. He has published two books, one on the research foundations of hypnosis and another on integrating hypnosis into clinical practice. He is a Diplomat in Clinical Psychology (ABPP), and is the recipient of 18 national and international awards for his scientific, clinical and teaching accomplishments. Amanda Barnier is an Associate Professor and Australian Research Council (ARC) Australian Research Fellow in the Macquarie Centre for Cognitive Science, Macquarie University, Sydney, Australia. Amanda began her career in Psychology at Macquarie University, graduating in 1991 with a BA (Hons). She completed a PhD in Psychology (1996) at the University of New South Wales (UNSW), and postdoctoral work at the University of California, Berkeley. Amanda then returned to Australia and UNSW as an ARC Postdoctoral Fellow and later as an ARC Queen Elizabeth II Fellow. She returned to Macquarie University in 2007.

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The Oxford Handbook of

Hypnosis Theory, Research and Practice

Edited by

Michael R. Nash Psychology Department, University of Tennessee, Knoxville, TN, USA

Amanda J. Barnier Macquarie Centre for Cognitive Science, Macquarie University, Sydney, NSW, Australia

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Great Clarendon Street, Oxford OX2 6DP Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide in Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries Published in the United States by Oxford University Press Inc., New York © Oxford University Press, 2008 The moral rights of the author have been asserted Database right Oxford University Press (maker) First published 2008 First published in paperback 2012 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this book in any other binding or cover and you must impose this same condition on any acquirer British Library Cataloguing in Publication Data Data available Library of Congress Cataloguing in Publication Data Data available Typeset in Minion by Cepha Imaging Pvt Ltd, Bangalore, India Printed in Great Britain on acid-free paper by Ashford Colour Press, Gosport, Hampshire ISBN 978–0–19–857009–7 ISBN 978–0–19–964580–0 10 9 8 7 6 5 4 3 2 1

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Contents

Contributors vii 1. Introduction: a roadmap for explanation, a working definition 1 Amanda J. Barnier and Michael R. Nash

SECTION I: Domain of hypnosis 2. The domain of hypnosis, revisited 21 John F. Kihlstrom

3. Generations and landscapes of hypnosis: questions we’ve asked, questions we should ask 53 Kevin M. McConkey

SECTION II: Theoretical perspectives 4. Dissociation theories of hypnosis 81 Erik Z. Woody and Pamela Sadler

5. Social cognitive theories of hypnosis 111 Steven Jay Lynn, Irving Kirsch and Michael N. Hallquist

6. How hypnosis happens: new cognitive theories of hypnotic responding 141 Amanda J. Barnier, Zoltan Dienes and Chris J. Mitchell

7. Intelligent design or designed intelligence? Hypnotizability as neurobiological adaptation 179 David Spiegel

8. A psychoanalytic theory of hypnosis: a clinically informed approach 201 Michael R. Nash

SECTION III: Contemporary research 9. Measuring and understanding individual differences in hypnotizability 225 Jean-Roch Laurence, Dominic Beaulieu-Prévost and Thibault du Chéné

10. Hypnosis scales for the twenty-first century: what do we need and how should we use them? 255 Erik Z. Woody and Amanda J. Barnier

11. Parsing everyday suggestibility: what does it tell us about hypnosis? 283 Anthony F. Tasso and Nicole A. Pérez

12. Advances in hypnosis research: methods, designs and contributions of intrinsic and instrumental hypnosis 311 Rochelle E. Cox and Richard A. Bryant

13. Hypnosis and the brain 337 Arreed F. Barabasz and Marianne Barabasz

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vi · Contents

14. Hypnosis, trance and suggestion: evidence from neuroimaging 365 David A. Oakley

15. Hypnosis and mind–body interactions 393 Grant Benham and Jarred Younger

SECTION IV: Clinical hypnosis: treatment and consultation A. Models of clinical intervention 16. Psychoanalytic approaches to clinical hypnosis 439 Elgan L. Baker and Michael R. Nash

17. Reclaiming the cognitive unconscious: integrating hypnotic methods and cognitive-behavioral therapy 457 Joseph Barber

18. An Ericksonian approach to clinical hypnosis 467 Stephen Lankton

B. Methods of clinical intervention: techniques and cases 19. Foundations of clinical hypnosis 487 Michael R. Nash

20. Hypnosis in the relief of pain and pain disorders 503 Mark P. Jensen and David R. Patterson

21. Hypnosis and anxiety: early interventions 535 Richard A. Bryant

22. Hypnotic approaches to treating depression 549 Michael D. Yapko

23. Hypnosis for health-compromising behaviors 569 Gary Elkins and Michelle Perfect

24. Treating children using hypnosis 593 Eric L. Scott, Ann Lagges and Linn LaClave

25. Medical illnesses, conditions and procedures 611 Nicholas A. Covino

26. Hypnosis in the treatment of conversion and somatization disorders 625 Franny C. Moene and Karin Roelofs

27. Trauma-related disorders and dissociation 647 Mary Jo Peebles

28. Hypnosis in sport: cases, techniques and issues 681 William P. Morgan and Aaron J. Stegner

C. Evidence base of clinical intervention and consultation 29. Clinical hypnosis: the empirical evidence 697 Mark Moore and Anthony F. Tasso

30. Making a contribution to the clinical literature: time-series designs 727 Jeffrey J. Borckardt and Michael R. Nash

31. Hypnosis in the courts 745 Michael Heap

Name Index 767 Subject Index 779

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Contributors

Elgan L. Baker, PhD Indiana University Indianapolis, IN, USA [email protected]

Nicholas A. Covino, PsyD Massachusetts School of Professional Psychology Boston, MA, USA [email protected]

Arreed F. Barabasz, PhD Washington State University Pullman, WA, USA [email protected]

Rochelle E. Cox, PhD Macquarie University Sydney, NSW, Australia [email protected]

Marianne Barabasz, PhD Washington State University Pullman, WA, USA [email protected]

Zoltan Dienes, PhD University of Sussex Brighton, UK [email protected]

Joseph Barber, PhD University of Washington Seattle, WA, USA [email protected]

Thibault du Chéné, BA Concordia University Montreal, Quebec, Canada [email protected]

Amanda J. Barnier, PhD Macquarie University Sydney, NSW, Australia [email protected]

Gary Elkins, PhD Baylor University Waco, TX, USA [email protected]

Dominic Beaulieu-Prévost, PhD Concordia University Montreal, Quebec, Canada [email protected]

Michael N. Hallquist, MS State University of New York–Binghamton Binghamton, NY, USA [email protected]

Grant Benham, PhD University of Texas–Pan American Edinburg, TX, USA [email protected]

Michael Heap, PhD Wathwood Hospital Rotherham, UK m.heap@sheffield.ac.uk

Jeffrey J. Borckardt, PhD Medical University of South Carolina Charleston, SC, USA [email protected]

Mark P. Jensen, PhD University of Washington Seattle, WA, USA [email protected]

Richard A. Bryant, PhD University of New South Wales Sydney, NSW, Australia [email protected]

John F. Kihlstrom, PhD University of California, Berkeley Berkeley, CA, USA [email protected]

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viii · Contributors

Irving Kirsch, PhD University of Hull Hull, UK [email protected]

Michael R. Nash, PhD University of Tennessee Knoxville, TN, USA [email protected]

Linn LaClave, PhD Indiana University Indianapolis, IN, USA [email protected]

David A. Oakley, PhD University College London / Cardiff University London / Cardiff, UK [email protected]

Ann Lagges, PhD Indiana University Indianapolis, IN, USA [email protected]

David R. Patterson, PhD University of Washington Seattle, WA, USA [email protected]

Stephen Lankton, MSW Arizona State University Phoenix, AZ, USA [email protected]

Mary Jo Peebles, PhD Bethesda, MD, USA [email protected]

Jean-Roch Laurence, PhD Concordia University Montreal, Quebec, Canada [email protected] Steven Jay Lynn, PhD State University of New York–Binghamton Binghamton, NY, USA [email protected] Kevin M. McConkey, PhD The University of Newcastle Newcastle, NSW, Australia [email protected] Chris J. Mitchell, PhD University of New South Wales Sydney, NSW, Australia [email protected] Franny C. Moene, PhD De Grote Rivieren, Organization for Mental Health Dordrecht, The Netherlands [email protected] Mark Moore, PhD Joan Karnell Cancer Centre at Pennsylvania Hospital Philadelphia, PA, USA [email protected] William P. Morgan, EdD University of Wisconsin–Madison Madison, WI, USA [email protected]

Nicole A. Pérez, MA University of Tennessee Knoxville, TN, USA [email protected] Michelle Perfect, PhD University of Arizona Tucson, AZ, USA [email protected] Karin Roelofs, PhD University of Leiden Leiden, The Netherlands [email protected] Pamela Sadler, PhD Wilfrid Laurier University Waterloo, Ontario, Canada [email protected] Eric L. Scott, PhD Indiana University Indianapolis, IN, USA [email protected] David Spiegel, MD Stanford University Palo Alto, CA, USA [email protected] Aaron J. Stegner, PhD University of Wisconsin–Madison Madison, WI, USA [email protected]

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Contributors · ix

Anthony F. Tasso, PhD Fairleigh Dickinson University Madison, NJ, USA [email protected] Erik Z. Woody, PhD University of Waterloo Waterloo, Ontario, Canada [email protected]

Michael D. Yapko, PhD Fallbrook, CA, USA [email protected] Jarred Younger, PhD Stanford University Palo Alto, CA, USA [email protected]

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CHAPTER 1

Introduction: a roadmap for explanation, a working definition Amanda J. Barnier and Michael R. Nash

1.1. Introduction As an area of scientific inquiry and clinical practice, hypnosis dates back over 220 years. Although interest in hypnosis has waxed and waned over two centuries, today, in the first decade of the twenty-first century, it remains strong. People are as fascinated as ever by hypnosis and by the experiences of the hypnotized person. In a recent survey of cultural views and attitudes about hypnosis, the responses of 280 college students from Australia, Germany, Iran and the USA revealed strong interest in hypnosis and positive attitudes towards it, but also misapprehensions (Green et al., 2006; see also McConkey, 1986; Wilson et al., 1986; Spanos et al., 1987; Johnson and Hauck, 1999). Common assumptions about hypnosis—that a hypnotized person is like a robot, that hypnosis is like being asleep, that hypnotizable people are weak or gullible, that hypnosis can make a person do things they couldn’t or wouldn’t ordinarily do, that hypnosis is all just faking—although incorrect, reflect genuinely important and interesting basic questions—about the impact of hypnosis on behavioral control versus monitoring, about hypnosis as an altered state, about the correlates of hypnotizability, about the impact of hypnotic

suggestions and about the best explanation for hypnotic effects. These questions continue to interest and tax the ingenuity of workers in the field (as we will see in the chapters of this book). The aim of scientific hypnosis is to go beyond popular perceptions and misperceptions to reveal the true nature of hypnosis and the value of its applications. As Kihlstrom (1992; see also Chapter 2, this volume) once noted: ‘hypnosis has matured as both a fascinating topic for scientific research and an effective technique for clinical application’ (p. vii). This handbook is a review of our triumphs and trials as a field of scientific and clinical endeavor. What do we know, what can we do? What do we still not know, what are we still learning or trying to do? This handbook offers 31 chapters from leading hypnosis theorists, researchers and practitioners from all over the world; their chapters comprehensively cover definitions, theory, research and practice. We offer to our colleagues—‘both the seasoned veteran and the newcomer to the field’ (Fromm and Nash, 1992, p. ix)—a hands-on tool for working in the field of hypnosis. In this Introduction, we: (1) reflect on the challenges of understanding hypnosis; (2) locate our handbook in a tradition of taking stock; (3) offer

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a working definition of hypnosis and highlight important themes in the domain and across our chapters; and (4) sketch the 30 chapters that follow.

1.2. Separating the wheat

from the chaff Efforts to separate the truth from the hype of hypnosis have a long history, almost as long as the field of hypnosis itself. In 1784, the King of France, Louis XVI, established a Commission of Inquiry into Animal Magnetism (the forerunner of hypnosis). Known as the ‘Benjamin Franklin Commission’, because it was presided over by Benjamin Franklin, then American Commissioner to France, its aim was to differentiate ‘the instantaneous effects of the fluid upon the animal frame excluding from these effects all the illusions which might mix with them’ (Tintertow, 1970, p. 93; see also McConkey and Barnier, 1991). Using systematic methods of public observation, selfstudy, case study and hypothesis testing, the Commissioners sought to identify the true causes of the effects of animal magnetism (McConkey and Barnier, 1991; McConkey and Perry, 2002; Perry and McConkey, 2002; for more references to the Franklin Commission, see Kihlstrom, Chapter 2; McConkey, Chapter 3; Lynn et al., Chapter 5; Spiegel, Chapter 7; Laurence et al., Chapter 9; Tasso and Perez, Chapter 11; Benham and Younger, Chapter 15, this volume). Nearly two centuries later, the influential theorist, researcher and practitioner, Martin Orne, likewise aimed to separate essence from artifact in hypnosis with equally clever methodologies and experiments (including the real–simulating paradigm; Orne, 1959; see also Cox and Bryant, Chapter 12, this volume). In this handbook, these discussions—of what hypnosis is and what it is not, of what hypnosis can do and what it cannot—continue, but as McConkey points out in his chapter, with new generations of questions and answers (McConkey, Chapter 3, this volume). As noted above, hypnosis has always fascinated people. Laurence et al. (Chapter 9, this volume) write about the lure of the highly hypnotizable person. In some ways, the rather

flamboyant and seemingly inexplicable behavior of the hypnotized person, at least given the ‘mere words’ of the hypnotist (White, 1941), has been as demanding as it has been captivating. Hypnosis has been considered not only difficult to study, but not quite scientific. Nearly 50 years ago, Gordon Hammer (1961), the influential Australian hypnosis researcher, argued that although psychologists generally do not need to justify their interest in exploring a particular phenomenon and that any topic is as worthy of attention as any other, the study of hypnosis is often not considered in the same generous spirit. Hammer cited Clark Hull, who once said that those who investigate hypnosis must have ‘the courage to brave the semi-superstitious fears of the general public and the uneasy suspicions of their “orthodox scientific brethren”’ (Hammer, 1961, p. 9). Despite this need for courage, workers in the field have contributed to a legacy of thoughtful conceptualizing, clever research and confident practice that extends back many decades. In fact, the field of hypnosis has attracted some of the brightest names across many disciplines—both for research and for practice. To use a popular sporting analogy, the field of hypnosis has ‘punched above its weight’. For instance, in 2002, Haggbloom and colleagues published a rank-ordered list of the 100 most eminent psychologists of the twentieth century, based on journal citations, introductory textbook citations and survey responses from members of the American Psychological Society. Fourteen of the 99 reported by Haggbloom et al. (2002) conducted research on hypnosis, wrote about hypnosis or directly influenced hypnosis research. These include familiar ‘hypnosis names’ such as Sigmund Freud (3), William James (14), Clark Hull (21) and Ernest Hilgard (29), but also Hans Eysenck (13), Kurt Lewin (18), Ivan Pavlov (24) Ulric Neisser (36; who wrote his classic 1967 book ‘Cognitive Psychology’ while visiting Martin Orne’s lab), Endel Tuving (36), Gordon Bower (42), Stanley Milgram (46; whose classic experiments on obedience inspired Orne’s real–simulating model), Elizabeth Loftus (58), Robert Rosenthal (84) and Wilhelm Wundt (93.5). In other words, over 14 percent of psychologists ranked as the most eminent of the twentieth

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century were involved in some fashion with hypnosis. As McConkey (Chapter 3, this volume) notes, across many generations these and other contributors to the field tackled challenging questions. And hypnosis is challenging because, at its heart, hypnosis is a private experience. Influential theorists such as White (1941), Sutcliffe (1960, 1961) and Shor (1979) all pointed to the hypnotic subject’s belief that the effects he or she experiences in response to the hypnotist’s suggestions are real (for more recent discussions, see Sheehan and McConkey, 1982; McConkey, 1991; Sheehan, 1991, 1992). Sutcliffe (1961) referred to the hypnotized person as ‘deluded’. Perhaps naturally, the principal index of the profound changes wrought by hypnotic suggestion is the person’s subjective reports of the quality of their experiences: did it feel involuntary, did it seem real (Weitzenhoffer, 1974; see also Barnier et al., Chapter 6, this volume)? Although overt behavior is a crucial part of hypnotic measurement, and is enshrined in the field’s standardized measures, it can be misleading (for more on hypnotizability measures, see Woody and Barnier, Chapter 10, this volume). For instance, one item in the Stanford Hypnotic Susceptibility Scale, Form C (SHSS:C; Weitzenhoffer and Hilgard, 1962; the ‘gold standard’ of hypnotizability measurement; Kihlstrom, Chapter 2, this volume) suggests to the hypnotized person that they will hear a mosquito buzzing around their right hand, landing on their hand and tickling. The subject may well appear to brush the mosquito away and thus pass the behavioral scoring criterion for that item. But did they really hear or feel the mosquito? Did they simply swat because they felt the hypnotist was expecting them to? We can only know by asking the subject. Developers of standardized measures of hypnotizability quickly realized that although predictive, positive behavioral responses to hypnotic suggestions are not necessarily accompanied by or reflective of a matching subjective experience (McConkey et al., 1999). The most important and interesting aspect of hypnosis—the phenomenon to be explained—is the individual’s private experience of hypnotic suggestions. When subjects describe their experiences, we are obliged to accept them at their word.

Given findings that highly hypnotizable individuals are not blatantly lying when they report on their hypnotic responses (Kinnunen et al., 1994), we have good reason to accept their verbal reports as valid evidence. But there remains the possibility that hypnotized individuals’ reports are misguided, misattributed or motivated in particular ways (Spanos, 1986; McConkey, 1991; Sheehan, 1992). Whereas Sutcliffe recommended that researchers start by accepting verbal reports as a meaningful guide to the occurrence of a hypnotic experience but check them by other means (e.g. behavior or physiology; for a similar, but more recent view, see Oakley, Chapter 14, this volume), Hilgard (1965) preferenced verbal report over physiological measures as the accurate indicator of, for example, pain (Sheehan and Perry, 1976). As the authors of this handbook make clear, especially with their clever approaches to understanding hypnosis, drawing inferences from subjective responses is a challenging, but necessary, fact of life in hypnosis (e.g. Cox and Bryant, Chapter 12, this volume). We’ll return to the nature of hypnosis in a moment. Despite the challenges of theory and inference in this area, or perhaps inspired by them, our colleagues past and present have put hypnosis to good use. As generations of researchers focused on the phenomenon of hypnosis itself (in intrinsic research) or used hypnosis to investigate phenomena outside the domain (in instrumental research; see Reyher, 1962, for the first use of this distinction; see also Barnier et al., Chapter 6; Cox and Bryant, Chapter 12; Oakley, Chapter 14, this volume), generations of clinicians developed and validated hypnotic treatments for a broad spectrum of disorders and issues. In reviewing the evidence for clinical hypnosis, Moore and Tasso (Chapter 29, this volume) conclude ‘that much impressive work has been done in evaluating the empirical status of clinical hypnosis; and that more remains to be done’ (p. 721). In this handbook, in Chapters 16–31, distinguished and successful colleagues describe clinical hypnotic approaches to pain, anxiety, depression, health-compromising behaviors, medical problems, disorders in childhood, conversion and somatization disorders, and dissociative disorders, as well as the use of hypnosis in forensic settings and in sport. They clearly

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distinguish what is useful in hypnosis from what is not—the truth from the hype, the wheat from the chaff.

1.3. A handbook, a roadmap One aim of this handbook is to capture the discipline of hypnosis at a particular moment in time. From time to time the field has found it valuable to take stock, and this volume sits firmly in a tradition of texts begun by Erika Fromm and Ronald E. Shor in 1972. In their 1972 volume, ‘Hypnosis: Research Developments and Perspective’, Fromm and Shor aimed to summarize the most important theoretical and empirical developments since the revival of hypnosis research in the mid-1950s, by ‘earmarking the obstacles that have stood in the way of the study of hypnosis as a science, presenting the current state of knowledge concerning hypnosis, and pointing the way toward future study’ (Fromm and Shor, 1972, p. vii). In taking stock, contributing authors: (1) reflected on underlying theoretical issues (Fromm and Shor) and considered hypnosis from historic perspectives (Shor); (2) surveyed seven broad areas (hypnosis and sleep by Evans, hypnosis as a research method by Levitt and Chapman, suggested behavior by T. X. Barber, hypnosis and psychophysiological outcomes by Sarbin and Siagle, hypnotic amnesia by Cooper, hypnosis and creativity by P. Bowers and K. S. Bowers, and hypnosis and imagination by Sheehan); (3) described five lines of individual research (effects of neutral hypnosis by Edmonston, hypnotic programming techniques by Blum, evidence for a developmentalinteractive theory of hypnotic susceptibility by J. R. Hilgard, the real–simulating paradigm by Orne, and measuring hypnotic depth by Tart); (4) summarized five areas of individual research within specific areas (humanistic aspects of hypnotic communication by Field, hypnosis and adaptive regression by Gruenewald, Fromm and Oberlander, hypnotic dreams and night dreams by E. R. Hilgard and Nowlis, co-operation and submission by hypnotized subjects by Shevrin, and hypnosis as a means of studying cognitive and behavioral control by Zimbardo, Maslach and Marshall); and (5) looked to future research (Fromm).

As a final and major contribution to the field, Fromm and Shor included a 52 page bibliography. Twenty years after its publication, Kihlstrom (1992) said of this volume that it ‘quickly found a place on the bookshelf of everyone interested in hypnosis’ (p. vii). In their second volume in 1979, ‘Hypnosis: Developments in Research and New Perspectives’, Fromm and Shor aimed to capture the exciting changes in the field in six short years. They noted that ‘more than 1,000 scientific publications on hypnosis have appeared since the first edition of this book was published in 1972’ (Fromm and Shor, 1979, p. xiii). This updated version included an entirely new section (and three chapters) on theories of hypnosis. Also, 13 of the 20 chapters from the first edition were updated by the authors; half of these extensively, such that, according to Fromm and Shor, they ‘essentially amount to new chapters’ (p. xiii). Only four chapters remained unchanged, in areas where the authors judged that no real progress had been made since 1972. Overwhelmingly, this second edition reflected a field continuing to develop quickly and productively. In taking stock in this edition, contributing authors: (1) reflected on underlying theoretical issues (Fromm and Shor) and considered hypnosis from historic perspectives (Shor); (2) introduced or further developed three influential theories (E. R. Hilgard’s neodissociation theory, Fromm’s ego-psychological theory, and Shor’s phenomenological model); (3) surveyed seven broad areas (hypnosis and sleep by Evans, hypnosis as a research method by Levitt and Chapman, suggested behavior by T. X. Barber, hypnosis and psychophysiological outcomes by Sarbin and Siagle, hypnotic amnesia by Cooper, hypnosis and creativity by P. Bowers and K. S. Bowers, and hypnosis and imagination by Sheehan); (4) described five lines of individual research (effects of neutral hypnosis by Edmonston, hypnotic programming techniques by Blum, imaginative involvements in everyday life and hypnosis by J. R. Hilgard, the real– simulating paradigm by Orne, and measuring hypnotic depth by Tart); (5) summarized four areas of individual research within specific areas (humanistic aspects of hypnotic communication by Field, hypnosis and adaptive regression by Gruenewald, Fromm and Oberlander,

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A handbook, a roadmap · 5

co-operation and submission by hypnotized subjects by Shevrin, and hypnosis as a means of studying cognitive and behavioral control by Maslach, Zimbardo and Marshall); and (6) looked to future research (Fromm). This edition included a 68 page bibliography and 342 new references. Of Fromm and Shor’s two volumes, Kihlstrom (1992) wrote: ‘It is hard to imagine more essential reading for the scientist or practitioner interested in hypnosis—not just for their constituent chapters, but also for the comprehensive, meticulously verified reference lists found at the back’ (p. vii). In their 1992 volume,‘Contemporary Hypnosis Research’, Fromm and one of us, Michael R. Nash, aimed to continue the Fromm and Shor tradition. But this edition was entirely new because, as Fromm and Nash (1992) wrote: . . . there have been so many changes and advances in the field of experimental hypnosis since 1979 that a simple update of the Fromm and Shor volume would be quite inadequate. New laboratories, new ideas, and new methodologies have transformed the research landscape as familiar theories are further refined, new ones emerge, and some old ones fade away (p. ix).

The aim of this third edition was again to provide a usable and comprehensive reference text—a survey of contemporary hypnosis theory, research, and methodology. In taking stock of the field more than a decade after the second edition, contributing authors: (1) offered theoretical and historical perspectives on hypnotic responsiveness (Woody, Bowers and Oakman) and on questions addressed in hypnosis research (Dixon and Laurence); (2) presented four current empirically based theories (E. R. Hilgard on dissociation theories, Spanos and Coe on a social-psychological approach, Fromm on an ego-psychological theory, and Nash on hypnosis, psychopathology and psychological regression); and (3) surveyed 11 broad areas (research designs by Barabasz and Barabasz, hypnosis as a research method by Holroyd, the neuropsychophysiology of hypnosis by Crawford and Gruzelier, correlates of hypnotic responsiveness by Kirsch and Council, the hypnotizable subject as creative problem-solving agent by Lynn and Sivec, hypnosis and creativity by Shames and Bowers, the phenomenology of hypnosis by

Sheehan, self-hypnosis by Kahn and Fromm, forensic hypnosis by McConkey, clinical hypnosis research by Brown, and the measurement of hypnotic ability by Perry, Nadon and Button). Like the Fromm and Shor volumes, Fromm and Nash provided a collected bibliography of over 80 pages as a reliable reference source for professionals and students. Kihlstrom (1992) wrote that ‘like its predecessors, this volume stands as a monumental summary of where hypnosis has been, where it stands today, and where it is heading tomorrow’ (p. viii). These three texts served as important markers to the continuing growth and sophistication of the field, especially as reflected in theory and research. Following this tradition, we likewise take stock of the field of hypnosis. But our handbook is not a mere updating of any of the earlier editions. Our aim is far broader than these texts. In this single handbook we include chapters on definition, theory, research and practice. This breadth distinguishes our handbook not only from the Fromm and Shor, and Fromm and Nash texts, but from a number of other texts published in recent years including, for instance, Lynn and Rhue’s (1991) ‘Theories of Hypnosis’, Rhue et al.’s (1993) ‘Handbook of Clinical Hypnosis’, McConkey and Sheehan’s (1995) ‘Hypnosis, Memory and Behavior in Criminal Investigation’, Heap et al.’s (2004) ‘The Highly Hypnotisable Person’ and Jamieson’s (2007) ‘Hypnosis and Conscious States’, to name just a few. Our coverage of theory, research and practice also distinguishes it from classic texts including, for instance, Hilgard’s (1965) ‘Hypnotic Susceptibility’, T. X. Barber’s (1969) ‘Hypnosis: A Scientific Approach’, Sheehan and Perry’s (1976), ‘Methodologies of Hypnosis’, Bowers’s (1976), ‘Hypnosis for the Seriously Curious’, Hilgard’s (1977) ‘Divided Consciousness: Multiple Controls in Human Thought and Action’, and Sheehan and McConkey’s (1982) ‘Hypnosis and Experience: An Analysis of Phenomena and Experience’, again to name just a few. Although all of these texts remain important and useful, they have focused on specific parts of the domain of hypnosis: on only theories or methods or clinical applications, or on only specific dimensions of hypnosis (e.g. hypnotizability, hypnosis and memory, the cognitive neuroscience of hypnosis).

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6 · CHAPTER 1 Introduction: a roadmap for explanation, a working definition

The aim of our handbook is to cover the whole terrain of hypnosis in one integrated text—a complete roadmap to the field of hypnosis at the beginning of the twenty-first century. To give a sense of the scope of this roadmap, first we highlight some central themes that run through the field and through these chapters, and then we sketch briefly the 30 chapters to follow in our handbook.

1.4. A working definition and

central themes Looking across the chapters of this handbook, as well as across the field of hypnosis as a whole, we can identify a number of themes of continuing dialog and debate. The first, and perhaps most important, is that of definition. Some others are: the nature of hypnotic ability, its correlates and context of expression; hypnosis as an altered or identifiable state; the role of method in theory and inference; and the link between definition and practice. Since, in our view, almost everything flows from definition, we take this opportunity to present our views (see also Barnier et al., Chapter 6; Nash, Chapter 8).

1.4.1. Definitions: crafting our words carefully and generously First, let us quickly come to grips with what a definition is, and what it is not. A definition is a concise description. A definition is the sketch; a description is the chiaroscuro. Definitions and descriptions identify the object of interest and its characteristics. Theories (or explanations) are accounts of the causes of the phenomenon. We require a pragmatic, nontendentious definition of hypnotic phenomena; the scientific process proceeds through a description, and ends in a theoretical analysis, thereby providing complete understanding (Killeen and Nash, 2003). However, it all begins with a definition. A definition can be either underdone or overdone. When underdone, the definitional frame affords maximal freedom, but researchers have little common ground for discourse.

Methodological replication mostly occurs only by coincidence. When overdone, the definitional frame provides a well-articulated commonground, but researchers are confined to so narrow a focus that replication is practically inevitable, and almost always uninteresting. So where to start? For guidance, we note Auke Tellegen’s (1978/1979) splendidly austere rough sketch of what probably interests most of us about hypnosis: The individual’s capacity to: ... represent suggested events and states imaginatively and enactively in such a manner that they are experienced as real (p. 220).

With interestingness in mind then, we must first define what constitutes a hypnotic situation. The trick is to do so without sacrificing too much of the term’s ecological vitality and relevance to the human condition in vivo. Arguably, there are two elements of a hypnotic situation: ‘hypnosis-as-procedure’ and ‘hypnosis-as-product.’ Ironically, only very recently has our field come to grips with the word ‘hypnosis’ as used in these two ways. What do we mean when we say ‘the hypnotized group?’ Is it a group of people who have been administered a hypnotic procedure? Or is it a group of people who are in a hypnotic state? The two are clearly not the same. We must define what a hypnotic procedure is concisely, while capturing the domain of interest. We know that hypnosis (the product) is not achieved just because hypnosis (the procedure) has been administered. After all, low hypnotizables, unwilling subjects and simulators of all stripes inhabit our laboratories and consulting rooms. We define the hypnotic situation in part by defining hypnosis-as-procedure. We then apply criteria to determine how confident we are that the result is hypnosis-as-product. Those criteria are usually indices of responsiveness: behavioral, experiential and physiological. Much the same can be said for medical anesthesia. Prior to major abdominal surgery surely it is not enough to know that one will be ‘anesthetized’ in the procedural sense of receiving a standard cocktail of medications tailored to the needs of the average patient. As patients we want to know more. We want to know (with confidence) that we will be ‘anesthetized’ in the

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product sense of having no awareness during surgery. We trust that our anesthesiologist is as interested in anesthesia-as-product as we are!

1.4.2. Hypnosis-as-procedure 1.4.2.1. What is necessary? Happily, the recent APA Division 30 (Psychological Hypnosis) definition explicitly described the two necessary components of a hypnotic procedure: Hypnosis typically involves an introduction to the procedure during which the subject is told that suggestions for imaginative experiences will be presented. The hypnotic induction is an extended initial suggestion for using one’s imagination, and may contain further elaborations of the introduction. A hypnotic procedure is used to encourage and evaluate responses to suggestions. When using hypnosis, one person (the subject) is guided by another (the hypnotist) to respond to suggestions for changes in subjective experience, alterations in perception, sensation, emotion, thought or behavior (Green et al., 2005, p. 263).

Hence, a procedure is a hypnotic procedure as long as it has these two required (and together sufficient) components: 1. Introduction: the person administering the procedure tells the subject that what is to follow involves suggestions for imaginative experiences. This introduction might be as simple as: ‘I am going to ask you to imagine some changes in the way you think and feel. Is that OK? Let’s see what happens’. This introduction then distinguishes the hypnotic situation from other forms of suggestion, which do not invite this type of participation by the subject (e.g. placebo, illusion, social influence; for a review, see Tasso and Perez, Chapter 11, this volume). 2. The first suggestion: the definition stipulates that the first imaginative suggestion is administered and operates as the induction. This is an exceedingly important point. If the committee had merely stated ‘and then the hypnotic induction happens’ it would be begging the question: so what exactly is a hypnotic induction? The committee elegantly

operationalized the induction as the first suggestion after the introduction.

1.4.2.2. What is not necessary First, as noted above, the APA definition does not require the recitation of a special stylized induction ritual. Instead, the induction is the first suggestion after the introduction. In our standardized protocols, this first suggestion is typically an extended suggestion that may (or may not) contain further elaborations of the introduction. Table 1.1 lists the first suggestions for nine standardized hypnotic procedures. In its decision to operationalize the ‘induction’ as simply the first suggestion, the committee was also following Hull (1933) who noted that the active element in a hypnotic procedure might be the first suggestion itself. For Hull (1933), hypnosis was synonymous with hypersuggesbility, so when he described the active element in the induction that causes hypersuggestibility he noted: Hypersuggestibility is a kind of spontaneous excess effect resulting from positive response to any direct suggestion, sometimes analogous to transfer of training (p. 393).

Indeed, the ‘induction’ of the Stanford Hypnotic Arm Levitation Induction and Test (SHALIT; Hilgard et al., 1979) is the one and only suggestion in the 6 min procedure. The text of some first suggestions may mention relaxation more than others, but relaxation is not necessary (Bányai and Hilgard, 1976; Mitchell and Lundy, 1986; Pavia and Stanley, 1988). Some first suggestions may be longer than others, but length of the ‘induction’ does not appear to matter, with some inductions being less than a minute (Kroger, 1977; Matheson and Grehan, 1979; Hariman, 1980; Wicks, 1982; Page and Handley, 1989; Syrjala and Abrams, 1996). Some first suggestions use indirect wording and some do not, but again this does not matter (Matthews et al., 1985; Lynn et al., 1993). These parameters are of little or no importance. What matters is that all of the ‘inductions’ used in our research scales include at least one main suggestion (and sometimes more). Second, the APA definition does not require that the word ‘hypnosis’ be used as part of the introduction to hypnosis or during the

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Table 1.1 The ‘induction’ suggestion and the first test suggestion of common research scales Scale

‘Induction’ suggestion

Next suggestion

Harvard Group (HGSHS:A)

Eye closure

Arm/hand movement

Stanford A (SHSS:A)

Eye closure

Arm/hand movement

Stanford B (SHSS:B)

Eye closure

Arm/hand movement

Stanford C (SHSS:C)

Eye closure

Arm/hand movement

Stanford Profile:I (RSPSHS:I)

Arm/hand movement

Perceptual Alteration

Stanford Profile:II (RSPSHS:II)

Arm/hand movement

Perceptual alteration

Stanford Arm Levitation (SHALIT)

Arm/hand movement

Arm/hand movement

CURSS (Modified)

Perceptual alteration

Arm/hand movement

Waterloo Group Scale (WGSHS)

Eye closure

Arm/hand movement

HGSHS:A, Harvard Group Scale of Hypnotic Susceptibility, Form A (Shor and Orne, 1963); SHSS:A, Stanford Hypnotic Susceptibility Scale, Form A and SHSS:B, Stanford Hypnotic Susceptibility Scale, Form B (Weitzenhoffer and Hilgard, 1959); SHSS:C, Stanford Hypnotic Susceptibility Scale, Form C (Weitzenhoffer and Hilgard, 1962); RSPSHS:I, Revised Stanford Profile Scale of Hypnotic Susceptibility, Form I and RSPSHS:II, Revised Stanford Profile Scale of Hypnotic Susceptibility, Form II (Weitzenhoffer and Hilgard, 1967); SHALIT, Stanford Hypnotic Arm Levitation Induction and Test (Hilgard et al., 1979); CURSS, Carlton University Responsiveness to Suggestion Scale-Modified (Comey and Kirsch, 1999); WGSHS, Waterloo-Stanford Group Scale of Hypnotic Susceptibility (Bowers, 1998).

suggestions. The definition committee noted that whereas some think it essential, others do not.

1.4.2.3. Why defining hypnosis-as-procedure is important Just as manualization is now standard in psychotherapy research, defining what we mean by ‘hypnosis-as-procedure’ is essential because when we define what a hypnotic procedure is (and is not) we influence, and to some degree constrain, our methodologies. In turn, our methodologies inform our theories (Sheehan and Perry, 1976). This is why the Division 30 definition and others like it (Kihlstrom, Chapter 2; Spiegel, Chapter 7, this volume; Tellegen, 1978/1979) are so foundational to a discipline that wishes to remain relevant. A line of research dating back before the Division 30 definition illustrates the problem of an overly constrictive definition. In a series of papers, Kirsch and Braffman (Braffman and Kirsch, 1999; Kirsch and Braffman, 1999) made minimal changes to a standard hypnotic procedure (Carlton University Responsiveness to Suggestion Scale-Modified; CURSS; Comey and Kirsch, 1999) and declared the resulting procedure to be nonhypnotic. Figure 1.1 details the alterations. Condition #1 is the CURSS

procedure unchanged. For condition #2, the authors retained the introduction of the CURSS hypnotic procedure, changing only the single instance of the word ‘hypnosis’ to the word ‘imagination,’ (as per Figure 1.1); and they deleted the protocol’s first suggestion (skipping directly from the Introduction to the second suggestion). For them, condition #2 was nonhypnotic because it did not use the word ‘hypnosis’ and it skipped the first suggestion (or as they termed it ‘the induction’). The authors reasoned that the difference in how subjects responded in condition #1 and how they responded in condition #2 is de facto the effect of hypnosis. They claimed that the determinants of hypnotic suggestibility have been found, and they are nonhypnotic suggestibility (i.e. condition #2) and social factors (see also Lynn et al., Chapter 6, this volume). However, both of these conditions adhere fully to the two necessary (and together sufficient) components of a hypnotic procedure as stipulated by the APA Division 30 definition. First, both conditions have an introduction that informs the subject that changes in experience will be described and that subjects are ‘to be receptive and responsive to ideas and to allow these ideas to act upon you without interference’. Second, both conditions have a first

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INTRODUCTION “In this part of the study, we want to assess your ability to use ‘HYPNOSIS’ OR ‘IMAGINATION’ to experience various things that will be described to you on audiotape. Your ability to experience them depends largely on your willingness to be receptive and responsive to ideas and to allow these ideas to act upon you without interference. So all you will need to do is close your eyes, relax, and try to imagine the experiences that I will describe to you.”

HYPNOTIC CONDITION #1

HYPNOTIC CONDITION #2 (purported “non-hypnotic”)

SUGGESTIONS PERCEPTUAL ALTERATIONS (FIRST SUGGESTION) Arm Levitation Arms Moving Apart Arm Catalepsy Arm Immobility Auditory Hallucination Visual Hallucination Amnesia

SUGGESTIONS ARM LEVITATION (FIRST SUGGESTION) Arms Moving Apart Arm Catalepsy Arm Immobility Auditory Hallucination Visual Hallucination Amnesia

Fig. 1.1 Two hypnotic conditions (by APA Division 30 Definition) once used to contrast hypnotic and nonhypnotic suggestibility as described in Braffman and Kirsch (1999). Necessary components of definition are in bold for each protocol.

suggestion (see Fig. 1.1). In condition #1, the first suggestion is for a perceptual alteration. In condition #2, the first suggestion is for an arm/hand movement. Arm/hand movement is the induction suggestion (i.e. first suggestion) for three different Stanford scales of hypnotic susceptibility; see Table 1.1). Because both conditions are hypnotic by Division 30 standards, it is not surprising then that the authors found that their ‘nonhypnotic’ condition correlated with their hypnotic condition at r = 0.66, fairly close to the test–retest reliability of most hypnotizability tests. Because both conditions had an introduction and because they both had a first suggestion, the relevant difference between these two hypnotic conditions is a contextual one: use of the word ‘hypnosis’ in the introduction of condition #1 and ‘imagination’ in condition #2. If we were to

accept the rationale of the Kirsch and Braffman method, this would mean that the question of a ‘hypnotic effect’ then pivots on ‘Does using the word “hypnosis” in the protocol make a difference to how people respond to subsequent suggestions over and beyond how they respond when the word ‘hypnosis’ is not mentioned’. This is a context question of modest interest. It is not a conceptual matter. Many years ago, T. X. Barber (T. X. Barber, 1969; T. X. Barber and Wilson, 1978) compared the effects of instructions with and without the word ‘hypnosis’, and concluded that this is one of several independent variables that can influence responses to suggestions. However, he made this observation without presenting the finding as pivotal. The problem with these types of constricted definitions is that they drain the science of

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its relevance. An example from outside the field of hypnosis helps to illustrate this point. If we wished to study the ‘effect of psychotherapy’, we would have to define psychotherapy-the-procedure. Manuals do this. Would the domain of psychotherapy be adequately captured by the operational definition that: ‘It is only psychotherapy if the word “psychotherapy” is used with the patient; and if the word “psychotherapy” is never used with the patient the procedure ceases to be psychotherapy?’ One might take this approach. But it would be a fateful decision. Using the word ‘psychotherapy’ with the patient is neither necessary nor sufficient for psychotherapy to occur. We know of no psychotherapy researcher who would say it is. Does using the word ‘psychotherapy’ as opposed to not using it make some sort of difference in patient improvement? It is conceivable. But is that what anyone really means by the ‘effect of psychotherapy?’ How interesting is it to define ‘an effect of psychotherapy’, as the difference between how much patients improve with a treatment protocol that mentions the word ‘psychotherapy’ and the same treatment protocol that does not? We believe that the study of hypnosis is worthwhile only to the extent it reveals something truly interesting about human nature. Scientific understanding is advanced by defining the domain of interest with an optimal definitional resolution that is neither too narrow nor too broad. Such a definition invites empirical and theoretical pluralism, recognizes the incompleteness of our concepts, and thereby enables us to ask and answer questions that matter about human nature more easily. The Division 30 definition and many of the definitions of hypnotic procedure described in the chapters of this handbook are suitable for this purpose.

1.4.3. Hypnosis-as-product When the introduction and the first suggestion are in place, hypnosis-as-procedure has occurred. The subject has been hypnotized in the sense of being administered the hypnotic procedure. Whether hypnosis-as-product has been elicited is another matter. The hypnotic procedure does not ensure that hypnosisas-product has or will occur. The necessary

elements must also be present. Broadly speaking, these two elements are attitude and aptitude (see also Barnier and McConkey, 2004).

1.4.3.1. Attitude As with perhaps all performances, whether they are spelling bees, SAT exams, athletic events, or job evaluations, some variance in performance is explained by attitude. So it is with hypnotic response. Without the right attitude—motivation, expectations and willingness—the subject will not experience hypnosis. The correlations between these variables and hypnotizability scores are typically in the range of 0.20–0.30 (de Groh, 1989; see also Laurence et al., Chapter 9, this volume). Even this very modest relationship between attitude and hypnotizability must be qualified. Spanos and his colleagues (Spanos et al., 1987; Katsanis et al., 1988) warned that the relationship between these variables and hypnotic performance is fan-shaped, such that: strong negative attitudes and expectations suppressed hypnotizability, whereas positive attitudes and expectations allow subjects to attain high hypnotizability scores. However, positive attitudes and expectations in and of themselves do not engender high hypnotizability (Spanos, 1991, p. 331).

In other words, the relationship between attitude and hypnotizability is less like a dosage effect (the more positive the attitude, the better the performance) and more like a threshold effect (it does not help to be especially willing, but one must be at least somewhat willing).

1.4.3.2. Aptitude The necessary cause that ‘keeps on giving’ in hypnosis research is aptitude: hypnotizability. One of the earliest and most surprising facts uncovered by hypnosis research is that the extent of a subject’s behavioral response to hypnosis is as stable across time as IQ tests (25–30 years, Piccione et al., 1989) and is stubbornly robust across a host of contextual features that one might otherwise expect would impact performance rather dramatically: wordings of procedures, length of procedure, experience level of operator, sex of operator and perceived prestige of operator. This qualifies hypnotizability as a necessary cause—in the complete absence of hypnotizability, there exists no introduction,

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no series of suggestions that can induce hypnosisas-product. No wood, no fire; just a spent match. Of course, in most cases, there is at least some kindling, and in this sense then hypnotizability.

1.4.3.3. When can we say hypnosis-as-product has been attained? ‘State’ (i.e. hypnosis-as-product) will serve our purpose as long as we keep in mind that the term ‘hypnotic state’ is not causal, and is not a unique condition, unvisited by unhypnotized people. What criteria do we apply in determining whether a hypnotic state has been attained? The motor responses of a hypnotized subject provide publicly measurable dependent variables. Generally, if the constellation of responses to standardized suggestions satisfies a criterion, we infer that the procedure induced hypnosisas-product. But there is little that is unique about these responses, at least as they occur descriptively. There is no superhuman strength; no change in volitional capacity (Kihstrom, Chapter 2, this volume). It is the subject’s experience that makes the hypnotic state exceptional. A key aspect of the hypnotic state is a befuddling of the subject’s ability to identify the causal agent of an action: was it me that moved my right hand, or did it happen by itself (see also Barnier et al., Chapter 6, this volume)? In all cases then, it is necessary to measure the constellation of evidence, both objective and subjective aspects, to validate the presence of the hypnotic state; i.e. we must determine the extent to which we are confident in saying that a hypnotic state has been attained. It is the alignment of the hypnotic procedure with able and willing subjects that results in hypnotic responses— both objective (e.g. inability to move, motor response to post-hypnotic suggestion) and subjective (e.g. reports of altered sensations)—which constitute hypnosis-as-product. Any one of these can be present with or without the others; our evidence for the hypnotic state increases as our knowledge of these factors increases. But this does not mean that the depth of the state is itself decreased if there is no evidence for one of these factors; we are just less certain hypnosis-as-product has been attained (Killeen and Nash, 2003). The issue is our level of confidence that the hypnotic state has been attained. This is

something like what we do in the laundry room when we suspect (but do not know) that the iron might have been left in the ‘on’ position overnight. We slowly approach the iron with caution to test whether it is hot relative to the ambient temperature. If it is, it’s ‘on’ and we are pretty confident about that. If it’s exceptionally hot, we might detect it earlier, and be more confident that it is on, but that does not mean that the iron is exceptionally ‘on.’ Likewise, when a subject scores exceptionally high on a standardized hypnotic scale (and subjective measures of experience), we are tempted to say that the subject is exceptionally hypnotized (or deeply hypnotized). This is not the case. Higher scores on difficult hypnotic scales merely allow us to be more confident that the hypnotic state has been attained. In this sense, the criteria we apply (hypnotizability scores and self-reports) function more like alpha levels in statistical sampling theory: nothing about effect size, everything about confidence that key parameters of the system have shifted. Hence, only when we are reasonably confident that all members of a group have attained a hypnotic state are we then privileged to label that group as ‘hypnotized’ in the sense of hypnosis-as-product.

1.4.3.4. Why is defining hypnosis-as-product important? Calling a cluster of parameter settings a ‘state’ is a matter of semantics and pragmatics, not ontology. It has nothing to do with what ‘is’, and everything to do with the mundane practicalities of simple description. States are not, after all, causal variables; they are indications that key parameters of a system are within a new range (see also Barabasz and Barabasz, Chapter 13; Oakley, Chapter 14, this volume). An iron is off or on. You don’t get burned because the iron is on, you get burned because it is hot. A hurricane’s meteorological parameters place it in one of five categories. Your roof blows off, not because it’s a category V hurricane, but because of wind. The state of a system is the status of its key variables at a point in time. A change in these indicates a different state. All of this matters because it impacts methodology. If we wish to study hypnosis-as-product, we have to use instruments and methodologies that allow us to be relatively certain that a hypnotic

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state has been attained (for more on the role of method in inference, see Sheehan and Perry, 1976; Cox and Bryant, Chapter 12, this volume). As Kihlstrom points out in his chapter (Chapter 2, this volume), all too often researchers do not screen for hypnotizability at all, or if they do they screen with a single group-administered measure of hypnotic responsiveness with insufficient range (e.g. typically not enough ceiling). This type of methodology is better suited to look for an effect of hypnosis-as-procedure; i.e. questions such as ‘Broadly speaking what effect does a hypnotic procedure have on behavior and experience?’ However, this methodology is singularly ill-suited to testing for an effect of hypnosis-as-product. In an unscreened sample we cannot be certain that the necessary conditions (attitude and ability) for hypnosisas-product have been obtained with every subject. Nor can we assume that a low score means that the subject is only a ‘little hypnotized’, and that a high score means that the subject is ‘deeply hypnotized’. Hence, when we wish to study hypnosisas-product, we require a group of subjects for whom the necessary conditions of attitude and ability are clearly satisfied and for whom shifts in key parameters of behavior and experience allow us to have a high degree of confidence that hypnosis-as-product has occurred. To identify these individuals, we need to screen subjects carefully. The minimum would seem to be an initial screening with a group procedure (e.g. HGSHS: A; Shor and Orne, 1963), followed by an individually administered procedure of a scale with more difficult items (e.g. SHSS:C; Weitzenhoffer and Hilgard, 1962; or RSPSHS: I and II; Weitzenhoffer and Hilgard, 1967); for other recommendations, see Kihlstrom, Chapter 2; Laurence et al., Chapter 9; Woody and Barnier, Chapter 10, this volume). When highly hypnotizable subjects survive this type of rigorous screening we can be more confident that our dependent measures are tracking something having to do with hypnosis-as-product. We can then ask questions such as: ‘When a person is experiencing a hypnotic hallucination, what is happening in the brain?’ or ‘What are the cognitive shifts that accompany hypnotically induced amnesia?’ or ‘How do individuals move during hypnotically induced partial paralysis?’ Finally,

when we wish to make strong claims about the impact of hypnosis on psychological or medical conditions, we need to be confident that our methods involve hypnosis-as-product and not simply hypnosis-as-procedure, and that clinical clients are experiencing something to do with hypnosis-as-product, and not simply hypnosisas-procedure. Summing up, we need to be clear when we talk about hypnosis. Hypnosis is not just what we, as researchers and clinicians, do to people. It is also, much more importantly, what people experience. It is both hypnosis-as-procedure and hypnosis-as-product. In the chapters that follow, our authors may focus on one aspect more than another, they may take different views on these two aspects, or they may agree or disagree with our views. But whatever our individual views may be, as a field we need to be clearer and more generous in our definition of hypnosis because it delineates the entire landscape of enquiry: the questions, the means of answering those questions and the possible answers. We turn now to describe briefly the four sections of this handbook and their 30 chapters.

1.5. A roadmap, revisited Just as Fromm and Shor (1972, 1979) and Fromm and Nash (1992) solicited chapters for their books from the leading and currently active researchers of the time, so too have we solicited chapters from the most influential and productive experimental and clinical workers in the field. None of the chapters has been published elsewhere. They were written exclusively for this handbook. The chapters present the very latest in theorizing, research and clinical applications of hypnosis. We encouraged our authors to write in such a way that researchers, clinicians and students could all benefit. As Fromm and Nash (1972) noted, readers with extensive background in the field will see wider implications and appreciate challenging subtleties. But, we believe, there is something for everybody here. We encouraged ‘cross-talk’ amongst our authors, sharing the chapters as they were written and revised. Thus, there is some overlap and substantial cross-referencing to build ‘dialog’ across the chapters. In the

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various sections, outlined in a moment, we aimed for a consistent structure to help the reader to develop a coherent picture of the field and of specific areas within it.

1.5.1. Section I: Domain of hypnosis In two chapters in this section, two of our leading scholars introduce the field of hypnosis. In Chapter 2, Kihlstrom offers his influential definition of hypnosis. He reflects on each element of this definition, especially its historical evolution and current status. Drawing on both earlier discussions of the domain of hypnosis (Hilgard, 1965, 1975; Kihlstrom, 1985) and the very latest theory and research, Kihlstrom sets out the basic terminology and parameters of the field. In Chapter 3, McConkey reflects on generations and landscapes of hypnosis. He explores the evolution of the field and the ways in which particular questions about hypnosis and how they’ve been answered have been influenced by people, places and times. He surveys the current landscape of the field and lays out the questions that he believes contemporary workers should be addressing now. Readers should keep these questions in mind as they turn to the chapters to follow.

1.5.2. Section II: Theoretical perspectives In five chapters in this section, current workers in the field describe present (and past) theoretical accounts of hypnosis. In Chapter 4, Woody and Sadler summarize dissociation theories, focusing in particular on the value to hypnosis of theories of dissociated experience versus dissociated control (Hilgard, 1979, 1992; Woody and Bowers, 1994). In Chapter 5, Lynn et al. describe socio-cognitive theories, focusing in particular on their response set theory (Kirsch and Lynn, 1999) and the implications of a growing body of evidence on the neural substrates of hypnosis. In Chapter 6, Barnier et al. introduce two new cognitive theories: cold control and discrepancy-attribution, which draw heavily from areas outside the domain of hypnosis, especially from cognitive psychology—cold control draws from recent theorizing about conscious awareness and higher-order states,

while discrepancy-attribution draws from recent theorizing and research on memory illusions such as false recall and false recognition. In Chapter 7, Spiegel discusses neurobiological approaches to hypnosis, and argues that hypnotizability is a neurobiological adaptation involving flexible control over attention and perception. Spiegel carefully reviews the very latest data on the neurobiology of hypnosis from his own laboratory and others. Finally, in Chapter 8, Nash offers a clinically-oriented psychoanalytic theory of hypnosis. He argues that a good theory of hypnosis needs ongoing dialog between researchers and practitioners, and that a psychoanalytically informed theory can be the conduit for that dialog. Whereas some of the theoretical perspectives described in these chapters are well established, some are the latest installment of a particular theoretical tradition, and some are entirely new. But all aim to define the phenomena to be explained and present a coherent account of hypnotic behavior and experience. These authors are historically aware. In paying debts to previous workers in the field, their theoretical accounts offer continuity with accounts presented in Fromm and Shor (1972, 1979) and Fromm and Nash (1992; see also Lynn and Rhue, 1991). Notably, all of these theorists draw broadly for their answers, looking outside the field for ‘inspiration and perspiration’ (McConkey, Chapter 3, this volume, p. 74). In looking outside the domain for help in answering questions, these theorists and their theories highlight that the study of hypnosis is but one part of an overall investigation of psychological processes. Two final features of these chapters: first, they all point to areas of current and future research—lots of testable ideas for the budding researcher; and second, they all consider the implications of their theories for applications of hypnosis, especially in clinical contexts.

1.5.3. Section III: Contemporary

research In seven chapters in this section, current researchers address important empirical and conceptual issues in the field. In Chapters 9, 10 and 11, the authors address individual

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differences in hypnotizability (and related constructs) in distinct, but complementary ways. In Chapter 9, Laurence et al. describe the history of the highly hypnotizable person and carefully review successes and failures in the search for correlates of hypnotizability. They consider theoretical implications of this long search and point to the most promising avenues for future research. In Chapter 10, Woody and Barnier survey current hypnotizability measures and their uses, and highlight conceptual and methodological problems that remain to be resolved. They describe work to differentiate the building blocks of hypnotic response and suggest new methods, measures and items for assessing hypnotic ability. In Chapter 11, Tasso and Perez take a broader view of hypnotizability and ask ‘What is the domain of suggestibility?’, ‘Are there individual differences in response to suggestion?’ and ‘Is hypnotizability a part of the domain of suggestibility?’ Their answers are surprising and imply that terms such as suggestibility, waking suggestibility and hypnotic suggestibility are problematic, if not meaningless. In Chapter 12, Cox and Bryant discuss methodologies of hypnosis that are relevant to all of the chapters that come before and after. They illustrate a variety of techniques and controls with research conducted in their very productive Australian laboratory. As we did above, and as many authors do throughout this handbook, Cox and Bryant distinguish between intrinsic and instrumental hypnosis research. They provide cogent examples of both kinds of research and make a convincing case for the intrinsic interest and instrumental value of hypnosis. In Chapters 13 and 14, Barabasz and Barabasz, and Oakley, respectively, focus on a burgeoning area of research: the neural underpinnings of hypnosis. In Chapter 13, Barabasz and Barabasz consider advances in neurophysiological techniques and findings during and since ‘the decade of the brain’. They provide a useful sketch of modern neurophysiological techniques and technologies and summarize research presented at the 2002 Tennessee Conference on Brain Imaging and Hypnosis and published since the conference. In Chapter 14, Oakley focuses in detail on intrinsic and instrumental studies of hypnosis involving two brain scanning tech-

niques, positron emission tomography (PET) and functional magnetic resonance imaging (fMRI). He carefully reviews the designs of recent studies to highlight the link between method and inference in this important area. Together, these authors draw attention to an increasingly clear picture of the neurophysiological underpinnings of hypnosis and point towards the need for multilevel explanations. Lastly, in Chapter 15, Benham and Younger provide the link between the theory, method and data in the preceding chapters to the clinical chapters that follow. They present a scholarly review of mind–body interactions in hypnosis. They highlight issues of methodology and inference, and identify the many areas in which hypnosis plausibly may be useful in influencing and healing the body, and the areas in which hypnosis has convincingly been demonstrated to do so.

1.5.4. Section IV: Clinical hypnosis:

treatment and consultation This section on applied aspects of hypnosis is easily the largest section of the book, containing 16 of the book’s 31 chapters. With chapters authored by the world’s leading authorities on clinical hypnosis, this section stands shoulder to shoulder with the earlier sections on theory and empirical work. Clinical theory, supported by sound case material (and clinical transcripts) from the world’s leading clinicians provides a sturdy hands-on reference for novice and advanced clinicians interested in how hypnosis can be productively woven into treatment planning. This section is divided into three parts: (A) Models of clinical intervention; (B) Methods of clinical intervention: techniques and cases; and (C) Evidence base of clinical intervention and consultation. In three chapters on models of clinical intervention, three influential clinicians present their distinct models of practice for clinical hypnosis. In Chapter 16, Baker (with Nash) outlines a psychoanalytic approach that emerges smoothly from Nash’s earlier psychoanalytic model of hypnosis. In Chapter 17, Barber outlines a cognitive-behavioral approach. He offers a schematic overview of how hypnosis can be incorporated into cognitive-behavioral

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therapies, and illustrates this work with case transcripts. In Chapter 18, Lankton outlines an Ericksonian approach. He thoroughly reviews the corpus of Milton Erickson’s work, and illustrates the major principles from case material. In the next 10 chapters, experienced clinicians describe in detail their clinical work across a wide range of approaches and disorders. Here the emphasis is less on theory, and more on specific clinical technique. All of these chapters are richly illustrated with cases and clinical transcripts. In Chapter 19, Nash lays out the foundations of hypnotic technique: patient preparation, induction techniques, deepening, self-hypnosis and troubleshooting are all covered, with word-for-word scripts for those just beginning. In Chapter 20, Jensen and Patterson describe hypnotic approaches to pain: chronic, acute and medical procedure-related; both inpatient and outpatient. In Chapter 21, Bryant describes hypnotic approaches to anxiety, detailing how to incorporate hypnosis into cognitive-behavioral treatments for anxiety, and giving two detailed clinical examples: one of hypnosis in the treatment of post-traumatic stress disorder, and another in the treatment of simple phobia. In Chapter 22, Yapko specifies five specific targets of hypnotic interventions for depression. He presents detailed case material for two patients, one suffering from major depressive disorder with impulse control deficits, and the other suffering from dysthymia. In Chapter 23, Elkins and Perfect describe hypnotic approaches to treat health-compromising behaviors such as smoking, obesity and eating disorders, and outline the step-by-step progress patients make through the treatment protocols. In Chapter 24, Scott, Lagges and LaClave describe hypnotic approaches to work with children. They offer a helpful protocol for working, not just with the child, but with the parents. They illustrate this with two well-structured cases, one of an 11-year-old child with Crohn’s disease, and another of a 16-year-old preparing for a stem cell transplant. In Chapter 25, Covino describes hypnotic approaches to medical problems encountered in consultation. This is another chapter rich in clinical vignettes. In Chapter 26, Moene and Roelofs describe hypnotic approaches to somatoform disorders. This chapter comes from what is generally considered

to be the world’s leading treatment facility for conversion paralysis. In Chapter 27, Peebles describes hypnotic approaches to trauma-related dissociative disorders. This is a very sophisticated and detailed account of the outpatient treatment of two very disturbed patients. Finally, in Chapter 28, Morgan and Stegner describe the use of hypnosis on and off the sporting field with athletes. This chapter is organized entirely around extremely interesting case studies. In three chapters on the evidence base of clinical intervention and consultation, experienced research-practitioners highlight the value of hypnosis by assessing empirical evidence, methods of measuring clinical utility, and hypnosis in the forensic context. In Chapter 29, Moore and Tasso comprehensively review the outcome research in clinical hypnosis, offering guidance on where hypnosis stands as an empirically validated treatment. In Chapter 30, Borckardt and Nash discuss and illustrate with examples how practitioners can make important contributions to the outcome research in hypnosis by using an N of 1 approach. Finally, in Chapter 31, Heap describes the uses and misuses of hypnosis in the courtroom both in the UK and in the USA. Heap organizes his chapter around topics, but uses cases to illustrate issues and outcomes. Together these 31 chapters capture the ongoing vitality of a discipline that continues to contribute tremendously to our understanding of human nature by asking questions that matter. It is a field that embraces the unexpected and coaxes it to tell a story—in our theory, in our research and with our patients. It is here, as editors, that we are most mindful of how indebted we are to the precedent of sturdy curiosity and relentless scholarship established 36 years ago by Erika Fromm and Ronald E. Shor in their first edited book (1972). We have expanded it, but it is their vision. We believe the authors of our 31 chapters have realized that vision.

Acknowledgments We would like to express our appreciation to a number of people. First, we wish to acknowledge our terrific authors—a Who’s Who of the field, both well-established colleagues and stars

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of the future. Thank you for your splendid contributions and for your assistance in shaping this collaborative volume. Second, we acknowledge those esteemed colleagues in whose footsteps we follow, especially Dr Erika Fromm and Ronald E. Shor as noted above. We wish also to acknowledge Ernest R. Hilgard and John F. Kihlstrom who, as much as anyone, have defined the domain of hypnosis for its workers. Third, in the same way, we acknowledge our mentors from a number of generations, colleagues in the field who have made it a home for us, and members of our laboratories who are a crucial ingredient in the continued success of our field. There are far too many people to mention by name, but we thank you all for your ‘inspiration and perspiration’. Fourth, we would like to acknowledge support from various organizations that have seen the value in hypnosis research and practice, and hypnosis researchers and practitioners. Amanda Barnier wishes to acknowledge in particular the continuing support she has received from the Australian Research Council. Fifth, we acknowledge and thank our close collaborators and friends who have helped to shape us in hypnosis. For Amanda Barnier, especially Kevin McConkey, Peter Sheehan and Richard Bryant. For Mike Nash, especially Erika Fromm and Elgan Baker. We thank also the many people who helped us in preparing this handbook, especially Rochelle Cox and Celia Harris, as well as our Editors at Oxford University Press, especially Martin Baum, Carol Maxwell and Anna Reeves. Finally, we acknowledge and thank our families without whose unwavering support we would not have completed this massive undertaking. Thank you to Peter and Oliver, and to Jenny, Logan and Gemma.

References Bányai, E. I. and Hilgard, E. R. (1976) A comparison of active-alert hypnotic induction with traditional relaxation induction. Journal of Abnormal Psychology, 85: 218–224. Barber, T. X. (1969). Hypnosis: A Scientific Approach. Van Nostrand Reinhold, New York. Barber, T. X. and Wilson, S. C. (1978) The Barber Suggestibility Scale and the Creative Imagination Scale: experimental and clinical applications. American Journal of Clinical Hypnosis, 21: 84–108.

Barnier, A. J. and McConkey, K. M. (2004) Defining and identifying the highly hypnotisable person. In M. Heap, R. Brown and D. Oakley (ed.) The Highly Hypnotisable Person: Theoretical, Experimental and Clinical Issues, pp. 30–60. Brunner-Routledge, London. Bowers, K. S. (1976) Hypnosis for the Seriously Curious. Norton, New York. Braffman, W. and Kirsch, I. (1999) Imaginative suggestibility and hypnotizability: an empirical analysis. Journal of Personality and Social Psychology, 77: 578–587. Comey, G. and Kirsch, I. (1999) Intentional and spontaneous imagery in hypnosis: the phenomenology of hypnotic responding. International Journal of Clinical and Experimental Hypnosis, 47: 65–85. de Groh, M. (1989) Correlates of hypnotic suggestibility. In N. P. Spanos and J. F. Chaves (ed.) Hypnosis: The Cognitive-behavioral Perspective, pp. 32–63. Prometheus Books, Buffalo, NY. Fromm, E. and Nash, M. R. (eds.) (1992) Contemporary Perspectives in Hypnosis Research. Guilford Press, New York. Fromm, E. and Shor, R. E. (eds.) (1972) Hypnosis: Research Developments and Perspectives. Aldine-Atherton, Chicago Fromm, E. and Shor, R. E. (eds.) (1979) Hypnosis: Developments in Research and New Perspectives, 2nd edn. Aldine, New York. Green, J. P., Barabasz, A. F., Barrett, D. and Montgomery, G. H. (2005) Forging ahead: the 2003 APA Division 30 definition of hypnosis. International Journal of Clinical and Experimental Hypnosis, 53: 259–264 Green, J. P., Page, R. A., Rasekhy, R., Johnson, L. K. and Bernhardt, S. E. (2006) Cultural views and attitudes about hypnosis: a survey of college students across four countries. International Journal of Clinical and Experimental Hypnosis, 54: 263–280. Haggbloom, S. J., Warnick, R., Warnick, J. E., Jones, V. K., Yarbrough, G. L., Russell, T. M. et al. (2002) The 100 most eminent psychologists of the 20th century. Review of General Psychology, 6: 139–152. Hammer, A. G. (1961) Reflections on the study of hypnosis. Australian Journal of Psychology, 1: 3–22. Hariman, J. (1980) What is hypnotism? A proposal. Australian Journal of Clinical Hypnotherapy, 1: 2–11. Heap, M., Brown, R. and Oakley, D. (eds.) (2004) The Highly Hypnotisable Person: Theoretical, Experimental and Clinical Issues. Brunner-Routledge, London. Hilgard, E. R. (1965) Hypnotic Susceptibility. Harcourt, Brace and World, New York. Hilgard, E. R. (1965) Hypnosis. Annual Review of Psychology, 16: 157–180. Hilgard, E. R. (1975) Hypnosis. Annual Review of Psychology, 26: 19–44. Hilgard, E. R. (1977) Divided Consciousness: Multiple Controls in Human Thought and Action. WileyInterscience, New York. Hilgard, E. R. (1979) Consciousness and control: lessons from hypnosis. Australian Journal of Clinical and Experimental Hypnosis, 7: 103–115. Hilgard, E. R. (1992) Dissociation and theories of hypnosis. In E. Fromm and M. R. Nash (ed.) Contemporary Hypnosis Research, pp. 69–101. Guilford Press, New York.

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Hilgard, E. R., Crawford, H. J. and Wert, A. (1979) The Stanford Hypnotic Arm Levitation Induction and Test (SHALIT): a six minute hypnotic induction and measurement scale. International Journal of Clinical and Experimental Hypnosis, 27: 111–124. Hull, C. L. (1933) Hypnosis and Suggestibility: An Experimental Approach. Appleton, New York. Jamieson, G. (ed.) (2007) Hypnosis and Conscious States: The Cognitive Neuroscience Perspective. Oxford University Press, Oxford. Johnson, M. E. and Hauck, C. (1999) Beliefs and opinions about hypnosis held by the general public: a systematic evaluation. American Journal of Clinical Hypnosis, 42: 10–20. Katsanis, J., Barnard, J. and Spanos, N. P. (1988) Selfpredictions, interpretational set and imagery vividness as determinants of hypnotic responding. Imagination, Cognition and Personality, 8: 63–77. Kihlstrom, J. F. (1985) Hypnosis. Annual Review of Psychology, 36: 385–418. Kihlstrom, J. F. (1992) Hypnosis: a sesquicentennial essay. International Journal of Clinical and Experimental Hypnosis, 50: 301–314. Killeen, P. R. and Nash, M. R. (2003) The four causes of hypnosis. International Journal of Clinical and Experimental Hypnosis, 51: 195–231. Kinnunen, T., Zamansky, H. S. and Block, M. L. (1994) Is the hypnotized subject lying? Journal of Abnormal Psychology, 103: 184–191. Kirsch, I., and Braffman, W. (1999) Correlates of hypnotizability: the first empirical study. Contemporary Hypnosis, 16: 224–230. Kirsch, I. and Lynn, S. J. (1999) Hypnotic involuntariness and the automaticity of everyday life. In I. Kirsch, A. Capafons, E. Cardena-Buelna and S. Amigo (ed.) Clinical Hypnosis and Self Regulation: Cognitivebehavioral Perspectives, pp. 49–72. American Psychological Association, Washington, DC. Kroger, W. (1977) Clinical and Experimental Hypnosis. Lippincott, Philadelphia, PA. Lynn, S. J. and Rhue, J. W. (eds.) (1991) Theories of Hypnosis: Current Models and Perspectives. Guilford Press, New York. Lynn, S. J., Neufeld, V. and Mare, C. (1993) Direct versus indirect suggestions: a conceptual and methodological review. International Journal of Clinical and Experimental Hypnosis, 41: 124–152. Matheson, G. and Grehan, J. F. (1979) A rapid induction technique. American Journal of Clinical Hypnosis, 21: 297–299. Matthews, W. J., Bennett, H., Bean, W. and Gallagher, M. (1985) Indirect versus direct hypnotic suggestions: an initial investigation. International Journal of Clinical and Experimental Hypnosis, 33: 219–223. McConkey, K. M. (1986) Opinions about hypnosis and self-hypnosis before and after hypnotic testing. International Journal of Clinical and Experimental Hypnosis, 34: 311–319. McConkey, K. M. (1991). The construction and resolution of experience and behavior in hypnosis. In S. J. Lynn and J. W. Rhue (ed.) Theories of Hypnosis: Current Models and Perspectives, pp. 542–563. Guilford Press, New York.

McConkey, K. M. and Barnier, A. J. (1991) The Benjamin Franklin report on animal magnetism: a summary comment. Australian Journal of Clinical and Experimental Hypnosis, 19: 77–86. McConkey, K. M. and Perry, C. (2002) Benjamin Franklin and mesmerism, revisited. International Journal of Clinical and Experimental Hypnosis, 50: 320–331. McConkey, K. M. and Sheehan, P. (1995) Hypnosis, Memory, and Behaviour in Criminal Investigation. Guilford Press, New York. McConkey, K. M., Wende, V. and Barnier, A. J. (1999) Measuring change in the subjective experience of hypnosis. International Journal of Clinical and Experimental Hypnosis, 47: 23–39. Mitchell, G. P. and Lundy, R. M. (1986) The effects of relaxation and imagery inductions on responses to suggestions. International Journal of Clinical and Experimental Hypnosis, 34: 98–109. Orne, M. T. (1959) The nature of hypnosis: artifact and essence. Journal of Abnormal and Social Psychology, 58: 277–299. Page, R. A. and Handley, G. W. (1989) The Rapid Induction Susceptibility Scale. Psychology: A Journal of Human Behavior, 26: 49–55. Pavia, M. and Stanley, R. O. (1988) Effect of defining induction as hypnosis or relaxation. Australian Journal of Clinical and Experimental Hypnosis, 16: 11–21. Perry, C. B. and McConkey, K. M. (2002) The Franklin Commission Report, in light of past and present understanding of hypnosis. International Journal of Clinical and Experimental Hypnosis, 50: 387–396. Piccione, C., Hilgard, E. R. and Zimbardo, P. G. (1989) On the degree of stability of measured hypnotizability over a 25-year period. Journal of Personality and Social Psychology, 56: 289–295. Reyher, J. (1962) A paradigm for determining the clinical relevance of hypnotically induced psychopathology. Psychological Bulletin, 59: 344–352. Rhue, J., Lynn, S. and Kirsch, I. (eds.) (1993) Handbook of Clinical Hypnosis. American Psychological Association, Washington, DC. Sheehan, P. W. (1991) Hypnosis, context, and commitment. In S. J. Lynn and J. W. Rhue (ed.) Theories of Hypnosis: Current Models and Perspectives, pp. 520–541. Guilford Press, New York. Sheehan, P. W. (1992) The phenomenology of hypnosis and the Experiential Analysis Technique. In E. Fromm and M. R. Nash (ed.) Contemporary Hypnosis Research, pp. 364–389. Guilford Press, New York. Sheehan, P. W. and McConkey, K. M. (1982) Hypnosis and Experience: An Analysis of Phenomenon and Process. Erlbaum, Hillsdale, NJ. Sheehan, P. W. and Perry, C. W. (1976) Methodologies of Hypnosis: A Critical Appraisal of Contemporary Paradigms of Hypnosis. Lawrence Erlbaum, Oxford. Shor, R. E. (1979) A phenomenological method for the measurement of variables important to an understanding of the nature of hypnosis. In R. E. Shor (ed.) Hypnosis: Developments in Research and New Perspectives, pp. 105–135. Aldine, Chicago.

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Shor, R. E. and Orne, E. C. (1963) Norms of the Harvard Group Scale of Hypnotic Susceptibility, Form A. International Journal of Clinical and Experimental Hypnosis, 11: 39–47. Spanos, N. P. (1986) Hypnotic behaviour: a socialpsychological interpretation of amnesia, analgesia, and ‘trance logic’. Behavioral and Brain Sciences, 9: 449–502. Spanos, N. P. (1991) A sociocognitive approach to hypnosis. In S. J. Lynn and J. W. Rhue (ed.) Theories of Hypnosis: Current Models and Perspectives, pp. 324–361. Guilford Press, New York. Spanos, N. P., Brett, P. J., Menary, E. P. and Cross, W. P. (1987) A measure of attitudes toward hypnosis: relationships with absorption and hypnotic susceptibility. American Journal of Clinical Hypnosis, 30: 139–150. Sutcliffe, J. P. (1960) ‘Credulous’ and ‘skeptical’ views of hypnotic phenomena: a review of certain evidence and methodology. Journal of Abnormal and Social Psychology, 62: 189–200. Sutcliffe, J. P. (1961) ‘Credulous’ and ‘skeptical’ views of hypnotic phenomena: experiments on esthesia, hallucination and delusion. Journal of Abnormal and Social Psychology, 62: 189–200. Syrjala, K. L. and Abrams, J. R. (1996) Hypnosis and imagery in the treatment of pain. In R. J. Gatchel and D. C. Turk (ed.) Psychological Approaches to Pain Management: A Practitioner’s Handbook, pp. 231–258. Routledge, New York.

Tellegen, A. (1978/1979) On measures and conceptions of hypnosis. American Journal of Clinical Hypnosis, 21: 219–237. Tintertow, M. M. (1970) Foundations of Hypnosis: From Mesmer to Freud. Charles C. Thomas, Springfield, IL. Weitzenhoffer, A. M. (1974) When is an ‘instruction’ an instruction? International Journal of Clinical and Experimental Hypnosis, 22: 258–269. Weitzenhoffer, A. M. and Hilgard, E. R. (1962) Stanford Hypnotic Susceptibility Scale, Form C. Consulting Psychologists Press Palo Alto, CA. Weitzenhoffer, A. M. and Hilgard, E. R. (1967) Revised Stanford Profile Scales of Hypnotic Susceptibility. Consulting Clinical Psychologists Press, Palo Alto, CA. White, R. W. (1941) A preface to the theory of hypnotism. Journal of Abnormal and Social Psychology, 36: 477–505. Wicks, G. R. (1982) A rapid induction technique, mechanics and rationale. Australian Journal of Clinical and Experimental Hypnosis, 10: 117–119. Wilson, L., Greene, E. and Loftus, E. F. (1986) Beliefs about forensic hypnosis. International Journal of Clinical and Experimental Hypnosis, 34: 110–121. Woody, E. Z. and Bowers, K. S. (1994) A frontal assault on dissociated control. In S. J. Lynn and J. W. Rhue (ed.) Dissociation: Clinical and Theoretical Perspectives, pp. 52–79. Guilford Press, New York.

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SECTION I

Domain of hypnosis

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CHAPTER 2

The domain of hypnosis, revisited John F. Kihlstrom

Hypnosis is a process in which one person, designated the hypnotist, offers suggestions to another person, designated the subject, for imaginative experiences entailing alterations in perception, memory and action. In the classic case, these experiences are associated with a degree of subjective conviction bordering on delusion, and an experienced involuntariness bordering on compulsion. As such, the phenomena of hypnosis reflect alterations in consciousness that take place in the context of a social interaction.

2.1. Introduction I have employed one or another close variant of the above definition of hypnosis at least since 1982 (Kihlstrom, 1982, 1985), and it has also served as the starting-point for the ‘consensus’ definition and description of hypnosis crafted by the American Psychological Association’s Division 30, the Society for Psychological Hypnosis, in 1993 (Kirsch, 1994a,b; for later definitional developments, see Killeen and Nash, 2003; Green et al., 2005a). In this chapter, I reflect on each element of the definition, its historical evolution, and its current status.

2.2. Hypnosis The term hypnosis itself is, of course, something of a misnomer, because the phenomenon in

question has nothing to do with sleep. Although the deep roots of hypnosis may reach back to the ancient temples of Aesculapius (Ellenberger, 1970; Gauld, 1992; but see Stam and Spanos, 1982), the immediate historical predecessor of hypnosis is the animal magnetism of Franz Anton Mesmer (for a definitive biography, see Pattie, 1994). Or was it? Peter has recently argued that the true ancestor of hypnosis is the exorcism practiced by Johann Joseph Gassner (1729–1779), a Catholic priest who performed exorcisms throughout Europe right before Mesmer came onto the scene (Peter, 2005). Although the similarity between some of Gassner’s practices and Mesmer’s practices is undeniable, the prize probably should remain with Mesmer. After all, Gassner offered a supernatural theory of illness, while Mesmer at least embraced the principle that disease had natural causes and cures. But Mesmer’s theory—that his effects were mediated by a physical force analogous to magnetism—was wrong too, and from a scientific perspective we can now understand both his cures and Gassner’s cures as the product of ‘imagination’—but no less genuine for that. It is not Mesmer’s fault that, in the late nineteenth century, psychology was not permitted the status of a true science. Mesmer’s theory was discredited in 1784, by a French royal commission chaired by Benjamin

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Franklin (Bailly, 1784/2002; Franklin et al., 1784/2002; for recent commentaries, see Forrest, 2002; Kihlstrom, 2002; Laurence, 2002; Lynn and Lilienfeld, 2002; McConkey and Perry, 2002; Perry and McConkey, 2002; Spiegel, 2002), but his practices lived on—first as mesmerism, a term introduced to English in 1784 by Benjamin Franklin himself (Pepper, 1911), and which lasted long enough to be used by Elliotson (1843/1977) and Esdaile (1846/1977). But while Mesmer’s practices were revived in the early nineteenth century, their identification with the man himself must have created a public relations problem; a new label was needed. Puysegur (1807), Deleuze (1813) and others among the second generation of mesmerists proffered the master’s own preferred label, animal magnetism, a term which persisted almost into the modern era (Binet and Fere, 1888). But this was unsatisfactory—not least because the Franklin Commission had disproved the notion that magnetism had anything to do with the phenomenon. Of course, a major transition in conceptions of hypnosis had begun in 1784, even before the Franklin Commission had completed its work, when Puysegur magnetized Victor Race, a young shepherd on his estate. Instead of undergoing a magnetic crisis, Victor fell into a sleeplike state in which he was nonetheless responsive to instructions, and from which he awoke with amnesia for what he had done. Artificial somnambulism—a term introduced by Puysegur himself—had a double advantage, in eliminating references to both Mesmer and magnetism, and also eliminating the convulsive seizures that were the hallmark of the mesmeric crisis. Here, I think, we have the true predecessor of modern hypnosis: a sleep-like state in which the subject is responsive to the—to the what? Mesmerist won’t do, nor will magnetizer, for the reasons stated. Perhaps somnambulizer? Not likely. The problem was solved once and for all by Braid, who coined the terms neurypnology and neuro-hypnotism—which quickly—and, as Gauld (1992, p. 281) remarks, ‘mercifully’—dissolved into hypnotism. Although Puysegur had offered a psychological theory of animal magnetism, in terms of the influence of the magnetizer’s will on the subject, Braid (1855) also offered the first psychophysiological theory of

hypnosis, involving monoideism—the concentration of attention on a single object. With this one–two punch, renaming the phenomenon and offering a new, more scientifically acceptable theory to explain it, Braid buried Mesmer and animal magnetism once and for all (Kravis, 1988). Although the term hypnosis had appeared before Braid’s time (Gravitz and Gerton, 1984; Pattie, 1990), Braid gave us the whole vocabulary for hypnosis as we understand it today, offering clear definitions of the terms hypnotic, hypnotize, hypnotized, hypnotism, dehypnotize, dehypnotized and hypnotist (Kihlstrom, 1992b). According to the Oxford English Dictionary, the word hypnosis entered the medical dictionary in 1882—although the same entry flirted with Braidism. These terms have stuck with us, through what Gauld (p. xi) aptly termed ‘the heyday of hypnotism’ in the run-up to the twentieth century (Charcot, Janet, Liebeault, Bernheim, James, Prince and Sidis), through the first systematic experimental work by Young (1925, 1926) and Hull (1933), and into the post-war revival of clinical and experimental hypnosis at the hands of Weitzenhoffer (1953), Gill and Brenman (1959), Orne (1959), Sutcliffe (1960, 1961), E. R. Hilgard (1965), Barber (1969), and Sarbin and Coe (1972). Although some authorities were once so disturbed by the term that they felt compelled to enclose it in scare quotes (e.g. Barber, 1964), that is all over now (Barber, 1999). Unfortunately, the word hypnosis has also been appropriated by anesthesiologists, to refer to the loss of consciousness that is one of the three aspects of ‘balanced anesthesia’ (the others are areflexia, or the paralysis of the skeletal musculature, and analgesia, or the lack of pain sensation; see Kihlstrom and Cork, 2005). We now know that hypnosis is not anything like sleep, physiologically (Evans, 1979); nor is general anesthesia, for that matter. And although sleep is a frequent metaphor used in hypnotic inductions, and relaxation is a typical accompaniment to hypnosis, we now know that neither is necessary for hypnosis to occur (Banyai and Hilgard, 1976; Alarcon et al., 1999). At this point, then, it is clear that the term hypnosis has become functionally autonomous of its origins (Allport, 1937). Nevertheless, the term has long served to label a particular set of phenomena that we are

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interested in, of human mental function, and we should just stick with it.

2.3. Process In the first sentence of previous versions of the definition given at the outset, I described hypnosis as a ‘social interaction’—which indeed it is. However, hypnosis is not just a social interaction: it also involves certain changes in experience, thought and action. As such, one could just as easily write that ‘hypnosis is an altered state of consciousness …’. Describing hypnosis as a social interaction acknowledges the role that social influence plays in the process, but it also may privilege the social over the cognitive. Accordingly, I now prefer the somewhat more neutral term process (‘Hypnosis is a process in which one person …’), in the dictionary sense of a dynamic series of ongoing actions or events. Certainly hypnosis is a process in this sense, beginning with an induction procedure, continuing with whatever transpires while the subject is hypnotized, and ending with the termination of hypnosis and, perhaps, the testing of posthypnotic suggestions. What goes on in this process—both interpersonally and intrapsychically—is what interests us as hypnosis researchers and as practitioners.

2.4. Hypnotist The mythical image of the hypnotist is, arguably, the character Svengali in George du Maurier’s 1895 novel Trilby, and the 1931 film made from it, starring John Barrymore and Marian Marsh (Kihlstrom, 1987): the eyes, the passes with the hands, the rapport with the subject, the undercurrent of sexuality (of course, Svengali is male and Trilby female), the risk of harm and the intimations of the paranormal. More importantly, though, there is the idea that the hypnotist possesses a particular personality, which affords him a special power to control others—for good and for evil. In stark contrast to this image, the literature on hypnotist characteristics, and their effects on hypnosis, is remarkably thin. Partly, I think, this is due to methodological considerations. Simply to investigate the effect of the hypnotist’s gender on hypnotizability would require that a fairly large, representative sample of men

and women be trained as hypnotists and then turned loose on an even larger group of subjects (Coe, 1976; D’Eon et al., 1979; Banyai, 1991, 1998). It’s all a very daunting task. So far as the laboratory is concerned, we assume that the hypnotist functions much like a coach, or a tutor, whose job is to help subjects to become hypnotized, and to experience hypnotic suggestions. The coach–tutor analogy breaks down, however, in that it is arguably helpful if a tennis coach can play tennis, or if a math tutor knows mathematics. But it does not seem to be important whether the hypnotist is hypnotizable. Ted Barber was, by the accounts of those who knew him, highly hypnotizable; Jack Hilgard was not. It is tempting to speculate on the role these individual differences might have played in designing their programs of hypnosis research, with Barber (1969) believing that hypnotic phenomena were possible for anyone who tried hard enough, and E. R. Hilgard (1965) developing a whole battery of scales for measuring hypnotizability. Surely the most experienced hypnotist of all time is the person whose voice is heard on the standard recording of the Harvard Group Scale of Hypnotic Susceptibility, Form A—a professional radio announcer without any training in psychology or hypnosis (L. Dumas, 1964; Orne, 1964). In the clinic, things may be different. But even there, the empirical literature—as opposed to folklore—on hypnotist effects is sparse (Diamond, 1984). While anyone can be a hypnotist, it takes special training to use hypnosis appropriately in medicine, dentistry or psychotherapy. Some of that training is in hypnosis, and in an age when hypnotists advertise in the Yellow Pages, consumers naturally wonder how they can ensure that a practitioner is appropriately trained. Fortunately, there are organizations in the USA such as the Society of Clinical and Experimental Hypnosis which provide workshops in various skill areas, and agencies such as the American Board of Clinical Hypnosis to certify competence in the use of hypnosis in medicine, dentistry, psychotherapy and clinical social work. Similar organizations exist around the world, including in Australia and the UK. These organizations and agencies have their place, but when it comes to evaluating a clinical hypnotist the heuristic offered by Martin Orne

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(personal communication, frequently repeated) is probably the best: nobody should treat a condition with hypnosis that they are not qualified to treat without hypnosis. The idea that hypnosis involves two people, a hypnotist and a subject, would seem immediately contradicted by the phenomenon of selfhypnosis, in which there does not seem to be any hypnotist at all. At one level, we can say that there is no contradiction, because in a very real sense all hypnosis is self-hypnosis. The hypnotist can recite an induction procedure and make suggestions for various experiences, but it is the subject who must actively participate in the process; without that active participation, nothing happens. Comparisons of self-hypnosis with more traditional ‘hetero’-hypnosis show that they are highly correlated (Shor and Easton, 1973; Orne and McConkey, 1981; L. S. Johnson et al., 1983). It may be more difficult to give oneself a suggestion that there is a fly buzzing annoyingly around one’s head, and easier to believe that the fly is there when one does not already know that it is simply a suggestion from a pre-printed script. But it is clear that the overlap between the two forms of hypnosis is considerable. At the same time, it must be said that much of what passes for ‘self-hypnosis’, especially in the clinic, more closely resembles a relaxed state of reverie, and imagery, in which subjects are allowed to construct their own experience without any particular direction from the hypnotist (Fromm et al., 1981; Olness, 1981). The relationship of this form of hypnosis to the more traditional ‘hetero’ form is open to question (Kahn et al., 1989)—as is the question of whether this form of ‘self-hypnosis’ should really be called hypnosis at all.

2.5. Subject Surely the main reason that the hypnotist has so little impact on what goes on in hypnosis is, simply, that virtually all the action is in the subject. The importance of individual differences in hypnotic susceptibility has long been recognized (Friedlander and Sarbin, 1938), and the development of the Stanford Hypnotic Susceptibility Scales, Forms A, B and C (SHSS:A, B and C; Weitzenhoffer and Hilgard, 1959, 1962) put the

measurement of hypnotizability on a firm quantitative basis (E. R. Hilgard, 1965). By introducing a standardized procedure for subject selection, the Stanford scales made it possible for different laboratories to replicate and extend each other’s studies. Moreover, the Harvard Group Scale of Hypnotic Susceptibility, Form A (HGSHS:A; Shor and Orne, 1962) injected substantial economies of scale into the assessment procedure. The availability of reliable and valid instruments for measuring hypnotizability makes it possible to examine the personality and cognitive correlates of this cognitive skill. Here, it must be said, the yield has been relatively light. One of the most frustrating aspects of the post-war revival of hypnosis research was the discovery that, while hypnotizability could be reliably measured, hypnotizability simply did not appear to correlate substantially with the sorts of personality characteristics measured by the major personality inventories, such as the Minnesota Personality Inventory (MMPI) and the California Psychological Inventory (CPI; E. R. Hilgard, 1965). Nor does hypnotizability appear to be related to individual differences in ‘cognitive style’, such as field dependence–independence (A. H. Morgan, 1972). The mystery was gradually resolved by the discovery that hypnotizability does correlate with scales measuring the tendency to have experiences such as those of hypnosis, but outside the hypnotic situation (Shor, 1960; As, 1962, 1963; As et al., 1962; Shor et al., 1962; J. R. Hilgard, 1965). The strongest correlate of hypnotizability discovered so far is absorption, or the tendency to become absorbed in various sorts of sensory, cognitive and imaginal experiences (Tellegen and Atkinson, 1974; for a review, see Roche and McConkey, 1990). Absorption and imaginative involvement simply were not represented on the scales of the MMPI and CPI; put another way, the individual differences measured by these inventories fall outside the domain of hypnosis. However, absorption is related to at least some facets of openness to experience, one of the ‘Big Five’ dimensions in the structure of personality (Glisky et al., 1991). Even the correlation between hypnotizability and absorption is still too small to permit individual levels of hypnotizability to be predicted

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with any confidence from personality measures. But at least they tell us that individual differences in the specific domain of hypnosis are connected with individual differences in the wider domain of personality. Still, even openness is multifacted: while hypnotizability is correlated with absorption, it is not correlated with intellectance or liberalism (Glisky and Kihlstrom, 1993). Other than this, we know remarkably little about hypnotizable individuals. Despite the implications of the Svengali myth, there is no appreciable gender difference in hypnotizability (Weitzenhoffer and Weitzenhoffer, 1958), and any difference there might be should not be taken too seriously, as the literature on gender differences presents a host of interpretive difficulties (Maccoby and Jacklin, 1974; Tavris, 1992; Hyde, 2005). Stereotypically ‘feminine’ individuals are no more hypnotizable than stereotypically ‘masculine’ ones (Kihlstrom, 1980). Part of the difficulty in establishing meaningful correlates of hypnotizability may be methodological. Individual differences in personality are commonly measured by questionnaires, while hypnotizability is measured by work samples of actual performance. Such heteromethod correlations (Cronbach and Meehl, 1955; Loevinger, 1957; Campbell and Fiske, 1959) are usually low. Nevertheless, the typical personality–hypnosis correlation—including the correlation between absorption and hypnotizability —is low even by the standards of Mischel’s (1968) ‘personality coefficient’. It may be that more interesting results will be obtained when both predictor and criterion are measured by the same performance-based methods. As an example of the sort of work that might be done, Dixon and his colleagues found that hypnotizability was correlated with individual differences in automatic processing, as measured by the Stroop test (Dixon et al., 1990; Dixon and Laurence, 1992). Research of this sort may help link the domain of hypnosis to the wider domain of attention, at both the psychological and neuroscientific levels of analysis. Hypnotizability shows an interesting developmental trend across the lifespan (Cooper and London, 1971; A. H. Morgan and Hilgard, 1973), but the results of these cross-sectional studies remain to be confirmed by longitudinal research.

Moreover, the determinants and correlates of this developmental trend remain largely unexplored (J. R. Hilgard, 1970). For example, little has been done to connect the development of hypnotizability with the development of the theory of mind in young children (Welchross, 1999). Surely, the child’s capacity to be hypnotized must be related to his or her ability to appreciate mental states as such, as well as the distinction between reality and imagination. Along the same lines, response to direct and challenge ideomotor suggestions may follow different developmental trajectories, possibly related to the development of the general capacity to inhibit action; a similar point may apply to positive versus negative hallucinations, and to age regression as opposed to amnesia. Once established, hypnotizability seems to be about as stable as other cognitive skills, such as intelligence (Morgan et al., 1974; Piccione et al., 1989). But how is it established? Some research seems to indicate a genetic contribution to individual differences in hypnotizability (A. H. Morgan et al., 1973), possibly mediated through the attentional system (Raz et al., 2004a). Evidence for the acquisition of hypnotizability through experience comes mostly from studies of childhood imaginative involvements (J. R. Hilgard, 1970). Perhaps the most interesting developmental finding to date is of an ageby-gender interaction, such that women of childbearing age tend to be more hypnotizable than their male counterparts (A. H. Morgan and Hilgard, 1973). On the assumption that most of these women were in fact stay-at-home mothers, one interpretation of this finding is that a capacity for hypnosis is sustained in parents— male or female—who participate in their children’s imaginative involvements (J. R. Hilgard, 1970). Given the cultural changes that have occurred since the early 1970s, a more balanced test of this hypothesis is now possible. Although modern theories of individual differences generally assume that personality characteristics are distributed along continuous dimensions (such as the ‘Big Five personality traits; Wiggins and Trapnell, 1990) as opposed to discrete categories (such as the classical typology of melancholics, cholerics, sanguines and phlegmatics; Kant, 1798/1978), the notion that individual differences may resolve into more or

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less discrete types has currently regained a foothold in the literature (Gangestad and Snyder, 1985; Waller et al., 1996). Perhaps hypnotic virtuosos constitute a discrete type of person, qualitiatively different from those who do not possess a particular talent for hypnosis (Balthazard and Woody, 1989; Oakman and Woody, 1996). For that matter, White (1937) once suggested that there was more than one type of hypnosis. Perhaps the existence of more or less discrete profiles of hypnotic ability (E. R. Hilgard, 1965; Brenneman and Kihlstrom, 2006;) suggests that there may be several different kinds of hypnotic virtuosos.

2.6. Suggestions Suggestion is central to hypnosis. On the HGSHS:A and SHSS:C, hypnosis is induced by suggestions for relaxation, focused attention and eye closure; and hypnotizability is measured by response to suggestions for arm catalepsy, age regression, auditory hallucination, posthypnotic amnesia, and the like. The connection between hypnosis and suggestion is so strong that the two domains have been concatenated throughout the modern history of the field (Bernheim, 1886/1889; Hull, 1933; Weitzenhoffer, 1953; Braffman and Kirsch, 1999; Kirsch and Braffman, 2001). The concept of neutral hypnosis, as a distinct psychological state independent of the subject’s response to suggestions, has had its advocates (e.g. Ludwig and Levine, 1965; Kihlstrom and Edmonston, 1971; Edmonston, 1977, 1981). Still, the fact remains that what is perennially interesting about hypnosis is how the hypnotized individual responds to suggestions. It has to be said, however, that not all suggestions, or forms of suggestibility, belong in the domain of hypnosis (for a detailed analysis, see Tasso and Perez, Chapter 11, this volume). The suggestion that there is a fly in the room, buzzing annoyingly around the subject’s head, or that there is a voice coming over a loudspeaker asking the subject questions, is not the same as Joseph’s suggestion, recorded in Genesis (xl, 14) that Pharaoh let him out of prison; or the suggestion, written on a slip of paper deposited in a box provided for this purpose, that the library install wireless Internet access.

Eysenck and Furneaux (1945) distinguished between primary ideomotor suggestibility, involving direct verbal suggestions for bodily movements, and secondary suggestibility, involving indirect, nonverbal suggestions for sensoryperceptual experiences. Although this distinction makes some sense, conceptually, it has not always held up empirically (Evans, 1967). Moreover, it seems clear that there are forms of suggestibility that go beyond the primary– secondary distinction. For example, Eysenck proposed a category of tertiary suggestibility, to cover persuasion effects in attitude change (Eysenck, 1947). Social psychologists have studied aspects of tertiary suggestibility involving conformity, persuasion and other forms of social influence (Zanna et al., 1987; Zimbardo and Leippe, 1991; Forgas and Williams, 2001); these appear to be largely unrelated to hypnotizability (Moore, 1964). There is also the placebo effect, and related effects of suggesting to patients that they are receiving medical treatment (Harrington, 1997; Shapiro and Shapiro, 1997; Kihlstrom, 2003). Although placebo responses are mediated by expectation (Kirsch, 2004), and expectation plays some role in hypnosis (Council et al., 1986), hypnotic analgesia appears not to be mediated by the placebo response (Evans, 1967, 1976; McGlashan et al., 1969). Furthermore, expectancies turn out to play only a modest role in hypnotic responsiveness (Shor et al., 1984; Benham et al., 2006). Finally, there is interrogative suggestibility, assessed in terms of the responses of eyewitnesses, patients and others to leading questions (Gudjonsson, 1984; Doris, 1991; Eisen et al., 2002; Shobe and Kihlstrom, 2002). This also appears to be independent of hypnotizability (Register and Kihlstrom, 1988). The domain of hypnosis will be defined more clearly as the relationships among the various forms of suggestibility, and their respective underlying mechanisms, receive further study (Gheorghiu et al., 1989; Schumaker, 1991). Based on present knowledge, hypnotic suggestions most closely resemble primary ideomotor suggestions, suggesting that they belong to overlapping domains (E. R. Hilgard, 1965). Still, the overlap is far from complete: in the first place, indirect suggestions such as those that characterize secondary suggestibility are not

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unknown in hypnosis (Yapko, 1983; McConkey, 1984; Lynn et al., 1993). Both hypnosis and primary ideomotor suggestibility entail responses to direct suggestions, but close analysis reveals that hypnotic suggestions are directed toward perceptual-cognitive experiences, rather than overt motor behaviors. We do not suggest to subjects simply that their outstretched arms are rising or falling; rather, we suggest that they are weighted down by a heavy object or being lifted up by helium balloons. In hypnosis, the overt motor behavior follows from the subjective experience—a point to which we shall return. There are further complexities even within this expanded domain of primary suggestion. In the first place, ideomotor suggestions can be further classified into two types: direct suggestions for the facilitation of some motor behavior, such as eye closure or arm catalepsy; and challenge suggestions for the inhibition of motor behavior, such as arm rigidity or arm immobilization. Moreover, hypnotic suggestions can affect perceptual and cognitive experiences as well as motor behaviors. Interestingly, these perceptual-cognitive suggestions also come in two forms that roughly parallel direct and challenge ideomotor suggestions. Some cognitive suggestions involve the production of percepts and memories, such as the dream and positive auditory hallucination (‘loudspeaker’) items of SHSS:C; others involve the inhibition of percepts and memories, such as the negative visual hallucination (‘three boxes’) and post-hypnotic amnesia items of the same scale. In every case, however, there is a more or less direct suggestion that a state of affairs exists that does not accord with objective reality. The Stanford scales, which assess the subject’s response to such suggestions, thus represent a prototype that defines the domain of hypnosis. The distinctions between direct and challenge ideomotor suggestions, and between ideomotor and cognitive suggestions, has been repeatedly confirmed by multivariate analyses of the Stanford and Harvard scales (e.g. E. R. Hilgard, 1965; Spanos et al., 1980; for a review, see Balthazard and Woody, 1985). Discovery of the multidimensional nature of hypnotic suggestion led to the development of the Stanford Profile Scales of Hypnotic Susceptibility, Forms I and II (SPSHS:I and II; Weitzenhoffer and

Hilgard, 1963, 1967). Unfortunately, interpreting these three factors is complicated by the fact that their constituent items differ in difficulty levels. Direct suggestions tend to be relatively easy, while challenge and cognitive suggestions tend to be relatively difficult. Accordingly, some theorists (e.g. Coe and Sarbin, 1971) have argued that the apparent factor structure of hypnotic suggestions is actually an artifact of item difficulty, and that, appearances to the contrary, a ‘single role-relevant skill’ (p. 1) runs through the matrix of item correlations. Untangling content from difficulty level is not easy, because difficulty levels of the items of the Stanford and Harvard scales are fixed by the standardized procedures established for their administration and scoring. Some progress can be made, however, once it is understood that the difficulty levels of various items, as fixed in the standardized scales of hypnotic susceptibility, are largely arbitrary. For example, the hand-lowering suggestion of HGSHS:A, generally considered a very easy item, can be made more difficult by requiring that the subject’s hand drop further, faster, than what is specified in the standardized scale. Similarly, post-hypnotic amnesia, generally considered a difficult item, can be made easier by adopting a looser criterion for initial forgetting or subsequent reversibility (Kihlstrom and Register, 1984). When item difficulty levels are adjusted in this manner, the three-factor structure still emerges (Tellegen and Atkinson, 1976; Kihlstrom et al., 2006). Moreover, a cluster analysis of the original standardization data for SPSHS:I and II uncovered 12 distinct profiles of hypnotic ability, independent of overall level of hypnotic response (Brenneman and Kihlstrom, 2006). A recent, highly sophisticated multivariate analysis confirms that the three basic factors of hypnotizability—direct, challenge and cognitive suggestions—are not an artifact of item difficulty (Woody et al., 2005). The situation is thus roughly analogous to the structure of intelligence, with various group factors collected by a single overarching factor of general hypnotizability. Hypnosis is closely related to primary suggestibility, but the domain of primary suggestibility must be expanded to include perceptual-cognitive effects as well as ideomotor responses.

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2.7. Imaginative experiences Hypnotic experiences take place in the realm of imagination—there isn’t really a balloon lifting up the subject’s hand, or glue holding the subject’s hands together, or a loudspeaker on the wall; nor does the age-regressed subject grow smaller in the chair. Nevertheless, the relationship between hypnosis and mental imagery is rather vexed. For example, hypnotizable individuals have no better mental imagery abilities than the rest of us—though here, admittedly, the fault might lie with the scales used to measure mental imagery (Kearns and Zamansky, 1984; K. S. Bowers, 1992; Glisky et al., 1995). Of course, it may simply be that better, more performance-oriented, methods of assessing imagery (Kosslyn et al., 1984) will yield substantial correlations with hypnosis, of a sort that have so far eluded empirical investigation. On the other hand, examination of the structure of hypnotic suggestions, and of the phenomenology of hypnotic experience, suggests that hypnotic experiences bear only a tangential relationship to mental imagery as we typically experience it. Note, first, that while hypnotic experiences surely take place in imagination, hypnotic suggestions do not typically ask subjects to imagine anything. Consider, for example, the Fly Hallucination item (#9) on HGSHS:A. Subjects are not asked to imagine that there is a fly buzzing around the room. Instead, they are informed—it is suggested— that there is one. And hypnotic subjects respond accordingly. Hypnotic experiences take place in imagination, but they do not have the same experiential qualities as ordinary mental imagery. Mental images are deliberately, consciously constructed, while hypnotic experiences are generally accompanied by an experience of involuntariness. It is this experience of involuntariness, not the vividness of mental images that gives hypnotic experiences their hallucinatory quality. There are exceptions, of course, even on HGSHS:A itself. But in general, when hypnotic suggestions use the word imagine, they do so in much the same way that they use the word sleep. If a mental image is defined as a percept in the absence of a stimulus, then hypnotic suggestions definitely involve imagery. But if a hallucination

is defined as a mental image that is out of control, hypnotic experiences are closer to hallucinations than to ordinary mental images. In this respect, just as hypnosis should not be solely identified with suggestion, so hypnosis should not be narrowly identified with imagination. Accordingly, to relabel hypnotic susceptibility as imaginative suggestibility (Braffman and Kirsch, 1999; Kirsch and Braffman, 2001) would be to risk making a category mistake.

2.8. Perception, memory

and action The phenomena of hypnosis are mostly cognitive in nature, involving alterations in perception and memory. Hypnotized subjects perceive things that aren’t there, and fail to perceive things that are there. They experience themselves as if they were young again. They dream even though they are not asleep. They cannot remember what happened to them while they were hypnotized, and they remember things that did not actually happen to them. Even the ideomotor phenomena of hypnosis are cognitive in nature, because the motor behaviors follow from suggestions for perceptual change. In the direct suggestions, subjects perceive balloons tied to their wrists, or heavy objects in their hands, and then the limbs move accordingly. In the challenge suggestions, they feel their hands glued together, and have difficulty taking them apart; they feel their outstretched arms stiffening, and then have difficulty bending them. So too, for post-hypnotic suggestions, the essence of which is not that subjects touch their ankles when the experimenter taps, but that they feel an urge to do so, do not know why and do not remember the suggestion. The behavioral responses by which we measure hypnotizability follow from suggestion-induced changes in perception and memory. Perceptual-cognitive changes lie at the heart of most hypnotic phenomena, but cognition is not all there is to mental life. As Kant put it, ‘there are three irreducible faculties of mind: knowledge, feeling, and desire’ (Kant, 1781/1929, p. 14). So what of the other two elements in the ‘trilogy of mind’ (E. R. Hilgard, 1980)? What role do emotion and motivation

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play in the phenomena of hypnosis? These have mostly gone unexamined, but there are hints in the literature that hypnosis can affect emotional and motivational processes as well. For example, Damaser et al. (1963) employed hypnotic suggestion to investigate the physiological correlates of various emotional states. Levitt and his colleagues observed the effects of suggested anxiety, covered by a further suggestion for post-hypnotic amnesia, on various aspects of test performance (Levitt, 1967; Levitt and Chapman, 1979). Similarly, Blum and his colleagues explored the effects of hypnotically suggested arousal on various aspects of performance (e.g. Blum and Porter, 1972). This research, as well as Watkins’s clinical work on the ‘affect bridge’ (Watkins, 1971), set the stage for Bower’s use of hypnotically suggested emotions in his pioneering studies of moodcongruent and mood-dependent memory (Bower et al., 1978, 1980; Bower, 1981). The memory effects originally reported by Bower have since been replicated using nonhypnotic methods (e.g. Eich, 1995; Bower and Forgas, 2000). However, difficulties in replicating the original hypnosis experiments have perhaps contributed to a decline in research on hypnotically elicited emotion. This is an area that warrants further investigation—especially as interest in emotion is being revived within psychology, and researchers seek reliable means of manipulating subjects’ emotional states (Larsen and Sinnett, 1991; Westermann et al., 1996; Nummenmaa and Niemi, 2004; Goritz and Moser, 2006). Many of the cognitive effects of hypnosis come in contrasting forms, such as the positive and negative hallucinations, and this may be the case for the emotional effects as well. In the Bower studies, the hypnotic suggestion appears to operate in the manner of a positive hallucination—subjects experience an emotion in the absence of the appropriate stimulus. By analogy to negative hallucinations, Bryant and his colleagues have employed suggestions for ‘emotional numbing’, which may reduce subjects’ conscious awareness of their emotional states (Bryant and Mallard, 2002; Bryant, 2005). Although hypnotic analgesia reduces both the sensory-perceptual and affective components of pain (E. R. Hilgard, 1967; Knox et al., 1974), appropriately worded suggestions can also

dissociate them—so that, for example, the hypnotized patient can feel pain but not suffer from it. Interestingly, these suggestions produce different patterns of brain activity: sensory pain activates the primary somatosensory cortex, while suffering activates the anterior cingulate gyrus (Rainville et al., 1997, 1999; Price et al., 2002). Emotional numbing may operate in the manner of a suggestion for analgesia, or amnesia, at the level of conscious awareness. Just as Hilgard’s ‘hidden observer’ studies showed that pain can be represented subconsciously despite the experience of analgesia (Knox et al., 1974; E. R. Hilgard et al., 1975, 1978), so it may be that hypnotically suggested emotional numbing impairs explicit, or conscious, affective experience but spares implicit, or unconscious, representations of emotional state (Kihlstrom et al., 2000). So far as motivation is concerned, it should be noted that Hilgard’s attraction to the field was partly an outgrowth of his longstanding interest in problems of motivation, and in particular the distinction between voluntary and involuntary acts (E. R. Hilgard, 1964). Theorists of a psychodynamic bent have also made use of hypnosis to study problems of unconscious motivation—an enterprise which E. R. Hilgard (1961, 1964) also endorsed. In one prominent line of research, based on a paradigm originally devised by Luria (1932), subjects received suggestions for a paramnesia, or false memory, that they had committed some socially undesirable act—the suggestion itself was covered by a further suggestion for amnesia (Huston et al., 1934; Reyher, 1967; Sommerschield and Reyher, 1973). Alternatively, subjects received suggestions for a variant on age regression, in which they were asked to relive a conflictual, ego-threatening event from childhood (Blum, 1967, 1979). Unfortunately, the demand characteristics of such experiments are fairly clear, making interpretation of the results difficult (Reyher, 1969; Sheehan, 1969, 1971b). Nevertheless, the work deserves to be remembered as an important line of experimental research on psychodynamic theory. Motivation is also relevant to a question that has intrigued investigators ever since the beginning of experimental hypnosis research: whether hypnotic suggestions of various kinds can enhance human performance—what Marcuse

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(1959) called ‘the generation of hypers’ (as in hyperpraxia, or enhanced muscular performance, hyperesthesia, or enhanced sensory acuity, and hypermnesia, or enhanced memory) and the ‘wantos’ (as in ‘Want to make the weak as strong as a lion?’). A vast experimental literature on the hypnotic transcendence of normal voluntary capacity, mostly with variants on the London–Fuhrer paradigm (London and Fuhrer, 1961) in which hypnotizable and insusceptible subjects were tested in baseline, nonhypnotic and control conditions, yielded largely negative results (e.g. Evans and Orne, 1965; Orne, 1966; Sheehan and Perry, 1976). In general, these studies found that appropriately motivated insusceptible subjects performed as well or better on measures of muscular strength and endurance than hypnotizable subjects. Similarly, there is no experimental evidence that hypnosis reliably enhances learning or memory (Council on Scientific Affairs, 1985; Kihlstrom and Eich, 1994; Whitehouse et al., 2005). Finally, provocative evidence that hypnosis could improve visual acuity in myopic subjects (Graham and Leibowitz, 1972) has been called into question by more recent analyses (Raz et al., 2004b). Most of these studies employed direct suggestions and exhortations for improved performance. However, Slotnick et al. (1965) obtained different results when they added involving instructions to the usual exhortations. In these instructions, subjects were asked not simply to improve their performance, but also to think of themselves as ‘stronger and more capable’. Under these conditions, exhortation plus involvement yielded a marked improvement in performance over exhortations alone, and this was true even when the involving instructions were administered in a nonhypnotic control condition. Because all the subjects in this experiment were hypnotizable, it seems likely that the effects of the involving instructions were mediated by the capacity for absorption and imaginative involvement that is correlated with hypnotizability. Although it would be useful to replicate this experiment with insusceptible subjects as well, it is possible that imagining oneself stronger can in fact make one (a little) stronger, in the manner of the self-fulfilling prophecy (Snyder, 1984), whether that imagination takes place in hypnosis or not.

One motivational application of hypnosis is in sports psychology (Unestahl, 1979; W. P. Morgan, 1980, 2002; Mairs, 1988; Taylor et al., 1993). Unfortunately, field studies in this area have rarely taken advantage of the analytical power of paradigms such as the London–Fuhrer design. As a result, it is often unclear whether any improvements in performance are actually mediated by increased motivation—as opposed to selfdistraction, analgesia-like pain relief or even absorption in the athletic performance (i.e. ‘flow’; Csikszentmihalyi, 1990; Grove and Lewis, 1996; Pates and Maynard, 2000).

2.9. Classic instance The effects of hypnotic suggestions—the classic case or instance—are not experienced by, or observed in, everyone who is hypnotized. The phenomena that have enticed theorists from James, Freud and even Pavlov to today are most likely to occur in those subjects who are most highly hypnotizable (Heap et al., 2004). And, as a corollary, there is little point in studying hypnosis in subjects who cannot experience it. Accordingly, hypnosis researchers devote an extraordinary amount of time, effort and resources to assessing the hypnotizability of the subjects who participate in their experiments (for a comprehensive summary of assessment procedures, see Barnier and McConkey, 2004). The optimal screening procedure for hypnosis research is to begin with HGSHS:A, which allows subjects to familiarize themselves with hypnotic procedures, and also provides a first approximation of their hypnotizability. Then, high-scoring subjects can be invited to return for a final assessment with SHSS:C. The Stanford group developed the Stanford Profile Scales of Hypnotic Susceptibility, Forms I and II (SPSHS:I and II), to permit more fine-grained assessments of hypnotizability, particularly with respect to different patterns of ability within the high range (E. R. Hilgard et al., 1963; Weitzenhoffer and Hilgard, 1963, 1967; for a review, see McConkey and Barnier, 2004), but these never entered into common use. Instead, SHSS:C can be ‘tailored’ for special assessment purposes, without losing its value as a standard psychometric instrument (Hilgard et al., 1979).

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Nowhere else in psychology, except perhaps in neuropsychology, is so much effort devoted to subject screening and selection prior to formal experimental research. In this respect, hypnosis may serve as a model for individual differences research throughout psychology. Unfortunately, the sheer economics of such a rigorous assessment scheme naturally provides an incentive for investigators to take shortcuts. One of these is a group-administered version of SHSS:C, the Waterloo–Stanford Group Scale of Hypnotic Susceptibility: Form C (WSGC; K. S. Bowers, 1993)—which, while offering some of the same economies as HGSHS:A, eliminates the individual administration that permits detailed inquiry into the subject’s experience. Another trend, more disturbing, is reliance on HGSHS:A as the sole screening instrument for hypnosis research. The problem is that HGSHS:A does not contain enough difficult and cognitive items to provide a good assessment of hypnotic abilities; as a result, its ability to identify ‘hypnotic virtuosos’ is relatively poor (Register and Kihlstrom, 1986). In this respect, SHSS:C remains the ‘gold standard’ of hypnotizability measures. Another unfortunate trend is the proliferation of alternative scales to measure hypnotizability, including the Barber Suggestibility Scale (BBS; Barber, 1965), Carleton University Responsiveness to Suggestion Scale (CURSS; Spanos et al., 1983a), Creative Imagination Scale (CIS; Wilson and Barber, 1978) and Hypnotic Induction Profile (HIP; Spiegel, 1972; Orne et al., 1979). When different laboratories use different scales to measure hypnotizability, the virtues of standardization are lost, and it becomes all the more difficult for one laboratory to replicate and extend another’s work. Some of the newer scales are shorter than HGSHS:A and SHSS:C, and thus arguably more economical to use, but abbreviation comes at the expense of content validity. The CURSS does include assessments of subjective experience and experienced involuntariness, but these can easily be added to the Stanford and Harvard scales without compromising their essential properties (P. Bowers, 1982; Register and Kihlstrom, 1986). As valuable as the standardized scales have been for research purposes, it is sadly the case that hypnotizability is rarely measured in the clinic.

It is not clear why this is the case. Some clinicians, especially those working in the tradition of Milton H. Erickson, may discount the importance of individual differences in hypnotizability (Frankel, 1985). They may fear that a finding of low hypnotizability will reduce a patient’s motivation for treatment, but the scant evidence available suggests that this is not the case (Frankel et al., 1979). It would seem obvious that candidates for hypnotherapy, or for hypnosis as an adjunctive treatment, should be screened to determine whether they are, in fact, hypnotizable. While it is true that such assessment takes time, clinicians often take time to administer other instruments, such as the Rorschach and the Thematic Apperception Test, that are less relevant to treatment. In any event, the Stanford group developed a set of abbreviated scales that afford valid assessment of hypnotizability in clinical contexts (A. H. Morgan and Hilgard, 1978–1979a,b). These should be more widely used in clinical research and practice than they seem to be. Can anyone become a hypnotic virtuoso? Hull thought of hypnosis as a habit phenomenon, but, while practice may help subjects become hypnotized more readily, it does not seem to make them more hypnotizable. We now think of hypnotizability as a cognitive skill, and we generally think of skills as things that can be acquired, refined and perfected through experience. Nevertheless, attempts to modify hypnotizability have mostly produced ambiguous results (Diamond, 1974, 1977a,b, 1982; Perry, 1977). More recently, a package known as the Carleton Skills Training Program (CTSP) has been proposed as a means for enhancing hypnotizability (Gorassini and Spanos, 1986; Gorassini et al., 1991; Gorassini, 2004). Here, too, however, the enhancement of hypnotizability appears to be heavily laced with demands for overt behavioral compliance (Bates et al., 1988; Bates and Brigham, 1990; Bates and Kraft, 1991; Bates, 1992). Although this point has been vigorously debated by advocates of the CSTP (e.g. Spanos et al., 1989–1990; Gorassini, 2004), few if any laboratories have abandoned subject selection based on formal measurements of hypnotizability, such as HGSHS:A and SHSS:C, in favor of creating virtuoso subjects wholesale out of unselected subjects with the CSTP.

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The phrase classic instance can refer to depth of hypnosis as well as to hypnotic ability. In the nineteenth century, Braid attempted to characterize the various stages of hypnotic sleep, Charcot described catalepsy, lethargy and somnambulism as representing three stages of hypnosis, and both Liebeault and Bernheim offered criteria for diagnosing the various stages of hypnosis (for a review, see E. R. Hilgard, 1965). Indeed, some of the very first scales of hypnotizability were actually labeled as scales of hypnotic depth (Friedlander and Sarbin, 1938; LeCron, 1953). However, modern scales of hypnotic depth have usually been offered as supplements to, rather than substitutes for, the assessments of hypnotic ability provided by the conventional standardized scales (e.g. Tart, 1970). Perhaps the simplest measure of hypnotic depth is a 1–10 rating of ‘how deeply hypnotized’ subjects feel themselves to be (O’Connell, 1964; Register and Kihlstrom, 1986). Such global depth ratings, based on purely subjective (and probably idiosyncratic) criteria, are likely to reflect little more than the subject’s involvement with the hypnotic procedure, and are to be taken with a grain of salt. However depth is measured, there is a definite conceptual difference between depth and ability. Presumably, highly hypnotizable subjects can experience ‘lighter’ or ‘deeper’ stages of hypnosis, in much the same way that a virtuoso pianist can play more or less well, depending on the circumstances. Someone who lacks the ability to play the piano, however, can never play really well. Insusceptible subjects, on this model, lack the ability to become deeply hypnotized, no matter how hard they try. The classic instance, the prototype or defining example of the domain of hypnosis, is a hypnotizable person who is deeply hypnotized.

2.10. Subjective conviction Subjective experience lies at the heart of hypnosis. It is not interesting that a hypnotized subject will lower his outstretched arm when told that it is becoming heavy. What is interesting is that the arm actually begins to feel heavy. It is the subject’s conviction that the suggested event is really happening that distinguishes a genuine hypnotic experience from overt

behavioral compliance. This point was made early on in a series of studies of Barber’s ‘task motivation’ paradigm of hypnosis, which puts very strong pressure on subjects for overt behavioral compliance with suggestions (Barber, 1969, 1972). In one study, Barber and Calverley (1964) reported that subjects in a task motivation control condition gave reports of the ‘reality’ of suggested hallucinations that were comparable with those given by hypnotic subjects. K. S. Bowers (1967) replicated this finding, but found that the reality ratings of task motivation subjects returned to baseline levels following demands for honesty in reporting. Next, Spanos and Barber (1968) confirmed this finding, but found that the hallucination ratings of hypnotic subjects were not corrected by honesty demands. Finally, K. S. Bowers and Gilmore (1969) found that honesty ratings corrected the hallucination reports of simulating, but not real, hypnotic subjects. The entire cycle of research just summarized underscores the importance of subjective conviction in distinguishing what is hypnosis from what is not and who is genuinely hypnotized from who is not. Orne’s real–simulator design also provides a means to this end. The real–simulator paradigm was intended, largely, to serve as a means to verify the ecological validity of laboratory experiments on hypnosis and other phenomena (Orne, 1959, 1962, 1969, 1970, 1972, 1973). But because Orne’s hypnosis research was part of a larger interest in the objective study of subjective states, including sleep and the detection of deception, the real–simulator design was also a vehicle for careful post-experimental inquiry into subjects’ private experiences of hypnosis. Similarly, the Experiential Analysis Technique was developed as a means for systematically inquiring into subjects’ (retrospective) impressions of hypnotic procedures and their response to them (Sheehan et al., 1978; Sheehan and McConkey, 1982; McConkey and Barnier, 2004). Both procedures have their place in hypnosis research, but they—especially the real–simulator design—can also be expensive to implement. Although the Stanford-type hypnotizability scales were deliberately constructed with behavioral as opposed to subjective measures of response, assessments of subjective experience

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can be easily added to them. For example, subjects can simply be asked whether each suggestion succeeded in producing its intended effect (Register and Kihlstrom, 1986). One comparative study found that ratings of subjective experience corrected the behavioral scores of the BSS strongly downward, but had significantly less effect on scores of the SHSS:A (Ruch et al., 1974). Perhaps the correlations between subjective experience and objective response are high on the Stanford-type scales because the scales themselves put so much emphasis on subjective experience, despite their behavioral scoring. Still, direct assessment of subjective experience makes the point that subjective experience lies at the heart of the domain of hypnosis, and that behavioral responses flow from subjective conviction. Of course, the subjective experience of hypnosis can go beyond subjective conviction in the suggested effects (Sheehan and McConkey, 1982; McConkey and Barnier, 2004). Following in the tradition of nineteenth-century descriptions of the depth or stages of hypnosis, a number of modern investigators have proposed that the subjective experience of hypnosis can be assessed along a number of different dimensions. For example, Shor (1962) proposed that hypnotic depth be evaluated along three conceptually independent dimensions: the loss of the generalized reality orientation (Shor, 1959); nonconscious involvement; and archaic involvement. Later, he suggested five additional dimensions on which the phenomenal experience of hypnosis should be assessed (Shor, 1979; Kihlstrom et al., 1989): drowsiness; physical and mental relaxation; mental imagery; absorption in the ongoing experience; and access to normally unconscious ideas and memories. Along the same lines, Field (Field, 1965; Field and Palmer, 1969; Kihlstrom et al., 1989) and Pekala (Pekala et al., 1985; Pekala and Kumar, 2000; Pekala, 2002) have developed questionnaire techniques for assessing a number of subjective experiences thought to be associated with hypnosis. To some extent, these proposals obviously reflect their originators’ theoretical preconceptions concerning the nature of hypnosis. As such, they risk constituting a kind of Procrustean bed into which subjects’ experience of hypnosis

must be fit at all costs. For example, we now know that hypnosis need not be relaxing, and hypnotized subjects need not be drowsy (Vingoe, 1968; Banyai and Hilgard, 1976; Malott and Goldstein, 1981; Alarcon et al., 1999). Whether subjects are relaxed or active, alert or drowsy, what really belongs in the domain of hypnosis is subjective conviction in the experiences that are suggested to them. As Sutcliffe (1960, 1961) put it, the hypnotized subject is, in some sense, deluded about the actual stimulus state of affairs.

2.11. Experienced

involuntariness Whether subjects are relaxed or active, alert or drowsy, another element in the subjective experience of hypnosis is the experience of involuntariness in response to hypnotic suggestions. The outstretched arm does not just feel heavy: it appears to become heavier all by itself, without the subject deliberately constructing the image. The experience of involuntariness is part and parcel of subjective conviction: one cannot believe that one’s arm has become light, being pulled up by helium balloons, if one is deliberately imagining that it is so, or voluntarily raising the limb. The experience of involuntariness is what distinguishes a suggestion from an instruction (Weitzenhoffer, 1974, 1980); nonconscious involvement (Shor, 1959, 1962, 1979) is also what distinguishes hypnotic experience from mere behavioral compliance. In view of the centrality to hypnosis of the experience of involuntariness, it is somewhat surprising that it is so seldom considered in the assessment of hypnotizability. Both HGSHS: A and SHSS:C rely exclusively on observed or self-reported behavioral response, as does the BSS. This general failure to include an inquiry into the experience of involuntariness was criticized by Weitzenhoffer (1980a) himself, as part of his analysis of the classic suggestion effect (Weitzenhoffer, 1974). Following the argument of Bernheim (1886/1889, p. 125), who asserted that ‘The most striking feature of a hypnotized subject is his automatism’, Weitzenhoffer asserted that only involuntary responses to suggestion should count as truly hypnotic in

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nature (see also Weitzenhoffer, 1980). Thus, at least in principle, assessments of hypnotizability that do not assess involuntariness may be contaminated by mere behavioral compliance. In reply, E. R. Hilgard (1981) argued that the vast majority of subjects experience their response to hypnotic suggestions as involuntary, so that the degree of contamination may not be great. Of course, the degree of such contamination is an empirical question. K. S. Bowers (1981), examining response to an abbreviated version of SHSS:A, found that 80 percent of passed items were experienced as involuntary behaviors, and only 20 percent as voluntary. Moreover, subjects who experienced their response as involuntary scored higher on SHSS:A, and on a subsequent SHSS:C, than those who did not, regardless of whether they passed the item according to the behavioral criterion. Subsequent studies of scales of the Stanford type also found low rates of voluntary response (P. Bowers, 1982; Farthing et al., 1983; P. Bowers et al., 1988). Such studies indicate that most positive responses to hypnotic suggestions are, in fact, associated with the experience of involuntariness. Still, the fact that some positive behavioral responses are experienced as voluntary suggests that ratings of experienced involuntariness can be of value in the assessment of hypnotizability—a point with which E. R. Hilgard (1981) concurred. For example, in the normative study of the CURSS, which includes subjective and involuntariness scores as well as the usual objective score, requiring subjects to pass both the objective criterion and rate the response as at least moderately involuntary, cut the mean score in half and shifted the distribution of scores dramatically to the left (Spanos et al., 1983a,b,c). While such findings suggest that the CURSS behavioral scores might be heavily contaminated with compliance, Spanos and his colleagues have argued that contamination extends to the Stanford scales as well (Spanos et al., 1986a,b). However, this was clearly not the case in the studies of Kenneth and Patricia Bowers, or in Hilgard’s own studies, where honesty demands and involuntariness ratings had little effect on SHSS scores. Although the published versions of the Harvard and Stanford scales do not contain assessments of experienced involuntariness,

these are easily inserted into the procedure. Again, perhaps the simplest procedure is a rating scale, with opposite poles labeled ‘Deliberate, Effortful, Voluntary’ and ‘Automatic, Effortless, Involuntary’ (P. Bowers, 1982). However, ratings in the midrange of a continuous dimension of involuntariness remain somewhat ambiguous. While the meanings of high and low ratings on such a scale are fairly clear, intermediate ratings might mean that the subject’s response was perceived as partially voluntary and partially involuntary; or a response that began voluntarily might have continued involuntarily. Accordingly, P. Bowers et al. (1988) introduced a categorical rating system, which allowed for such alternatives as well as the more extreme alternatives of deliberate versus involuntary responding to suggestion. It is one thing to assess the experience of involuntariness; it is quite another to explain it. Early authorities, such as Bernheim (1886/1889), really seem to have believed that the hypnotic subject was some sort of automaton. Similarly, Arnold’s (1946) theory of ideomotor action held that behavioral responses to hypnotic suggestions occurred automatically whenever the subject vividly imagined some suggested state of affairs. Beginning in the mid-1970s, cognitive psychologists began to elaborate a technical concept of automaticity, couched in the framework of limited-capacity models of attention and information processing (LaBerge and Samuels, 1974; Posner and Snyder, 1975; Schneider and Shiffrin, 1977). According to this view, automatic processes share four characteristics in common: (1) they are inevitably evoked by the presence of certain stimuli in the environment; (2) once evoked, they are incorrigibly executed, in a ballistic fashion; (3) they are effortless, in the sense that they do not consume cognitive resources; and (4) they are processed in parallel, so that they do not interfere with other ongoing cognitive processes. So defined, automatic processes are involuntary in the same way that reflexes and instincts are involuntary. Based on this technical definition, however, it appears that hypnotic experiences are not involuntary after all (Lynn et al., 1990). For example, response to post-hypnotic suggestion is sensitive to the context in which the cue is presented (Spanos et al., 1987); even highly

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hypnotizable subjects can resist hypnotic suggestions (E. R. Hilgard, 1963); and execution of a post-hypnotic suggestion consumes cognitive capacity, so that post-hypnotic responses can interfere with other resource-demanding processes (Hoyt, 1990). Accordingly, many modern theories of hypnosis incline toward the view that hypnotic experiences are not actually automatic in nature, even though they may be experienced as involuntary. In E. R. Hilgard’s (1977) neodissociation theory of divided consciousness, for example, automatic processes running in parallel serve to illustrate the idea of divided consciousness. But the theory itself suggests that the experience of involuntariness occurs because the cognitive module that executes the suggestion does so outside of phenomenal awareness (Kihlstrom, 1992a, 1998). As another example, Spanos’s (1986a) socialcognitive view of hypnosis explains the experience of involuntariness in terms of self-deception on the part of the subject, who mistakenly attributes his or her response to external rather than internal factors—a mistake encouraged by various features of the social situation in which hypnosis takes place. In both Hilgard’s and Spanos’s theories, the experience of involuntariness has some of the qualities of an illusion— although for Hilgard the source of the illusion is to be found in the communications among cognitive subsystems, while for Spanos the source is to be found in the structure of suggestions and other features of the social milieu. It should be noted, in passing, that Spanos has elsewhere suggested that reports of involuntariness stem from subjects’ strategic attempts to create an impression that they are deeply hypnotized (Spanos et al., 1985). In this view, the experience of involuntariness is no such thing. In stark contrast, some modern approaches seem to hold that hypnotic experiences actually occur automatically. For example, Woody and Bowers (1994; see also Woody and Sadler, 1998) drew on neuropsychological theories to suggest that hypnosis alters the functioning of executive control systems associated with the prefrontal cortex, with the result that hypnotic responses are truly involuntary even if they are not technically automatic (see also Haggard et al., 2003). And, somewhat paradoxically, Kirsch and Lynn (Kirsch and Lynn, 1998b,c, 1999; Kirsch, 2001)

have revived Arnold’s theory of ideomotor responding, suggesting that hypnotic experiences are an automatic consequence of positive response expectancies. It will take some time to sort all of this out, but at present it appears that the theoretical battleground in hypnosis has shifted, from explaining response to hypnotic suggestions in general, and debating the mechanisms of various hypnotic suggestions in particular, to accounting for subjects’ experience of involuntariness in response to hypnotic suggestions.

2.12. Altered state of

consciousness Over the years, much ink has been spilled over whether, and in what respects, hypnosis represents an altered state of consciousness (Ludwig and Levine, 1965; Chaves, 1968; Spanos, 1970, 1986b, 1987a,b; Spanos and Chaves, 1970; Barber, 1972; Sarbin and Coe, 1972; E. R. Hilgard, 1973a,b, 1992; Blum, 1978; Kihlstrom, 1992a, 2007; Sarbin, 1992; Kirsch and Lynn, 1998c; Oakley, 1999a, 1999b; Kallio and Revensuo, 2000, 2003). Sometimes the debate has been couched in terms of the validity of trance or special-process theories of hypnosis. Sometimes it has been framed as a conflict between alternative paradigms for the investigation of the phenomenon. Sometimes, it seems to be a local manifestation of a broader conflict over whether mentalistic entities such as consciousness have any place in a scientific explanation of behavior. Nevertheless, the conclusion that hypnosis reflects an altered state of consciousness seems unavoidable (Kihlstrom, 2005). After all, consciousness has two principal aspects (Kihlstrom, 1984): monitoring ourselves and our environment, so that objects, events and our internal mental states are accurately represented in phenomenal awareness; and controlling ourselves and the environment, through the voluntary initiation and termination of thought and action. And hypnosis alters both of them: hypnotized subjects see things that are not there, and fail to see things that are there; they fail to remember things that they just experienced, and they remember things that didn’t happen; they

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cannot control their bodily movements, and they execute post-hypnotic suggestions without knowing why they are doing so. From this point of view, it would seem that the only way to deny that the phenomena of hypnosis reflect alterations in consciousness would be to deny that the phenomena themselves are genuine—to assert, for example, that hypnotic subjects really do feel pain, and really do remember, despite what they say after they have been given suggestions for analgesia and amnesia. Perhaps, though, the problem lies in the way that altered state is defined. If we believe that every state of consciousness is associated with some unique physiological signature, much as sleep is associated with the absence of alpha activity in the electroencephalogram (EEG) and dreaming with the occurrence of rapid eye movements (REM), then the lack of a physiological indicator for hypnosis may be taken as evidence that hypnosis is not an altered state of consciousness after all. But of course, this puts the cart before the horse. Physiological indices are validated against self-reports, as when Aserinsky and Kleitman (1953) awakened their subjects up during periods of REM and nonREM sleep to ask them if they were dreaming. For this reason, physiological variables have no privileged status over introspective self-reports as indices of consciousness. Arguably, it would be useful if states of consciousness had distinct physiological correlates. But our present knowledge of mind–body relationships is simply not sufficient to make such correlates a necessary part of the definition. After all, cognitive neuroscience has made very little progress in the search for the neural correlates of ordinary waking consciousness (Metzinger, 2000; Coltheart, 2006a,b). It is very difficult to infer from a particular pattern of brain activity just what the subject is doing (Poldrack, 2006). How far in the future do the neural correlates of altered states of consciousness, such as hypnosis, await? And even when they become available, how reliably will we be able to determine that subjects have been hypnotized, just by examining their brains? Even at the psychological level of analysis, it may not be possible to find any unique cognitive or behavioral change associated with hypnosis. Hull (1933) thought that the hallmark of

hypnosis was hypersuggestibility; but while hypnosis may—may—enhance suggestibility, at the very least it is clear that suggestibility is something that also occurs in the normal waking state (Weitzenhoffer and Sjuberg, 1961; Braffman and Kirsch, 1999; Kirsch and Braffman, 2001). More recently, Orne (1959) suggested that hypnosis was characterized by trance logic, which he described (informally, to colleagues; but, alas, never in print) as a kind of ‘peaceful co-existence between illusion and reality’. For example, Orne reported that some hypnotized subjects, hallucinating a companion, saw through their hallucination to the back of the chair on which they sat; or they also saw the real person, sitting nearby; simulators, Orne reported, never did these things. Everyone who has ever worked with a hypnotized subject has observed trance logic; but the implication that trance logic was unique to hypnosis—it’s ‘essence’—was vigorously challenged by R. F. Q. Johnson (1972; for a critique, see E. R. Hilgard, 1972; for a rejoinder, see R. F. Q. Johnson et al., 1972). Later studies employing a battery of test items confirmed that hypnotizable subjects were more likely to display trance logic than insusceptible subjects (e.g. Peters, 1973; Obstoj and Sheehan, 1977; Perry and Walsh, 1978), but it also became clear that trance logic was observed in other situations as well, such as nonhypnotic imagination (McConkey et al., 1991). Despite the human species’ deep epistemic desire to carve nature at its joints, and slot different states of consciousness into discrete categories, in the final analysis it may be best to treat hypnosis and other altered states of consciousness as natural concepts, represented by a prototype or one or more exemplars, each consisting of features that are only probabilistically associated with category membership, with no clear boundaries between one altered state and another, or between altered and normal consciousness (E. R. Hilgard, 1969; Kihlstrom, 1984, 2005). And because we cannot have direct knowledge of other minds, altered states of consciousness must also remain hypothetical constructs, inferred from a network of relationships among variables that are directly observable (Garner et al., 1956; Campbell and Fiske, 1959; Stoyva and Kamiya, 1968), much in the manner of a psychiatric diagnosis (Orne, 1977). From this point

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of view, the diagnosis of an altered state of consciousness can be made with confidence to the extent that there is convergence among four kinds of variables: an induction procedure; alterations in subjective experience; associated changes in overt behavior; and physiological correlates. Operationally, an altered state of consciousness can be defined, in part, by the means employed to induce it—or, alternatively, as the output resulting from a particular input (Barber, 1969). Operational definitions of this sort are a residue of functional behaviorism in psychology, but the role of an induction procedure in hypnosis remains open. Certainly an induction procedure helps to define the situation as hypnosis, as opposed to something else, so that the subject has some sense of what to expect and what to do. But it is not sufficient to produce hypnosis: the subject must also be hypnotizable—and then there is the nontrivial fact that any effect elicited while the subject is hypnotized can also be elicited outside hypnosis, by means of post-hypnotic suggestion. And an induction procedure may not be necessary either: highly hypnotizable subjects may not benefit much from an induction, and highly experienced subjects may not need the ministrations of the hypnotist in order to enter hypnosis. In contrast, introspective self-reports of changes in subjective experience would seem to be central to the definition of any altered state of consciousness. After all, the domain of hypnosis is defined by suggested changes in perception, memory and the voluntary control of behavior—analgesia, amnesia, the experience of involuntariness, and the like. If the hypnotist gives a suggestion—for example, that there is an object in the subject’s outstretched hand, getting heavier and heavier—and the subject experiences nothing of the sort, it is hard to say that he or she has been hypnotized. Of course, self-reports have always made psychologists nervous, even in the heyday of introspectionism (Boring, 1953; Robbins, 2004). Accordingly, another residue of behaviorism is a methodological choice to focus on overt behavior. If a subject hallucinates an object in his outstretched hand, and feels it grow heavier and heavier, eventually his arm ought to drop down to his side. Note, however, that overt behavior is

a consequence of the subject’s altered subjective experience, and is of no interest in the absence of corresponding subjective experience. There is really no getting away from self-reports; the methodological trick is to collect them under circumstances where subjects believe it is legitimate for them to reflect accurately on their experiences. Because both self-reports and overt behaviors are under voluntary control, and thus subject to distortion by social influence processes, hypnosis researchers have long been interested in psychophysiological indices of response. Over the years, a number of such indices have been offered, including galvanic skin conductance (O’Connell and Orne, 1968), EEG alpha (R. A. Dumas, 1977) and theta (Crawford and Gruzelier, 1992) activity, and increased activation of both right (MacLeod-Morgan and Lack, 1982) and left (Maquet et al., 1999) cerebral hemispheres, but these have often proved to be artifacts of confounding variables such as relaxation, or otherwise not intrinsic to hypnosis. The ambiguities and controversies surrounding hypnosis were not resolved by psychophysiology, and they are unlikely to be resolved by neuroscience. Because subjects can have a wide variety of experiences while they are hypnotized, it was probably a mistake to expect that there would be any neurophysiological correlates of hypnosis in general, following an induction procedure but in the absence of any specific suggestions. Investigators who are interested in the neural correlates of hypnosis are more likely to find something interesting when they focus on the correlates of specific hypnotic suggestions—as in brain imaging work that shows specific changes in brain activity corresponding to hypnotic auditory (Szechtman et al., 1998) and visual (Kosslyn et al., 2000) hallucinations, analgesia (Rainville et al., 2002) or agnosia (Raz et al., 2005). Note, however, in these cases, the brain signature associated with the hypnotic effect was not unique to hypnosis. In the Kosslyn et al. (2000) study, for example, hypnotized subjects received a suggestion to perceive a grayscale stimulus as colored, and a colored stimulus in grayscale. A positive response to these suggestions was associated with changes in the ‘color area’ of the occipital cortex, but these

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changes were the same as those observed when nonhypnotized control subjects perceived colored or grayscale stimuli, or when they simply imagined the stimuli as such. The brain changed with the experience, but the origins of the experience—whether in stimulation, hypnotic suggestion or vivid imagination—did not much matter. Setting aside the issue of how altered states of consciousness can be defined in general, how can we characterize the alterations in consciousness observed in hypnosis? The clearest answer is that the core phenomena of hypnosis—the ones that really matter, and that distinguish the domain of hypnosis from that of other forms of suggestibility—entail a division in consciousness affecting percepts, memories and other mental contents that are normally accessible to conscious awareness and are instead processed subconsciously (E. R. Hilgard, 1977; Kihlstrom, 1984, 1992a, 1998, 2007; K. S. Bowers and Davidson, 1991). In post-hypnotic amnesia, the phenomenon that gave hypnosis its name, explicit memory or conscious recollection is impaired, but priming and other expressions of implicit or unconscious memory (Schacter, 1987) are spared. Posthypnotic suggestion can likewise be construed as a failure of conscious prospective memory (Einstein and McDaniel, 1990; Graf and Uttl, 2001; Zimmer et al., 2001); the post-hypnotic response is, in this view, an implicit expression of memory for the post-hypnotic suggestion itself. Analgesia suggestions disrupt explicit perception (Kihlstrom et al., 1992) of the pain stimulus, but leave implicit expressions of pain, such as psychophysiological responses, intact. Hilgard’s ‘hidden observer’ is a metaphor for the continuing subconscious representation of the pain stimulus. Dissociations between explicit and implicit memory, and between explicit and implicit perception are not a unique signature of hypnosis: they are also observed elsewhere, in a wide variety of normal and pathological conditions. But they do appear to be the signature of the kind of alteration in consciousness that occurs within the domain of hypnosis.

2.13. Social interaction At the very least, hypnosis entails a dyadic relationship between two individuals, the subject

and the hypnotist; in the case of self-hypnosis, one person takes on both social roles. Then there is the situation in which hypnosis takes place, including the physical environment (laboratory, clinic), as well as the whole socio-cultural matrix that surrounds the transaction— Mesmer, the Svengali myth, stage hypnosis, Saturday-morning cartoons, The Manchurian Candidate, the listings of hypnotists in the telephone directory, advertisements in the newspapers and other media, and all the rest. Hypnosis is linked in the popular mind with persuasion, compliance and other aspects of social influence, including subliminal influence—a link that can reach mythological proportions. A recent Google search on the terms Hitler and hypnotist yielded 48 000 hits, including ‘The George W. Bush Hypnosis File’. And not just in the popular mind: George Estabrooks, a leading authority on hypnosis before its current revival, said of Hitler: ‘We can, I think, make out a very convincing case that basically Hitler’s emotional domination of the crowd ... was only the attack of the stage hypnotist one step removed’ (Estabrooks, 1943/1957, pp. 120–121). But we do not have to go as far as Estabrooks to acknowledge that hypnosis provides much grist for the social-psychological mill. This was true even before there was a social psychology. The Franklin Commission’s studies of the role of imagination in mesmerism are recognized today as the first experiments in psychology (Kihlstrom, 2002). In his chapter on hypnosis in ‘Principles of Psychology’, James (1890/1980) underscored the role of the subject’s expectations and the hypnotist’s skill in developing rapport, and suggested that ‘the bodily symptoms of the Salpetriere patients’, which Charcot attributed to neurological changes, were ‘all of them results of expectation and training’ (p. 1198). Suggestion, as exemplified by hypnosis, was one of the ‘simple and sovereign’ concepts (the others were sympathy and imitation) by which pre-experimental social psychologists sought to explain interpersonal behavior (Allport, 1954). Ross’s 1908 textbook, the first to have ‘social psychology’ in its title, attempted to explain all social behavior in terms of suggestion and imitation—terms which he used interchangeably (Ross, 1908). McDougall’s text, following only a few months later, offered a more extensive set of principles, but suggestion and submission still played a large role in his

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approach (McDougall, 1908). Both made extensive references to the literature on hypnosis, especially the work of the Nancy School of Liebeault and Bernheim (Gauld, 1992). A fully fledged social-psychological approach to hypnosis had to wait until after the Second World War, when the emergence of social psychology as an experimental discipline coincided with a revival of research interest in hypnosis. Interestingly, Sarbin’s (1954) role theory, intended as a general theoretical framework for understanding social behavior, found its most popular application in hypnosis (Sarbin, 1950; Sarbin and Andersen, 1967; Sarbin and Coe, 1972; Coe and Sarbin, 1991). Unfortunately, the theory’s reliance on a dramaturgical metaphor for behavior led some to conclude that hypnosis was somehow akin to faking. Sarbin and his associates repeatedly disavowed this interpretation—although, to be fair, the theory’s reliance on a definition of role-playing as as-if behavior certainly encouraged the idea that hypnotized subjects weren’t analgesic, amnesic, and so on— they were only behaving as if they were. Still, with such concepts as role perception, role enactment, role location, self-role congruence, role expectations, role skills, role demands, role preparation and the audience, role theory certainly offered a rich vocabulary for the analysis of the interpersonal aspects of hypnosis. Role theory emerged from a sociological social psychology, which emphasizes explanatory concepts (such as role) that reside in the institutional, societal and cultural context of individual behavior, and that rejects mentalistic constructs. As their labels indicate, two other social-psychological approaches are more explicitly allied with the cognitive traditions in psychological social psychology, which place considerable weight on the individual’s internal beliefs, attitudes and explanations. Spanos’s socio-cognitive perspective (Spanos, 1991) began as a revision of Barber’s (1969) task-motivational approach to hypnosis, which emphasized the role of attitudes and expectancies, as well as the subject’s willingness to think and imagine with the themes of suggestions (Barber et al., 1974). Spanos’s theory then spent time as a ‘cognitivebehavioral perspective’ (Spanos and Chaves, 1989a,b) and as a ‘social-psychological interpretation’ (Spanos, 1986a). In its final form, Spanos’s

‘socio-cognitive’ theory described hypnosis as a strategic enactment shaped by the subject’s understanding of task demands, as negotiated with the hypnotist, in the context of specific historical circumstances. For example, Spanos argued that reports of experienced involuntariness were in part misattributions shaped by the structure of the suggestions administered to subjects (Spanos and DeGroh, 1983), as well as a strategy for subjects to present themselves as deeply hypnotized (Spanos et al., 1985). These elaborations of role theory, coupled with a debunking tendency (e.g. Spanos et al., 1982), also left the impression that hypnotic subjects were engaged in something akin to faking. Despite the similarity in names, a rather different perspective on hypnosis is found in the ‘social cognitive’ approach to hypnosis offered by Lynn, Kirsch and their colleagues (Kirsch, 1991; Lynn and Rhue, 1991; Kirsch and Lynn, 1995, 1998b,c)—sometimes with a hyphen, sometimes without. Partly rooted in Rotter’s (1954) cognitive-social learning theory of personality, the theory emphasizes the importance of response expectancies as determinants of both behavior and experience (Kirsch, 1985; Kirsch and Council, 1989). The antecedent expectancies are shaped by the usual sorts of interpersonal processes, including all the sorts of interpersonal influence that social psychologists study. But once these expectancies are formed, their causal effect on hypnotic responding is mediated by a process of ideomotor action very similar to that described by Arnold (1946). In this social-cognitive model, social processes shape expectancies and other cognitions; and response expectancies generate responses by a mechanism similar to the self-fulfilling prophecy (Merton, 1948) and other expectancyconfirmation processes (Snyder and Swann, 1978; Darley and Fazio, 1980; Snyder, 1984; Jones, 1986). The difference between Kirsch and Lynn’s social-cognitive approach and Spanos’s sociocognitive approach can be seen in the analysis of experienced involuntariness. Expectancies, shaped by suggestions and other aspects of the social context function like ideas; and the idea of an action leads automatically to its execution. Thus, involuntariness is neither a misattribution nor an element of strategic self-presentation;

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instead, it is a subjectively convincing phenomenal experience that follows from the mechanism that links suggestions to responses. Hypnosis is simply a more general case of these basic phenomena of suggestion and ideomotor action (Braffman and Kirsch, 1999; Kirsch and Braffman, 2001). As another contrast with Spanos’s position, Kirsch and Lynn, while assuming an appropriate stance of scientific skepticism concerning various claims about hypnosis, apparently feel no need to engage in a program of debunking. Hypnotic effects can be accepted as reflecting genuine subjective experiences, even if these effects are to be attributed to suggestion, not to hypnosis per se (Raz et al., 2006). Still, the social-cognitive approach to hypnosis shares some undesirable features with contemporary work in social cognition, and indeed social psychology generally—which is, frankly, that it is not very social (Carlson, 1984). For all the talk about social-psychological approaches to hypnosis, relatively little experimental work has been devoted to core topics in social psychology. What is the relationship between attitudes towards hypnosis and hypnotic behavior (McConkey, 1986; Capafons et al., 2004)? What actually transpires between the hypnotist and the subject (Sheehan, 1971a; McConkey and Sheehan, 1976, 1980, 1982; Baker and Levitt, 1989)? How do hypnosis and other forms of suggestibility relate to susceptibility to other forms of social influence (Moore, 1964; Orne and Evans, 1965; Evans, 1967)? How do individual subjects influence each other in group hypnosis, such as the HGSHS:A? (Evans and Mitchell, 1986)? What cognates of hypnosis can be found in non-Western cultures (Mischel and Mischel, 1958; Kirmayer, 1992)? Consider hypnosis as something that happens between two people, and then scan the table of contents of any introductory survey of social psychology: we have only scratched the surface of the domain of hypnosis.

2.14. Two ways in hypnosis

and a third way Actually, this is true for both aspects of hypnosis—the alterations of consciousness and the social interactions. As hypnosis enters the

twenty-first century, we are reminded that, as Hull prepared the monograph summarizing his research program, he also left the field detailed descriptions of 102—not 100, nor 101, but 102—hypnosis experiments that had not been done, and which were, in his view, well worth doing (Hull, 19930a,b) and some 40 studies of waking suggestibility as well (Hull, 1929). Most of these experiments remain undone, and most of these remain well worth doing. And how much more remains to be done, given that we know so much more about both mental processes and social interactions! For most of its recent history, the socialpsychological approach to hypnosis has defined itself in opposition to those approaches that focused on alterations of consciousness occurring in hypnosis (Ludwig and Levine, 1965; Chaves, 1968; Spanos, 1970, 1986b, 1987a,b; Spanos and Chaves, 1970; Barber, 1972; Sarbin and Coe, 1972; E. R. Hilgard, 1973a,b, 1992; Blum, 1978; Kihlstrom, 1992a, 2007; Sarbin, 1992; Kirsch and Lynn, 1995, 1998a,b,c; Kirsch and Lynn, 1998c; Oakley, 1999a,b; Kallio and Revensuo, 2000, 2003). The result has been to give the literature on hypnosis some of the features of a zero-sum game, in which evidence for the involvement of some socialpsychological process, such as variations in the wording of suggestions, is taken as evidence against the involvement of some cognitive process, such as divided consciousness (e.g. Spanos and Hewitt, 1980; Laurence et al., 1983; Spanos, 1983; Green et al., 2005b,c; Kihlstrom and Barnier, 2005). But it does not necessarily follow that, because interpersonal processes shape hypnosis, hypnosis cannot also involve an alteration in consciousness. There is a third way, and it has been available to us from the beginning. William James, considering the competing claims of the Salpetriere and Nancy schools concerning the nature of hypnosis, concluded that ‘The suggestion-theory may therefore be approved as correct, provided we grant the trance-state as its prerequisite (James, 1890/1980, p. 1201, italics original). Fifty years later, at the dawn of the modern era of hypnosis research, R. W. White asserted that ‘The theory of hypnotism will never prosper until, outgrowing the dialectic dichotomy of “striving” and

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“state”, it considers the possibility of interaction’ (White, 1941, p. 502). Martin T. Orne (1959), White’s protégé as both an undergraduate and a graduate student at Harvard, famously tried to distinguish between artifact and essence of hypnosis (Orne, 1959), but a careful reading of his work makes it clear that the demand characteristics that surround hypnosis are as important as any ‘trance logic’ that might arise within hypnosis. R. E. Shor, writing in the first edition of this volume, noted that ‘The fundamental problem in hypnosis research is that it is faced with two dangers, which, like the rock and whirlpool of Scylla and Charybdis, are so situated that they must be encountered together, as if they are one’ (Shor, 1972, p. 15). Shor thought that the problem was that of simultaneously ‘maintaining both the disciplined skepticism of the scientist and the confident persuasiveness of the hypnotist’ (p. 15). Today, we can rephrase the problem as follows: that of simultaneously maintaining an interest in the cognitive processes by which consciousness is divided in hypnosis, and an interest in the social context in which hypnosis takes place. Tracing the history of hypnosis in four stages from Mesmer to Hull, Shor asked: ‘How well have modern investigators learned to sail between Scylla and Charybdis? To what extent will modern viewpoints be seen through time as true advances—perhaps to a fifth stage of sophistication—and to what extent merely as changes to culturally more acceptable misnomers and disguised returns to old mistakes?’ (1972, p. 40). Shor did not know the answer then, and the answer is not clear even now. But it is clear what we should do, which is abandon the stance of either–or and adopt a new stance of both–and. This ‘third way’ in hypnosis research construes hypnosis simultaneously as both a state of (sometimes) profound cognitive change, involving basic mechanisms of cognition and consciousness, and as a social interaction, in which hypnotist and subject come together for a specific purpose within a wider socio-cultural context. To get beyond the misnomers and mistakes of the past, hypnosis researchers must have a vision as large as the phenomenon they seek to study. And the domain of hypnosis is very large indeed.

Acknowledgments The point of view represented in this chapter is based on research supported by Grant MH35856 from the National Institute of Mental Health. I thank Patricia A. Register, Leanne Wilson, Paula Niedenthal, Ernest Mross, Jeanne Sumi Albright, Martha Glisky and Susan McGovern for their contributions to that program of research. I also thank Amanda Barnier for her thoughtful and thorough editorial comments.

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Weitzenhoffer, A. M. and Weitzenhoffer, G. B. (1958) Sex, transference, and susceptibility to hypnosis. American Journal of Clinical Hypnosis, 1: 15–24. Welchross, M. K. (1999) Preschoolers understanding of mind: Implications for suggestibility. Cognitive Development, 14: 101–131. Westermann, R., Spies, K., Stahl, G. and Hesse, F. W. (1996) Relative effectiveness and validity of mood induction procedures: A meta-analysis. European Journal of Social Psychology, 26: 557–580. White, R. W. (1937) Two types of hypnotic trance and their personality correlates. Journal of Psychology, 3: 279–289. White, R. W. (1941) A preface to the theory of hypnotism. Journal of Abnormal and Social Psychology, 36: 477–505. Whitehouse, W. G., Orne, E. C., Dinges, D. F., Bates, B. L., Nadon, R. and Orne, M. T. (2005) The cognitive interview: does it successfully avoid the dangers of forensic hypnosis? American Journal of Psychology, 118: 213–234. Wiggins, J. S. and Trapnell, P. D. (1997). Personality structure: the return of the Big Five. In S. R. Briggs, R. Hogan and W. H. Jones (ed.) Handbook of Personality Psychology, pp. 737–765. Academic Press, Orlando, FL. Wilson, S. C. and Barber, T. X. (1978).The Creative Imagination Scale as a measure of hypnotic responsiveness: applications to experimental and clinical hypnosis. American Journal of Clinical Hypnosis, 20: 235–249. Woody, E. Z. and Bowers, K. S. (1994) A frontal assault on dissociated control. In S. J. Lynn and J. W. Rhue (ed.) Dissociation: Clinical and Theoretical Perspectives, pp. 52–79. Guilford Press, New York. Woody, E. Z. and Sadler, P. (1998) On reintegrating dissociated theories: commentary on Kirsch and Lynn (1998). Psychological Bulletin, 123: 192–197. Woody, E. Z., Barnier, A. J. and McConkey, K. M. (2005) Multiple hypnotizabilities: differentiating the building blocks of hypnotic response. Psychological Assessment, 17: 200–211. Yapko, M. D. (1983) A comparative analysis of direct and indirect hypnotic communication styles. American Journal of Clinical Hypnosis, 25: 270–276. Young, P. C. (1925) An experimental study of mental and physical functions in the normal and hypnotic states. American Journal of Psychology, 36: 214–232. Young, P. C. (1926) An experimental study of mental and physical functions in the normal and hypnotic states: additional results. American Journal of Psychology, 37: 345–356. Zanna, M. P., Olson, J. M. and Herman, C. P. (ed.) (1987) Social Influence, Vol. 5. Erlbaum, Hillsdale, NJ. Zimbardo, P. G. and Leippe, M. R. (1991) The Psychology of Attitude Change and Social Influence. McGraw-Hill, New York. Zimmer, H. D., Cohen, R. L., Guynn, M. J., Engelkamp, J., Kormi-Nouri, R. and Foley, M. A. (2001) Memory for Action: A Distinct Form of Episodic Memory? Oxford University Press, New York.

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CHAPTER 3

Generations and landscapes of hypnosis: questions we’ve asked, questions we should ask Kevin M. McConkey

3.1. Introduction: the essence

of hypnosis For more than 220 years, researchers and practitioners have strived to understand the essence of hypnosis from the vantage point of scientific theory and method. The essential nature of hypnosis still fascinates and eludes. This volume sets out the key issues, activities and directions for experimental and clinical hypnosis as the twenty-first century lets go of the twentieth century and the researchers and practitioners in the field of hypnosis define the field in fresh ways. In his chapter, John Kihlstrom surveyed the state of knowledge about the fundamental parameters of the domain of hypnosis, and argued the need to step back from the either–or interpretations of hypnotic process and phenomena that have dominated the field in the second half of the twentieth century, and the need to step forward to a new ‘third way’ of hypnosis research if we are genuinely to progress the field. In this chapter, I first explore some of the reasons why the field has evolved in modern times in the way

that it has, and I consider when and why our field has asked particular questions about hypnosis to generate its theoretical and empirical knowledge base. I argue that what we have asked, as well as how we have answered, has been influenced by people and places at particular times. As an Australian, and as a product of a strong Australian tradition of and legacy to experimental and clinical hypnosis, I will illustrate this influence of generations of researchers and the landscape of the field with Australian examples. Following this, I survey the landscape of our field, and suggest some of the next generation of questions that we need to be asking as well as some of the methods that we should be using. I also point to some yardsticks for the next generation of theoretical and empirical contributions to the field, including those described in other chapters in this volume. Before turning to the questions, generations and landscapes of hypnosis, we first must be clear about the phenomena of interest, and Kihlstrom (Chapter 2, this volume) has elegantly set out the domain of hypnosis and discussed various issues of concept and definition

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(see also Killeen and Nash, 2003; McConkey, 2005–06; Green et al., 2005; Nash, 2005). From my perspective, most contemporary thinking about hypnosis can be traced to the insights of Robert White of Harvard University, who worked in the field in the 1930s and 1940s. White (1937), for instance, noted that the hypnotic setting contains various paradoxes if the communications of the hypnotist are taken literally. When the hypnotist says, for instance, that subjects are getting sleepier and sleepier, the hypnotist does not mean this in a literal sense. Similarly, when the hypnotist says that subjects are now 5 years of age, or can see nothing, or can remember nothing, the hypnotist does not mean this literally. Rather, the hypnotist is asking the subject to experience at a phenomenal level the state of affairs that would occur if his/her communications were correct in a literal sense. The hypnotist is conveying his/her wish, and the subject must interpret these wishes in a way that makes sense and then behave accordingly. Thus, individuals’ interpretations of the communications of the hypnotist rather than the words themselves shape the responses that occur in the hypnotic setting. One truism that we too often forget is that it is what people hear, rather than what others say, that matters. A related truism in hypnosis is that it is the ability of the individual, rather than the ‘power of the hypnotist’, that leads to the hypnotic response. Unfortunately, some in our field, as well as many in the ‘lay hypnosis’ field, too often forget this truism. White (1937) also pointed to the importance of understanding how an individual’s own expectations and wishes influence and determine the hypnotic responses that occur. In this respect, he considered that the relationship between the hypnotized person and the hypnotist was a key element. He spoke, for instance, in the language of the time of the ‘pleasure of obedience’ in which, at least for a period of their interaction, carrying out the wishes of the hypnotist becomes the overriding goal of the subject. Moreover, he argued that hypnotized individuals bring ‘natures predisposed’ to interpret and respond to the communications of the hypnotist in a way that is consistent with their role. In this sense, hypnotized persons process information on the basis of an inherent ability and a preparedness to respond in a particular way,

and this allows them to make sense of the communications of the hypnotist. A few years later, White (1941) placed greater emphasis on the social psychology of the interaction between the hypnotized individual and the hypnotist. He argued that ‘hypnotic behavior is meaningful, goal-directed striving, its most general goal being to behave like a hypnotized person as this is continuously defined by the operator and understood by the subject’ (p. 483). The notion that goal-directed striving is central to the responses of hypnotized subjects underscores that both the subject and the hypnotist are in a ‘hypnotic setting’—a setting that is unusual in many respects—for a particular reason. This reason is for the individual to experience phenomenal events and to display behavior that he or she may not experience and display in a nonhypnotic setting. For White (1941), the fact that ‘mere words’ from the hypnotist could initiate a variety of profound changes in the experience and behavior of individuals was an intriguing state of affairs. Twenty years later, two influential Australian psychologists and contributors to the field, A. Gordon Hammer and J. Philip Sutcliffe, focused on what they believed to be the distinctive essence of hypnosis. Writing in 1961 and later in an Encyclopedia Britannica entry in 1974 with Martin Orne, Hammer argued that: Hypnosis … is a collaborative enterprise in which the inner experience of the subject can be dramatically altered (Orne and Hammer, 1974, p. 138; see also Hammer, 1961).

Writing in 1961, Sutcliffe argued that: the distinguishing feature of hypnosis appears to be the subjective state; and the main feature of this state is the hypnotized subject’s emotional conviction that the world is as suggested by the hypnotist, rather than a pseudoperception of the suggested world (Sutcliffe, 1961, p. 200).

So, for White, Hammer and Sutcliffe, to understand hypnosis one needed to understand: the relationship between the hypnotist and the subject; the subject’s interpretation of the hypnotist’s communications in that situation; the abilities, expectancies and strivings of the hypnotized person that influenced their response to those communications; and, perhaps most

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importantly, the mechanism by which ‘mere words’ lead to convincing alterations in experience (see Kihlstrom, Chapter 2, this volume). As we will see in the next section, the asking and answering of these questions about hypnosis has depended on the people and places, the generations and landscapes, of the field of hypnosis over the past 50 years.

3.2. Hypnosis in the twentieth

century Hypnosis can be said to have many dates of birth, with some of the common ones being in the times of the ancient temples of Aesculapius (Ellenberger, 1970; Gauld, 1992), the times of Johann Joseph Gassner (Peter, 2005) and Franz Anton Mesmer (McConkey and Perry, 1985, 2002; Pattie, 1990, 1994), and the times of James Braid (Gauld, 1992). Setting aside the many births, and many parents, of hypnosis, the twentieth century was largely dominated by the development of a scientific approach to its investigation, and this approach can be best understood through a comment on people and places.

3.2.1. The ‘big five labs’, and hypnosis in Australia From the earliest years of scientific research into hypnosis, our field has been shaped by particularly productive individuals and their engaged research laboratories. For instance, in the early decades of the twentieth century, experimental hypnosis research at Harvard University by Morton Prince, P. C. Young, Henry Murray and Robert White motivated other programs, including George Estabrooks’s at Colgate University, Milton Erickson’s at Worcester State Hospital and Clark Hull’s at the University of Wisconsin, interestingly which he could not transfer to Yale University, the place of his major contributions to psychology. This culture of major experimental programs led to the establishment of the ‘big five’ laboratories in the middle of the twentieth century. These were the laboratories of: E. R. and J. R. Hilgard at Stanford University, M. T. and E. C. Orne at Harvard University and later the University of Pennsylvania, T. X. Barber at the Medfield

Foundation, T. R. Sarbin at the University of California, Berkeley, and A. G. Hammer and J. P. Sutcliffe at the University of Sydney. These five laboratories generated an explosion of interest and activity in hypnosis in the second half of the twentieth century. The leading personalities from these labs and their research programs shaped the field of hypnosis in the last half of the twentieth century. Arguably, although most of them are deceased, they shape it still today via the transmission of concepts, methods and values to continuing generations of hypnosis researchers. Many of today’s leading researchers in our field can trace their intellectual lineage to one or more of these laboratories, and some can trace their lineage to even earlier Titans of psychology. In Australia, the birth of hypnosis can be traced directly to a graduate seminar taught by Gordon Hammer at the University of Sydney in 1954. Australian hypnosis research developed in the mid-1950s to mid-1960s when two major groups of researchers formed at that university, one around Hammer and the other around Sutcliffe, both of whom had also been influenced by the work of Hans Eysenck in the 1950s. Hammer was the supervisor of Sutcliffe’s 1958 doctoral thesis which led to two very influential articles in which he introduced and developed a distinction between credulous and skeptical approaches to hypnotic phenomena (Sutcliffe, 1960, 1961). Sutcliffe (1960) stated that ‘what might be called the “credulous” view takes the hypnotic subject’s testimony on faith’ and ‘the “skeptical” view [is held by] those who doubt the subject’s testimony and contend that he actually perceives the situation as it is while acting as if it were suggested by the hypnotist’ (p. 73). Sutcliffe’s distinction introduced a more sophisticated vocabulary and empirical approach to the old question of whether hypnotic phenomena are ‘real’. Sutcliffe believed strongly that, although they are mistaken, hypnotized individuals are convinced that their hypnotic experiences are indeed real. As importantly, Sutcliffe’s work together with Hammer’s work set the conceptual and methodological stage for at least three generations of Australian researchers who followed. Hammer and Sutcliffe supervised a number of graduate students at the University of Sydney

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in the early 1960s—including Fred Evans, Campbell Perry and Peter Sheehan. Although Sutcliffe moved away from hypnosis research to concentrate on more general issues in psychology (see Sutcliffe, 1996), Evans, Perry and Sheehan continued in the field, and either moved to or spent time in North America, and trained their own students. Campbell Perry established an influential laboratory at Concordia University, where he trained another generation including Jean-Roch Laurence (see Laurence et al., Chapter 9, this volume) and Robert Nadon (e.g. Nadon, 1997). Meanwhile, Peter Sheehan returned to Australia after time in North America to establish a hypnosis laboratory at the University of Queensland, where he trained a number of his own students, including myself—a third-generation Australian hypnosis researcher. In turn, at Macquarie University and then at the University of New South Wales in Australia, I supervised a fourth generation of researchers including Amanda Barnier and Richard Bryant (see their chapters in this volume; for more discussion of the students and successors of Hammer and Sutcliffe, see Sheehan, 1985). As Barnier and Bryant train the fifth generation of Australian hypnosis researchers, it is worthwhile reflecting on the intellectual influences of Hammer and Sutcliffe. For instance, it is interesting to see the conceptual similarities in some of the writings of Hammer (e.g. Hammer, 1961) and of Barnier (e.g. Barnier, 2002) on post-hypnotic suggestion. Although separated by over 40 years, their writings reflect the transmission of a particular sensibility and a particular approach to hypnosis research across generations.

3.2.2. Generations of questions

and methods Indeed, the questions asked, the methods used and the inferences made from empirical work over the last 50 years reflect strong interdependence within and between laboratories. Since the rise of the big five laboratories 50–60 years ago, certain questions or obsessions, as well as personalities, have gripped the field. These ‘hot topics’ and the rise and fall of interest in hypnosis across the twentieth century were influenced by social and historical events, as well as by

particular people, theories, methods and findings, both inside and outside the field. Barnier and McConkey (2003) identified some of the major topics, people and findings of various periods as follows: 1. William James and the Twentieth Century Hypnotists: Hypnosis at the Turn of the Century (James, 1890; Kihlstrom and McConkey, 1990). 2. Clark Hull and the Twentieth Century Experimentalists: Hypnosis in the First Half of the Twentieth Century (Hull, 1930–31a,b, 1933; White, 1937, 1941). 3. The Measurement Imperative: Hypnosis in the 1950s (Hilgard, 1965a; Sheehan and McConkey, 1982; Balthazard and Woody, 1985). 4. Hypnotic Control and the Manchurian Candidate: Hypnosis in the 1960s (Watkins, 1947; Barber, 1961; Orne, 1961, 1972a; Orne and Evans, 1965). 5. The Hidden Observer and the Theory Wars: Hypnosis in the 1970s (Hilgard, 1973a,b, 1974, 1975, 1979; see also Barber, 1979; Spanos, 1986). 6. The Correlates of Hypnotizability: Hypnosis in the 1970s (Bowers, 1974; Hilgard, 1965a; see Laurence et al., Chapter 9, this volume). 7. Forensic Hypnosis, Eyewitness Memory and Hypnotic Coercion: Hypnosis in the 1980s (Orne, 1979; Perry 1979; Laurence and Perry, 1983, 1988). 8. Repressed Memory, Memory Wars, and the Battering of Hypnosis: Hypnosis in the 1990s (Orne et al., 1984; Scheflin and Shapiro, 1989; McConkey and Sheehan, 1995; Lynn and McConkey, 1998). In the context of all of this, individual researchers also follow a personal journey that is shaped by, and sometimes shapes, the field. For instance, over 30 years ago I conducted my first piece of hypnosis research, which formed the basis for my undergraduate honours thesis in psychology at the University of Queensland in Australia (McConkey, 1975; McConkey and Sheehan, 1976). In that research, I examined the effect of very different styles of interpersonal orientation of the hypnotist on the responses of

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high and low hypnotizable subjects on a range of test items. In an application of the real–simulating paradigm (Orne, 1959, 1972b), I allocated the highs and lows to the ‘real’ and ‘simulating’ conditions, respectively, and, as the hypnotist, I interacted with them in ways that were either ‘collaborative’ or ‘contractual’. The collaborative context used a structured process of mutual selfdisclosure to promote a much friendlier and more open communication between the subject and the hypnotist than would typically occur in the more traditional, or contractual, laboratory context of the time. I was interested in the effect of these different styles of interpersonal orientation on subjects’ attitudes to the hypnotic setting and on their patterns of response to the test items. I found that the context of testing had an appreciable effect on subjects’ attitudes, but relatively little effect on their performance on the test items. The real, high hypnotizable individuals were much more likely to engage in open dialog with the hypnotist in the collaborative setting than were the simulating, low hypnotizable ones. The real, hypnotized individuals who were tested in the collaborative, rather than the contractual, context reported very positive feelings for the setting overall, for the hypnotist as a person and for their experience of hypnosis. Notably, however, they did not perform any differently in an objective sense across the range of test items. I mention this early contribution to the literature to make the point that hypnosis research is a product of its place and time and of the people involved. One prominent theoretical issue within the field then was the nature and influence of the social relationship between the subject and the hypnotist. In the late 1960s and early 1970s, a number of researchers were investigating the impact of the status, sensitivity, warmth, familiarity, competence and experience of the hypnotist, albeit with mixed results (e.g. Greenberg and Land, 1971; Hedberg, 1974). This work was consistent with debates taking place within psychology, and outside the field of hypnosis, at that time. In psychology, some were arguing that psychological research should adopt a more humanistic approach and that a personalized laboratory setting would change and improve our understanding of various psychological phenomena and processes.

Also at that time, research was focusing on the role of self-disclosure in the development of warm and trusting social relationships (e.g. Jourard, 1968; Argyris, 1975). So, my first piece of hypnosis research, with its collaborative approach and self-disclosure techniques, can be situated within the generations and landscapes of hypnosis and psychology of the mid-1970s; one might say of this research, and of much hypnosis research, that it was on the cutting edge, as well as a product of its time. In the same way, a decade or so later, throughout much of the 1980s and 1990s, ambitious hypnosis researchers in Australia and indeed throughout most of the world were working on the topic of hypnosis and memory. This interest in the interaction of hypnosis and memory was not new (see, for instance, Laurence and Perry’s, 1988, historical review of hypnosis and memory in the legal setting), but it was particularly fervent in the 1980s and 1990s as research on hypnosis intersected with research on eyewitness memory, coercion, clinical disorders of forgetting, and repression (e.g. McConkey and Sheehan, 1995; Lynn and McConkey, 1998). Methods in hypnosis research are also a product of their place, their time and the people involved. One major methodology in the field when I conducted my first hypnosis research was the real–simulating model, which had been developed by Orne (1959, 1972b). Orne’s simulating technique simply determines whether the behavior of hypnotized individuals can be accounted for on the basis of their perceptions of the demand characteristics of the experimental setting. Given that Peter Sheehan was supervising my honours thesis, that he had worked with Orne in the 1960s and that he had written extensively about the simulating technique (e.g. Sheehan, 1971; Sheehan and Perry, 1976), it was essentially predetermined that my first piece of research was going to use that model. This is a nice example of the influence of the landscape of the field of hypnosis, and the influence of the direct and personal transmission across generations of researchers—from Orne, to Sheehan, to me—of the understanding and application of the real–simulating model. Sometimes, methodological advances, and the asking and answering of old or new questions, had to wait for the development of

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new technologies. A good case in point is the Experiential Analysis Technique (EAT), a technique that Peter Sheehan and I developed in the late 1970s and early 1980s (Sheehan and McConkey, 1982). This technique came about, in part, because of the widespread availability of reliable videotape technology at that time. The EAT asks the subject to watch a videotape of their hypnosis session in the presence of an independent experimenter and then to comment on their subjective experience. Although the development of this method of inquiry was motivated by a particular, interactionist model of hypnosis, rather than by the technology itself, the availability of the technology enabled the EAT to be used relatively easily, cheaply and widely. A more recent example of the impact of new technology is the ‘dial method’, a technique that I developed with Amanda Barnier and others in the early 1990s, which took advantage of improvements in computing hardware and software. The dial method involves subjects turning a dial at the same time that they are experiencing a hypnotic suggestion to indicate the strength, the reality, or whatever, of their experience of that hypnotic suggestion (e.g. McConkey et al., 1999b). In general, the findings from research that has used the EAT and the dial method have highlighted theoretically important processes of experience as well as performance aspects of behavior that were not being captured by existing methods. The development and use of these techniques allowed us as experimenters to hear the voices of the hypnotized individuals in new ways and to map the multiple pathways to their experience, and I will comment in more detail on some of this research in a moment. Of course, the development and availability of the tools and techniques of neuroscience are exerting an enormous influence across many disciplines at the moment, and the potential of these tools and techniques is being explored in our field of hypnosis (see Cox and Bryant, Chapter 12; Barabasz and Barabasz, Chapter 13; Oakley, Chapter 14, this volume).

3.2.3. Selected investigations of

hypnosis, from an Australian laboratory To illustrate in more detail the influence of generations and landscapes—of people, place and

time—on questions and methods, let me turn again to research on hypnosis in Australia. From the very beginning of serious theorizing and research on hypnosis in Australia (see Evans and Burrows, 1998), Australians have focused strongly on the methodology and experimental design aspects of the study of hypnosis. In this sense, the methodological emphasis has been consistent with that of Australian psychology generally (e.g. Sheehan and Perry, 1976; Sheehan and McConkey, 1982; Sheehan, 1989, 1998). As noted earlier, Sutcliffe’s (1960, 1961) distinction between credulous and skeptical approaches to understanding hypnosis became a major stimulus for debate in the literature of the time, and the distinction is still relevant today. Sutcliffe (1961; see also Sutcliffe, 1996) pointed out that ‘methodological weaknesses render equivocal much of the available, clinical and experimental evidence on these issues…. [He said that] Evidence alleged to support the credulous view can be shown to be consistent with the skeptical view, and most points at issue remain unresolved’ (p. 190). He proposed methodologically rigorous ways in which to analyze experience, by attempting to validate it against objectively defined patterns of behavior, both simulated and unsimulated (Sheehan and Perry, 1976; see also Cox and Bryant, Chapter 12, this volume). The legacies of Sutcliffe and of Hammer in their writings and in their influences on Australian researchers as well as on our field in general can be captured in terms of a focus on understanding the experience of the hypnotized subject and on ensuring that understanding is derived from experimentation that involves clear problem statement, meticulous design and precise inference. Interestingly, the spirit of critical inquiry that they engendered (or, more correctly, demanded) in the Australian approach to hypnosis research is consistent with the classic approach of the famous 1784 report into mesmerism by the Royal Commission established by Louis XVI and presided over by Benjamin Franklin (see McConkey and Perry, 1985, 2002; Perry and McConkey, 2002). This demanding characteristic of the Australian approach to hypnosis is consistent with the emphasis at the University of Sydney at that time on an appreciation of the historical basis of

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a field, a commitment to a close integration of theory and methodology, and a relative lack of concern for practical relevance (O’Neil, 1987). This approach was very different from that which could be seen in North American laboratories at the time, and it was for these reasons, among others, that influential researchers such as Martin Orne were attracted to spend time at the University of Sydney in the early 1960s (Sheehan, 1985). In this next section, I illustrate some of the distinctive questions and methods of Australian hypnosis research by selectively describing work on internally and externally generated experience, tracking experience, testing the limits of hypnotic experience and testing the limits of post-hypnotic experience.

3.2.3.1. Internally and externally generated experience Many individuals seem capable of creating private events, such as images, that they describe as being similar to actual percepts in the sense of having qualities such as vividness, detail and dimensionality. In normal circumstances, most of us do not confuse our private experience with an actual, externally based experience even though we may feel and say that the two are very similar. In circumstances such as hypnosis, however, some people seem to confuse their internally generated images with their externally based experiences. In the case of a visual image, for instance, during hypnosis the image may take on a quality of compelling and realistic externality. Orne and McConkey (1981) considered how to determine whether an internally constructed experience takes on the quality of being externally based in response to hypnotic suggestions. We developed a procedure that asked subjects to compare their experiences of hypnotic suggestions with their experience of a ‘suggestion’ that was generated externally but that subjects believed to be solely the result of a hypnotic suggestion. We gave hypnotized individuals a series of suggestions such as ‘Your arm is floating upwards’, ‘Your arm is stiff and rigid’, ‘The metal ball you are holding is becoming hot’ and ‘You are lying on the beach and feeling the warmth of the sun’. These were presented as routine suggestions. Inside the metal ball, however, we had placed chemicals and water that generated

an exothermic chemical reaction and that made the ball warm. Because the hypnotist handled the ball normally and gave no indication of the physical reality of the suggested heat, we considered that subjects would think that the alterations in the temperature of the ball were internally generated in much the same way as their arms being stiff and rigid, and being at the beach feeling the warmth of the sun. McConkey and Barnier (2001) used this ‘hot ball’ paradigm to investigate the way in which hypnotized subjects experienced internally and externally generated events. In one experiment, we tested high hypnotizable subjects in conditions where the ball was normal or heated, and we asked them to rate the hot ball item and the other five hypnotic items on a number of dimensions. Our findings indicated that the ratings were similar across the normal and heated conditions. In other words, the high hypnotizable subjects experienced the suggestion for heat hallucination similarly whether the ball was presented in a normal or a heated condition. In addition to rating their belief in the heat similarly, when they were asked to rank it against the other hypnotic items the high hypnotizable subjects in both conditions ranked it as one of the top three ‘real’ items, but not necessarily as the most real. The comments in the post-experimental inquiry indicated that none of the subjects considered that the heat was being generated from within the ball and none of them suspected that we had done something to warm the ball; on the contrary, they typically said that their hand was heating the ball. In another experiment, we replicated and extended the first by testing high and low hypnotizable subjects in either normal or heated conditions and we asked for ratings immediately after the suggestion, and then after an additional 20, 40 and 60 s while the subjects were still holding the metal ball. Our findings indicated that highs gave higher ratings of heat and of belief than did lows, and that the ratings increased over time for highs but not for lows. The post-experimental inquiry comments of highs indicated that they thought the source of the heat they experienced was based on the suggestion of the hypnotist. No high hypnotizable subjects in the heated condition commented about an external heat source; rather, they

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considered that the source of the heat was within them, as it were. However, most low hypnotizable subjects in the heated condition commented, for instance, about ‘something strange going on’ with the ball. This work on internally and externally generated experience underscores the fusion that can occur between internally and externally generated hypnotic experiences, the equivalent reality values that can be placed on internally and externally generated experiences, and the attributions that subjects make for their experiences. Notably, this experimental work and the inferences drawn from it can be traced through a research lineage to the visit of Martin Orne to the University of Sydney in the early 1960s and to some of his writings during that time, as well as to Sutcliffe’s focus on delusion and his call for more sophisticated research designs to understand the subjective experience of hypnosis. Moreover, it highlights the relevance of hypnosis research to the conceptual and methodological challenge of private subjective experience, which has been a matter of debate across psychology since the classic work of Perky (1910).

3.2.3.2. Tracking experience Assessing the experience of hypnosis has been of theoretical and practical interest throughout the history of the phenomenon (Hull, 1933; Hilgard, 1987), and the importance and difficulty of understanding the essentially private experience of the hypnotized person has been discussed in various ways (see Sheehan and McConkey, 1982; McConkey, 1991). The development of a way of measuring and tracking the experience of hypnosis concurrently with that experience has great appeal, especially since the experience of hypnosis is typically inferred from the limited behavioral response of subjects on standard tests, such as the Stanford Hypnotic Susceptibility Scale, Form C (Weitzenhoffer and Hilgard, 1962). On these tests a suggestion is given, for instance, that the subject’s hand and arm are too heavy to hold out in front, and a positive response to that suggestion is scored if the hand and arm lower a certain distance following the suggestion. Although this type of behavioral criterion allows us to determine response in a rough way, and also allows us to separate people into categories such as high,

medium and low hypnotizability, it does not provide very much information about the precise nature of the subjective experience and the relationship of that experience to the communications of the hypnotist and other factors and influences in the test setting (Sheehan and McConkey, 1982; McConkey, 1991). To index and track ongoing hypnotic experience better, McConkey et al. (1999b) developed a ‘dial’ method of tracking the subjective experience of hypnosis. This method involved asking subjects to turn a dial to indicate changes in the strength of their experience of the hypnotically suggested event. The dial was connected to a computer that recorded the position of the pointer (i.e. rating of experience) every second across the three phases of the item (i.e. suggestion or onset, test and cancellation or offset). These three phases can be illustrated in terms of the standard suggestion of hand lowering: the suggestion or onset phase involves asking the individual to hold his/her hand out and the hypnotist saying that the hand is becoming too heavy to hold out there; the test phase involves the hypnotist telling the subject to see how heavy it is and then observing quietly for, say, 10 s; and, the cancellation or offset phase involves the hypnotist telling the person to put his/her hand back into a resting position and saying that the hand is now back to normal and is no longer heavy. Most research in the field of hypnosis has focused on the test phase, with only a few investigators, including Gordon Hammer and Ernest Hilgard, being interested in the experience of hypnotized subjects during the onset and offset phases. Consistent with the Australian approach of seeking a more complete understanding of the experience of hypnosis (Sutcliffe, 1960, 1961; Hammer 1961; Sheehan and McConkey, 1982) we were interested in developing and using a methodology that generated a more detailed profile of subjects’ experiences across the entire test item. Moreover, for theoretical and practical reasons, we were interested especially in exploring the experience of subjects during the onset and offset of selected hypnotic items. McConkey et al. (1999b) asked high, medium and low hypnotizable subjects to use the dial across three different hypnotic items: arm levitation (an ideomotor item), arm rigidity

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(a challenge item) and anosmia (a cognitive item). Hypnotizability follows a normal distribution with about 10–15 percent of individuals being able to experience a wide range of hypnotic suggestions, about 10–15 percent being able to experience very few hypnotic suggestions, and the rest of us being able to experience some, but not other, hypnotic suggestions. Ideomotor suggestions, such as arm levitation (or your arm feeling light and floating up) can be experienced by most people; challenge suggestions, such as arm rigidity (or your arm being too stiff and rigid to bend) is typically not experienced by lows, but is experienced by most mediums and highs; and, cognitive items, such as anosmia (or not being able to smell a distinctive scent such as oil of wintergreen) is typically only experienced by highs. We expected that the continuous nature of recording the strength of subjects’ experience would reveal patterns across the types of subjects, types of items and phases of each item. We found that the subjects showed different patterns of dial ratings across the three hypnotic items. Overall they showed greater experiential involvement in arm rigidity than arm levitation and anosmia. In other words, they showed greater involvement in the challenge item than in the ideomotor or cognitive items. Subjects who passed an item in terms of the behavioral criterion reported a greater strength of experience for that item than did those who did not meet the behavioral criterion. In other words, there was a substantial match between behavior as assessed by the specific criterion and experience as assessed by the dial. Although highs responded behaviorally more so than mediums or lows, the dial pattern of highs and mediums was essentially similar for each of the items and was different from that of lows. The different patterns of dial ratings across the items underscored that hypnotic items tap particular dimensions of hypnotic responding, and these dimensions involve different aspects of experiential engagement as well as different behavioral responses. Our findings suggested that these items do not differ simply in terms of difficulty, but rather in a more complex amalgam of demands that are placed on and experienced by the hypnotized person. In terms of the pattern of ratings across the phases of the hypnotic items, our findings

indicated that the experience of subjects changed across the phases and that these changes were different for different types of subjects and for different types of items. Whereas during cancellation of arm rigidity, both high and medium hypnotizable subjects showed a decreasing strength of experience, during cancellation of anosmia, highs showed an increasing strength and mediums showed a decreasing strength of experience. It seems that for highs, their positive experience during the test of anosmia enhanced and encouraged the intensity of their experiential involvement and this intensity was not diminished by the explicit instruction from the hypnotist to cancel their experience. In this respect, it was striking that the pattern of dial ratings indicated that across the items the offset of the experience progressed relatively slowly and in a way that was very different from the pattern that characterized the onset of the experience. In summary, our work on tracking experience, which used a number of hypnotic test items, highlighted the sometimes inconsistent relationship between behavior and experience in hypnosis, the importance of considering the onset and offset phases of hypnotic suggestion as well as the test phase, and the sometimes convergent and sometimes divergent findings across different measures of experience. Notably, the methodological and quantitative focus of this experimental work is consistent with the overall methodological emphasis of Australian psychology (O’Neil, 1987; Sheehan, 1989), and it is distinctive that the only work in North America along the same lines of developing a methodology to track experience was undertaken by Fred Evans (Evans and Orne, 1965) who was trained at the University of Sydney. As Kihlstrom (1999) pointed out, the Australian approach to hypnosis research has often been to develop particular techniques of inquiry or measurement that advance the field, while the rest of the world has been arguing over ‘theoretical’ issues. Moreover, the work on tracking experience underscores how the point at which we measure a phenomenon or process can substantially influence how we think about it. This has relevance not only in the field of hypnosis but in other fields of psychology as well.

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3.2.3.3. Testing the limits of hypnotic experience One way in which to test the nature and limits of the hypnotic experience is to seek to alter something that is highly personalized and held with conviction. Because of its personal significance, and following the work of Sutcliffe (1961), Noble and McConkey (1995) suggested a change of sex to hypnotic subjects. In the experiment, we used the real–simulating paradigm of Orne (1959). This paradigm involves high hypnotizable subjects who are tested normally and low hypnotizable subjects who are instructed to fake hypnosis; the hypnotist is unaware of who is faking and who is not. The simulation condition is a quasi-control one that allows inferences to be drawn about the extent to which the responses of the high hypnotizable, real subjects may be based in the nexus of cues operating in the experimental setting rather than in the subjective experience of hypnosis (see also Cox and Bryant, Chapter 12, this volume). The uses of the simulating paradigm and the inferences that can be drawn from it have distinctive links to the Australian approach to hypnosis research. For instance, although the paradigm was introduced by Orne (1959), Sheehan (1971; Sheehan and Perry, 1976) has done more than perhaps any other researcher in the field to explicate the inferences that can and cannot be drawn from its use, and to point to the ways in which its use sometimes helps and sometimes does not help us to understand particular hypnotic phenomena. The real– simulating paradigm is a very demanding one in terms of its practical application in the laboratory (requiring multiple, blind experimenters) and is a very demanding one in terms of its outcomes (most studies do not find strong differences between real and simulating subjects). Thus, those researchers who use it must have a particularly masochistic streak; notably, the paradigm has been used mostly by researchers in Australia or with close links to Australia. Noble and McConkey (1995) used excellent hypnotic subjects (labeled hypnotic virtuosos by Ernest Hilgard) and high hypnotizable subjects as reals, and low hypnotizable subjects as simulators. We found that a compelling hypnotic experience could be established among

virtuoso subjects in particular. In addition, we challenged subjects’ experiences of hypnotic sex change through procedures of contradiction in which a hypothetical authority figure questioned their experience, and confrontation in which they looked at an image of themselves on a video monitor. The experimental technique of creating an experience and then seeking to contradict or challenge that experience occurs consistently in Australian hypnosis research. This technique can be traced intellectually to the views of O’Neil (1987) and Hammer (1961), in particular, about one way in which to test the nature and boundaries of psychological phenomena. We found that virtuosos were more likely to change their names to one consistent with the suggested sex and to give higher ratings of the reality of the sex change experience. Most notably, virtuosos were more likely than highs or simulators to maintain their response when challenged. In particular, these excellent hypnotic subjects appeared willing and able to reinterpret conflicting information in a way that confirmed their suggested experience, and this is consistent with other work on hypnotic blindness (e.g. Bryant and McConkey, 1989; see also Cox and Bryant, Chapter 12, this volume). In a similar vein, Burn et al. (2001) used hypnotic sex change to explore information processing in hypnotic experience. We were interested in the degree to which subjects selectively interpret information that is consistent with their hypnotic experience. We used hypnotic virtuoso and high hypnotizable individuals as reals, and low hypnotizable subjects as simulators. We gave subjects a hypnotic suggestion for sex change and, during that experience, we asked them to listen to a structured story that involved a male and female character; following hypnosis, we asked subjects to recall the story. We found that a similar number of virtuoso, high hypnotizable and simulating subjects responded to the sex change suggestion; they were equally likely to change their names and to give similar ratings of the reality of the suggested sex and the experience of their actual identity. Our focus, however, was on the responses to the story. After listening to the story involving the male and female character, virtuosos were less likely to identify with the character that was consistent with their suggested sex.

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Interestingly, however, when asked to recall the story after hypnosis, the virtuosos recalled more information about the character that was consistent with their suggested sex than did the highs or the simulators. In other words, virtuosos were less likely to identify with the character consistent with their suggested sex, but they recalled significantly more information relevant to that character. Thus, selectivity in information processing seemed to occur during the encoding stage, and character identification alone was not the major factor that influenced the enhanced recall of virtuosos (see also Cox and Bryant, Chapter 12, this volume). These findings suggest that the processing of information by hypnotic virtuosos involved dimensions other than character identification (see McConkey et al., 2001). In particular, they interpreted certain aspects of the information as more significant to their internal belief. This suggested that different cognitive processes were operating during the development and maintenance of the delusory experience in hypnotic virtuoso subjects. One explanation for these findings is that virtuosos experienced greater ego-involvement in the suggestion than did highs and simulators. Consequently, while listening to the story during the sex change experience, they related to themselves, or self-referenced, the information about the character consistent with their suggested sex, rather than related it to the actual (male or female) character. Indeed, comments by virtuosos indicated that they perceived certain information as self-referential and highly significant in the context of their ongoing sex change experience. In summary, our work on hypnotic experience underscored the resistance to challenge of hypnotic phenomena among virtuosos, the processing and reinterpretation of information to support hypnotic phenomena and the role of links to the self in establishing and maintaining hypnotic phenomena. In drawing the link of this work to people and place, let me leave to one side the frivolous part of the comment by Kihlstrom (1999) that ‘only in Australia’ would the focus of a hypnosis experiment be on a suggestion for sex change. Let me agree, however, that the nature of the societal influences in North America probably mean that it would be very unlikely for researchers there to pick up

this paradigm; certainly, a number of North American colleagues have said to me that they could ‘never do’ that type of research in their laboratories. The influence of place on the type of phenomena that can be investigated in psychology generally and in hypnosis specifically has not been considered in any detail in terms of the impact that it has on our understanding of those phenomena. Moreover, the work on sex change not only gives us insight into the nature of hypnosis, but also offers a way to investigate delusion in the laboratory setting, especially since the transient characteristics of our ‘sexchanged’ subjects were similar in many ways to the counterfactual beliefs that one sees in clinically deluded individuals (for more on hypnotic delusions, see Cox and Bryant, Chapter 12, this volume).

3.2.3.4. Testing the limits of post-hypnotic experience Another way to test the nature and limits of hypnosis is through post-hypnotic suggestion. Post-hypnotic suggestion involves instructing a hypnotized person to show certain behavior or have certain experiences after hypnosis. Post-hypnotic behavior is characterized by an apparent lack of awareness of the reason for the response and a reported experience of compulsion to respond (Orne et al., 1968; Sheehan and Orne, 1968; Kihlstrom, 1985). Explanation of this phenomenon has been clouded by scientific neglect and by amazing anecdotes. Historical reports, for instance, tell us of a woman seeing the suggested image of her absent husband for 24 h, a woman seeing the tail of her cat as black rather than spotted for 3 days, and a man seeing a suggested portrait on a visiting card for more than 2 years (for other wonderful historical anecdotes, see Laurence and Perry, 1988; Gauld, 1992). Barnier and McConkey (1998) focused on post-hypnotic responding away from the experimental setting and the people associated with that setting. We conducted two experiments to investigate the limits of post-hypnotic suggestion. In the first experiment, we gave high hypnotizable individuals a post-hypnotic suggestion or made a social request to mail one postcard every day to the experimenter; the post-hypnotic suggestion either did or did not specify how long this should continue. We gave

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the subjects 120 postcards and we contacted them 16 weeks after the hypnosis session and asked them to return for an interview. We measured how many postcards each person returned overall and the number of cards they returned each week. Our findings indicated that those who were given the social request returned a greater percentage of postcards and responded more consistently than those who were given the post-hypnotic suggestion. There were, however, differences in the experiences reported by individuals given the post-hypnotic suggestion and those given the social request. Most notably, those given the suggestion were more likely to report feeling a sense of compulsion and to characterize their responding as requiring little effort. For instance, some said that the suggestion to mail the postcards had been implanted in their ‘subconscious’, which caused them to send a postcard every day. In contrast, social request subjects generally attributed their responding to a ‘contractual’ arrangement between themselves and the hypnotist; they were more likely to characterize their responding as planned and effortful. In a second experiment we conducted a replication and extension of the first. We gave real, hypnotized subjects and simulating, unhypnotized subjects a post-hypnotic suggestion to mail one postcard every day to the experimenter; also, we gave nonhypnotic, control subjects a social request to perform the same task. The post-hypnotic suggestion or request either did or did not specify how long this should continue. We gave each person 100 postcards and we contacted them 8 weeks after the session and asked them to return for an interview. Again, we measured how many postcards each person returned overall and the number of cards they returned each week; we were also interested in the number of cards returned each week by those given the specified duration and unspecified duration suggestion/ request. Our findings indicated that real, hypnotized and control subjects returned a higher percentage of postcards than did simulators. Also, those who were given the suggestion or request of specified duration returned a higher percentage than those who were given the unspecified duration version.

Approximately half of the subjects reported that they had a routine for sending the postcards and that they used strategies to help them remember. For example, although some participants experienced an ‘automatic trigger’ to send the postcards, others had a set daily routine and used strategies such as writing in their diary or placing the postcard in a particular spot to help them recall. For many subjects, family and friends played an important role, whether positive or negative, in their responding. Some of them reported that they were encouraged and assisted, whereas others were ridiculed for responding or were actively discouraged from responding. Moreover, although control subjects responded for as long as hypnotized subjects, the two groups reported quite different experiences. Real, hypnotized subjects were more likely to attribute their responding to a sense of compulsion, whereas control subjects said they responded because they had agreed to do so and they wanted to meet that agreement. Few simulators responded; they said that they either saw no reason to do so or that they simply forgot. Our findings underscored that although a social request was as effective behaviorally as a post-hypnotic suggestion in eliciting the desired response, the experience underlying that response was quite different. The people who were given the social request typically interpreted the task in terms of a contract between themselves and the hypnotist-experimenter. In contrast, those who were given the post-hypnotic suggestion interpreted the hypnotist’s message in more varied and idiosyncratic ways, and they typically reported a compulsive quality to their experience and response. Thus, it could be said that a post-hypnotic suggestion operates at the level of experience rather than behavior. Whereas the behavioral reaction to a post-hypnotic suggestion may be no different in an objective sense from that associated with a social response, the subjective experience is quite different. Moreover, the subjects who responded most to the posthypnotic suggestion outside the laboratory were those who placed their own personal meaning on the task and who found a substitute for the hypnotist, as it were, in their families, friends or even themselves. These subjects constructed a social setting and engaged in interpersonal

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interactions that helped them maintain their suggested experience and behavior. Accordingly, post-hypnotic responding outside the suggestion setting might best be represented in terms of the extent to which individuals enmesh the suggested task within their own social interactions and personal commitments. In summary, our work on post-hypnotic experience highlighted the behavioral similarity and experiential dissimilarity of responding to a social request and a hypnotic suggestion, the sense of compulsion associated with some but not all post-hypnotic responding and the role of social interactions and influences in enhancing or inhibiting response to a post-hypnotic suggestion away from the hypnotic setting. In reflecting on the relevance of people and place to this research, let me make two points. First, in most of the research in the field of hypnosis stemming from North America and Europe—and very little comes from Asia or elsewhere—there have been virtually no attempts to understand hypnotic phenomena in the context of the everyday life experiences of subjects. In other words, many researchers have set up their experiments as if they were dealing with a distinctive, if not unique, phenomenon that is isolated from other events in the life of subjects. Thus, it is perhaps not surprising that those researchers then tend to argue for the disconnection of hypnotic experience from everyday life. Secondly, although there have been some attempts to do ‘post-hypnotic postcard’ research in North America, they have been limited and are unpublished. It may be that the nature and expectations of research participants in North American laboratories would not allow this type of research to be conducted meaningfully. I am not saying that our Australian subjects were acquiescent in going along with the research task, but I am saying that the Australian culture perhaps encourages or allows a more engaged involvement than do some other cultures in which the focus is more on individual rather than collective good. Setting aside the inferences about the nature of hypnosis that one can draw from this research, it carries important messages about the power of a simple social request given in a particular social context, something that Orne (1962) highlighted long ago. The relevance of the social interaction between experimenter

and subject and the construction of social support for particular actions can be seen in the behavior of these subjects.

3.3. Generations, landscapes

and new questions The lesson from this brief review of a small portion of history and of selected hypnosis research from Australia is that knowledge, attitudes and skills in a field are transmitted directly and indirectly, not only via its literature, but also via the generations of researchers that come and go. People involve themselves in the field, they leave the field and they leave the world. They influence both the questions that are asked and the methods used to answer them. We can see also that there is always an identifiable landscape of the field that can substantially influence—indeed allow or disallow—the research questions that are asked, the way in which questions are investigated and the way in which findings are interpreted.

3.3.1. Landscapes of the field of hypnosis Various features can be identified that have defined the landscape of the field in significant ways at various points in time. The single most important feature in the second half of the twentieth century was the standardized measurement of hypnotizability (for a detailed discussion, see Barnier and McConkey, 2004; see also Woody and Barnier, Chapter 10, this volume). This has been the critically defining feature for the field for almost 50 years, especially the scales developed by André Weitzenhoffer and Ernest Hilgard at Stanford University (e.g. Weitzenhoffer and Hilgard, 1959, 1962; Hilgard, 1965a). This feature allowed the conduct of scientific research in both experimental and clinical settings by many researchers in many countries on many questions. Although they have served us well, it is time to improve this aspect of the landscape. This is a view that Woody et al. (2005) have explored and argued recently (see also Woody, 1997; Woody and Barnier, Chapter 10, this volume). In essence, we need to update and improve the measurement of hypnotizability, which will help to maintain

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individual differences in hypnotic ability as a distinctive and defining feature of the landscape of the field (see also Laurence et al., Chapter 9, this volume). There are at least two other ways to think of landscapes: the landscape of psychology broadly, and the landscape of the general community. The scientific and professional landscape of psychology will influence where hypnosis is located in the reputational order, and the concerns of the general community will shape how psychology and hypnosis are seen and considered. For instance, the understandings and misunderstandings surrounding the nature of human memory have been a dominant feature of psychology throughout its undulating history (e.g. Bartlett, 1932; Lynn and McConkey, 1998; McNally, 2003), as well as being of interest to the general community. The many aspects of this feature have not only shaped a significant part of the work of psychological scientists, but have also influenced the field of hypnosis directly and indirectly. The obsession with hypnosis and memory during the 1980s and 1990s in particular was both a help and a hindrance to our field. It was a help in that it generated a substantial number of important findings, it forced many of us to engage with broader questions in psychology and in the general community, and it exposed many of our scientific and professional methods and findings to other—sometimes unfamiliar and uncomfortable—processes, such as crossexamination in the court of law and close scrutiny in the court of media opinion. It was a hindrance in that hypnosis found itself taking the blame, as it were, for things that were part of the normal vagaries of memory— rather than specific problems of hypnosis—and it either led to or exacerbated too many personal and political conflicts within our field. Moreover, we will never really know the opportunity cost of so many of us becoming obsessively involved in conducting research on hypnosis and memory. Research on hypnosis and memory continues of course, but we need to be more cautious in the future about getting caught up in transient obsessions that are really an aspect of the landscape of psychology broadly and the general community.

Our field of hypnosis lies not only within disciplines such as psychology, but also within the general community and culture. That general community and culture can exercise substantial influence on how we think about research questions in the field, on whether we can engage public interest when we investigate those questions and on how our answers to those questions are received. Also, how we interact with that general community can influence how people think generally about hypnosis, and whether the members of the public want hypnosis to be part of the clinical procedures that they are offered. As with the other landscapes, one can point to various issues or features that have significantly defined the landscape of the general community and culture over time, and one can point to how those issues or features have influenced the field of hypnosis. Sex is a defining feature of the broader community and culture, and an ascribed association between hypnosis and sex has been around for a long time. Indeed, over 220 years ago the Commission established by Louis XVI and presided over by Benjamin Franklin not only presented a report that provided an immaculate conception for the scientific analysis of hypnosis (see McConkey and Perry, 1985, 2002; Perry and McConkey, 2002), but also a subset of its members presented a secret report that focused on the moral dangers associated with animal magnetism. This secret report noted that it is always men who magnetized women, that this typically involved touching the neighborhood of the most tender parts of the woman’s body and that ‘in lively and sensitive women … the end of the sweetest of emotions, is often a sort of convulsion’. The report noted that a scoundrel could easily exploit such a situation, and that even the most moral of magnetizers may find that he is unable to resist the temptations that are presented by the magnetized woman (see also Sheehan and Perry, 1976; Gauld, 1992; Pattie, 1994). There is a long-standing view about hypnosis and sex that exists in the general community, and we as a field seem to have done very little to deal with this and other potentially negative and harmful views in terms of research or education. Similar comments can be made about so-called ‘stage hypnosis’ in live theatres and on television.

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Crawford et al. (1992), for instance, reported that although most participants in a stage hypnosis show described their experience as benign, others described it in negative terms, as confusing, annoying and frightening. We need to reach out more directly to the general community. For whatever reason—perhaps we think that our research is not strong enough in these areas, or perhaps we think that these are irritating but essentially harmless matters that are not worth worrying about—as a field we seem to turn our eyes away from aspects of the general community and culture’s view about hypnosis. My point is that we should engage more obviously and directly with the landscape of the general community, and we should advance more obviously the positive and sanitize the negative influences and views about hypnosis. We need public intellectualism to be more apparent in our field. The article by Michael Nash (2001) that appeared in Scientific American is a nice example of what is needed. Although this type of public engagement is difficult and can be frustrating, it is essential that it be a more obvious part of the twenty-first-century activity in our field.

3.3.2. Asking old questions in new

ways: three generations of questions I have argued that generations of people and landscapes of the field have combined to determine the questions that have been asked about hypnosis in the past. Woody and McConkey (2003) pointed out that as the field of hypnosis matures, people in the field need to identify new generations of research questions more explicitly. We can see this type of maturing in other fields in the discipline of psychology, and we need to be more intentional about this maturing in our own field. For instance, in a discussion of social-psychological research on the attitude– behavior relationship, Zanna and Fazio (1982) long ago identified three generations of research questions. A first-generation question in this area was whether attitudes and behaviors are related. This question led to the secondgeneration question of when, and under what conditions, they are related. Finally, this question led to the third-generation question of what processes determine and influence the relationship between attitude and behavior.

As a field matures, the nature of questions that lead the field must also change. The new questions not only need to embed and reframe previous questions, but also they need to go beyond them. So what types of questions is our field asking now, and what types should it be asking as it moves to new generations and landscapes?

3.4. Hypnosis in the twenty-

first century In evaluating the field of hypnosis in this first decade of the twenty-first century, there is burgeoning interest and many opportunities, but there are also challenges to be faced. The level of interest and opportunities for hypnosis from outside the field has been steadily increasing in recent years after a period of relative decline and disinterest. For instance, cognitive psychologists and neuroscientists have increasingly looked to hypnosis researchers and hypnotic techniques to assist in asking and answering questions about problems of consciousness, perception and action (see Cox and Bryant, Chapter 12; Barabasz and Barabasz, Chapter 13; Oakley Chapter 14, this volume). This is a nice example of the availability of new methods allowing us the opportunity to answer old questions in new ways and to ask questions that we have not thought of before. In doing so, however, there is a need to be careful about integrating this work with existing work, and a need to ensure that we add more sophisticated and better integrated levels of explanation (Barnier and McConkey, 2003). There are at least three challenges to be addressed in moving the field forward. The first is that some hypnosis research still focuses on rather sterile and unproductive first-generation questions such as: ‘Is there a special state of hypnosis?’‘What is the nature of the trait that makes some people high in hypnotic ability and other people low?’, ‘Are hypnotic subjects just faking or lying?’. For instance, although all thoughtful theorists would agree that hypnotic behavior is not simply faking, Kossyln et al. (2000) framed their otherwise path-breaking neuroimaging study of positive and negative color hallucinations with the question of whether hypnosis ‘is a distinct psychological state … that allows one …

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to marshal one’s resources in unusual ways’ or whether it is ‘acting, … simply a role that people can adopt’ (p. 1279). Despite concluding from their results that ‘hypnosis is not simply role enactment’, framing the work in this way shows that first-generation questions (real or faking) can haunt the field of hypnosis long after most thought the theoretical battle was over (Woody and McConkey, 2003). We need to move to more mature questions, and we need to do this in ways that are convincing both inside and outside the field of hypnosis. Another challenge is that in designing hypnosis research, some investigators cling to ‘old ways’ of theory testing, which makes it difficult to advance our understanding of hypnosis or to connect to new areas outside the field. Predictions about hypnotic behavior and experience are still sometimes couched in terms of longstanding and outmoded ways of conceptualizing certain issues, where a favored theory is compared against a straw-man (for related discussion of this approach to theory testing, see Kihlstrom, Chapter 2; Laurence et al., Chapter 9, this volume). A better way is to attempt a more nuanced comparison of competing theories of specific underlying processes. The goal of this new generation of hypnosis research would be to examine simultaneously two or more theoretical perspectives that suggest underlying processes for particular hypnotic phenomena under particular conditions. This is difficult to do, but it is at the heart of the interactionist approach (Sheehan and McConkey, 1982), and the third way in hypnosis research described by Kihlstrom (Chapter 2, this volume). Yet another challenge is that sometimes in the field of hypnosis, questions and methods fall out of alignment. Even though there is an essential view that theory and methods should be strongly linked (Sheehan and Perry, 1976), researchers sometimes use methods and measures that are inconsistent with their theoretical approach or insufficient for their theoretical inferences (e.g. drawing inferences about the cognitive abilities of highs when you only screen them for testing on simple, ideomotor items). Alternatively, researchers sometimes use novel methods and measures (e.g. neuroscience techniques) simply because they can, even though

the methods and measures are disconnected from behavioral and experiential data, absent of appropriate selection procedures and without a clear idea of the underlying processes involved (for a detailed analysis, see Barnier and McConkey, 2003; for a review of current research and practice in this area, see Barabasz and Barabasz, Chapter 13; Oakley, Chapter 14, this volume). And finally, researchers often fail to apply multiple sets of procedures to collect data that will allow convergence and strong inferences. As Sheehan and Perry (1976) noted, the nature of a problem must ultimately dictate the methods the experimenter should adopt, but there is definite value in the application of multiple sets of procedures when the problem facilitates such an approach—and most investigators ignore this fact (p. 247).

Relatedly, they also noted that the multiple application of specific paradigms to the same issue is instructive … it illustrates the potential advantages of convergent inquiry by pointing in illustrative fashion to the kinds of artifact that are necessarily eliminated by such a strategy (p. 248).

Sheehan and Perry (1976) argued strongly and correctly that the use of ‘multiple operationism’ in which different sets of methods are used to test a notion will lead to stronger inference as a hypothesis survives the confrontation of different methods of testing. We have lost this rigor from aspects of contemporary hypnosis investigation, and we need to regain it if the field is going to maintain an appropriate level of scientific standing. Again, as Sheehan and Perry (1976) noted, the proponents of the [hypnosis] models argue distinctively for the legitimacy of their procedural applications and their own accounts of hypnotic phenomena. …. one decided advantage of this …. is that the domain of hypnotic study can be widened considerably as research reveals new and interesting data which raise further issues to be explored. But one disadvantage in pursuing separateness of approach is that procedural differences become too formally demarcated and theory tends to polarize around particular viewpoints and

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strategies of research. Penetrating analysis of phenomena is put at some risk when inquiry focuses only on a limited number of ways in which inferences about data can be checked (p. 254).

Interestingly, as noted above, Kihlstrom (1999) pointed out that the Australian approach to hypnosis research has been almost the reverse: to develop particular techniques of inquiry or measurement that advance the field while the rest of the world has been arguing over ‘theoretical’ issues. Arguing over theory is not bad, of course, but only arguing over theory does not advance the field very much.

3.5. Toward a new generation

of questions and methods As we move toward a new generation of questions and methods, there are two areas in particular that demand continued, but innovative, exploration: hypnosis as a state; and the nature of individual differences.

3.5.1. The state of hypnosis An enduring theme for hypnosis researchers and practitioners has been whether there exists a special, unique state of hypnosis. The idea that we should be looking for some unequivocal indicator of a special or altered state in hypnosis dies hard. Ernest Hilgard sometimes commented that it is a shame that there is not a light on people’s foreheads that comes on to indicate when they are hypnotized. The advent of brain imaging technology seems to offer vastly expanded terrain in which to search for this indicator light—namely, somewhere inside the skull. However, such a search may be an inappropriate perseveration of a first-generation question. Rather, the field needs to replace the search for a static signature of the hypnotic state with a more sophisticated version of the question—in other words, the field needs to stop simply asking is hypnosis a special state or is it not. As Woody and McConkey (2003) suggested, the field needs to adopt the dynamic systems concept of a state, which is a concept that is often used by physicists and other natural scientists. From this perspective, the term ‘system’ denotes the set of related or interacting variables

that characterizes a hypnotized person. Thus, rather than simply continuing to look for a unique signature of the hypnotic state, Woody and McConkey (2003) argued that the field needs to turn to later-generation questions such as: What diversity of states occurs within hypnosis? How can we characterize them in a multivariate way? What are the important patterns of change in these states over time? It is the neural underpinnings of these dynamic states that will be of interest, rather than the discovery of the ‘indicator light’ inside the head (for more on the neural underpinnings of these states, see Barabasz and Barabasz, Chapter 13; Oakley, Chapter 14, this volume). In other words, we should study the variety of continuous states that occur within hypnosis, characterizing the dimensions of the state space in a multivariate way and examining the pattern of change in these states across time (see also Laurence et al., Chapter 9, this volume). This position is consistent with the interactionist theory that I and others have argued in the seemingly endless debate about whether hypnosis is mostly a cognitive or a social phenomenon (see also Kihlstrom, Chapter 2, this volume). Some investigators have argued that hypnosis reflects specific and special cognitive processes and that the focus must be on these processes if we are to understand hypnosis (e.g. Shor, 1959, 1962, 1979; Hilgard, 1973a, 1979). Others have denied the importance of such cognitive processes and have argued that hypnosis can be best understood on the basis of conventional social influence processes (e.g. Spanos and Barber, 1974; Spanos, 1986). On the surface, it would seem difficult to have it both ways. But this isn’t so. The interactionist position considers that hypnosis involves genuine, subjectively compelling alterations in conscious awareness, and that hypnosis is shaped powerfully by the social context in which the hypnotic encounter occurs. From the interactionist perspective, the key issue is to determine and to explain the conditions under which either cognitive or social processes are more influential in determining the experience and behavior of the hypnotized individual. The interactionist position is not new of course. White’s (1937, 1940) views about hypnosis were essentially interactionist, and before him

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William James’s (1890) views at the end of the nineteenth century were also essentially interactionist. As Kihlstrom and McConkey (1990) pointed out, behavior inside the context of hypnosis (as well as outside that context) is ultimately the outcome of a reciprocal interaction between internal personal factors and external environmental influences. One major value of the techniques and technologies of neuroscience will be that they can provide another measure of this interaction (Barabasz and Barabasz, Chapter 13; Oakley, Chapter 14, this volume). Their informed use will allow us to investigate a new generation of questions about the hypnotic state; of course, we must avoid their uninformed use, which will simply lead to a new phrenology (e.g. see Friston, 2002; Grodzinsky, 2002).

3.5.2. Individual differences Individual differences exist in the ability of people to experience hypnosis, and it is essential that we understand the basis of those individual differences. Woody and McConkey (2003; see also Woody et al., 2005b; Laurence et al., Chapter 9; Woody and Barnier, Chapter 10, this volume) noted that when thinking about hypnotic responding, we need to adopt a componential approach. This approach considers that different hypnotic responses require different components of underlying abilities, and that for a particular type of response, one or more components may be necessary. However, it is also possible that various alternative combinations of components may be sufficient for the production of the response, thus providing more than one way to produce it. Given that individuals differ in their profile of abilities to enact various specific underlying components, it may be the case that individuals who lack a necessary component cannot produce that response. However, people with different profiles of abilities may possibly produce the same response in different ways. This argument has been tacit in a substantial amount of previous work, but there has been no coherent approach to its investigation. For that to occur, the field needs new methods and models, and some of these have been provided by McConkey, Woody and Barnier (e.g. McConkey and Woody, 2003;

Barnier and McConkey, 2004; McConkey and Barnier, 2004; Woody et al., 2005b; Woody and Barnier, Chapter 10, this volume).

3.5.3. Hypnotic state and individual

differences: emergent properties Woody and McConkey (2003) argued that hypnosis may have emergent properties, and that there may be changes in consciousness during hypnosis (e.g. loss of agency, archaic involvement) that are preconditions for some kinds of hypnotic performance. Related to the notion that component processes can intersect and shape the emergence of hypnotic performance (Woody and Barnier, Chapter 10, this volume), it is important to ask whether some experiences in hypnosis have emergent properties, or properties that are essential to some kinds of hypnotic behavior? To illustrate the possibility of emergent properties of hypnotic and nonhypnotic components, Woody and McConkey (2003) offered a schematic componential diagram; see Figure 3.1. The squares represent components that are more or less unique or special to hypnosis, whereas the circles represent components that may be involved in some hypnotic responses, but are not unique to it. Thus, the large triangle roughly indicates the domain of components of special relevance to hypnosis (see also Kihlstrom, Chapter 2, this volume). The various groupings of squares and circles indicated by dotted lines show sets of components that may be activated by different hypnotic suggestions. These groupings lead to a number of interesting implications. First, different suggestions may call on somewhat overlapping, but also somewhat different, sets of components. Second, there may be a core underlying component, or components, that all hypnotic suggestions call on; in other words, across different types of suggestions and hypnotic effects, there may be some necessary common component(s). Notably, one possible candidate for this would be the capacity to alter one’s sense of agency (‘the classic suggestion effect’; for varying accounts of this, see Woody and Sadler, Chapter 4; Lynn et al., Chapter 5; Barnier et al., Chapter 6, this volume; for an analysis of the relationship between suggestibility,

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Figure 3.1 A schematic componential diagram of hypnotic and nonhypnotic components. From Woody and McConkey (2003, p. 317). Reproduced with permission of the International Journal of Clinical and Experimental Hypnosis.

hypnotic and nonhypnotic, see Tasso and Perez, Chapter 11, this volume). Third, two or more different sets of components may be sufficient to produce a particular hypnotic response, and thus represent alternative ways to respond to particular hypnotic suggestions. In other words, different people (or the same person on two different occasions) may be able to respond to an item via different underlying processes; indeed, this was evident in much of the work of Sheehan and McConkey (1982). Despite this array of interesting possibilities, to date there has not been a coherent approach to organizing and investigating the issues. As Woody and McConkey (2003) pointed out, the field needs to develop new approaches, conceptual and methodological, to examine new generation

questions, such as: What sets of component abilities are related to which classes of hypnotic behavior? How do these components combine (e.g. necessary versus sufficient sets of conditions)? How are they organized (see also Woody et al., 1992)? Is there a core, common underlying component, or components? If so, is it unique to hypnosis, or shared with some nonhypnotic phenomena? Are there multiple pathways to the same hypnotic response, enacted by different subjects, or even by the same subject on different occasions? How should we distinguish and measure these multiple pathways given the current state of our tools and techniques? As Woody and McConkey (2003) argued, using neuroscience as an example, decomposing hypnotic behavior into its underlying

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psychological components is absolutely essential for building a bridge between behavioral function and underlying brain activity. It is also essential to find appropriate equivalence classes— that is, groups of participants who are responding in the same basic way—for neuroimaging studies, which usually require averaging across multiple participants for sufficient power (for similar comments, see Barabasz and Barabasz, Chapter 13; Oakley, Chapter 14, this volume).

3.5.4. New generation methods This component and emergent view is also important for our methods. If we suspect componential and emergent qualities, then we need measures of hypnotic susceptibility that make componential distinctions, especially among those who are highly hypnotizable (see Woody and Barnier, Chapter 10, this volume). If high hypnotizable subjects are the most interesting to us, then differences among these highs are also fascinating (see Laurence et al., Chapter 9, this volume). We need the methods to do justice to their complexity as hypnotized, and sentient, individuals. To illustrate, consider that the psychometric tradition tells us where we can reasonably expect homogeneity or equivalence: once we have added up the number of suggestions each subject passed, we assume that one person scoring 9 is basically the same as another person scoring 9; i.e. there are not different kinds of 9s. However, most hypnosis researchers do not hold this assumption. First, they sometimes discuss the standardized scales in ways that clearly suggest a componential conceptualization. Second, in addition to pre-testing on general hypnotic susceptibility, researchers often also pre-test on the specific ability of interest in the particular study, whether that is the capacity for amnesia, hallucinations, or whatever. To progress beyond the general fact of individual differences in hypnotic responsiveness, we need to turn to later-generation questions that emerge from a componential perspective. Woody et al. (2005; see also Woody and Barnier, Chapter 10, this volume) recently tried to move the field in this direction by applying full-information factor analysis, which is a sophisticated analytical approach for dichotomous items, to a large data set that we drew from

using the Harvard Group Scale of Hypnotic Susceptibility, Form A (Shor and Orne, 1962) and the Stanford Hypnotic Susceptibility Scale, Form C (Weitzenhoffer and Hilgard, 1962) over many years. Our analysis yielded the four subscales of direct motor, motor challenge, perceptual-cognitive and post-hypnotic amnesia responding, and we argued that these subscales point to the building blocks of hypnotic response. To test this argument, we used these subscales as simultaneous predictors of hypnotic responses across four experiments in order to distinguish the contribution of each specific component from general hypnotizability. This led us to argue that the four different components may arise because the subjective phenomena that underlie them are qualitatively distinct. For example, in hypnotic responses of the perceptual-cognitive type, the crucial subjective experience appears to be one of a feeling of external reality in the face of an inconsistent actual reality; a hallucination is the prototype of this kind of experience. In contrast, the crucial subjective experience in hypnotic responses of the motor challenge type appears to be a feeling of involuntariness or ineffectiveness of one’s will; trying to do something but failing is the prototype of this kind of experience. An individual experiencing a hallucination does not have the conviction of involuntariness, nor does an individual who tries to move but cannot move necessarily have the conviction of external reality (Woody et al., 2005).

3.5.5. What else do we need? A full understanding of hypnosis, whatever it turns out to be, needs to be integrated seamlessly into general psychological principles, and one yardstick of the next generation will be how much and how well the questions, methods and inferences in the field call on general psychological principles and evidence (whether in abnormal psychology, cognitive psychology, social psychology or neuroscience). Another important yardstick will be the degree to which the field moves away from static snapshots to an understanding that hypnotic processes and phenomena unfold across time, since this will bring together issues of individual differences and psychological process. Generally, the time

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course of hypnotic responding has not been built productively into hypnosis research (McConkey et al., 1999a; but see discussion of work by Ray and de Pascali on temporal aspects of hypnotic processes in Barabasz and Barabasz, Chapter 13, this volume). As Woody and McConkey (2003) noted, the relevance of time course links closely with a componential view of traits, in that the study of hypnotic phenomena as they unfold across time may illuminate how component abilities combine sequentially, or the different ways they are organized to produce behavior. Likewise, recall that earlier, in discussing the ‘hypnotic state’, we advocated studying the variety of continuous states that occur in hypnosis by examining their patterns of change across time. Finally, an essential yardstick of the next generation will be how much we can develop convergent understanding of the classic suggestion effect and volition. To do this, we need more subtle distinctions and language. Experiences of ‘nonvolitional’ responding are often confused with the vividness and reality of suggested effects by participants (and sometimes by researchers). Relatedly, a lack of cognitive effort, or ‘effortless experiencing’, is sometimes confused with, but is not necessarily the same thing as, a diminished capacity to exert will or control. As the next generation evolves, there are central questions about changes in sense of agency that include: whether the phenomenon of nonvolition is suggested or unsuggested, or manipulable through suggestions; whether changes in the sense of volition are always or necessarily in the direction of a reduced sense of agency; and whether the sense of involuntariness related to aspects of hypnotic behavior is a precursor of experiencing, a product of behavioral enactment or some sort of reciprocal, bi-directional event that unfolds over time. These are the sorts of questions that will energize a new generation of people and laboratories, and that will transform the field.

3.6. Concluding comments Laurence (1997) eloquently argued that ‘we should not be afraid to take a position and clearly state that any theory of hypnosis should be based on or substantiated by reliable

scientific evidence. To do so, however, we have to be willing to eliminate from our own theories concepts that have no reason to survive other than their traditional or historical link to hypnosis research’ (p. 287). A couple of years before these comments, Kirsch and Lynn (1995) in their important article in American Psychologist said ‘there are broad areas of agreement among all serious hypnosis researchers and theoreticians, as popular myths about hypnosis have been dispelled by research and clinical observation’ (p. 856). Kihlstrom (1997), however, commented ‘it would be a grave mistake for the community of hypnosis researchers to settle on one or another false consensus that obscures differences in approach and sweeps areas of conflict under the rug’ (p. 329). As Kihlstrom (1992) and others have argued, ‘a satisfactory theoretical account of hypnosis must invoke both social-psychological and cognitive-psychological constructs. Individual investigators may wish to focus their efforts in one direction or another, as their preferences dictate, but the ultimate goal must be a kind of synthesis out of which comprehensive understanding will emerge’ (p. 311). This kind of synthesis can be seen in the Australian approach to hypnosis research, where the hypnotized individual is seen as an active participant who employs appropriate cognitive strategies to resolve the multiple problems posed by the hypnotic setting (Sheehan and McConkey, 1982; McConkey, 1991). Hypnotized individuals develop a commitment to the phenomenal reality of their suggested experience, and they make attributions about their experiences during hypnosis that appear to protect the integrity of their hypnotic responses. So, to genuinely assist the field in this early part of the twenty-first century, what do we need to do? First, we need to continue to strive for rigorous scientific research in our field. If we do not champion scientific investigation and evidence-based clinical approaches, then there will be a quick backslide down the slope of nonsense inside and outside the field in terms of views, attitudes and uses of hypnosis. Let us not be seduced by the short-term attractions of trite theory and popular therapy. And let us not

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mistake the tyranny of the majority as leadership of the field. Coe’s (1992) provocative socio-political analysis of hypnosis was correct in the sense that some people have a need to hold onto and to promote the notion that hypnosis is something much more special than it is. Second, we need to move away from doing more of the same in terms of research, and we must try to do some things differently. We need transformational as well as incremental advances in knowledge. This is easier said than done, of course, but we are at a natural point in the evolution of generations and landscapes that provides an opportunity to transform our field in very positive and major ways. Third, we need to be more adventurous and collaborative in our hypnosis research for the sake of the relevant disciplines and professions as a whole. We need to reach outside the field for inspiration and perspiration, and we need to better ensure that the methods and findings of our field are appreciated and used in our broader disciplines and professions. Fourth, there is a special need in hypnosis with the passing of many of the Titans of the last 50 years of hypnosis research—and with the aging of their immediate successors—to think about how to stimulate, encourage and reward those who are earlier in their careers to engage further in hypnosis research. Ours is a tough field in which to work, and we have to make sure the rewards are worth it. In the traditions of the volumes that have come before (Shor and Fromm, 1972, 1979; Fromm and Nash, 1992), the chapters in this volume allow us to evaluate the field via the contributions of both established and emerging researchers as they consider the essence, the explanations and the evidence of hypnosis. As we read these contributions, consider the questions they ask and the answers they offer. They are all products of the generations and landscapes that came before, and they are all shaping those that will follow.

Acknowledgments I am grateful to Jacquelyn Cranney for a critical reading of this chapter, and to Amanda Barnier for her collaborations over many years and her thoughtful assistance and perseverance.

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McConkey, K. M. and Barnier, A. J. (2004) High hypnotisability: unity and diversity in behavior and experience. In M. Heap, R. J. Brown and D. A. Oakley (ed.) High Hypnotisability: Theoretical, Experimental, and Clinical Issues, pp. 61–84. Brunner-Routledge, London. McConkey, K. M. and Perry, C. (1985) Benjamin Franklin and mesmerism. International Journal of Clinical and Experimental Hypnosis, 33: 122–130. McConkey, K. M. and Perry, C. (2002) Benjamin Franklin and mesmerism revisited. International Journal of Clinical and Experimental Hypnosis, 50: 320–331. McConkey, K. M. and Sheehan, P. W. (1976) Contrasting interpersonal orientations in hypnosis: collaborative versus contractual modes of response. Journal of Abnormal Psychology, 85: 390–397. McConkey, K. M. and Sheehan, P. W. (1995) Hypnosis, Memory, and Behavior in Criminal Investigation. Guilford Press, New York. McConkey, K. M., Gladstone, G. L. and Barnier, A. J. (1999a) Experiencing and testing hypnotic anaesthesia. Contemporary Hypnosis, 16: 55–67. McConkey, K. M., Wende, V. and Barnier, A. J. (1999b) Measuring change in the subjective experience of hypnosis. International Journal of Clinical and Experimental Hypnosis, 47: 23–39. McConkey, K. M., Szeps, A. and Barnier, A. J. (2001) Indexing the experience of sex change in hypnosis and imagination. International Journal of Clinical and Experimental Hypnosis, 49: 123–138. McNally, R. J. (2003) Remembering Trauma. Harvard University Press, Cambridge, MA. Nadon, R. (1997) What this field needs is a good nomological network. International Journal of Clinical and Experimental Hypnosis, 45: 314–323. Nash, M. R. (2001) The truth and the hype of hypnosis. Scientific American, 285: 46–55. Nash, M. R. (2005) The importance of being earnest when crafting definitions: science and scientism are not the same thing. International Journal of Clinical and Experimental Hypnosis, 53: 265–280. Noble, J. and McConkey, K. M. (1995) Hypnotic sex change: creating and challenging a delusion in the laboratory. Journal of Abnormal Psychology, 104: 69–74. O’Neil, W. M. (1987) A Century of Psychology in Australia. Sydney University Press, Sydney. Orne, M. T. (1959) The nature of hypnosis: artifact and essence. Journal of Abnormal and Social Psychology, 58: 277–299. Orne, M. T. (1961) The potential uses of hypnosis in interrogation. In A. D. Biderman and H. Zimmer (ed.) The Manipulation of Human Behavior, pp. 169–215. Wiley and Sons, New York. Orne, M. T. (1962) On the social psychology of the psychological experiment: with particular reference to demand characteristics and their implications. American Psychologist, 17: 776–783. Orne, M. T. (1972a) Can a hypnotized subject be compelled to carry out otherwise unacceptable behavior? International Journal of Clinical and Experimental Hypnosis, 20: 101–117.

Orne, M. T. (1972b) On the simulating subject as a quasicontrol group in hypnosis research: what, why and how. In E. Fromm and R. E. Shor (ed.) Hypnosis: Research Developments and Perspectives, pp. 399–443. Aldine-Atherton, Chicago. Orne, M. T. (1979) The use and misuse of hypnosis in court. International Journal of Clinical and Experimental Hypnosis, 27: 311–341. Orne, M. T. and Evans, F. J. (1965) Social control in the psychological experiment: antisocial behavior and hypnosis. Journal of Personality and Social Psychology, 1: 189–200. Orne, M. T. and Hammer, A. G. (1974) Hypnosis. Encyclopaedia Britannica, pp. 133–140. William Benton, Chicago, IL. Orne, M. T. and McConkey, K. M. (1981) Images: imagined and believed. Journal of Mental Imagery, 4: 50–53. Orne, M. T., Sheehan, P. W. and Evans, F. J. (1968) Occurrence of posthypnotic behavior outside the experimental setting. Journal of Personality and Social Psychology, 9: 189–196. Orne, M. T., Dinges, D. F. and Orne, E. C. (1984) On the differential diagnosis of multiple personality in the forensic context. International Journal of Clinical and Experimental Hypnosis, 32: 118–169. Pattie, F. A. (1990) On the origin of the word hypnotism. American Journal of Clinical Hypnosis, 33: 137. Pattie, F. A. (1994) Mesmer and Animal Magnetism: A Chapter in the History of Medicine. Edmonston, Hamilton, NY. Peter, B. (2005) Gassner’s exorcism—not Mesmer’s magnetism—is the real predecessor of modern hypnosis. International Journal of Clinical and Experimental Hypnosis, 53: 1–12. Perky, C. W. (1910) An experimental study of imagination. American Journal of Psychology, 21: 422–452. Perry, C. (1979) Hypnotic coercion and compliance to it: a review of evidence presented in a legal case. International Journal of Clinical and Experimental Hypnosis, 27: 187–218. Perry, C. and McConkey, K. M. (2002) The Franklin Commission Report in light of past and present understandings of hypnosis. International Journal of Clinical and Experimental Hypnosis, 50: 387–396. Scheflin, A. W. and Shapiro, J. L. (1989) Trance on Trial. Guilford Press, New York. Sheehan, P. W. (1971) A methodological analysis of the simulating technique. International Journal of Clinical and Experimental Hypnosis, 19: 83–99. Sheehan, P. W. (1985) The study of imagery and hypnosis in Australia. In N. T. Feather (ed.) Australian Psychology: Review of Research, pp. 158–184. Allen and Unwin. Sydney, NSW. Sheehan, P. W. (1989) The nature of Australian psychology: from cross-cultural theorizing about the role of context in hypnosis. International Journal of Psychology, 24: 315–331. Sheehan, P. W. (1991) Hypnosis, context and commitment. In S. J. Lynn and J. W. Rhue (ed.) Theories of Hypnosis: Current Models and Perspectives, pp. 520–541. Guilford Press, New York.

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Sheehan, P. W. (1998) Contemporary trends in hypnosis research. In J. G. Adair, D. Belanger and K. L. Dion (ed.) Advances in Psychological Science, Vol 1: Social, Personal, and Cultural Aspects, pp. 111–136. Psychology Press, Hove, UK. Sheehan, P. W. and McConkey, K. M. (1982) Hypnosis and Experience: The Exploration of Phenomena and Experience. Erlbaum, Hillsdale, NJ. Sheehan, P. W. and Orne, M. T. (1968) Some comments on the nature of posthypnotic behavior. Journal of Nervous and Mental Disease, 146: 209–220. Sheehan, P. W. and Perry, C. W. (1976) Methodologies of Hypnosis: A Critical Appraisal of Contemporary Paradigms of Hypnosis. Erlbaum, Hillsdale, NJ. Shor, R. E. (1959) Hypnosis and the concept of the generalized reality orientation. American Journal of Psychotherapy, 13: 582–602. Shor, R. E. (1962) Three dimensions of hypnotic depth. International Journal of Clinical and Experimental Hypnosis, 10: 23–38. Shor, R. E. (1979) A phenomenological method for the measurement of variables important to an understanding of the nature of hypnosis. In E. Fromm and R. E. Shor (ed.) Hypnosis: Developments in Research and New Perspectives, 2nd edn., pp. 105–135. Aldine, New York. Shor, R. E. and Orne, E. C. (1962) Harvard Group Scale of Hypnotic Susceptibility, Form A. Consulting Psychologists Press, Palo Alto, CA. Spanos, N. P. (1986) Hypnotic behavior: a socialpsychological interpretation of amnesia, analgesia, and ‘trance logic’. Behavioral and Brain Sciences, 9: 449–502. Spanos, N. P. and Barber, T. X. (1974) Toward a convergence in hypnosis research. American Psychologist, 29: 500–511. Sutcliffe, J. P. (1960) ‘Credulous’ and ‘skeptical’ views of hypnotic phenomena: a review of certain evidence and methodology. International Journal of Clinical and Experimental Hypnosis, 8: 73–101. Sutcliffe, J. P. (1961) ‘Credulous’ and ‘skeptical’ views of hypnotic phenomena: experiments on esthesia, hallucination, and delusion. Journal of Abnormal and Social Psychology, 62: 189–200.

Sutcliffe, J. P. (1996) Ce que j’ai fait, et ce qui reste a faire. In C. R. Latimer and J. Michell (ed.) At Once Scientific and Philosophic: A Festschrift for John Philip Sutcliffe. Boombana Publications Brisbane, Queensland. Watkins, J. G. (1947) Antisocial compulsions induced under hypnotic trance. Journal of Abnormal and Social Psychology, 42: 256–259. Weitzenhoffer, A. M. (1997) Hypnotic susceptibility: a personal and historical note regarding the development and naming of the Stanford scales. International Journal of Clinical and Experimental Hypnosis, 45: 126–143. Weitzenhoffer, A. M. and Hilgard, E. R. (1959) Stanford Hypnotic Susceptibility Scale, Forms A and B. Consulting Psychologists Press, Palo Alto, CA. Weitzenhoffer, A. M. and Hilgard, E. R. (1962) Stanford Hypnotic Susceptibility Scale, Form C. Consulting Psychologists Press, Palo Alto, CA. White, R. W. (1937) Two types of hypnotic trance and their personality correlates. Journal of Psychology, 3: 279–289. White, R. W. (1941) A preface to the theory of hypnotism. Journal of Abnormal and Social Psychology, 36: 477–505. Woody, E. Z. (1997) Have the hypnotic susceptibility scales outlived their usefulness? International Journal of Clinical and Experimental Hypnosis, 45: 226–238. Woody, E. Z. and McConkey, K. M. (2003) What we don’t know about the brain and hypnosis, but need to: a view from the Buckhorn Inn. International Journal of Clinical and Experimental Hypnosis, 51: 309–338. Woody, E. Z., Bowers, K. S. and Oakman, J. M. (1992) A conceptual analysis of hypnotic responsiveness: experience, individual differences, and context. In E. Fromm and M. Nash (ed.) Contemporary Perspectives in Hypnosis Research, pp. 3–33. Guilford Press, New York. Woody, E. Z., Barnier, A. J. and McConkey, K. M. (2005) Multiple hypnotizabilities: differentiating the building blocks of hypnotic response. Psychological Assessment, 17: 200–211. Zanna, M. P. and Fazio, R. H. (1982) The attitude–behavior relation: moving toward a third generation of research. In M. P. Zanna, E. T. Higgins and C. P. Herman (ed.) Consistency in Social Behavior: The Ontario Symposium, Vol. 2, pp. 283–301. Erlbaum, Hillsdale, NJ.

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SECTION II

Theoretical perspectives

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CHAPTER 4

Dissociation theories of hypnosis Erik Z. Woody and Pamela Sadler

4.1. Introduction What do we in truth understand by the word dissociation? Is it a psychological event with underlying physiology, or just a metaphor? Frankel (1994a)

Dissociation theories of hypnosis start out with an unpromising enigma: What exactly is the word ‘dissociation’ supposed to mean in the context of hypnosis? Hilgard (1977), who appropriated the term ‘dissociation’ from Janet (1901), called his theory of hypnosis ‘neodissociation theory’ to distinguish it from some of Janet’s ideas, such as the concept that people who show dissociation have a particular form of mental deficit or biologically based weak-mindedness. However, in Hilgard’s hands, the concept of dissociation then evolved so that it appeared to mean several quite different things, as we will review in a moment. Bowers (1990, 1992) eventually pointed out that, in effect, neodissociation theory was virtually at war with itself. For example, Hilgard used the concept of dissociation to derive opposite, obviously inconsistent explanations of hypnotic phenomena. With regard to hypnotic analgesia, Hilgard and Hilgard (1975) inferred that ‘For the highly hypnotizable subject within hypnosis, pain reduction is essentially effortless’ (p. 156); whereas Hilgard (1977) inferred that to reduce pain,

‘The successful subject must use considerable effort, initiative, and ingenuity to achieve success’ (p. 181). As we will explain in more detail later, these contrasting predictions have to do with whether the concept of dissociation is applied to control processes (implying increased effortlessness) or to monitoring processes (implying decreased self-awareness of effort). Clinical instances of dissociative phenomena, such as fugue states and depersonalization, have often been characterized as ‘the spontaneous mobilization of hypnotic experience’ (Spiegel, 1990, p. 127; for critical discussions of the literature see Nash, 1992; Horevitz, 1994). If indeed hypnotic responding recruits individual differences in the tendency or ability to dissociate, then one might reasonably expect that measures of individual differences in dissociative tendencies should correlate strongly with individual differences in responsiveness to hypnosis. However, real-life dissociative tendencies, as measured by the Dissociative Experiences Scale (Bernstein and Putnam, 1986), turn out to be only very modestly related to hypnotizability (e.g. Faith and Ray, 1994), and it is possible to argue that even this modest relationship is an artifact of context effects (Kirsch and Council, 1992). Given this unexpected nonrelationship, the idea has been advanced that dissociative tendencies and hypnotizability are more or less orthogonal, crossing individual difference factors, such that

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individuals who are high on both variables have even been regarded as ‘double dissociators’ (e.g. Peebles-Kleiger, 2005). Such a proposal clearly does not resolve the issue of what it might mean to link hypnosis to dissociation; instead, it wraps this enigma inside a further one—namely, the concept of a double dissociator. In short, partly due to vagueness and inconsistencies, dissociation theories of hypnosis have been open to fairly strong lines of criticism (e.g. Spanos and Burgess, 1994; Kirsch and Lynn, 1998). Further, Frankel (1994b) argued that the mischief in the rather vague concept of dissociation has spread beyond the realm of hypnosis research, partly because the concept appears to have been legitimized by this research. He pointed out that uses of the term ‘dissociation’ in the clinical realm tended to be strikingly unclear; moreover, ‘Clinicians have claimed for dissociation a large series of observable clinical behaviors and reported experiences that could equally well, if not more persuasively, be explained by other mechanisms’ (Frankel, 1994b, p. 87). In a similar vein, Kihlstrom (1994) noted that using the label ‘dissociative’ for certain psychopathologies is ‘somewhat vexatious, because the term has a number of meanings in psychology’ (p. 383). Given all these problems, one might understandably suspect that, because of its lack of clarity, the concept of dissociation is not a very good vantage point from which to solve the puzzles of hypnosis and its relationship to the rest of psychology. Nonetheless, in this chapter we will argue that certain ideas that may be grouped under the term ‘dissociation’ hold great promise in understanding hypnosis. As the foregoing discussion illustrates, however, we need to aim for the greatest possible clarity about the particular meaning of the concept that is denoted by each such idea.

4.2. The development of

dissociation theories of hypnosis 4.2.1. Janet’s concept of dissociation Janet’s (1901, 1907, 1925) original concept of ‘désagrégation,’ translated as dissociation, was

a mechanism he proposed to underlie both hypnosis and hysteric disorders, which he viewed, like hypnosis, as suggestive phenomena. In dissociation, one of the subunits of mental life becomes split off from the rest, and thereby separated from both awareness and voluntary control. Suggestion works by activating these dissociated ideas, which remain outside of awareness. Thus, for Janet, hypnosis involved two essential features: (1) a constriction of awareness, in which subjects are unaware of material to which they would have conscious access under other circumstances; and (2) the special influence on behavior of this material excluded from awareness through activation by suggestion. Accordingly, we could argue that from Janet’s view, a prototypical hypnotic suggestion would be something like the post-hypnotic ankle touching suggestion on the Harvard Group Scale of Hypnotic Susceptibility, Form A (HGSHS:A; Shor and Orne, 1962). In this suggestion, after a tapping noise is demonstrated to the hypnotic subjects, they are told, ‘When you hear the tapping noise, you will reach down and touch your left ankle. You will touch your left ankle, but forget that I told you to do so’ (italics added). The lack of awareness for the instruction and the behavioral enactment through activation of this idea excluded from awareness are both central to Janet’s conception. It is interesting to note, given Janet’s influence on modern hypnosis research, that only a tiny minority of the test suggestions on widely used standardized scales of hypnotizability are of this form, in which material excluded from awareness is activated by suggestion. Nor does the scoring for such a suggestion attempt to verify that the people who touch their ankles are actually unaware of the earlier instruction (see Sadler and Woody, 2004, who argue that this problem produces a 12 percent rate of spurious passes for this item, as shown in its pseudo-guessing parameter). Janet qualified his notion of dissociation by positing that dissociation may often be partial, rather than complete (James, 1890). In the partial case, awareness and voluntary control for the dissociated material are reduced, but not eliminated. Despite this proviso, subsequent work testing Janet’s dissociation concept of hypnosis tended to focus on a more extreme interpretation: If an area

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of mental activity is indeed ‘split off ’ functionally from the rest, then hypnotic subjects should be able to engage in two simultaneous mental activities (one within that area and another outside it) without their interfering with each other (Hull, 1933; White and Shevach, 1942; Rosenberg, 1959). This research was generally interpreted as failing to support Janet’s concept of dissociation. For example, Hull (1933, p. 50) concluded, ‘Whatever else so-called hypnotic dissociation may be, it is not a functional independence between two simultaneous mental processes’.

4.2.2. Hilgard’s neodissociation

theory In going back to Janet’s work, Hilgard focused more on Janet’s theme of conscious versus unconscious processes in dissociation. From Janet, Hilgard borrowed the concept of dissociation as ‘the splitting off of certain mental processes from the main body of consciousness with various degrees of autonomy’ (Hilgard, 1992, p. 69). He elaborated this idea with two particular metaphors, the ‘amnesia-like barrier’ (or ‘cloak of amnesia,’ Hilgard, 1994, p. 45) and

Constraints on Ego Autonomy (Including Hypnosis)

the ‘hidden observer’ (Hilgard, 1977). Specifically, Hilgard found that in some hypnotically analgesic subjects, it was possible to suggest the presence of a so-called ‘hidden observer’, which could report the presence of pain at the same time as the other part of the self experienced no pain. This finding suggested to Hilgard that parallel streams of consciousness co-exist, separated by amnesic barriers that divide experience into separate, simultaneous channels. This became an important plank in Hilgard’s neodissociation theory of hypnosis. Another, perhaps more important and enduring direction in Hilgard’s theorizing was his attempt to advance a model of hierarchical levels of control mechanisms as a framework for explaining hypnotic phenomena (Hilgard, 1977, 1991, 1992). His diagram of this model, presented many times in his writings (originally in Hilgard, 1973; reprinted, for example, in Hilgard, 1991, 1992, 1994), is reproduced as Figure 4.1. At the lower level in this model, there are many co-existing cognitive control subsystems, three of which—labeled Cognitive Control Structures 1, 2 and 3—are shown in the diagram. Each of these control subsystems is

Executive Ego; Central Control Structure

Cognitive Control Structure 1

Input

Cognitive Control Structure 2

Input

Output

Output

Cognitive Control Structure 3

Input

Output

Figure 4.1 Hilgard’s hierarchical model of cognitive control. From ‘A neodissociation interpretation of pain reduction in hypnosis’ (p. 405) by E. R. Hilgard, 1973, Psychological Review, 80: 396–411. Copyright 1973 by the American Psychological Association. Reprinted by permission.

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capable of operating somewhat independently, with its own input and output. However, these subsystems are ordinarily subordinate to a higherorder executive system—labeled ‘Executive Ego’— which monitors and co-ordinates their activation and interaction. Hilgard hypothesized that hypnosis alters the function of this executive system and its hierarchical relationship to the subsystems. For example, he argued as follows: Effective suggestions from the hypnotist take much of the normal control away from the subject. That is, the hypnotist may influence the executive functions themselves and change the hierasrchical arrangements of the substructures. This is what takes place when, in the hypnotic context, motor controls are altered, perception and memory are distorted, and hallucinations may be perceived as external reality (Hilgard, 1991, p. 98).

More specifically, Hilgard speculated that hypnosis may have several distinguishable effects on the executive system. First, hypnosis may reduce its planning and initiative functions; hence, ‘the hypnotized person does not independently undertake new lines of thought or action’ (Hilgard, 1979, p. 50). Second, hypnosis may reduce the monitoring functions of the executive system; hence, hypnotic subjects become unaware of some aspects of their mental operations, such as the role of their own volition in their hypnotic experiences. Third, hypnosis may disturb the ‘balance’ between the monitoring and executive control functions (Hilgard, 1994), such that the monitor fails to correct the control functions: ‘The monitor does not offer a correction; hence imagination may be confused with external reality’ (Hilgard, 1992, p. 97). As we shall see, these three insights provide the foundation for current dissociation theories of hypnosis. Unfortunately, however, Hilgard never offered an integrated cognitive model of these hypothesized effects, which he might have attempted, for example, by showing how they could be incorporated into a representation such as Figure 4.1. (Crucially, Figure 4.1 does not show executive control and executive monitoring as separable functional units.) Instead, Hilgard attempted to fuse his hierarchical control model of hypnosis, broadly derived from cognitive psychology, with the concepts of the amnesic barrier and the hidden

observer, broadly derived from Janet. For example, he argued that the effects of hypnosis on the executive monitor are attributable to the splitting of its operation into conscious and unconscious parts: ‘Some fraction of it exists behind an amnesia-like barrier’ (Hilgard, 1992, p. 99). Indeed, Hilgard came to emphasize the idea, derived from Janet, that hypnosis represents a constriction of awareness, in which, due to such amnesic barriers or ‘fractionations’ (Hilgard, 1992, p. 97), crucial information about mental operations, which would ordinarily be available, is walled off from access. As a result, the monitor ‘can report’ the hypnotic experiences ‘without being a party to how they came about’ (Hilgard, 1992, p. 98). An important limitation of this attempted fusion is that ideas like the amnesic barrier and hidden observer are metaphors that lie comfortably within neither the cognitive nor the physiological domain. Thus, what they mean is somewhat unclear. In addition, Hilgard tended to describe mental operations somewhat anthropomorphically, as if the hypnotist, the executive control system and the monitoring system were three individuals involved in some kind of magic show: The monitor may express surprise that an arm cannot be bent, or amusement over some fantasied reality, such as floating on a cloud. ... The executive system, in collaboration with the hypnotist, succeeds in giving rise to the actuated experiences. How this has been done may be concealed from the monitor (Hilgard, 1992, pp. 97–98).

In short, rather than offering a more complete explanation at a particular level, Hilgard tended to mix together incomplete explanations across somewhat vaguely defined levels. This problem has made his neodissociation theory readily open to attack.

4.2.3. Bowers’s critique and reformulation of neodissociation theory Perhaps the most prominent critic of neodissociation theory was Spanos (1986, 1987, 1991). He characterized Hilgard’s theory as a ‘special process view’, because of its reliance on unusual processes, especially dissociation. The approach

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used by Spanos was generally not to criticize Hilgard’s theory directly, but instead to try to show that its special constructs were completely unnecessary for explaining hypnotic behavior. In contrast to Hilgard’s tendency toward somewhat vague metaphors and anthropomorphizing, Spanos posed seemingly straightforward explanations of hypnotic behaviors in terms of the same general purpose socialpsychological processes that may be used to explain everyday, nonhypnotic social behavior. He characterized this ‘social psychological’ view of hypnosis as follows: The responses of high hypnotizables to suggestions for amnesia, analgesia, and so on, are often not what they seem, and … such responses in fact reflect mundane social-cognitive processes such as compliance-induced reporting biases, alterations in attentional focus, and misattribution of experience, rather than such special processes as dissociation (Spanos and Coe, 1992, p. 110).

Spanos published a very extensive corpus of experimental work in support of this claim. One response by defenders of neodissociation theory was to award Spanos a partial victory, especially with regard to people who lack high hypnotic talent; however, they argued that dissociation still has its place in explaining the rarer responses of the most hypnotically capable. For example, consider the following remarks from Kihlstrom (1985): The behavior of hypnotic ‘virtuosos’, who make extreme scores on the scales of hypnotic susceptibility, may best be analyzed in terms of underlying dissociative changes in the cognitive system. For the remainder (arguably the greater portion of the population at large), it may be more profitable to focus on the cognitive strategies that they deploy to construct responses to hypnotic suggestions, and the situational factors that lead them to do so (p. 409).

A more combative defense of neodissociation theory came from Bowers, who yielded no ground. In particular, Bowers and Davidson (1991) provided a detailed critique of weaknesses in Spanos’s conceptual framework. For example, they alleged that Spanos conflated the issue of whether hypnotic behavior is purposeful, in the sense that it is goal directed, with the issue of whether it is performed on purpose,

in the sense that it stems from executive initiative and effort; thus, Spanos incorrectly inferred from the goal-directed nature of hypnotic acts that they cannot be nonvolitional. In addition, Bowers and Davidson provided a thorough re-examination of some of the experimental work by Spanos and his colleagues, arguing that many of Spanos’s attempts to discredit neodissociation theory are ‘both irrelevant and misleading’ (p. 114). One shortcoming of some of Spanos’s work is that mechanisms he proposes as alternatives to dissociation often sound very intuitively plausible, but do not bear up well under closer experimental scrutiny. An example would be his proposal of ‘goal-directed fantasies’ as the cognitive strategies that mediate hypnotic responsiveness. In fact, careful subsequent research has clearly shown that goal-directed fantasies, although present, play a very minor, or even counterproductive role in producing hypnotic behavior (e.g. Hargadon et al., 1995; Comey and Kirsch, 1999). In light of Bowers’s vigorous advocacy of Hilgard’s neodissociation theory, it is interesting that he himself became troubled by some inconsistencies in the theory. In particular, Bowers (1990, 1992) argued that amnesic barriers were an unlikely mechanism for much hypnotic behavior. Consider that for an amnesic process to be the origin of the subjective experience of nonvolition, as Hilgard claimed, the amnesia would usually need to be spontaneous, rather than suggested. This is because, aside from specific suggestions for amnesia, other kinds of hypnotic suggestions do not typically include the suggestion of amnesia. However, the experience of nonvolition is quite common, whereas the occurrence of unsuggested amnesia is rare (Cooper, 1966). Therefore, the amnesic barrier mechanism is an explanation of relatively frequent and pervasive hypnotic phenomena in terms of a rare and peculiar one. Further, Bowers (1992) pointed out that neodissociation theory requires that the amnesic barriers be arbitrarily selective: ‘The pain and cognitive effort to reduce it is hidden behind an amnesic barrier, but not the original suggestions for analgesia, nor the goal-directed fantasies that typically accompany the reductions in pain’ (pp. 261–262). This ad hoc quality, too, seems implausible.

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In addition, Bowers (1990, 1992) drew attention to the fact that the mechanism of the amnesic barrier implies, contrary to the rest of Hilgard’s hierarchical control model, that hypnotic responses do not involve any change in the actual control of behavior. That is, a hypnotic response could be enacted voluntarily and effortfully in the ordinary way, but then this mental fact could be hidden from awareness behind an amnesic barrier. In this case, the subject’s experience of the response as involuntary and effortless would simply be an illusion. In contrast, Hilgard (1977) alternatively argued that a hypnotic response may be a true reflection of an underlying alteration in the hierarchy of control of behavior. Specifically, the response may stem from a subsystem of control being activated directly by a suggestion, in a manner that bypasses executive initiative and effort. In this case, the subject’s experience of the response as involuntary and effortless would be accurate, rather than illusory. Thus, neodissociation theory makes exactly opposite predictions about the nature of cognitive effort in hypnosis (both low and high) and its relationship to the subjective experience of involuntariness (both correct and illusory). Partly to deal with this inconsistency, Bowers (1990, 1992) proposed a reformulation of neodissociation theory, which split it into two distinct, complementary components: dissociated experience and dissociated control. Dissociated experience refers to changes in how hypnotic subjects experience their behavior: in hypnosis, the effort and volition that may be operative in enacting suggestions are hidden or dissociated from consciousness, such that ‘the control being exercised is not consciously experienced’ (Bowers, 1990, p. 164). According to the dissociated experience account of neodissociation theory, cognitive effort in successful hypnotic responding is actually high, but mistakenly experienced as low: ‘The hypnotized subject remains for the most part unaware that a good deal of effort may have been exercised in order to produce the suggested state of affairs’ (Bowers, 1990, p. 162). In contrast, dissociated control refers to changes in the underlying control of behavior: in hypnosis, lower subsystems of control are activated more or less directly by suggestions, bypassing

the higher executive level of control, along with the processes of volition and sustained effort ordinarily contributed by it. According to the dissociated control account of neodissociation theory, cognitive effort in successful hypnotic responding is actually low and correctly experienced as low: The experience of volition or intention ordinarily reflects executive control over behavior. However, it is precisely such executive control that is minimized or bypassed when a hypnotized subject enacts the suggested state of affairs. Consequently, hypnotically suggested behaviors are typically experienced as nonvolitional (Bowers and Davidson, 1991, p. 107).

Although at first Bowers (e.g. 1990) conceptualized dissociated experience and dissociated control as ‘complementary aspects of hypnotic responsiveness’ (p. 160), he soon came to de-emphasize dissociated experience and strongly promoted dissociated control as the main dissociative process underlying hypnosis (e.g. Bowers and Davidson, 1991; Woody and Bowers, 1994). He viewed dissociated experience as problematic because of the previously mentioned conceptual implausibility of amnesic barriers as the underlying mechanism. In addition, he was troubled by the observation that the dissociated experience account, with its position that the hypnotic experience of nonvolition is illusory, seemed perilously close to the social-psychological model of Spanos (1986), which posits that hypnotic subjects maintain full volitional control over their behavior, but, consistent with various cues in the test situation, mistakenly, although sincerely, interpret their actions as involuntary. Indeed, rather than dissociated experience, it was the dissociated control version of neodissociation theory that Bowers and Davidson (1991) defended against the social-psychological alternative of Spanos. Further, Bowers pointed out that the dissociated experience account appeared to limit hypnotherapeutic effects to altering clients’ impressions of why therapeutic changes occur, rather than enhancing their ability to make such changes: The only conceivable advantage of high hypnotizability would thus be a very limited one: patients high in hypnotic ability would be more able than

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their low-hypnotizable counterparts to dissociate from consciousness any special effort or motivation involved in achieving treatment success (Bowers, 1990, p. 166).

can more or less directly activate subsystems of control, which are partially and temporarily dissociated from executive (intentional, conscious) control (Bowers and Davidson, 1991, p. 107).

He argued that this implied limitation was inconsistent with the actual range of effects of hypnotic treatments. In light of these issues, he eventually adopted the following position: ‘Dissociation is not intrinsically a matter of keeping things out of consciousness—whether by amnesia, or any other means’ (Bowers, 1992, p. 267). Despite Bowers’s misgivings about dissociated experience, it remains an important perspective, as we shall see, in the hands of other theorists such as Kihlstrom (e.g. 1985, 1992). In addition, Bowers’s formulation of dissociated control became the foundation for Woody and Bowers’s (1994) dissociated control theory, which we will review later. Bowers always portrayed his reformulation of neodissociation theory as simply clarifying and drawing out implications of ideas that had already been advanced by Hilgard himself. It is possible to quibble about the extent to which this claim is correct. First, Bowers strongly shifted the balance between the two concepts: dissociated experience is the predominant process in most of Hilgard’s writings, whereas dissociated control became the predominant process for Bowers. Second, Bowers described dissociated control as a somewhat simpler, more monolithic process than Hilgard, who described it as multifaceted and emergent. It is interesting in this regard to compare the following passages from Hilgard and Bowers, respectively:

Bowers’s account is more elegantly straightforward, but also much simpler in its conception of how dissociation unfolds. There is another, potentially more important way in which Bowers’s reformulation departed from Hilgard. Bowers drew a much stronger distinction between dissociated experience as a change in monitoring, and dissociated control as a change in executive control. In contrast, Hilgard (1994) noted, ‘It is artificial to sharply separate executive from monitoring functions since all initiated action is monitored’ (p. 45). He argued that a major function of the monitor is to offer ongoing correction to the executive control process:

A more massive dissociation, as far as the executive is concerned, may be the consequence of the summing up of many specific subsystems for which control has been relinquished. Such an interpretation permits hypnosis as a state to be a relative matter, the specific dissociation being identifiable, but the general state being a matter of how many specific dissociations are operative and how pervasive they are (Hilgard, 1992, p. 96). Hypnotic responsiveness involves a somewhat reduced influence of executive control over hypnotically enacted behavior. … In other words, suggestions administered to a hypnotized person

If one course of action does not work, another may be tried. Whether the second course works better is determined by the monitoring function; the executive function then acts on this information (Hilgard, 1994, p. 46).

Accordingly, as mentioned earlier, Hilgard sometimes proposed that dissociation of monitoring from executive control might be one candidate mechanism in hypnosis (e.g. Hilgard, 1994). Because Bowers’s reformulation portrayed monitoring and control as quite separable, rather than interdependent processes, it de-emphasized this possibility. Nonetheless, Bowers’s reformulation, with its emphasis on the concept of dissociated control, was important for refocusing attention on the idea that hypnosis may alter the control of behavior, rather than simply obscure its self-perception. This view of hypnosis had appeared previously at various times in the history of hypnosis research. One of the clearest early expressions of the concept of dissociated control is from Sidis (1899): The superior or the highest nervous centres … possess the function of choice and will. … These superior choice and will-centres, localized … in the frontal lobes …, on account of their selective and inhibitory function, may be characterized as inhibitory centres par excellence. In hypnosis the two systems of nervous centres are dissociated, the superior centres and the upper

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consciousness are inhibited, or, better, cut off, split off from the rest of the nervous system …, which is thus laid bare, open to the influence of external stimuli or suggestions (pp. 68–69).

Somewhat similar ideas came out of the Pavlovian school; for example, Völgyesi (1966) described hypnosis as a circumstance in which ‘the older subcortical nerve-organs … function much more independently and vigorously in relation to the higher centres than when they are subjected to the wakeful, inhibiting, braking supervision of the neo-cortical centres’ (p. 83).

4.2.4. Woody and Sadler’s proposal

for the reintegration of dissociation theories A further stimulus for the development of dissociation theories of hypnosis was an interesting critique by Kirsch and Lynn (1998). They focused on what they saw as unresolved conceptual problems and inconsistencies in these theories. They proposed a set of criteria that they believed any complete and adequate explanation of hypnosis should meet, and then they argued that dissociation theories, despite their complexity, fall short of fulfilling such a goal. In addition, they drew attention to the often striking inconsistencies between different versions of dissociation theory (such as dissociated experience and dissociated control), and they were particularly critical of the problematic special mechanisms—the amnesic barrier and the hidden observer—that appeared to lie at the heart of dissociation theories. In response, Woody and Sadler (1998) argued for a plurality of provisional theories of hypnosis, each being an admittedly incomplete and as yet inadequate work in progress: ‘Given the complexity of emerging empirical findings in hypnosis research, any theoretical view is likely to be highly provisional, requiring frequent revision and rethinking’ (p. 193). More importantly, they maintained that the various theoretical positions concerning dissociation are actually closely related and reasonably consistent with one another. Further, these positions can readily be reformulated without using the problematic mechanisms of the amnesic barrier and dual streams of consciousness, as in the hidden observer.

This reformulation can be achieved by viewing dissociation theories from the perspective of dual-system models of action, such as those advanced by Goldberg (1987), Lhermitte (1986), Mesulam (1986) and Norman and Shallice (1986). In these models, there are two complementary systems that manage the initiation and control of action: a higher, executive system principally responsible for volitional acts, and a lower, diverse system principally responsible for more environmentally driven, routine acts. One advantage of this perspective is that it opens hypnosis research to a broader horizon of work in cognitive neuroscience. For example, Goldberg has argued that the two systems represent a fundamental distinction in the evolutionary architectonics of the cortex, with an ‘archicortical trend’ involved with volitional behavior, and a ‘paleocortical trend’ involved with environmentally triggered behavior. Woody and Sadler posited that these kinds of ideas, which developed independently of Hilgard’s neodissociation theory, provide a sounder foundation for conceptualizing hypnotic dissociation than do the rather ad hoc mechanisms of amnesic barriers and hidden observers. Woody and Sadler (1998) then outlined a proposed reintegration of the dissociated experience and dissociated control theories. This reintegration also attempted to relate these theories to the social-psychological (or socio-cognitive) account of hypnosis. In the next part of this chapter, we offer an expanded, more complete version of this proposal. In developing this integrative framework, we further address aims suggested in our earlier proposal: 1. To specify and differentiate clearly the processes denoted by the proposed types of dissociation, while at the same time showing how they fit together conceptually. 2. To distinguish dissociation theories from otherwise similar, alternative accounts of hypnotic phenomena 3. To draw provisional links of hypnotic phenomena with psychopathological conditions, although this approach requires caution (cf. Dixon and Laurence, 1992).

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4.3. An integrative view of

dissociation theories of hypnosis 4.3.1. What are the phenomena to be explained? It is important to begin by briefly considering the range of hypnotic phenomena that theory may address. Table 4.1 presents a fairly comprehensive, although not exhaustive, breakdown of major classes of hypnotic behavior. There are two major types of suggestion—facilitating and blocking. These are crossed with three types of content—motor action; sensation and perception; and memory and identity. Within each combination of the two factors lies a respective realm of hypnotic behavior, as shown in the table. Facilitating suggestions for motor action give rise to so-called ideomotor behaviors, in which the suggested idea of a movement elicits the actual movement. Blocking suggestions for motor action give rise to the circumstance in which exerting will fails to produce movement; e.g. in motor challenge suggestions, effort by the subject is insufficient to counteract a previous motor suggestion. Facilitating suggestions for sensation and perception give rise to positive hallucinations in various modalities (e.g. visual, auditory and olfactory); whereas blocking suggestions for sensation and perception give rise to negative hallucinations, including analgesia. Finally, facilitating suggestions for memory and identity give rise to memory creation and altered identity (e.g. sexual identity; Noble and McConkey, 1995; Burn et al., 2001; McConkey et al., 2001), whereas blocking suggestions for this type of content give rise to phenomena such as post-hypnotic amnesia. Some suggestions may

combine two of these cells; e.g. a post-hypnotic suggestion may involve both facilitating a motor action (e.g. ankle scratching) and blocking memory (forgetting the suggestion). Even casual consideration of this table indicates that hypnosis is a multifaceted collection of phenomena involving a wide diversity of mental systems. Thus, the various hypnotic phenomena probably recruit somewhat differing patterns of individual differences and rely on multiple underlying processes (Shor et al., 1962; Hilgard, 1977; Spanos et al., 1980; Woody et al., 1992, 2005; Woody and McConkey, 2003). In light of this complexity, Woody and Sadler (1998) made the following observation: Any reasonably well-focused theory of hypnosis seems unlikely to explain all its features because of the multifaceted nature of the subject matter itself. Asking which is the one correct explanation for hypnosis may be like asking which is the one correct explanation for poverty (p. 193).

Nonetheless, across this diverse matrix of hypnotic behavior there is an essential common denominator: in hypnosis all these behaviors are accompanied by the subjective experience that the self is not the origin of the response. Weitzenhoffer (1980) called this alteration in the sense of agency the ‘classic suggestion effect’. It has also often been labeled as ‘involuntariness’ or ‘nonvolition’, although these terms tend to apply more directly to some hypnotic responses, such as motor acts and amnesia, than to others, such as hallucinations (which may indeed, in some sense, be involuntary imaginings, but this is not the phenomenal experience of the subject). A particularly apt attempt to capture the essential subjective quality of hypnotic responses is Tellegen’s (1978/1979, p. 220)

Table 4.1 Breakdown of major classes of hypnotic behavior Type of content Type of suggestion

Motor action

Sensation and perception

Memory and identity

Facilitating

Ideomotor behaviors

Positive hallucinations

Memory creation, Changes in identity

Blocking

Failures of willed action

Negative hallucinations, Analgesia

Post-hypnotic amnesia

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‘minimal’ descriptive definition of hypnotizability: ‘It is the ability to represent suggested events and states imaginatively and enactively in such a manner that they are experienced as real’. For a suggested state of affairs to appear as real, it must be experienced as occurring extra-volitionally. In summary, this change in the experience of volition accompanies virtually all true hypnotic phenomena; hence, any good theory of hypnosis ought to explain its origins. In addition, however, it is well to keep in mind the broader matrix of hypnotic behavior, as depicted in Table 4.1, in evaluating any candidate theory of hypnosis. It is possible that any particular explanatory scheme applies well to only certain types of suggestion or content and is difficult to extend to the others.

4.3.2. The overarching model Figure 4.2 depicts our integrative model of dissociation theories of hypnosis. This diagram is quite different from Hilgard’s (Figure 4.1). In particular, Hilgard’s diagram cannot represent the major features of dissociation theories (including his own neodissociation theory) because it does not distinguish between executive control and monitoring. In contrast, we have adopted from Frith (1992) the straightforward idea of representing the Executive Monitor as a separate functional unit, closely interconnected to Executive Control.

The model shows two levels of control of action: the higher executive level, comprised of Executive Control and Executive Monitoring; and the lower level, consisting of Subsystems of Control. Consistent with dual-system models of action (e.g. Norman and Shallice, 1986), it is the subsystems of control that directly handle the selection and tracking of behavior; the executive system offers a second level of control, associated with conscious volition, which functions by modulating and monitoring the subsystems of control. Note that there is a feedback loop between the executive functions and the subsystems of control (from Executive Control to Subsystems of Control via path b, from Subsystems of Control to Executive Monitoring via path e, and from Executive Monitoring to Executive Control via path d). This is the feedback loop by which executive oversight of action occurs. Within this feedback loop is another important feedback loop, which lies between Executive Control and Executive Monitoring (via paths c and d). Through these reciprocal connections, Executive Control passes information such as intentions to the Executive Monitor, and, in turn, the Executive Monitor passes information about ongoing activity in the subsystems to Executive Control. All dissociation theories of hypnosis may be viewed as proposing that these feedback loops, which inter-relate executive functions with subsystems of control, are disrupted from their

c a Suggestion

Executive Control

d

b

Executive Monitoring

e Subsystems of Control

Behavior

Figure 4.2 An integrative model of dissociation theories of hypnosis. A theory of dissociated experience involves the weakening of path c, and possibly of path e. A theory of dissociated control involves the weakening of path b, and possibly of path a. A theory of second-order dissociated control involves the weakening of path d.

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usual function in some way. The arrows labeled with lower case letters in the figure denote functional connections whose weakening may give rise to hypnotic responses, according to different theories of dissociation. First, according to the theory of dissociated experience, the weakening of path c, the functional connection from Executive Control to Executive Monitoring, is crucial. In this case, even when behavior is actually initiated voluntarily by Executive Control, this information is not passed to the Executive Monitor and thus remains inadequately represented in consciousness. It is also possible that a theory of dissociated experience would implicate a weakening of path e, from the Subsystems of Control to the Executive Monitor. The general implication is that the Executive Monitor is isolated (‘dissociated’) from important information about the self-mediated nature of behavior, and this information, which would generally be available in nonhypnotic circumstances, is unavailable to awareness. Therefore, in response to hypnotic suggestions, the subject can willfully initiate behavior without correctly monitoring this volition; as a result, he or she has the illusion that the ensuing behaviors occur extra-volitionally. Second, according to the theory of dissociated control, the weakening of path b, the functional connection from Executive Control to the Subsystems of Control, is crucial. In this case, lower Subsystems of Control can be activated more directly by suggestions, bypassing the input of Executive Control. It is also possible that a theory of dissociated control would implicate a weakening of path a, from the Suggestion to Executive Control. The general implication is that Executive Control is isolated (‘dissociated’) from the activation of behavior, and processes of volition and effort, which would generally play more of a role in nonhypnotic circumstances, are minimized. Therefore, in response to hypnotic suggestions, the subject can initiate behavior without the usual executive initiative and effort; as a result, he or she has the correct perception that the ensuing behaviors occur with less volition and effort than is usual outside hypnosis. Finally, note that the one functional connection we have not yet addressed in this feedback

system is path d, from Executive Monitoring to Executive Control. As mentioned earlier, Hilgard suggested that any action initiated by Executive Control is ordinarily tracked by the Executive Monitor to provide appropriate adjustments to the executive control process; in addition, he suggested that hypnosis may block this ongoing correction process. Indeed, this same idea is the focus of a recent revision of dissociated control theory proposed by Jamieson and his colleagues (Jamieson and Sheehan, 2004; Egner et al., 2005; Jamieson and Woody, 2007). They posit that during hypnosis, monitoring feedback becomes functionally dissociated from the executive control process. In our integrative model, this blocking or dissociation is represented by the weakening of path d, from monitoring back to control. The general implication is that in hypnosis, once Executive Control has initiated an action, the control process would not be updated by ongoing Executive Monitoring in the ordinary way. Therefore, monitor-detected discrepancies and inconsistencies that would normally lead to changes in control under nonhypnotic conditions may not influence the executive control process under hypnosis. As Jamieson and Woody (2007) point out, this type of dissociation involves a change in the control of control, i.e. a second-order level of cognitive control based on executive monitoring. Thus, for present purposes, we will call this the ‘theory of second-order dissociated control’. A little later in this chapter, we will provide a more extended account of each of these three dissociation theories of hypnosis, together with key research issues. However, at this point it should be clear that our integrative model both distinguishes the three proposed types of dissociation theory and shows how they fit together conceptually. This coherence does not necessarily mean that all three theories are right (indeed, none of them may be), but it does mean that they are potentially compatible, rather than mutually exclusive. Indeed, it is even possible that hypnosis could involve a fluid mix of the three types of processes, depending on the subject’s profile of individual differences and the particular suggestions used (cf. Woody and McConkey, 2003).

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4.3.3. What characteristics make dissociation theories different from other theories of hypnosis? In the 1980s, Bowers’s research focused somewhat separately on two problems: dissociation in hypnosis, and the nature of consciousness (e.g. Bowers, 1984, 1987). Strongly influenced by Hilgard, Bowers argued at this time that dissociated experience was the main mechanism underlying hypnotic responding (e.g. Bowers and Brenneman, 1981). At the same time, strongly influenced by the work of Nisbett and his colleagues (e.g. Nisbett and Wilson, 1977; Nisbett and Ross, 1980), he argued that conscious introspection offers a very limited window on the causes of one’s own behavior: ‘Introspection has no special or privileged access to the causal connections linking behavior to its determinants’ (Bowers, 1990, p. 147). That is, to a considerable extent, the self, in understanding the causes of one’s own behavior, is in the same position as an outside observer, making use of the same kinds of observations and common-sense hypotheses. There is an important inconsistency between these two positions: if the self has no special insight into the causes of one’s own behavior, then how can hypnosis work by ‘dissociating’ such insights from awareness? There would actually be no such insights to dissociate. Indeed, as Bowers later moved toward a dissociated control account of hypnosis in the early 1990s, he became convinced that the dissociated experience account was difficult to discriminate from the social-psychological (or socio-cognitive) alternatives (e.g. Woody and Bowers, 1994). This is because both perspectives argue that the hypnotic subject simply misperceives the causes of his or her behavior; i.e. it is the self-evaluation of hypnotic behavior, rather than its initiation and control, that is at stake. This discussion illustrates the importance of a general issue: What are the defining features of dissociation theories? What makes them essentially different from alternative views of hypnosis that may resemble them in some respects? Our analysis of this problem will necessarily be somewhat speculative, but hopefully illuminating.

We would argue, in contrast to Bowers, that consciousness includes a very important domain of special or privileged insight: whether the origin of an event is internal or external. In the simplest terms, the discrimination is, ‘Did I do that, or did it happen to me’? This discrimination applies to both overt events, such as body movements, and to covert events, such as images. It is made possible by the co-ordination of intentions and executive effort with subsequent activity in subsystems of control and ensuing behavior. For motor actions, this co-ordination is a process of ‘efference copy’, which is information fed forward from executive control to the monitor about the expected changes in body position when a voluntary movement is executed. By monitoring intentions to make movements, movements due to the self can be distinguished from ones with outside causes, and at least some of this process is registered consciously (Hershberger and Misceo, 1983; Blakemore et al., 1999). Similarly, covert behaviors, such as images and other thoughts, appear to be subject to a similar monitoring process, whereby one’s own productions are ‘tagged’ to distinguish them from externally originated perceptions (Bentall, 1990; Frith, 1992). A general term for this process is ‘efferent binding’ (Haggard, 2003). Accordingly, we would advance the proposition that dissociation theories are based on the assumption that there is a special, innate mechanism that ordinarily discriminates internally produced actions from externally produced ones. The special insight afforded by this mechanism is usually very robust and reliable, and normally breaks down only in psychotic disorders, such as schizophrenia (Frith, 1992), in which it produces symptoms such as delusions of control and hallucinations, and in dissociative disorders (Kihlstrom, 1994). Hypnosis in highly susceptible people may be viewed as transiently evoking a similar, and otherwise highly unusual, breakdown in this mechanism. This position strikes us as the essence of dissociation theories of hypnosis. Parenthetically, it is possible to have some doubt about whether standardized hypnosis scales really identify this kind of susceptibility well. For example, Szechtman et al. (1998) were able to divide people who scored very high on hypnosis scales into those who could hallucinate

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readily versus those who, although they could respond strongly to an invitation to imagine, could not hallucinate. There are other interesting phenomena that occur in only half or less of people who score high on hypnosis scales, including, for example, duality in age regression (experiencing oneself as both a child and an adult; Nogrady et al., 1983) and the post-hypnotic persistence of uncanceled suggestions (ones that continue to evoke responses beyond the end of hypnosis, even though there is no suggestion that they will; McConkey and Barnier, 2004). Some commentators, such as Kallio and Revonsuo (2003) and Weitzenhoffer (1989), have speculated that the widespread use of standardized hypnosis scales has led to the conflation of true hypnotic phenomena, as demonstrated by hypnotic ‘virtuosos’, with other, less interesting phenomena. In contrast to dissociation theories, other theories of hypnosis do not hypothesize the breakdown of a special, innate mechanism that ordinarily discriminates internally from externally produced actions. One strongly skeptical perspective is to argue that hypnotic subjects do not actually lose track of whether the origins of their behaviors are internal or external at all, but only comply (Wagstaff, 1991, 1998) or play-act (Sarbin, 2005) as if they do, because the circumstances of hypnosis give them tacit permission to do so. However, Kinnunen et al. (1994) demonstrated that hypnotic subjects are not misrepresenting or lying about their experiences. Another perspective is to argue that the sense of involuntariness and external reality, rather than stemming from an innate function or domain of special insight, is a secondary attribution. For example, socio-cognitive theorists hypothesize that hypnotic subjects infer nonvolition indirectly from situational cues indicating that their behavior is supposed to be nonvolitional (e.g. Spanos, 1986; Lynn et al., 1990; Kirsch and Lynn, 1997, 1999; Lynn, 1997). Woody et al. (1997) pointed out that this type of explanation fits the easier hypnotic suggestions, such as ideomotor ones, much better than difficult ones, such as hallucinations. This is because simple ideomotor responses, such as lowering one’s arm, are semi-automatic—they do not require executive control, but may be tracked by executive monitoring, a circumstance that,

according to Norman and Shallice (1986), is experienced as ambiguous with regard to will. Woody and Sadler (1998, p. 194) characterized this view as follows: At least some of the things we ask people to do in hypnosis may be ambiguous with regard to the role of volition, and hence situational factors might well lead them to make attributions of involuntariness, that is, that something about hypnosis made them act rather than their own will.

Another interesting theory that portrays the sense of involuntariness and external reality as a secondary attribution is Barnier and Mitchell’s (2005) discrepancy attribution theory of hypnosis. For example, consider the mental image of a cat. Barnier and Mitchell argue that the hypnotic subject infers the external reality of the cat from the surprising ease with which he or she generates the image in hypnosis. That is, because picturing the cat is easier than the subject expected it to be, he or she infers that the cat is real and, hence, experiences a hallucination. It is interesting that the Barnier and Mitchell (2005) account has some features that are clearly in common with dissociation theories. Like dissociated control theory, it ascribes key importance to reduced cognitive effort in hypnosis (which, according to dual-systems models, reflects low involvement of higher executive control). Like dissociated experience theory, it posits that the central characteristic of a hypnotic response is the mistaken evaluation of agency (the cat is attributed to external reality, rather than to one’s own covert mental act). Note, however, that in contrast to our characterization of dissociation theories, an underlying assumption of the discrepancy attribution theory appears to be that there is no innate mechanism by which people ordinarily know whether an image of a cat has internal or external origins. (If there were such a mechanism, it would presumably not be so readily overturned by relatively small increases in processing ease.) In summary, we propose that there are two defining characteristics of dissociation theories. First, they hypothesize the existence of a special, innate mechanism for discriminating the internal versus external origins of events. This discrimination is probably afforded by the co-ordination of executive control with

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executive monitoring. Second, dissociation theories hypothesize that for highly hypnotizable people, hypnosis transiently brings about a disruption of this mechanism. There are at least three ways to view the nature of this disruption, corresponding to the dissociated experience, dissociated control and second-order dissociated control theories. We will next examine these three theories in more detail. In our view, versions of dissociation theories that do not embed the foregoing two defining characteristics will be difficult to discriminate from other, competing theories. In addition, these characteristics have the advantage of connecting hypnosis research with a wealth of fascinating work in cognitive neuroscience, as we shall explore in the rest of this chapter.

4.4. Key issues and research 4.4.1. Dissociated experience theory As mentioned earlier, a pure version of dissociated experience theory stipulates that hypnotic suggestions are enacted voluntarily, in the same way as nonhypnotic behavior. According to this account, the crucial difference is that in hypnosis, volition is not monitored correctly and hence the subject has the illusion of involuntariness. The classic suggestion effect, then, is basically a mild delusion of control, in which the subject mistakes an internally generated action for an externally caused one. Even a hallucination, by this account, is a cognition (an image) that has escaped from the supervision of the executive monitor—in effect, an oversight of executive oversight. Dissociated experience theory provides a reasonably comprehensive explanation of hypnotic behavior. Referring back to Table 4.1, we can provide the following account from this perspective. Hypnotic responses to facilitating suggestions involve the failure to monitor (and thus be aware of) one’s own initiation of acts; whereas hypnotic responses to blocking suggestions involve the failure to monitor (and thus be aware of) one’s own inhibition of acts. If this monitoring failure pertains to a motor action, then we have phenomena such as body movements and lack thereof that are falsely experienced as involuntary. Specifically, in response

to ideomotor suggestions, hypnotic subjects would actually initiate movement in the usual nonhypnotic way, but misperceive the result to be involuntary; and, in response to motor challenge suggestions, they would actually inhibit their own movement in the usual nonhypnotic way, but again misperceive the result to be involuntary. Exactly the same argument can be applied to the two other major types of content in hypnosis: sensation and perception; and memory and identity. The failure to monitor the initiation (or construction) of images and other thoughts correctly would lead to perceptions falsely attributed to sources outside the self, such as positive hallucinations and false memories. Likewise, the failure to monitor the inhibition of images and other thoughts correctly would lead, according to this view, to negative hallucinations and amnesia. In addition, the lack of monitoring may make hypnotic amnesia more effective than its nonhypnotic counterparts, such as thought suppression, in which monitoring tends to overturn suppression (e.g. Bowers and Woody, 1996). Kihlstrom (1992) has been an eloquent advocate of the dissociated experience account of hypnosis. A representative statement of his view is the following: When the cognitive control system that executes the response to a hypnotic suggestion is dissociated from conscious awareness, [the subject] will experience that response as automatic and nonvolitional … however, that experience is illusory—obviously, there is some executive control involved in hypnotic responding, even if the hypnotized [subject] does not experience it as such (Kihlstrom, 1992, p. 308).

An interesting indication of the breadth of this dissociated experience framework is that Kihlstrom (1994) has also used it masterfully to organize a wide range of dissociative disorders. Like hypnotic responses, the symptoms of these disorders can be conceptualized as the result of faulty executive monitoring, and, thus, these conditions may be regarded essentially as disorders of consciousness. In ‘dissociative disorders of motor function’ (such as psychogenic aphonia and urinary retention), the monitoring of voluntary initiation or inhibition of motor behaviors is disrupted, so that these behaviors are not experienced as under voluntary control.

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In ‘dissociative disorders of sensation and perception’ (such as psychogenic blindness and tactile anesthesia), disrupted monitoring leads to changes in conscious perception, and in ‘dissociative disorders of memory and identity’ (such as psychogenic amnesia and multiple personality), disrupted monitoring leads to loss or alteration of autobiographical memory. Moreover, the distinction we drew between facilitating and blocking hypnotic suggestions is closely paralleled by Kihlstrom’s distinction in these disorders between ‘positive’ symptoms, in which there is some addition to normal experience, and ‘negative’ symptoms, in which there is some loss of normal experience. For example, within dissociative disorders of sensation and perception, a negative symptom, such as psychogenic tunnel vision, involves the blocking of some aspect of normal conscious perception. In contrast, Kihlstrom provided the following intriguing account of a positive symptom, psychalgesia (the experience of pain in the absence of an organic basis): From the point of view of neodissociation theory, … the patient’s subjective experience of pain results from the construction of vivid mental images of pain, presumably based on memories of past experience. Hence, dissociation is a relevant term since the patients are unaware that they are generating these experiences for themselves. Because of this failure of reality monitoring, the pains are experienced as sensations rather than as images (Kihlstrom, 1994, p. 386).

Kihlstrom (1994) has also attempted to distinguish which aspects of behavior are affected by hypnosis and dissociative disorders versus which are not. He argued that ‘explicit’ forms of memory, perception and action are affected, whereas their ‘implicit’ forms are preserved. The terms explicit and implicit originally arose to denote two forms of memory: explicit memory refers to the conscious, intentional recall of an event, whereas implicit memory refers to other changes in behavior stemming from an event, such as priming effects and savings in relearning, which are independent of conscious recollection (Schacter, 1987). Kihlstrom posited that hypnotic suggestions for amnesia disrupt explicit memory, while largely sparing implicit memory (e.g. Kihlstrom and Hoyt, 1990).

Likewise, he has extended the distinction between implicit versus explicit to the realm of perception (Kihlstrom et al. 1992): explicit perception refers to the conscious detection of stimuli, whereas implicit perception refers to other effects of such stimuli, such as priming effects, which do not depend on conscious detection. Hypnotically suggested blindness or deafness appears to affect explicit perception while sparing implicit perception (e.g. the subject avoids walking into a table that he or she does not consciously see). Similarly, hypnotic suggestions for motor behaviors may be said to affect explicit forms of action, which are consciously directed, but not implicit forms, which are stimulus driven and automatic. Kihlstrom (1994) made the same argument for the dissociative disorders: they affect the explicit forms of action, perception and memory, while leaving their implicit forms intact. The dissociated experience theory of hypnosis also has strong conceptual links with other forms of psychopathology. Frith et al. (2000) discussed a wide variety of pathological abnormalities in the awareness of action. They argued that these generally involve faulty efference copy mechanisms, reflecting disrupted inter-relationships between representations of intended actions, in the prefrontal and premotor cortex, and representations of the current and predicted state of the motor system, in the parietal cortex and cerebellum. Indeed, Blakemore et al. (2003) have applied this model to the hypnotic experience of self-produced actions that are experienced as externally caused. Similarly, positive or first-rank symptoms in schizophrenia, such as hallucinations and delusions of control, may be the results of defective executive monitoring, whereby external stimuli and causes are not discriminated from internally generated thoughts (Feinberg, 1978; Bentall, 1990; Frith, 1992). Frith’s explanation of such positive symptoms as defects in executive monitoring is almost identical to the dissociated experience account of hypnosis: Patients with these symptoms are no longer aware of the ‘sense of effort’ or the prior intention that normally accompanies a deliberate act. … In the absence of an awareness of their own intentions, patients will experience their actions and thoughts as being caused, not by themselves, but by some

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alien force. A similar argument can be applied to auditory hallucinations. The patients perceive their own thoughts … as emanating, not from their own intentions, but from some source that is not under their control (Frith, 1992, pp.114–115).

There have been attempts to characterize more directly the failure in monitoring in this wide spectrum of phenomena. One speculation is that there is an underlying disturbance of ‘metarepresentation’ (second-order representation), or the capacity to entertain a representation of the self doing something. Perner (1993, p. 129) noted that without metarepresentation, a person lacks ‘that aspect in which a belief (thinking that) differs from mere thoughts, images (thinking of) and the like’. Frith (1992, p. 130) has proposed that for self-initiated mental acts, ‘the appropriate metarepresentation may depend upon an interaction between prefrontal cortex and those parts of the brain concerned with the primary representations that are the content of the relevant proposition’. Thus, poor integration of frontal and posterior or subcortical regions may correspond to faulty metarepresentation, and hence phenomena such as delusions of control and hallucinations. Another speculation is that the crucial aspect of monitoring that is involved is a felt or emotive component. The philosopher Proust (2003), in discussing anomalous perceptions of one’s own intentions due to faulty efference binding, characterized the experience of intention as follows: The impression of being or not being the agent in one’s actions is not inferred from what one believes and desires. It is a genuine, direct feeling, experienced dynamically in the changing world, a feeling functionally independent of the specific content of the corresponding intention (p. 317).

Likewise, another feeling that may be central in hypnotic responding is the sense of external reality. William James (1890) argued, ‘In its inner nature, belief or the sense of reality, is a sort of feeling more allied to the emotions than anything else’ (p. 283, italics in the original). Similarly, Jaspers (1963) noted, ‘Conceptual reality carries conviction only if a kind of presence is experienced’; however, this feeling of presence tends to be taken for granted until it is ‘disturbed pathologically and so we appreciate that it exists’ (pp. 93–94).

Woody and Szechtman (2000) have dubbed these felt experiences ‘feelings of knowing’, and they speculated that hypnosis may exert its effects by affecting such feelings of knowing. There is evidence that such felt components are extremely potent, as shown in psychopathological conditions such as delusional misidentification syndromes and derealization. For example, in Capgras delusion, the patient recognizes the face, tone of voice, and so forth of another person, such as a parent, yet denies their authenticity and insists that he or she is an imposter. Ellis and Young (1990) proposed that this condition is caused by the lack of an emotional ‘glow’ that normally accompanies the perception of a familiar person. Accordingly, Ellis and Lewis (2001) have discussed the neural mechanisms underlying perceptual recognition as involving two parallel streams, an overt/cognitive recognition route and a covert/affective recognition route, which are then integrated. It is fascinating that in Capgras delusion the lack of the covert, felt response is sufficient to overturn the rest of the patient’s perceptual detection mechanisms, which apparently are normal. This work suggests that ‘explicit’ perception, as discussed by Kihlstrom (1994), actually involves both an overt, cognitive component and a covert, affective component. Because of its covert quality, this affective component may appear to resemble implicit perception; however, Ellis and Lewis specifically argued that it is distinguishable from what Kihlstrom calls implicit perception. Alterations in such covert, affective components are what Woody and Szechtman (2000) proposed may underlie hypnotic effects. A further question of great interest is why hypnosis would create such alterations in feelings of knowing. What is it about the social context of hypnosis that leads to these changes? Woody and Szechtman (2007) argued that it may be promising to consider hypnosis as a circumstance that, perhaps inadvertently, taps into a pre-existing mental system that evolved for managing particular types of social behavior. One likely candidate for such a system is the one that originated to co-ordinate a group under a leader, such that group members’ perceptions and actions are entrained to the leader’s behavior. This system allows a group to function as if it has a unitary level of executive control, which

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has crucial survival value to virtually all mammals that live in groups (Wilson, 1975) and thus probably has fundamental neurophysiological underpinnings. In short, the shift in the determinants of feelings of knowing in hypnosis may reflect the engagement of a particular system for responding in a subordinate role to a dominant other, such that the words of the hypnotist tend to elicit feelings that direct perception and behavior, and higher, more autonomous contributions to information processing are temporarily weakened. Finally, the dissociated experience theory of hypnosis has interesting implications for the experience of effort in hypnosis. Namely, the perceived sense of effort, being at least partly illusory, should be quite manipulable through suggestion. Such manipulation of the sense of effort has fascinating effects. Williamson and his colleagues hypnotically manipulated the sense of effort during cycling through suggestions of level, uphill or downhill grades (Williamson et al., 2001). This manipulation elicited corresponding cardiovascular changes and patterns of brain activation probably involved in the integration of the sense of effort. Earlier studies had also shown respiratory changes in response to hypnotic manipulations of the sense of effort (Morgan et al., 1973, 1976). In another study, Williams and his colleagues used a hypnotic suggestion of imagined handgrip exercise, without any ongoing real exercise, unlike the cycling study. Patterns of brain activation showed the regulation of effort, even independent of muscle activity and muscle afferent feedback. The researchers interpreted the activation patterns as follows: ‘An individual’s sense of effort as interpreted by the anterior cingulate cortex (ACC) could potentially serve as a feedback signal, which is routed through the insular cortex to effect appropriate autonomic modulation’ (Williamson et al., 2002, p. 1323). In summary, despite Bowers’s (1992) concerns about the cogency of dissociated experience as a theoretical mechanism, it offers an intriguing account of many hypnotic phenomena. In retrospect, it would seem that Hilgard’s (1992, 1994) key term, ‘amnesic barrier’, had unfortunate connotations (such as the implication that all hypnotic phenomena are inherently amnesic). However, dissociated experience theory can

readily be reformulated without this problematic terminology.

4.4.2. Dissociated control theory Whereas dissociated experience theory focuses on the functional dissociation of executive monitoring, dissociated control theory focuses on the functional dissociation of executive control. The essence of this theory is conveyed by the following statement from Woody and Bowers (1994, p. 57): ‘Hypnosis alters not just the experience of behavior, but how it is controlled’. As mentioned earlier, according to dissociated control theory, hypnotic suggestions are enacted with less of a role for executive control than is typical for otherwise comparable nonhypnotic behavior. Thus, a pure version of this theory stipulates that the hypnotic subject’s experience of nonvolition and effortlessness—rather than being merely an illusion, as in dissociated experience theory— accurately reflects a genuine change in the usual hierarchy of control that governs behavior. Bowers’s (1992) original formulation of the concept of dissociated control highlighted a functional dissociation between executive control and lower subsystems of control, such that in hypnosis the lower subsystems are more directly activated than usual. Woody and Bowers (1994) pointed out that this distinction between two levels of control maps extremely well onto work in cognitive neuroscience concerning the willed versus automatic control of behavior. Specifically, they interpreted and elaborated the concept of dissociated control in terms of the dual-control model proposed by Norman and Shallice (1986). Norman and Shallice (1986) proposed that there are two distinguishable and complementary information-processing systems for the initiation and control of action. Although there is a wide variety of evidence pointing to the existence of two systems, some of the most compelling evidence comes from the study of various neurophysiological disorders, such as frontal lobe damage, in which the two systems can be differentially impaired (Shallice, 1988). In addition, there is considerable neurophysiological work on the structure of the brain supporting a dual-systems model of action (e.g. Goldberg, 1987). Finally, a range of somewhat odd, but

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nonpathological behaviors are intelligible in terms of a dual-systems model, such as action slips (Reason, 1979), in which another purposeful behavior replaces the intended one. (The classic example is William James going upstairs to change for dinner and finding himself putting on pyjamas and getting into bed instead.) In the Norman and Shallice (1986) model, the lower subsystems of control consist of a large number of decentralized action schemas that both compete and co-operate with one another. In the first type of control, called ‘contention scheduling’, the activation level of each schema is a function of environmental stimuli and of input from other schemas that are being activated at the same time. When the activation level of a particular schema surpasses a threshold, it is selected and the corresponding action is carried out, while competing schemas are temporarily inhibited. This type of control handles the selection of actions that are comparatively routine and stimulus driven; i.e. ones that do not require conscious attentional control. For circumstances that demand more novel responses or the overcoming of a strong habitual response, there is a second type of control, called the ‘supervisory attentional system’, which is centralized and highly flexible. The supervisory system both monitors activity in the contention-scheduling system and has access to the person’s higher-level goals. However, according to Norman and Shallice (1986), this executive, higher-level system influences action only indirectly, through biasing the activation levels of the schemas involved in the contentionscheduling process. Thus, rather than directly controlling behavior, the supervisory system operates by modulating contention scheduling. According to this dual-systems model, the individual’s experience of an action reflects the various ways the supervisory system may be involved. If the supervisory system is modulating the contention-scheduling process, the person has the conscious experience of will, or deliberate, effortful control. If the supervisory system is monitoring the contention-scheduling process but not modulating it, then the person has the conscious experience of the action immediately following the idea of it in the mind, which William James (1890) called ‘ideomotor’ to distinguish it from the experience of

a fully willed act. Finally, if the supervisory system is neither monitoring nor modulating the contention-scheduling process, the person experiences the action as automatic, not involving will. This model provides an attractive framework for understanding the altered experience of volition in hypnosis. Hypnosis, in highly susceptible people, may be conceptualized as changing the balance between the supervisory and contention-scheduling levels of control, such that the supervisory level is comparatively weakened. Because it is the operation of this higher level of control that is associated with the phenomenal experience of will, the hypnotic subject would therefore experience a weakened sense of will. The person’s responses would be especially dependent on the contention-scheduling level of control, and therefore more contextually dependent and stimulus driven than usual, and this control would not be as readily redirected in a deliberate manner. Thus, the experience of hypnotic involuntariness would be an accurate reflection of an underlying alteration in the hierarchy of control. The dissociated control theory explains not only the core hypnotic experience of involuntariness but also a range of other hypnotic phenomena quite differently from dissociated experience theory. Referring again to the major classes of hypnotic behavior in Table 4.1, we first consider motor actions. In standardized hypnosis scales, the distinction between facilitating and blocking types of suggestion corresponds to what are known as direct motor suggestions and motor challenge suggestions. These two types of suggested motor responses also differ in other important ways: (1) the direct motor suggestions tend to be much easier than the motor challenge suggestions; (2) the two types of suggestion form clearly separate factors, even controlling for the difference in difficulty (e.g. Woody et al., 2005); and (3) direct motor suggestions are quite strongly correlated with nonhypnotic suggestibility, whereas motor challenge suggestions are not (Woody et al., 1997). These differences indicate that the processes underlying the response to each type of suggestion may be distinct. The Norman and Shallice (1986) model casts an intriguing light on this distinction. Direct motor suggestions are so easy that virtually no

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supervisory modulation is needed to enact them. As the hypnotist directs attention to the act, the supervisory system monitors it, and the corresponding subjective experience is of the ideomotor type, which is neither clearly willed nor entirely unwilled. The hypnotic context biases this ambiguity by offering the subject the widely known idea that something about hypnosis causes such an act, rather than the subject’s will. In other words, no alteration of control in hypnosis is needed to explain the experience of nonvolition in response to direct motor suggestions. In contrast to direct motor suggestions, motor challenge suggestions appear to make an explicit appeal for the involvement of the supervisory system. In these suggestions, there is some initially suggested state of affairs, such as arm rigidity, followed by the instruction to try to overcome it, such as by bending one’s arm. Carrying out the instruction to try means the subject must attempt to exert will, and this exertion corresponds, in Norman and Shallice’s (1986) model, to the supervisory system making a bid to modulate contention scheduling. However, because of the hypnotic alteration of control, the subject may have the experience that effortful attention is less effective than it is outside hypnosis: willing does not work as well as it usually does. Thus, motor challenge suggestions, unlike direct motor ones, seem to be paradigmatic for the dissociated control theory of hypnosis. Another major class of hypnotic behavior explained readily by dissociated control theory is hypnotic alterations of memory. Shallice (1988) posited that for memory, as for action, the supervisory system offers a higher-order control system to assist with the management of nonroutine problems—in this case, ones that cannot be managed well by lower-level memory retrieval routines. Norman and Bobrow (1979) argued that in response to a nonroutine memory retrieval problem, the supervisory system formulates descriptions of what the relevant memories would be like if they existed, matches these descriptions with records to find likely candidates, and checks these candidates to verify their relevance (see also Conway, 2005). Accordingly, if hypnosis disrupts the contribution of the supervisory system, as posited by dissociated control theory, it should interfere

with some memory functions while leaving others unaffected. In particular, it should interfere with memory functions that are heavily dependent on the description and verification phases of supervisory system-directed memory processes. With regard to facilitating suggestions for memory (including inadvertent ones), hypnosis should interfere with verification; i.e. the ability to discriminate appropriate or accurate records from inappropriate or inaccurate ones. Consequently, hypnotic subjects should tend to mistake irrelevant or incorrect associations for the required memories and be falsely confident that these associations match the searched-for material. The evidence on hypnotic distortion of memory is consistent with these implications (Dywan and Bowers, 1983; Laurence and Perry, 1983; Orne et al., 1988). With regard to blocking suggestions for memory, hypnosis should interfere with access to memories when they require the formulation of preliminary descriptions, as in free recall, but not when they are externally cued, as in cued recall and recognition. Memory tasks that provide external cues should be relatively spared because these cues obviate the need for preliminary descriptions. The evidence on hypnotic amnesia is broadly consistent with these implications, in that hypnotic amnesia differentially impairs free recall, while leaving recognition and implicit memory tasks relatively unaffected (Kihlstrom and Shor, 1978; Evans, 1979; Kihlstrom, 1980; McConkey et al., 1980; McConkey and Sheehan, 1981; Spanos et al., 1982; Barnier et al., 2001). Finally, we turn to the explanation of hypnotic effects on sensation and perception. Woody and Bowers (1994) did not propose any dissociated control explanation for positive hallucinations, and it remains unclear how this might be done. Nonetheless, they did propose an explanation for the most important type of negative hallucination, namely analgesia. A key aspect of pain is that it grabs attentional resources in a peremptory way (McCaul and Malott, 1984). Norman and Shallice (1986) discuss such attention-grabbing qualities in terms of the computer science concept of an interrupt. That is, certain triggers may break in on any ongoing deliberative activity in the supervisory system by producing an interrupt, a signal of

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emergency or high priority. Many of the distressing and disrupting effects of pain result from these interrupts. Accordingly, Woody and Bowers (1994) proposed that a major component of hypnotic analgesia may be a diminished sensitivity of the supervisory system to such interrupts. With hypnosis, they argued, the capacity for pain to break in at the supervisory level may be lessened; in effect, pain would no longer draw attention to itself. Because a monitoring process would need to generate the interrupt, this explanation appeals to a dissociation of executive control from executive monitoring (i.e. a weakened path d in Figure 4.2), rather than a dissociation of executive control from subsystems of control (a weakened path b). Thus, in hindsight, it arguably falls within what we have called second-order dissociated control theory. Although the dissociated experience and dissociated control explanations for certain hypnotic phenomena are strikingly different, it is worth reiterating that the two types of underlying processes are not necessarily incompatible with each other; i.e. hypnosis may possibly bring about changes in both executive monitoring and executive control. In conceptually similar theories of psychopathology, the two corresponding types of processes are not regarded as inconsistent. For example, Frith (1992) interpreted the positive symptoms of schizophrenia, such as delusions of control and hallucinations, as ‘disorders of self-monitoring’, reflecting the failure to track intentions and executive effort. This explanation is akin to the dissociated experience explanation of hypnosis. He interpreted the negative symptoms of schizophrenia, such as avolition and lack of spontaneous behavior, as ‘disorders of willed action’, reflecting the failure of the supervisory system to modulate the lower subsystems of control. This explanation is akin to the dissociated control explanation of hypnosis. Moreover, Frith viewed both types of symptoms as dysfunctions of the same underlying dual system for the control of action. With regard to the neural basis for this system, he located the supervisory system in prefrontal regions—involving the dorsolateral prefrontal cortex, ACC and supplemental motor area, all interacting with one another—and the contention-scheduling system in subcortical

regions—the basal ganglia and the ventrolateral nucleus of the thalamus. The two systems are believed to interact through corticostriatal loops (Alexander et al., 1986), and Frith hypothesized that functional dissociations (or poor integration) between these two systems lead to both positive and negative schizophrenic symptoms. There are several lines of evidence in support of the dissociated control theory of hypnosis. One of the most important is a series of laboratory studies that Bowers and his colleagues conducted in the 1990s, the main thrust of which was to show that hypnotic phenomena do not operate through effortful control or other deliberate cognitive strategies. For example, Miller and Bowers (1993) showed that, unlike a cognitive-behavioral stress inoculation procedure, hypnotic analgesia did not impair concurrent performance on a cognitively demanding task, indicating that hypnotic analgesia occurs with little or no cognitive effort. Hargadon et al. (1995) demonstrated that hypnotic analgesia was just as effective in the absence of any deliberate cognitive strategies, such as engaging in counter-pain imagery. Eastwood et al. (1998) verified that hypnotic analgesia required low attentional resources or cognitive load, unlike stress inoculation. Similarly, another series of studies showed that hypnotic amnesia does not depend on any of a variety of proposed effortful cognitive strategies (Bowers and Davidson, 1991; Davidson and Bowers, 1991; Bowers and Woody, 1996; see also King and Council, 1998). Another approach is to measure cognitive effort during hypnosis indirectly. For example, Ruehle and Zamansky (1997) gave hypnotic and simulating subjects the suggestions to forget one number (8 or 11) and replace it with another number (9 or 12, respectively). Then they asked the participants to do addition problems involving these numbers in the solutions, and, as a baseline condition, they also had them do similar addition problems without a suggestion. In one study, Ruehle and Zamansky used decreased time estimation as a measure of cognitive effort and found that simulators required cognitive effort to carry out the suggestion, whereas the hypnotized participants did not. In another study, these investigators used the time required to carry out a suggested behavior as a measure of cognitive effort. Simulators complying with

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the suggestion were slower than control participants doing the same problems without the suggestions, whereas hypnotic subjects were just as fast as the controls. These results indicate that although simulators expended additional effort to change their numbers, the hypnotized participants did not. Another indirect approach to indexing cognitive effort is the use of heart rate, which increases with effort. Using this approach, Sadler and Woody (2006) showed that in hypnosis, the more vivid imagery of high hypnotizable participants compared to that of their low hypnotizable counterparts required no additional cognitive effort. Of course, the point of all these indirect approaches is to get around the self-report of cognitive effort, which both dissociated-experience and social-cognitive theories posit is an inaccurate measure of actual effort. A different approach to testing dissociated control theory is to focus on its apparent implications for frontal functioning. Because the frontal lobes are the site of executive control and monitoring, a comparatively broad interpretation of dissociated control theory would imply that people who are high in hypnotic susceptibility may show impaired executive cognitive control, and that this impairment may be increased by a hypnotic induction. For example, Woody and Bowers (1994, p. 57) noted, ‘A hypnotic induction, with its typically relentless monotony and many allusions to sleep, may be thought of as releasing lower-level functions from the integration that is normally imposed on them by consciousness’. Accordingly, there have been a few attempts to compare the frontal functioning in people of high versus low hypnotizability, both in and out of hypnosis (e.g. Gruzelier and Warren, 1993; Aikens and Ray, 2001; Kallio et al., 2001). These studies had small sample sizes and may therefore lack statistical power, and their results are rather mixed. Nonetheless, one conclusion that they appear to warrant is that hypnosis does not seem to involve a generalized shutdown of frontal functioning. Farvolden and Woody (2004) conducted a somewhat more focused study of frontal functioning in 30 high and 30 low hypnotizable participants. To subjects in both waking and hypnotic conditions, they administered

a battery of memory measures that are particularly sensitive to frontal functioning. Compared with low hypnotizables, high hypnotizable participants generally performed significantly less well on the frontally mediated memory tasks, but were comparable on control, nonfrontal memory tasks. Although this pattern of findings supports the trait implications of dissociated control theory, the memory performance of high hypnotizable participants was unaffected by hypnosis versus waking conditions, which is inconsistent with the state implications of the theory. Finally, a particularly interesting test of dissociated control theory is an experiment conducted by Jamieson and Sheehan (2004). Their work follows from Kirsch and Lynn (1998), who suggested that dissociated control theory may be tested by examining performance on the Stroop color-naming task. In this task, participants are shown color names presented in actual colors, and they are slower at naming the actual color when it is incongruent with the color word. The conscious selection of the correct response (saying the color) in the face of the stronger automatic response tendency (reading the word) is a prototypical executive function (Stuss et al., 1995). Thus, Kirsch and Lynn proposed that if hypnosis weakens frontal executive functioning, as hypothesized in dissociated control theory, then the performance on the Stroop task should decline in hypnosis, particularly for high hypnotizable participants. Several studies show exactly this type of effect (Sheehan et al., 1988; Kaiser et al., 1997; Nordby et al., 1999). However, their results are open to alternative interpretations due to confounds such as the effects of relaxation and preparatory strategies. Therefore, Jamieson and Sheehan (2004) carefully designed an experiment to deal with these confounds; their study also used ample samples of 66 high and 66 low hypnotizable participants. Consistent with dissociated control theory, they found that Stroop task errors increased significantly for high hypnotizable participants in hypnosis, but not for their low hypnotizable counterparts. Other results were also consistent with dissociated control theory. For example, the use of self-directed strategies, such as rehearsal, was significantly lower in high than low hypnotizables, particularly in the hypnosis condition.

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In accordance with a proposal by Woody and Farvolden (1998), Jamieson and Sheehan (2004) argued that what may look like attentional virtuosity in high hypnotizables is really a perseverative inability to disengage from the ongoing focus of attention: The deeply absorbed experiences that characterize high susceptibles, both in hypnosis and in daily life, are not the products of more efficient frontal networks of attentional control. Rather, they result from a perseveration in the object or theme of current awareness, due to the temporary and partial inhibition of these very processes of attentional control (p. 245).

This seeming paradox that weakened control could look like heightened control is explained more fully by second-order dissociated control theory, to which we now turn.

4.4.3. Second-order dissociated

control theory Whereas dissociated control theory, as originally proposed by Woody and Bowers (1994), focuses on the functional dissociation of lower subsystems of control from executive control (a weakened path b in Figure 4.2), second-order dissociated control theory, as proposed by Jamieson and his colleagues (Jamieson and Sheehan, 2004; Egner et al., 2005; Jamieson and Woody, 2007), focuses on the functional dissociation of executive control from executive monitoring (a weakened path d). Let’s consider a pure form of this theory, in which lower subsystems of control remain integrated with executive control (i.e. path b is not weakened), but executive control is cut off from executive monitoring. According to this view, the modulation of subsystems of control by executive control, representing a first level of cognitive control, is intact, whereas the feedback from executive monitoring to executive control, representing a second level of cognitive control, is disrupted. The normal function of such feedback is to allow adjustments of executive control by providing information about the effectiveness of the existing control, thereby making control more flexible and sensitive to changing task requirements (Cohen et al., 2004). Accordingly, if the effect of hypnosis is to disrupt this feedback, the hypnotic subject

should be able to modulate behavior at the first level of executive control, based on higher goals and rules, but relatively unable to adjust this control flexibly in the light of executive monitoring of response conflict, discrepancies, and the like. One implication is that executive control would not be as flexible and complex as it is in nonhypnotic circumstances. Another implication is that the executively monitored effects of suggestions may become quite divergent from the aims of an unchanging control program that is enacting them, because these effects do not lead to the usual executive adjustments to such a program. The dissociation of executive monitoring from executive control provides another explanation of the phenomenon of hypnotic involuntariness. In a reformulation of Norman and Shallice’s (1986) dual-control model, Perner (2003, p. 239) noted, ‘Intentional action is defined by the match between what the lower level produces and what the higher level stipulates should be done’. Accordingly, if hypnosis interferes with the fine-tuning of executive control by executive monitoring, the mismatches that result should be experienced as nonvolitional. Other theorists have also attached great importance to such mismatches. For example, Haggard (2003, p. 126) proposed the following: ‘The efferent binding process could have the dual function of bringing to consciousness mismatches between intention and action, and of making possible … consciousness of the relations between my intentions and my actions’. He argued that these aspects of consciousness are critical to the sense of self-agency, as well as the sense of self more generally. Thus, it stands to reason that if hypnosis increases mismatch due to the functional dissociation of executive control from monitoring, these mismatches would strikingly alter the hypnotic subject’s sense of agency. A pure version of second-order dissociated control theory has another potentially attractive implication. Because the first level of cognitive control—the governing of lower subsystems of control by executive control—would be intact, it would allow greater novelty in hypnotic responses than the original dissociated control theory, in which the lower subsystems are hypothesized to be relatively independent from

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executive control. Recall that a prime function of executive control, as advanced in Norman and Shallice’s (1986) model, is to foster the generation of novel behavior when the circumstances require it. Although some excellent hypnotic subjects do not seem to engage in such novelty generation, others evidently do. For example, the Experiential Analysis Technique (Sheehan and McConkey, 1982; McConkey, 1991; Sheehan, 1991) indicates that some highly hypnotizable subjects are quite cognitively active, devising sometimes fairly complex strategies in the face of the challenges posed by suggestions. To illustrate, McConkey et al. (1989) performed a detailed analysis on two hypnotic virtuosos and found that whereas one reported that the effects suggested by the hypnotist just happened passively by themselves, the other reported using a variety of cognitive strategies to respond to suggestions. Although the passive experience style of hypnotic responding is more consistent with the original formulation of dissociated control, the cognitively active style is more consistent with second-order dissociated control theory. Second-order dissociated control theory maps beautifully onto the neuropsychological model of cognitive control developed by Cohen and his colleagues (Cohen et al., 2004). This model distinguishes between the two levels of control in the executive system. The first is implemented by goal representations in the prefrontal cortex that enable nonroutine responses. The second is implemented by attentional monitoring that enables the adjustment of control based on the detection of interference or conflict in the processes being influenced by the currently active representations. This conflictmonitoring function is subserved by the ACC (Botvinick et al., 2001; Kerns et al., 2004; Ridderinkhof et al., 2004), which provides feedback for appropriate control adjustments. In particular, conflict detection serves as a signal to strengthen further the bias in appropriate task-relevant subsystems. Such recruitment of control resources is subserved by the left dorsolateral prefrontal cortex (Botvinick et al., 2004). Thus, this conflict-monitoring model of cognitive control distinguishes between executive monitoring and executive control, and locates major aspects of these functions anatomically.

MacDonald et al. (2000) developed a methodology using the Stroop task and functional magnatic resonance imaging (fMRI) so that they could separately measure the cognitive-control function of the dorsolaternal prefrontal cortex and the conflict-monitoring function of the ACC. Egner et al. (2005) used this paradigm to examine changes in cognitive control in hypnosis. Consistent with previous work by MacDonald and colleagues, they identified conflict-related activation in the ACC by contrasting high versus low response conflict conditions (color-naming incongruent trials versus, for example, word-naming congruent trials). Likewise, they identified demand-for-control activation in the left dorsolateral prefrontal cortex by contrasting high versus low control conditions (colornaming trials versus word-naming trials). For the regions of the ACC most sensitive to response conflict, Egner et al. (2005) found a statistically significant interaction of hypnotizability and hypnotic condition. Hypnosis increased conflict-related activation for the high hypnotizable individuals, but not for their low hypnotizable counterparts. The researchers interpreted this finding as showing decreased efficiency of the cognitive control system for the high hypnotizables under hypnosis, strongly consistent with the original version of dissociated control theory. However, they found no differences between high and low hypnotizable individuals in demand for cognitive control, as indexed by activation in the left dorsolateral prefrontal cortex. Thus, there seemed to be no difference in executive control, which is somewhat inconsistent with the original version of dissociated control theory. The cause of the lack of difference in executive control was elucidated by an EEG component of the study by Egner et al. (2005). They examined coherence, a measure of functional connectivity, between the left frontal and frontal midline recording sites, reflecting electrophysiological activity in the left lateral prefrontal cortex and ACC, respectively. In this way, they were able to assess the degree of integration between executive control and executive monitoring functions. The results indicated that in highly hypnotizable individuals under hypnosis, there is a breakdown in the integration of these functions during ongoing cognitive control.

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This finding strongly supports what we have called second-order dissociated control theory. Specifically, for highly hypnotizable individuals under hypnosis, the increased conflict-related activation in the ACC indicates mismatch of executive control with task demands, yet this mismatch fails to modulate ongoing demands for cognitive control in the dorsolateral prefrontal cortex. The neural underpinnings of second-order dissociated control theory crucially involve the ACC. Increased activation in the ACC is the most consistent finding in brain imaging studies of hypnotic suggestions and the hypnotic state (e.g. Rainville et al., 1997, 2002; Crawford et al., 1998; Szechtman et al., 1998; Faymonville et al., 2000; Derbyshire et al., 2004). However, the regions within the ACC that are activated differ somewhat across these studies. Jamieson and Woody (2007) have related these findings to recent research examining the integration of the affective functions of the ACC with its conflict-monitoring functions. The dorsal regions of the ACC appear to specialize in the detection of conflict, and this information is subsequently evaluated in more rostral regions of the ACC for its relationship to motivationally relevant outcomes. This evaluative monitoring, in turn, may then trigger adaptive changes in cognitive control. However, any such tidy picture of how the ACC is related to hypnotic responding is complicated by the findings of Raz et al. (2005). They found that a post-hypnotic suggestion to perceive words as nonsense strings led to decreased activity in the ACC during a Stroop task, suggesting superior conflict resolution (see also Sheehan et al., 1988; Raz et al., 2002). Thus, with appropriate hypnotic suggestions, the cognitive control of highly hypnotizable individuals appears to be quite malleable. In summary, second-order dissociated control theory focuses on breakdown in integration between executive functions within anterior regions of the brain, rather than breakdown in integration between anterior and subcortical or posterior regions, as implied by the original version of dissociated control theory. In addition, it paints a rather different picture of the highly hypnotizable person in hypnosis. It suggests that, rather than being frontally challenged, as implied by the original dissociated

control theory, highly hypnotizable individuals can set up unusual cognitive control programs and then sustain them in a quasi-perseverative fashion, whereas for low hypnotizables such strategies would be overturned by conflict monitoring. This idea has broad applicability to hypnotic phenomena. For example, consider the hypnotic suggestion that one’s arm is rigid like a bar of iron and one cannot bend it, despite the effort to do so. Both high and low hypnotizables can imagine and attempt to enact this suggested state of affairs, but for low hypnotizables conflict monitoring would feed in information indicating that reality, in the form of the state of one’s arm muscles, is inconsistent with this imagined state of affairs. Thus, for them the suggestion never becomes more than a tenuous imagining. In contrast, according to secondorder dissociated control theory, high hypnotizables are relatively unaffected by such reality testing (i.e. is the state of one’s muscles actually consistent with the attempt to bend one’s arm?). Therefore the actual state of their arm does not interfere with the phenomenological qualities of the suggested experience. In short, the dissociation of conflict monitoring from cognitive control unhooks the highly hypnotizable subject to some extent from the constraints of reality. Second-order dissociated control theory, with its emphasis on the isolation of control from executive monitoring, may provide an interesting perspective on other empirical findings in hypnosis research. To illustrate, Bryant and Wimalaweera (2006) found that during hypnosis the attempted suppression of an embarrassing thought led to its increased accessibility in low hypnotizable participants, but not in highs. Because such accessibility stems from an underlying monitoring process (Wenzlaff and Wegner, 2000), these results are consistent with the hypothesis that during hypnosis, monitoring is dissociated from control in highly hypnotizable individuals.

4.5. Conclusion It remains to be seen whether one of the foregoing dissociative mechanisms will prevail over the others in future research. An alternative possibility, as originally favored by Hilgard, is

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to conceptualize hypnosis in terms of a fluid plurality of dissociative mechanisms. Understanding hypnosis involves tough issues such as, how does volition work, and what is the nature of awareness? It also touches on philosophical problems such as, how does one know what is real, and what is free will? In short, hypnosis seems to lie at the crossroads of some of the most challenging problems in comprehending the nature of the mind. Thus, although understanding hypnosis is difficult, it is also potentially rewarding for its promise of illuminating a much broader range of human behavior. However, the empirical literature on hypnosis is immense, diverse and contradictory. The only hope for welding this mass into something truly enlightening is the development of stronger theory. In an interesting discussion of how results in the social sciences are confusing and misleading in the absence of strong theory, Hirsch (2002) quotes the eminent physicist Pauli, who once quipped about a scientific paper, ‘It is not even wrong’. Dissociation theories of hypnosis are at least wrong. And in some ways they may turn out to be right.

Acknowledgments Preparation of this chapter was supported by a grant from the Natural Sciences and Engineering Research Council of Canada to Erik Woody and a grant from the Social Sciences and Humanities Research Council of Canada to Pamela Sadler.

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Sheehan, P. W. and McConkey, K. M. (1982) Hypnosis and Experience: The Exploration of Phenomena and Process. Hillsdale, NJ, Erlbaum. Sheehan, P. W., Donovan, P. B. and MacLeod, C. M. (1988) Strategy manipulation and the Stroop effect in hypnosis. Journal of Abnormal Psychology, 97: 455–460. Shor, R. E. and Orne, E. C. (1962) Harvard Group Scale of Hypnotic Susceptibility. Consulting Psychologists Press, Palo Alto, CA Shor, R. E., Orne, M. T. and O’Connell, D. N. (1962) Validation and cross validation of a scale of selfreported personal experiences which predicts hypnotizability. Journal of Psychology, 53: 55–75. Sidis, B. (1899/1973) The Psychology of Suggestion. D. Appleton, New York. Reprinted in 1973, Arno Press, New York. Spanos, N. P. (1986) Hypnotic behavior: a socialpsychological interpretation of amnesia, analgesia, and ‘trance logic.’ Behavioral and Brain Sciences, 9: 449–467. Spanos, N. P. (1987) Hypnotic behavior: special process accounts are still not required. Behavioral and Brain Sciences, 10: 776–781. Spanos, N. P. (1991) A sociocognitive approach to hypnosis. In S. J. Lynn and J. W. Rhue (ed.) Theories of Hypnosis: Current Models and Perspectives, pp. 324–361. Guilford Press, New York. Spanos, N. P. and Burgess, C. (1994) Hypnosis and multiple personality disorder: a sociocognitive perspective. In S. J. Lynn and J. W. Rhue (ed.) Dissociation: Clinical and Theoretical Perspectives, pp. 136–155. Guilford Press, New York. Spanos, N. P. and Coe, W. C. (1992) A social-psychological approach to hypnosis. In E. Fromm and M. R. Nash (ed.) Contemporary Perspectives in Hypnosis Research, pp. 102–130. Guilford Press, New York. Spanos, N. P., Mah, C. D., Pawlak, A. E., D’Eon, J. L. and Ritchie, G. (1980) A multivariate and factor analytic study of hypnotic susceptibility. Unpublished manuscript, Carleton University, Ottawa, Ontario. Spanos, N. P., Radtke, H. L. and Dubreuil, D. L. (1982) Episodic and semantic memory in posthypnotic amnesia: a reevaluation. Journal of Personality and Social Psychology, 43: 565–573. Spiegel, D. (1990) Hypnosis, dissociation, and trauma: hidden and overt observers. In J. L. Singer (ed.) Repression and Dissociation: Implications for Personality Theory, Psychopathology, and Health, pp. 121–142. University of Chicago Press, Chicago. Stuss, D. T., Shallice, T., Alexander, M. P. and Picton, T. W. (1995) A multidisciplinary approach to anterior attentional functions. Annals of the New York Academy of Sciences, 769: 191–211. Szechtman, H., Woody, E. Z. Bowers, K. S. and Nahmias, C. (1998) Where the imaginal appears real: a positron emission tomography study of auditory hallucinations. Proceedings of the National Academy of Sciences, USA, 95: 1956–1960. Tellegen, A. (1978/1979) On measures and conceptions of hypnosis. American Journal of Clinical Hypnosis, 21: 219–237.

Völgyesi, F. A. (1966) Hypnosis of Man and Animals, 2nd edn.. Williams and Wilkins, Baltimore, MD. Wagstaff, G. F. (1991) Compliance, belief, and semantics in hypnosis: a nonstate, sociocognitive perspective. In S. J. Lynn and J. W. Rhue (ed.) Theories of Hypnosis: Current Models and Perspectives, pp. 362–396. Guilford Press, New York. Wagstaff, G. F. (1998) The semantics and physiology of hypnosis as an altered state: towards a definition of hypnosis. Contemporary Hypnosis, 15: 149–165. Weitzenhoffer, A. M. (1980) Hypnotic susceptibility revisited. American Journal of Clinical Hypnosis, 22: 130–146. Weitzenhoffer, A. M. (1989) The Practice of Hypnotism: Vol. 1. Traditional and Semi-traditional Techniques and Phenomenology. Wiley, New York. Wenzlaff, R. M. and Wegner, D. M. (2000) Thought suppression. Annual Review of Psychology, 51: 59–91. White, R. W. and Shevach, B. J. (1942) Hypnosis and the concept of dissociation. Journal of Abnormal and Social Psychology, 37: 309–328. Williamson, J. W., McColl, R., Mathews, D., Mitchell, J. H., Raven, P. B. and Morgan, W. P. (2001) Hypnotic manipulation of effort sense during dynamic exercise: cardiovascular responses and brain activation. Journal of Applied Physiology, 90: 1392–1399. Williamson, J. W., McColl, R., Mathews, D., Mitchell, J. H., Raven, P. B. and Morgan, W. P. (2002) Brain activation by central command during actual and imagined handgrip under hypnosis. Journal of Applied Physiology, 92: 1317–1324. Wilson, E. O. (1975) Sociobiology: The New Synthesis. Harvard University Press, Cambridge, MA. Woody, E. Z. and Bowers, K. S. (1994) A frontal assault on dissociated control. In S. J. Lynn and J. W. Rhue (ed.) Dissociation: Clinical and Theoretical Perspectives, pp. 52–79. Guilford Press, New York. Woody, E. Z. and Farvolden, P. (1998) Dissociation in hypnosis and frontal executive function. American Journal of Clinical Hypnosis, 40: 206–215. Woody, E. Z. and McConkey, K. M. (2003) What we don’t know about the brain and hypnosis, but need to: a view from the Buckhorn Inn. International Journal of Clinical and Experimental Hypnosis, 51: 309–338. Woody, E. Z. and Sadler, P. (1998) On reintegrating dissociated theories: comment on Kirsch and Lynn (1998). Psychological Bulletin, 123: 192–197. Woody, E. Z. and Szechtman, H. (2000) Hypnotic hallucinations: toward a biology of epistemology. Contemporary Hypnosis, 17: 4–14. Woody, E. Z. and Szechtman, H. (2007) To see feelingly: emotion, motivation, and hypnosis. In G. A. Jamieson (ed.) Hypnosis and Conscious States: The Cognitive Neuroscience Perspective, pp. 241–255. Oxford University Press, Oxford. Woody, E. Z., Bowers, K. S. and Oakman, J. M. (1992) A conceptual analysis of hypnotic responsiveness: experience, individual differences, and context. In E. Fromm and M. Nash (ed.) Contemporary Perspectives in Hypnosis Research, pp. 3–33. Guilford Press, New York.

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Woody, E. Z., Drugovic, M. and Oakman, J. M. (1997) A reexamination of the role of nonhypnotic suggestibility in hypnotic responding. Journal of Personality and Social Psychology, 72: 399–407.

Woody, E. Z., Barnier, A. J. and McConkey, K. M. (2005) Multiple hypnotizabilities: differentiating the building blocks of hypnotic performance. Psychological Assessment, 17: 200–211.

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CHAPTER 5

Social cognitive theories of hypnosis Steven Jay Lynn, Irving Kirsch and Michael N. Hallquist

5.1. Introduction On the face of it, a person’s experience during hypnosis is quite amazing. Many people report that ordinarily unremarkable actions such as lifting a hand have a startling involuntary quality; they experience unusual changes in sensations such as pain; they see things that are not present, and do not see things that are present; they feel that time is slowing down or speeding up; and they display the curious inability to recall the events of hypnosis when amnesia is suggested to them. Indeed, from a social cognitive perspective, hypnosis might well be defined as a situation in which people respond to imaginative suggestions of this sort, regardless of whether a formal hypnotic induction or even the term ‘hypnosis’ have been used (Hilgard, 1973; Kirsch, 1997, 2003). These sorts of changes in thoughts, feelings, actions and sensations appear to be so out-of-the-ordinary that they clearly imply that something extraordinary happens during hypnosis (e.g. Hilgard, 1965; Spiegel and Spiegel, 1978; Erickson, 1980; Edmonston, 1981; Spiegel, 1998). Indeed, for more than 200 years, the dominant view of hypnosis is that it activates special abilities, produces a trance or profoundly altered state of consciousness and compromises a person’s sense of agency. For more than a century, it was assumed that a trance or altered state of consciousness is

responsible for the seemingly remarkable effects of hypnosis. In these early theories, it was assumed that the trance state was a necessary precursor for the production of hypnotic experiences and behaviors, so much so that the presence of a trance was inferred from the presence of the behaviors. Thus, hypnotized subjects showing hallucinations were assumed to be in a deep trance, whereas those who only responded to easier suggestions were assumed to be in a lighter trance. The traditional trance explanation of hypnosis was challenged by the results of the first sustained series of experimental studies of hypnosis (Hull, 1933). In Hull’s studies, the exact same hypnotic suggestions were given with and without induction of hypnosis. These experiments revealed that the effect of inducing hypnosis is relatively small—‘probably far less than the classical hypnotists would have supposed had the question ever occurred to them’ (Hull, 1933, p. 298)—and that hypnotic and nonhypnotic suggestibility is very highly correlated. Hull’s research has since been replicated in several other laboratories (Weitzenhoffer and Sjoberg, 1961; Barber and Glass, 1962; Hilgard and Tart, 1966; Tart and Hilgard, 1966; Braffman and Kirsch, 1999, 2001), all using the same basic design and yielding the same basic results. In all of these studies, waking or nonhypnotic suggestibility was defined as

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responsiveness to imaginative suggestions without a prior hypnotic induction, whereas hypnotic responsiveness was defined as responsiveness following an induction. Conceptually, hypnotizability is the difference between waking and hypnotic suggestibility (see Hilgard, 1965; Weitzenhoffer, 1980), but it is rarely measured in this manner (for exceptions, see Braffman and Kirsch, 1999, 2001). Hull’s (1933) interpretation of his data retained the notion of the hypnotic trance as an explanatory or causal factor, but limited its impact to the relatively small increase in suggestibility that is produced by the hypnotic induction. As Hull phrased it, ‘no phenomenon whatever can be produced in hypnosis that cannot be produced to lesser degrees by suggestions given in the normal waking condition’ (Hull, 1933, p. 391). The essential question, as Hull saw it, was to establish why the hypnotic trance produced this effect. This view of hypnosis was later echoed by Hilgard (1965) in his altered state theory of hypnosis, and was supported by a series of studies showing that unhypnotized suggestible subjects can respond even to the most difficult suggestions for cognitive and perceptual alterations (Glass and Barber, 1961; Weitzenhoffer and Sjoberg, 1961; Barber and Glass, 1962; Hilgard and Tart, 1966). More recently, however, some theorists have resurrected the idea that at least some hypnotic responses cannot occur without the induction of a hypnotic state (e.g. Spiegel and Spiegel, 1978; Gruzelier, 1998; Kosslyn et al., 2000; Kallio and Revonsuo, 2003). In the 1950s and 1960s, social cognitive theorists (Sarbin, 1950; Barber, 1969) began to elucidate an alternative understanding of hypnosis, one that rejected the idea that a special state of consciousness is needed to explain either the experience of hypnotic suggestions or the increase in suggestibility following the induction of hypnosis. They also rejected the idea that one can infer the presence of a trance state from responses to hypnotic suggestions. Hypnotic responding is widely considered an ability. In that sense, it is similar to the ability to solve mathematical problems or accomplish other cognitive tasks. One does not infer that people are in a mathematical state when they succeed in solving difficult problems or that they are in an intelligent state if they score well on an IQ test. Olympic jumpers are not

in jumping states, and good typists do not have to enter typing states before they can type successfully. The poetry of Shakespeare, the symphonies of Beethoven, the landscapes of Cezanne and the sculpture and architecture of Michelangelo can produce profound and compelling emotional experiences in aesthetically sensitive people. They do so without prior induction of an aesthetic trance, and we do not infer that there is an aesthetic state which is a necessary precursor of those experiences. For the same reason, one cannot logically infer the presence of a trance state from successful hypnotic responding. From a social cognitive perspective, the experience of being in a trance is merely a response to suggestion, just like all of the other responses to suggestion that occur during hypnosis. Specifically, it is a response to a suggestion to become hypnotized, a suggestion that is termed a hypnotic induction (Wagstaff, 1998). It is for this reason that nonstate theorists (e.g. Kirsch, 1997) have endorsed Hilgard’s (1973) proposal that the domain of hypnosis can be defined without reference to the induction of an altered state. If this were accepted, the distinction between waking suggestibility and hypnotic suggestibility would disappear. Nevertheless, it is clear that hypnosis is not synonymous with suggestion. There are various types of suggestion that lie outside of the domain of hypnosis (for more, see Tasso and Perez, Chapter 11, this volume). What differentiates hypnotic suggestion from other types of suggestion is not the presence of a hypnotic induction, but the type of suggestions that are administered (see Kirsch, 2003; Kihlstrom, Chapter 2, this volume). Unlike placebos, misleading questions and other forms of indirect suggestion, hypnotic suggestions are requests for imaginative experiences, and for that reason they can also be termed imaginative suggestions (Braffman and Kirsch, 1999). They are suggestions for changes in experience independent of any changes in the world. When placebos are given, recipients are led to believe that the pill contains an active substance that it does not in fact contain. Leading questions imply that something that did not happen has in fact occurred. In contrast, hypnotic suggestions are not aimed at convincing the subject that something external is different from what it actually is.

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Instead, they are aimed at producing compelling subjective experiences even if they are at variance with what the subject knows to be the actual state of affairs. In the Stanford Hypnotic Susceptibility Scale, Form C (SHSS:C; Weitzenhoffer and Hilgard, 1962), for example, subjects are told ‘imagine that you are holding something heavy in your hand … maybe a heavy baseball or a billiard ball’ (p. 17, emphasis added), and ‘imagine that you have something sweet tasting in your mouth, like a little sugar’ (p. 19). There is no attempt to convince subjects that there really is something heavy in their hands or that there really is sugar in their mouths.1 Instead, the hypnotist says, ‘the hand and arm feel heavy, as if the weight were pressing down’ (p. 17) and ‘you are now beginning to have a sour taste in your mouth … as if you have some lemon in your mouth’ (p. 20). Thus, the essence of hypnotic suggestion involves having subjects experience the world ‘as if ’ the suggested state of affairs were true, and when asked, most highly responsive subjects report knowing that nothing in the external world has actually changed (Comey and Kirsch, 1999). Hypnosis theories are often dichotomized into state and nonstate theories, with social cognitive theories being the most prominent exemplars of nonstate theories. During the 1960s and 1970s, the altered state issue was acknowledged to be the most contentious issue in the field (Sheehan and Perry, 1976). Despite various pronouncements of convergence in the altered state debate (Spanos and Barber, 1974; Kirsch and Lynn, 1995), the controversy continues to simmer, if not boil. Some proponents of the altered state view have claimed that neurophysiological evidence for the neurological substrates of hypnosis is so compelling that the debate as to whether hypnosis is an altered state is no longer an issue to be resolved. For example, Gruzelier’s (1996) review of the psychophysiological concomitants of hypnosis concluded, ‘We can now acknowledge that hypnosis is indeed a “state” and redirect energies earlier spent on the “state–nonstate debate”’ 1 Hypnotic

suggestions are sometimes worded as if the suggested state of affairs was real, but the cultural context, the initial explanation of hypnosis and the wording of prior suggestions make it clear that they are to be interpreted metaphorically.

(p. 315; see also Barabasz and Barabasz, Chapter 13, this volume). We and other social cognitive theorists (e.g. Wagstaff, 1998) do not deny the possibility that reliable physiological markers of an altered state of hypnosis may one day be found, and underscore the importance of identifying the psychophysiological substrates of hypnosis. However, we have argued elsewhere (Lynn et al., 2007), as we will in this chapter, that the claim that neurophysiological data resolve the altered state issue is not warranted by the available evidence. There are a number of prominent hypnosis scholars whose positions on the state–nonstate issue do not fit this dichotomy easily (McConkey, 1991, Chapter 3, this volume; Sheehan, 1991; Brown and Oakley, 2004; Kihlstrom, Chapter 2; Woody and Sadler, Chapter 4, this volume). Kihlstrom (1985), for example, retains the altered state terminology, but uses it in a strictly descriptive sense, assigning no causal properties to it. According to what has been referred to as a weak interpretation of the altered state hypothesis (Kihlstrom, 1985), the hypnotic state is merely a descriptive term or label for the changes in consciousness, rather than a causal factor in the production of hypnotic experience. As in social cognitive theories, these experiences are deemed to be social psychological and cognitive processes. Thus, except for the preference for state terminology as a descriptor, these theories can also be considered as social cognitive in nature. In this chapter, we review the social cognitive theories of hypnosis. We begin with an overview of the social cognitive perspective. However, neither state nor nonstate theories of hypnosis are monolithic. Because there are a number of differently nuanced social cognitive theories of hypnosis, we will review them before we consider how social cognitive theorists have studied and conceptualized hypnotic phenomena that traditionally have been attributed to an altered state of consciousness.

5.2. Conceptions and

definitions The conceptual roots of the social cognitive perspective can be traced to the writings of Robert

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White (1941), which first emphasized the goaldirected nature of hypnotic responding. According to White, ‘Hypnotic behavior is meaningful, goal-directed striving, its most general goal by the subject being to behave like a hypnotized person as this is continuously defined by the operator and understood by the subject’ (p. 483). However, unlike the social cognitive theorists who followed him, White continued to believe that hypnotic behavior was linked to an altered state of consciousness accompanied by subtle cognitive changes (for more discussion of White, see McConkey, Chapter 3, this volume). The social cognitive theorists we review, while differing in emphasis and focus, share the assumption that hypnotic experience and behavior is similar to other complex social behaviors in a number of salient respects. More specifically, individuals who experience hypnosis, like their nonhypnotized counterparts, act in terms of their aims, according to their point of view, and in relation to their interpretation of appropriate behavior and feelings (Lynn and Rhue, 1991). Responses during hypnosis are goal directed— they are regulated in terms of participants’ self-perceptions, needs and intentions, and can be progressively changed to realize goals. How participants respond to the following sorts of questions affects their willingness to respond to hypnotic procedures, as well as their unique experiences during hypnosis: ‘What will happen if I am hypnotized?’ ‘What am I expected to do?’ ‘Do I have anything to fear?’ ‘What will it say about me if I respond to the hypnotist … that I am weak minded, imaginative or open to experience?’ Accordingly, rather than being robotic responders, people who experience hypnosis strive to: (1) make sense of what is required of them in order to respond in keeping with their understandings of what is appropriate to think, feel and do during hypnosis; and (2) actively create the experiences called for by suggestions (e.g. see Spanos, 1986; Kihlstrom, Chapter 2; McConkey, Chapter 3, this volume). Hypnotic responses are the product of diverse cultural, personal and interpersonal influences. Hypnosis occurs in an historically derived cultural context, to which particular meanings have been attached. Survey data (McCord, 1961; McConkey, 1986; Wilson et al., 1986; Green et al., 2006) consistently indicate that common conceptions of hypnosis typically include the

following beliefs: (1) hypnosis is an altered state of consciousness; (2) the hypnotist is a powerful figure; (3) hypnotizable subjects are passive and receptive; and (4) hypnotic suggestions are carried out automatically or effortlessly. These widely prevalent notions of hypnosis, along with specific suggestions that spell out the experiences or actions called for, provide the scaffolding for how participants respond to hypnosis. Responsive participants are thus invested in meeting the requirements of what they perceive to be the hypnotic role. Yet their responses do not reflect mere compliance or role playing absent genuine experiences of suggested events. Hypnotized subjects never truly lose control of their actions during hypnosis. Rather, they attune their experiences and actions to the broad demands of the situational context and the implications of the imaginative suggestions they receive to interpret some of their suggestionrelated responses as involuntary ‘occurrences.’ Finally, social cognitive theorists do not dispute the fact that profound alterations in consciousness can and often do occur during hypnosis. They differ from traditional state theorists, however, in that they consider the feeling of an altered state as merely one of the many subjective effects of suggestion. They do not consider these feelings as indicative of an actual trance state that is either a prerequisite for the experience of any other suggested effects (e.g. James, 1890; Kallio and Revonsuo, 2003) or that enhances suggestibility (e.g. Hull, 1933; Hilgard, 1965). Instead, they explain the response-enhancing effect of the hypnotic induction as a function of enhanced motivation and expectancy (e.g. Barber, 1969; Braffman and Kirsch, 1999). The name social cognitive captures this perspective’s emphasis on social psychological and cognitive variables as determinants of hypnotic responsiveness. Social cognitive theories encompass theories that have variously been termed social psychological, social cognitive and cognitive-behavioral. A guiding assumption is that all of the phenomena of hypnosis, including behavioral responses to suggestion, and subjective responses to suggestion, such as the subjective experience of a trance state, can be accounted for without postulating any special underlying state or condition. From this perspective, hypnotic experiences, like many other

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complex social experiences, are a product of diverse factors that encompass abilities, attitudes, beliefs, expectancies, attributions and interpretations, the relationship in which the behaviors unfold, and the way people wish to present themselves to others. Accordingly, social cognitive theorists and researchers seek explanations for puzzling and seemingly remarkable hypnotic behavior in mundane terms, and seek to apply rigorous experimental procedures to identify important determinants of suggestibility and rule out competing theoretical explanations for hypnotic phenomena.

5.2.1. The role of compliance Spiegel (1998) claimed that social cognitive theorists ‘... see hypnosis as nothing more than a minor variation on the theme of social compliance’ (Sarbin and Coe, 1972; Coe, 1978) and that the ‘fundamental factor involved in hypnosis is a general and widely distributed human tendency to comply with social pressure’ (p. 233). Although this characterization of social cognitive theories is not uncommon, it is nevertheless mistaken. If hypnosis were nothing more than compliance or faking, it would not be of much interest to anyone. Hypnosis is interesting to social cognitive theorists precisely because of the ‘believed in’ subjective alterations it produces. Indeed, social cognitive theorists have studied a gamut of hypnotic phenomena (e.g. suggestion-related involuntariness, trance logic, analgesia) that involve alterations in sensations, perceptions and cognitions. Social cognitive theorists differ in the role they accord to compliance. All social cognitive theorists have acknowledged that many, if not all, co-operative participants do their best to experience the subjective effects of hypnotic suggestions and, for the most part, succeed in this endeavor. Relative to other social cognitive theorists, Wagstaff (1991, 1998) has accorded compliance the greatest role in hypnotic responding. Nevertheless, Wagstaff has argued that before participants will comply with a hypnotic suggestion in the absence of a genuinely felt subjective response, they will first attempt to ‘try to work out what is appropriate to the hypnotic role or what is expected of them’ and then ‘apply cognitive strategies or activities to make the experiences veridical or ‘believable’ (p. 29).

It is only after these strategies to experience the suggested event as subjectively compelling fail that they are replaced by attempts to comply behaviorally or ‘sham’. Relatedly, Spanos (1991) claimed that ‘compliance, in and of itself, cannot account adequately for hypnotic behavior’ (p. 336). Indeed, social cognitive researchers have shown conclusively that hypnosis cannot be reduced to mere compliance or faking (Kirsch et al., 1989; Perugini et al., 1998). The surreptitious observation of hypnotized individuals provides the most persuasive evidence that people who respond to suggestions are not faking. In an attempt to ascertain the role of demand characteristics in accounting for hypnotic behavior, Evans and Orne (1971) devised the disappearing hypnotist scenario. Two types of subjects are involved. The first type is highly suggestible individuals who receive no particular instructions about how to respond. The second type of subject is selected for their inability to experience the effects of hypnosis, and is instructed to role-play or simulate the performance of a good hypnotic subject. This scenario consists of the following elements: (1) after a hypnotic induction, the hypnotist must leave due to an emergency; (2) after the hypnotist leaves, the subjects (both hypnotized and simulating) are surreptitiously observed to determine how long they remain hypnotized; and (3) after the experiment is completed, the behaviors of the hypnotized and simulating subjects are compared. Evans and Orne observed that simulating subjects usually stopped simulating when left alone, whereas hypnotized subjects continued to act like they were hypnotized for several minutes, suggesting that they continued to experience the effects of hypnosis and were not merely faking or role-playing, as was the case with simulators. To extend these findings, Kirsch and his colleagues (Kirsch et al., 1989; Perugini et al., 1998) developed the surreptitious observation design. While under the impression that they were alone and unobserved, simulating and hypnotized subjects listened to audiotaped hypnotic suggestions, while the researchers secretly observed them. Both groups also listened to the audiotapes while the researchers were present. Kirsch et al. found that when alone and unaware of being observed, simulators responded to

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significantly fewer suggestions than when they were openly observed. Nonsimulating subjects, on the other hand, were not affected by the manipulation: they responded to the same number of suggestions regardless of the environment. This research supports the conclusion that suggestible subjects genuinely experience the effects of hypnotic suggestions. Clearly, there is much to explain about hypnotic responding beyond mere compliance, and a variety of social cognitive theories we will review next have provided accounts of hypnotic suggestibility, the determinants of subjective experiences during hypnosis, and hypnotic phenomena.

5.3. Genesis of our own

point of view Our point of view is deeply rooted in the theories and research of pioneers who sketched the broad themes of the social cognitive perspective: Theodore Sarbin and his long-time colleague, William Coe; T. X. Barber and his former students Nicholas Spanos and John Chaves, and the London psychologist, Graham Wagstaff. After we review major programs of research grounded in the social cognitive perspective, we will describe response set theory that we (Kirsch and Lynn) have developed over the past decade.

5.3.1. Sarbin’s role theory In 1950, Theodore Sarbin challenged the traditional concept of hypnosis as a state. Before this time, hypnosis was universally assumed to be an altered state. Although skeptical earlier theorists (e.g. Hull, 1933; White, 1941; Bernheim, 1987) understood hypnotic phenomena in ways that reduced the importance of this hypothesized altered state considerably, Sarbin (1950) was the first to reject it outright. Sarbin conceived of hypnosis as a form of social psychological behavior. He and his colleague William Coe (Sarbin and Coe, 1972; Coe and Sarbin, 1977) have used social psychological role theory to explain hypnotic behavior. They argued that hypnosis could be conceptualized as ‘believed in imaginings’, and developed a theory of hypnosis that relied heavily on the social psychological concept of role. Being a hypnotized subject is a social role, in the same way that being

a psychotherapist, client, teacher, student and parent are social roles. In order to be hypnotized, one must want to adopt that role. Once in the role, people’s experiences are shaped by their perceptions of the role. Accordingly, people who are led to believe that hypnotized subjects display arm catalepsy, display that response when hypnotized (Orne, 1959). But it is not hypnosis that produces the response; it is the belief that this response is appropriate to the role of a hypnotized subject. A distinction that is quite crucial to understanding Sarbin’s theory, and social cognitive theories in general, is that between role-taking and role-playing. Sarbin used the term roletaking because role-playing in this context implies faking or pretending to experience hypnosis, whereas role-taking does not. Sarbin emphasized the degree to which ‘some actors report losing themselves completely in certain roles so that they are relatively unaware of the audience or of other physical or social objects’ (p. 260), and there is evidence from other areas of psychology that enacting a particular emotion or behavior can affect objective and subjective measures in the direction of the enactment (Cardena and Beard, 1996). Among other things, Sarbin used role theory to account for the experience of automaticity that characterizes many hypnotic responses. ‘Role-taking is organismic’, he maintained, ‘it embraces the entire organism, not merely the voluntary reaction-systems’ (p. 260). To say that we enact the role of a parent does not imply pretence. Similarly, when people take on the social role of hypnotic subject, they are not merely pretending to be hypnotized. As Sarbin stressed, the imaginings that form the basis of hypnotic experiences are believed in by the hypnotized subject. In fact, honesty is part of the hypnotic role (Spanos, 1986). Most individuals display hypnotic responses behaviorally only when they are able to achieve the subjective experience called for by the suggestion. If they are deceiving anyone when they say that they cannot bend their arms following a suggestion for arm rigidity, it may only be themselves (Sarbin, 1989). People differ in their role-taking ability. That is why some people are better actors than others. In fact, acting students respond better than

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science students to hypnotic suggestions (Sarbin, 1950). The research of Sarbin and his colleagues (Sarbin and Coe, 1972; Coe and Sarbin, 1991) highlighted the contribution of the following variables to subjects’ hypnotic responsiveness: (1) knowledge of what is required in the hypnotic situation; (2) self-and role-related perceptions; (3) expectations; (4) imaginative skills; and (5) situational demand characteristics. Sarbin (1950) explained individual differences as differences in the ability to become involved in the hypnotic role. More recently, Coe and Sarbin (1991) elaborated the constructs of self-deception, secrets, metaphors and narratives in an expansion of their earlier role theory. Narrative psychology holds that human actions and self-perceptions are storied. People experience hypnosis in terms of a widely available script regarding what it is like to be hypnotized and how ‘good’ subjects respond in the situation. Nevertheless, understanding and enacting of the script will vary in terms of exposure to information about hypnosis, and subjects’ goals and how they wish to present themselves. Accordingly, Coe and Sarbin’s narrative or dramaturgical model underlines the motivated, active and constructive nature of hypnotic experiences and performances.

5.3.2. Barber’s operational approach Theodore X. Barber (1969) was influenced by Sarbin’s theorizing and criticized the state concept because of its logical circularity (i.e. hypnotic responsiveness can both indicate the existence of a hypnotic state and be explained by it). If the presence of a hypnotic state is inferred from subjects’ responses to test suggestions, then there is no way of demonstrating or falsifying the hypothesis that those responses are dependent on that state. Barber’s operational approach to hypnosis was derived from logical positivism and neobehaviorism, whereas Sarbin’s position was based on social psychological role theory. In place of Sarbin’s deductive theoretical approach, Barber adopted an inductive strategy. In an extensive series of studies in the 1960s (Barber and Calverly, 1964; Barber, 1969) and early 1970s (Barber et al., 1974), Barber and his colleagues

systematically examined primary classes of independent variables that might be functionally related to hypnotic behavior. As a result of this research, Barber concluded that hypnotic responses were related to the following eight antecedent variables associated with the hypnotic procedures and test suggestions: attitudes; expectancies; the wording and tone of suggestions; motivation; the definition of the situation as ‘hypnosis’; suggestions for relaxation; the wording of the inquiry with which the response is assessed; and the behavior adopted by the experimenter. Barber’s initial experimental strategy was based on providing subjects with ‘task motivational instructions’. Instead of listening to a hypnotic induction, subjects were told that their ability to imagine was being tested. They were strongly urged to co-operate with the experiment by actively imagining the suggested effects, and were told that others had been successful in doing so. Barber and his colleagues observed the effects of these instructions and compared them with the effects of a standard hypnotic induction; and across many studies, the effects of task motivational instructions were found to be comparable with those of hypnosis. 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. A frequent criticism of Barber’s work has been that task motivational instructions may place greater pressure on subjects for compliance than is found in traditional hypnotic inductions. Task motivational statements such as ‘everyone passed these tests when they tried’, ‘I want you to score as high as you can’ and ‘If you don’t try to the best of your ability, this experiment will be worthless and I’ll tend to feel silly’ (Barber, 1969, p. 46) were seen as particularly problematic. Messages of this sort might lead some subjects to pretend to be more responsive than they actually are. Whether task motivational instructions are more likely than trance inductions to result in faked responses is not yet known. However, other methods of duplicating the effects of trance inductions on suggestibility have been devised, methods that do not involve the high pressure statements contained in task motivational instructions (e.g. Council et al., 1983).

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It is possible, of course, that different procedures (trance inductions, task motivational instructions) produce the same effects by way of different mechanisms. But if this is the case, then it remains to be empirically demonstrated. Until it is, parsimony demands that we assume a common mechanism. As argued above, there is no reason to believe that task motivational instructions create an altered state of consciousness. Nevertheless, they are as effective as trance inductions in enhancing suggestibility. Therefore, the existing data indicate that the notion of a special state of consciousness is not needed in order to account for hypnotic phenomena. The conclusion that alterations in conscious state are not causes of increased suggestibility does not mean that these changes in conscious state do not exist. Following a hypnotic induction, many people report that they feel themselves to be in an altered state, although most responsive subjects reject this idea and instead describe hypnosis as a ‘normal state of consciousness that simply involves the focusing of attention’ (McConkey, 1986, p. 314). There is no reason to doubt the truthfulness of the substantial minority who do report experiencing an altered state. But, rather than being a cause of other hypnotic phenomena, alterations in conscious state appear to be just one more effect of hypnosis, as much in need of explanation as hand levitation, catalepsy, amnesia, and other directly and indirectly suggested effects. More than any other social cognitive theorist, Barber (Wilson and Barber, 1981, 1983) emphasized individual differences in fantasy proneness and imaginative ability as determinants of hypnosis. Barber (1999) recently put forward the intriguing hypothesis that individuals may have distinct styles of responding to hypnotic suggestions, such that some individuals respond primarily in terms of their positive response set, whereas perhaps a much smaller percentage of individuals become more imaginatively or dissociatively (e.g. experience spontaneous amnesia) involved with suggestions. Barber’s formulation is open to the question of the extent to which dissociative and highly imaginative individuals’ excellent hypnotic performance is influenced by situational cues and social psychological variables (e.g. attitudes, beliefs, expectancies).

5.3.3. Spanos’s multifactorial model Nicholas P. Spanos (1986) extended Sarbin’s role theory and Barber’s cognitive-behavioral theory into one of the most influential contemporary theoretical approaches to the understanding of hypnotic behavior. Spanos and his colleagues (Spanos, 1986, 1991; Spanos and Chaves, 1989) focused on the importance of social psychological processes and the importance of goaldirected activities and strategic responding. Like his mentor T. X. Barber, Spanos advanced a multifactorial model of hypnotic suggestibility that acknowledged the role of attitudes, beliefs, imaginings, attributions and expectancies in shaping hypnotic phenomena. Extending Sarbin’s role theory, and White’s observations about the goaldirected nature of hypnosis, Spanos (1991) used the construct of strategic role enactment to explain how individuals transform imaginings, thoughts and feelings into experiences and behaviors that are consistent with their ideas of how a good hypnotic subject should respond to the overall hypnotic context and specific suggestions in particular. How subjects construe the hypnotic role is thus a key determinant of hypnotic responsiveness. Spanos chose the term ‘enactment’ to distinguish individuals’ attempts to fulfill the perceived requirements of the hypnotic role from pretence or faking. The term ‘strategic’ captures the consistent emphasis in Spanos’s research program on identifying cognitive strategies that individuals employ to create suggested effects. For example, in order to reduce pain in response to an analgesia suggestion, subjects may use a variety of attentional strategies (e.g. distraction) to attenuate their subjective responses to painful stimuli. Relatedly, suggestions often contain strategies that assist individuals in responding appropriately (Barber et al., 1974; Spanos and Barber, 1974; Spanos et al., 1985; see also Wagstaff, 1991, 1998). Raising the hand following suggestions for the hand to lift occurs as the subject imagines along with suggestions worded to imply that the hand will lift involuntarily (e.g. ‘Your hand is getting lighter and lighter, it will rise by itself ’). Spanos (1971) hypothesized that subjects tend to define their overt response to suggestion as involuntary when they become absorbed in goal-directed fantasies (GDFs).

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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 et al., 1977, p. 211). For instance, persons administered a hand levitation suggestion would exhibit a GDFr (i.e. goal-directed fantasy report) if they report such events as imagining a helium balloon lifting their hand, or a basketball being inflated under their hand. Studies have indicated that GDFrs are related to the tendency to define overt response to suggestion as involuntary occurrences. However, GDFrs are not necessarily correlated with the number of suggestions that subjects pass on a suggestibility scale (for a review, see Lynn and Sivec, 1992). In fact, several studies indicate that such fantasies may even diminish responding to suggestions (Hargadon et al., 1995; Comey and Kirsch, 1999). Why is this the case? Spanos argued that certain individuals can be fully absorbed in GDFrs yet passively wait for a suggested event, such as the lifting of an arm in response to a hand levitation suggestion, to ‘happen.’ Adopting this response set virtually guarantees failure. In contrast, individuals who understand that it is important to lift their arm will succeed in passing the suggestion. In short, how suggestions are interpreted is an influential determinant of whether or not they are accompanied by behavioral responses to suggested events. One of Spanos’s most important contributions has been to highlight the fact that hypnotic responsiveness is malleable and can be substantially modified and enhanced. According to Spanos, hypnotic responsiveness is not an immutable trait or propensity locked in at birth. Rather, it can be substantially modified by teaching subjects to do the following: (1) physically enact responses, as opposed to waiting passively for the suggested effects to happen to them (Spanos, 1986); and (2) use goal-directed imagery or fantasies In more than 15 studies (see Gorassini and Spanos, 1999), Spanos showed that between 50 and 80 percent of initially low hypnotizable subjects who underwent a multifaceted cognitive skill training program (termed the Carleton Skills Training Program; CSTP) scored as high hypnotizables at post-testing. The training program includes the following

components: (1) information to instil positive motivation, beliefs, attitudes and expectations about responding to hypnotic suggestions; (2) instructions regarding how to use imaginal strategies to promote successful responding; (3) instructions regarding how to interpret suggestions (e.g. one must actually lift the hand while imagining that it is rising by itself); (4) exposure to a videotaped model who enacts successful responses to suggestions and verbalizes imagerybased strategies to facilitate subjective response; and (5) practice in responding to test suggestions. Spanos (March 6, 1985, personal communication) also noted that the training program encourages rapport with the trainer/hypnotist. Not only have treatment effects been of large magnitude, but they also persist for an average of two and a half years after training (Spanos et al., 1988a), and generalize to novel, demanding test suggestions (e.g. Spanos, 1986). Research in Spain (Cangas and Perez, 1998), Poland (Niedzwienska, 2000) and the UK (Fellows and Ragg, 1992) provided cross-cultural support for the effectiveness of the CSTP. Finally, treatmentrelated gains are maintained even when tested in an entirely novel test context in which subjects fail to connect their earlier training and subsequent hypnotizability testing. Research that addressed this latter issue (Zivney and Lynn, 1996) provided strong evidence that large magnitude treatment gains cannot be attributable to simple compliance effects. Combined, these findings constitute strong support for Spanos’s model and challenge the received wisdom that hypnotic responsivity is a trait-like, stable attribute that can be modified only within narrow limits (for more discussion of the CTSP and modifiability of hypnotizability, see Laurence et al., Chapter 9, this volume). Spanos and his colleagues devoted substantial effort to testing hypotheses derived from Hilgard’s neodissociation theory (Hilgard, 1977). The hidden observer phenomenon is integral to Hilgard’s (1977) neodissociation theory, according to which all hypnotic experiences and responses are instances of dissociation. That is, they reflect a division of executive cognitive functioning into two parts, divided by an amnesic barrier. One part of consciousness (the hidden part) directs the person’s behavior and experiences stimuli normally, but the other is

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unaware of self-agency and experiences stimuli in a manner that is consistent with suggestions. Hilgard (1973) serendipitously discovered the hidden observer phenomenon in a class demonstration of hypnotic deafness with a blind person. Hilgard’s curiosity was aroused regarding whether a person who received a suggestion for complete deafness might be still aware of what was going on in his surroundings, despite his lack of startle response to loud noises. He told the person that, ‘Although you are hypnotically deaf, perhaps there is some part of you that is hearing my voice and processing the information. If there is I should like the index finger to rise as a sign that this is the case’ (Hilgard, 1994, p. 34). The person’s finger rose as requested, despite his denial of hearing anything. Posthypnotic inquiry revealed that the ‘separate part’ had been aware all along of everything that had been taking place. This demonstration inspired many studies of the hidden observer. Hidden observers were obtained in association with hypnotic suggestions for analgesia to experimental pain, deafness, negative hallucinations (i.e. not seeing something that is there) and ideomotor responses (reviewed in Kirsch and Lynn, 1998; also see Green et al., 2006). The basic paradigm of these studies is to select individuals who have demonstrated high levels of hypnotic suggestibility, tell them that there is (or may be) a hidden part of them that is more aware than their hypnotized part, establish a cue for communicating with the hypnotized part, administer a suggestion, and assess its effects with and without the hidden observer cue. Typically, hidden observers report higher levels of pain, less deafness and less blindness when the hidden observer cue is given. These hidden observer reports are interpreted as responses from the ‘normal (i.e. not hypnotized) part’ of the executive ego, the part that is fully experiencing stimuli and remembering information that is temporarily unavailable to the ‘hypnotized part’ of consciousness. For the hidden observer to constitute empirical support for neodissociation theory one must assume that it reveals a hidden part of consciousness that is present during hypnosis, independently of the subject’s expectations and the instructions used to communicate with it.

However, Spanos and his colleagues reported data in which hidden observer reports were affected by the nature of instructions given to subjects, leading these authors to the conclusion that the hidden observer is an experimental creation. In the first of these studies, Spanos and Hewitt (1980) provided two groups of highly suggestible subjects with very different information about the hidden observer. One group was provided with information modeled on Hilgard et al. (1975) that conveyed the expectation that the hidden part would give accurate pain reports. Other subjects were informed that the hidden part was ‘so deeply hidden’ that it would experience even less pain than the hypnotized part. These two different sets of instructions elicited hidden observers with opposite characteristics (i.e. high sensitivity versus greatly reduced sensitivity to pain). Spanos and his colleagues (Spanos et al., 1983) later replicated this effect using a within-subject manipulation. As instructions shifted to convey different expectations regarding the characteristics of the hidden observer, the same subjects reported either less hidden pain than overt pain or more hidden pain than overt pain. Spanos et al. (1984a) produced two hidden observers in each of eight, highly suggestible, research subjects. The subjects learned a list of concrete and abstract words and then were given a suggestion to forget them. Half of the subjects were told that abstract words were stored by their right hemisphere and that concrete words were stored by the left. The remaining subjects received the opposite information concerning where information was stored. They were also told that there was a hidden part of them connected to each cerebral hemisphere. When the hypnotist contacted the ‘hidden observer’ associated with the right and left hemispheres, the subjects were able to recall the information that they had been told was stored there. That is, when the hypnotist contacted the right hemisphere ‘hidden part’, the subject recalled all of the words purportedly stored in the right hemisphere (e.g. concrete words), but none of the words stored in the left hemisphere (e.g. abstract words), and vice versa. Spanos et al. (1988b) demonstrated a similarly flexible hidden observer in conjunction with suggested negative hallucinations. Previously,

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Zamansky and Bartis (1985) had reported a study in which they had administered negative hallucination suggestions for subjects to see a blank page when the page actually had a clearly visible number imprinted on it. The authors found that all of the subjects who had initially denied seeing the number on the page claimed they had seen the number when the experimenter contacted their ‘hidden observer’. Spanos et al. (1988) replicated this effect, using the number 18 as the stimulus that was not to be seen. However, half of the subjects were told that the hidden part reversed everything it saw. The results were clear-cut. Subjects’ hidden observers reported what they had been told about the hidden observer: those who received typical hidden observer suggestions reported that the number was 18, whereas those told that the hidden observer reversed what it saw reported that they saw the number 81. Most recently, Green and his colleagues (Green et al., 2006) tested high and low suggestible role-playing (simulating) subjects for the amount of effort they experienced in responding to an arm suspension (i.e. ideomotor) task across baseline, hypnosis, hidden observer and post-session trials. Subjects were told that their hidden observer would be more aware of the effort required to complete the task; less aware; or they received no specific instruction concerning how their hidden observer should respond. The authors found that both real and simulating subjects’ hidden observer reports of effort were influenced by the wording of the instructions they received. Support for a social cognitive account of the hidden observer also stems from findings that the frequency of hidden or covert reports varies with the explicitness of the suggestions used to elicit the phenomenon. Studies in which highly suggestible subjects receive very explicit suggestions to report a hidden observer, or are given practice at performing the ‘hidden tasks’, have produced hidden observer response rates ranging from 82 to 94 percent (Knox et al., 1974; Spanos and Hewitt, 1980; Mare et al., 1994). This high rate of response contrasts sharply with hidden observer response rates ranging from 25 to 42 percent in studies of hypnotic analgesia and deafness in which less explicit instructions were used (Hilgard et al.,

1975; Crawford et al., 1979; Laurence and Perry, 1981). Spanos et al. (1983) tested the hypothesis that hidden observer response rates depend on the explicitness of the instructions by varying the saliency of the behavioral cues within the hidden observer suggestion. In research on overt and covert reports of pain, they found that only 14 percent of high hypnotizable subjects displayed hidden observers (i.e. generated discrepant overt and covert reports) under the low cue condition. In contrast, the high cue condition resulted in hidden observers in 58 percent of subjects. This suggests that the hidden observer may be a product of perceived situational cues. Hidden observer studies indicate that hidden observer reports are exquisitely sensitive to situational demands produced by instructional cues. Depending on the instructions with which they are created, hidden observers report more or less pain than otherwise reported, they either do or do not reverse figures, and they report more or less effort associated with an ideomotor response. Accordingly, reports of ‘hidden entities’ appear to be byproducts of suggestions and contextual demands, rather than spontaneously occurring dissociated aspects of the personality (see Laurence et al., 1983; Nogrady et al., 1983; Kihlstrom, 1998, 2003, for a defense of the ‘hidden observer’, and a rebuttal by Spanos, 1991). Such findings led Kirsch and Lynn (1998) to dub the hidden observer a ‘flexible observer’. Instead of being the basis for all suggested responses, the hidden observer appears to be a suggested response that can be considered part of the domain of hypnosis (for a different view of the implications of the hidden observer, see Woody and Sadler, Chapter 4, this volume).

5.3.4. Kirsch’s response

expectancy theory Irving Kirsch’s response expectancy theory (Kirsch, 1985, 1991, 1994) is a recent extension of social learning theory (Rotter, 1954). According to this theory, expectancies for changes in subjective experience can affect experience directly and generate nonvolitional responses. More specifically, response expectancies are anticipations of automatic

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subjective and behavioral responses to particular situational cues, and they elicit automatic responses in the form of self-fulfilling prophesies. This is best documented by the ability of placebos to produce changes in pain, anxiety, depression, tension, sexual arousal and other subjective states, as well as in the physiological substrates of the states. Similarly, hypnotic response expectancies can produce hypnotic experiences. Support for the important role of response expectancies in producing hypnotic responses is provided by studies of the nature of hypnotic inductions and the determinants of hypnotic responses. More specifically, Kirsch maintains that hypnotic inductions are expectancy modification procedures that produce placebo effects without the use of placebos. Historically, hypnotic inductions have encompassed a variety of procedures, including stroking subjects, clanging oriental gongs, flashing bright lights and applying pressure to subjects’ heads. Although contemporary inductions often include suggestions for relaxation, relaxation is not a necessary component of hypnosis. In fact, the effect of ‘alert inductions’, such as when subjects pedal stationary bicycles (Banyai, 1991), are the same as those of traditional relaxation inductions (Banyai and Hilgard, 1976; Kirsch et al., 1992). Kirsch claims that the only common ingredient of these diverse inductions is the label hypnosis. When the effect of administering a drug is found to be independent of its specific ingredients (i.e. when an inert preparation produces the same effect), the drug is deemed to be a placebo. Similarly, hypnotic inductions must be expectancy manipulations, akin to placebos, because their effects on suggestibility are independent of any specific component or ingredient. In fact, it is possible to produce all of the suggestive effects of hypnosis by giving subjects a placebo and telling them that it produces a hypnotic state (Glass and Barber, 1961; Council et al., 1983; Baker and Kirsch, 1993). Not only do expectancies determine when hypnotic responses occur, they also play a large role in determining the nature of those responses. Following a hypnotic induction, subjects report increased or decreased involvement, time slowing down or speeding up, logical

thought becoming easier or more difficult, the hypnotist’s voice sounding closer or farther away, sounds being clearer or more muffled, and so forth (Henry, 1985). Henry’s data indicated that the direction of these alterations in awareness depended on the subject’s preconceptions about the effects of hypnosis. Kirsch (1991) identified expectancy and ability as two independent factors that determine hypnotic suggestibility, and this hypothesis has been supported empirically (Braffman and Kirsch, 1999; Benham et al., 2006). Most of the correlations between expectancy and suggestibility are moderate, accounting for approximately 10 percent of the variance in responding. However, substantially higher correlations have been reported in some studies. Very high correlations between hypnotizability and expectancy are obtained when waking suggestibility is measured or when expectancy is assessed after the provision of a hypnotic induction (but before the administration of test suggestions). Interestingly, expectancy remains a significant predictor of hypnotic response even with waking suggestibility controlled (Braffman and Kirsch, 1999). In short, hypnotic responding following a trance induction is regarded as nonhypnotic responding with enhancements due to increased expectancy and motivation. It is possible that expectancy is an epiphenomenon rather than a cause of responsiveness. More convincing evidence of causality is provided by studies in which manipulated expectancies produced changes in responsiveness. Three studies conducted in two separate laboratories have demonstrated that an experientially based expectancy manipulation can enhance responsiveness to hypnotic suggestion to an exceptionally large degree (Wilson, 1967; Wickless and Kirsch, 1989; Kirsch et al., 1999). Indeed, one of these studies indicated that the effect of this expectancy manipulation was so strong that most subjects wound up scoring in the high range of responsiveness and none in the low range. The influence of expectancies can be quite subtle. Tellegen and Atkinson (1974) originally conceptualized absorption as a trait-like capacity for absorbed and self-altering attention that ‘represents an essential component of hypnotic

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susceptibility’ (p. 276). This conclusion was based on the finding that the measure of absorption they constructed, which was comprised of items associated with hypnotic suggestibility in previous studies, correlated with hypnotic suggestibility in two independent samples (r = 0.27, P < 0.01, n = 142; r = 0.43, P 8) in three conditions: (1) when ‘alert’ and listening to ‘pleasant’ biographical information from their own lives whilst imagining what happened to them in the situations being described; (2) following the induction of a ‘hypnotic state’ (the procedure used was not described) during which they were ‘invited to have revivification of pleasant life experiences’; and (3) ‘hypnotized with forced color hallucinations’ in which they were ‘asked to focus on their preferred colors and to view settings and objects in these colors’. Subjects described their experiences in the ‘hypnotic state’ (condition 2) as involving ‘vivid, detailed and colorful revivifications of pleasant memories, having mentally re-enacted them’. No significant differences in activations were found between the two hypnosis conditions (2 and 3), suggesting that both these tasks made similar cognitive demands on the participants. The most prominent modality of experiences in the two hypnotic conditions was visual, with some somesthetic and olfactory imagery, but there were no reports of auditory imagery. Motor imagery was commonly reported when participants engaged in appropriate ‘actions’. Comparing both these ‘hypnosis’ conditions (2 and 3) with the ‘alert’ condition (1) revealed widespread increases in activation in the hypnosis conditions involving occipital, parietal, prefrontal and cingulate cortices, and relatively lower activations of temporal cortical areas. It seems clear from these results that listening to autobiographical information and engaging in related imagery without a hypnotic induction in the ‘alert’ condition activated brain areas

different from those when participants were involved in self-selected revivification of past events or hallucinating colorful objects and scenes after a hypnotic induction in the ‘hypnosis’ conditions. The differences, however, appear as likely to be attributable to the differing task demands as to the presence or absence of a hypnotic induction procedure or ‘hypnotic state’, particularly as studies reviewed in the previous section (Szechtman et al., 1998; Derbyshire et al., 2004) have indicated a clear distinction in brain processes between instructions to ‘imagine’ and suggestions to ‘experience’ phenomena even within the hypnosis condition. Strong engagement with visual experiences reported in response to the revivification/hallucination suggestion in the hypnosis conditions, for example, might account for increased activations found in the various occipital areas, and the more anterior activations seen in precentral, premotor and parietal areas would be expected in the presence of strong motor imagery. Equally, the relatively greater levels of temporal activation seen in the ‘alert’ condition could be seen as a reflection of the participants being required to listen to sentences containing pleasant information taken from their own past, particularly as the ‘relivings’ or ‘hallucinations’ in the two hypnosis conditions were not accompanied by significant auditory experiences. These results are interesting in illustrating that congruent brain processes accompany autobiographical relivings and visual hallucinations in hypnosis. It is not possible, however, to draw a firm conclusion as to the role of the hypnotic induction procedure or the ‘hypnotic state’ in producing the differences in brain activations observed between the hypnotic and alert states, as the tasks were different in the two conditions.

14.4.1.2. Analgesia Four studies have compared the effects of a hypnotic induction procedure combined with suggestions leading to analgesia with a variety of no-hypnosis conditions. In the first of these, specific analgesia suggestions were given following a hypnotic induction procedure (Wik et al., 1999). In the other three studies, the hypnotic suggestions were for the reliving of positive autobiographical memories (Faymonville et al., 2000, 2003) or guided imagery experiences

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(Schultz-Stubner et al., 2004), all of which resulted in incidental analgesia effects in the hypnosis condition compared with the no-hypnosis condition. Wik et al. (1999) used PET neuroimaging to explore cerebral mechanisms behind hypnotic analgesia in eight highly hypnotizable fibromyalgia pain patients (HGSHS:A scores >9). To control for potential differences in visual processing, participants in all conditions watched videos of people walking in a park. In the hypnotic analgesia condition, ‘hypnosis was induced by gently talking to the subjects, instructing them to be relaxed and to go into deep trance to watch the videotapes and not to feel any pain whatsoever’. For the no-hypnosis, ‘resting wakefulness’ control condition, the same participants ‘were told to be comfortable and watch the videotapes’. The hypnotic analgesia condition was accompanied by a modest but significant lowering of pain ratings from 4.3 to 3.2 (on a 0–10 scale). Brain changes associated with hypnotic analgesia were increases bilaterally in orbitofrontal and subcallosal cingulate cortices, unilaterally in the right thalamus and left inferior parietal cortex, and a decrease bilaterally in cingulate cortex. The authors concluded that this pattern of activation during hypnotic analgesia is consistent with widespread alterations in brain areas normally involved in the processing of nociceptive stimulation. The design of the study, however, does not allow for any conclusion as to whether the brain activation differences between the hypnosis and no-hypnosis condition are due to the induction procedure, the analgesia suggestions or a combination of the two. In an extension of the Maquet et al. (1999) study, Faymonville et al. (2000) focused on the ‘antinociceptive effects of hypnosis’, again using PET. The participants were 11 highly hypnotizable volunteers (SHSS:C >8) and were tested under three conditions: (1) resting state—in which they were encouraged to remain immobile and to ‘empty their minds’; (2) mental imagery—in which they had to listen (just before the scan) to sentences containing pleasant information from their own past and were then instructed during the scan to ‘vividly imagine a pleasurable autobiographical memory’; and (3) hypnotic state—consisting of a 3 min

induction involving muscle relaxation followed by the suggestion to ‘re-experience their pleasant autobiographical memory’. Participants were tested in all three of these conditions during exposure to either comfortably warm (39°C) or painfully hot (47°C) stimuli delivered during the scans to the participant’s right hand. Pain ratings were significantly lower in the ‘hypnotic state’ condition than in the other two conditions, confirming the expected analgesic effect of their hypnotic procedure. The ‘hypnotic state’ also differed from the other two conditions by showing increased activation of right extrastriate cortex and right ACC. As in Maquet et al. (1999), task demands appear to be different in the ‘hypnotic state’ condition compared with the two no-hypnosis conditions in this study irrespective of the induction procedure, and it is not clear whether the differences between conditions are attributable to the ‘hypnotic state’, the different cognitive tasks and suggestions being carried out or the analgesia effect. The extrastriate cortical activations may reflect some visual components of the reliving experience suggested to the participants only in the ‘hypnotic state condition’. In particular, the fact that ACC regional activation in this study varied in proportion to pain sensation indicates that it is related more to the analgesia effect than to any general aspect of the hypnotic state per se. Having demonstrated in their earlier study that ACC activity co-varies with the reduction in affective and sensory responses to noxious thermal stimulation in their ‘hypnotic state’ condition, Faymonville et al. (2003) set out, again using PET, to assess ‘changes in cerebral functional connectivity related to the hypnotic state compared to simple distraction and the resting state’. The participants were 19 highly hypnotizable volunteers (SHSS:C >8 out of 12) exposed as in the previous study to hot noxious or warm nonnoxious stimulation of the right hand under each of three conditions: (1) resting state (‘participants were asked to relax and empty their mind’); (2) mental imagery (‘subjects were instructed simply to imagine a pleasurable autobiographical memory and were urged not to enter the hypnotic state’); and (3) hypnotic state (‘induced using eye fixation, a 3 min muscle relaxation procedure and

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permissive and indirect suggestions’. The nature of the suggestions was not specified, but following the hypnotic induction ‘each subject was invited to re-experience very pleasant autobiographical memories’). No significant pain reduction was found in the mental imagery condition compared with the resting condition but, as in the previous study, pain reports were significantly lower in the ‘hypnotic state’ condition compared with these two no-hypnosis conditions. On the basis of their earlier studies, midcingulate cortex had been identified as being centrally involved in the mediation of these changes in pain perception, and Faymonville et al. (2003) explored here the hypothesis that ‘hypnosis induced analgesia can be explained by an enhanced modulation between the midcingulate cortex and the large neural networks involved in the sensory, affective and cognitive aspects of noxious processing’. Consistent with the hypothesis, analysis of the PET data showed that the ‘hypnotic state’ compared with normal alertness (i.e. rest and mental imagery) significantly enhanced the functional modulation between midcingulate cortex and a large neural network encompassing bilateral insula, pregenual ACC, presupplementary motor area, right prefrontal cortex and striatum, thalamus and brainstem. This is a further demonstration of the spontaneous analgesia associated with a suggested revivification of positive experiences following a hypnotic induction and implicates the midcingulate cortex in its mediation by the modulation of a large cortical and subcortical network underlying sensory, affective, cognitive and behavioral aspects of nociception. The design of the study, however, does not allow us to distinguish the contribution of the hypnotic induction procedure itself from that of the concurrent revivification task in producing these changes. It is also relevant to note here that a later study (Rainville et al., 2002) that used a hypnotic induction procedure without suggested revivification or analgesia suggestions found that the experience of pain was not altered by ‘hypnosis alone’. Schultz-Stubner et al. (2004) reported an fMRI study very similar in design to the previous two to explore ‘the putative effects of clinical hypnosis on pain’, but used suggested positive

imagery rather than revivification of autobiographical memories to create an incidental analgesia effect. The study involved 12 participants exposed to painful heat stimuli to their left forearm under a hypnosis and a no-hypnosis condition in counterbalanced order. No standardized test of hypnotic susceptibility was administered, but the hypnotic responsivity of the participants was indicated by a limb levitation test carried out during the hypnotic induction procedure. The hypnosis induction procedure, which was described to the participants as ‘deep relaxation’ rather than ‘hypnosis’, consisted of an eye fixation and eye closure followed by suggestions of heavy and warm body sensations, starting from the eyelids and spreading over the whole body, and then images such as lying on a beach and listening to the ocean waves were introduced. For the no-hypnosis condition participants were asked to think of ‘something nice’ and engage in images at their leisure. Participants were not blinded to the objectives of the study and were informed about the concept of hypnosis (without using the term hypnosis) as a ‘deep relaxation technique’. All participants reported reduced pain (7). Without hypnosis, activity was seen in response to the painful stimulus in the known pain network—insula, ACC and primary sensory cortex. In the hypnosis condition, there was new activation in basal ganglia but reduced activity in insula, middle cingulate gyrus and primary sensory cortex. Also, activation in left ACC was significantly increased under hypnosis whereas right ACC activity was unchanged. This study extends the previous two by showing that introduction of relaxing guided imagery following a hypnotic induction procedure is more effective than simply thinking positive thoughts plus spontaneous imagery without a hypnotic induction in creating an analgesic effect, and that this is accompanied by related changes in brain activity. Whether these differences are due to effects of the hypnotic induction procedure, to the different mental tasks involved in the two conditions or to the analgesia effect is again not fully resolvable, though the last of these seems likely to account for the majority of them.

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14.4.1.3. Catalepsy In what appears to have been the first PET study involving hypnosis, 15 ‘highly hypnotizable’ participants (SHSS:C—no scores are quoted) who had previously undergone ‘hypnotherapy’ for psychosomatic problems were scanned in a counterbalanced design in ‘resting wakefulness’ and while hypnotized ‘in order to elucidate the physiological effect of hypnosis’ (Grond et al., 1995). In both the hypnosis and the no-hypnosis conditions, the participants were ‘resting in a comfortable supine position, with eyes closed and ears unoccluded’. The ‘hypnosis’ condition also involved an induction procedure that included suggestions for catalepsy of the whole of the participant’s body except the arm used for catheterization required for the PET procedure. The type of induction procedure used and the suggestions used to induce the catalepsy were not reported, but the term ‘catalepsy’ commonly implies a suspension of sensibility and voluntary movement characterized by ‘waxy’ rigidity of the body and limbs, which maintain any posture in which they are placed (Orne, 1959). For the purpose of monitoring the persistence of the catalepsy, the noncatheterized arm was raised and remained extended at the elbow with hyperextension of wrist and index finger for approximately 30 min during the scans. The authors reported no significant change in metabolism in the whole brain and no lateralized differences. Using a relative change index, they reported that compared with the resting condition, the hypnosis condition was accompanied by significant underactivation in visual cortex and a significant but moderate overactivation in brain areas involved in sensorimotor functions (sensorimotor cortex, basal ganglia, thalamus and cerebellum). The authors interpreted the increased activation in sensorimotor areas in the hypnosis condition as a consequence of the protracted, uncomfortable arm elevation associated with the catalepsy suggestion. The reduction in visual cortex activation they felt was related to a switch from an external to an internal focus of attention, which could reflect a more general attribute of the hypnotic state or could be a more direct consequence of the catalepsy suggestions. Overall, it seems more parsimonious to conclude that all the differences

in brain activation referred to above relate specifically to the suggested catalepsy.

14.4.1.4. Color processing Kosslyn et al. (2000) used PET neuroimaging ‘to determine whether hypnosis can modulate color perception’. Participants were eight highly hypnotizable subjects pre-screened for the ability to experience color hallucinations. Hypnotizability was determined using the SHSS:C and the Hypnotic Induction Profile (HIP; Spiegel and Spiegel, 1978). Mean scores for the experimental group on the SHSS were 10.5 (out of 12) and on the HIP were 9.1 (out of 10). Scanning sessions were conducted in two blocks in counterbalanced order, and in both blocks participants were presented on some trials with a colored stimulus display and on other trials the same display rendered as a grayscale image. One block was preceded by participants ‘having undergone hypnotic induction’ (hypnosis condition) and the other block was not (no-hypnosis condition). The hypnotic induction procedure used was not described. In both the hypnosis condition and the no-hypnosis condition, participants were instructed on some occasions to perceive the stimuli veridically as colored or grayscale. In the hypnosis condition they were instructed on other occasions ‘to alter actively the stimulus, to drain or add color’ in order to create hallucinated colors when presented with the grayscale stimulus and the hallucinated absence of colors when presented with the colored stimulus. In the no-hypnosis condition, in order to provide a mental imagery control for the hypnotic hallucination instructions, participants were asked to ‘try to “remember and visualise” the stimulus in its other form’. Veridical viewing in both the hypnosis and no-hypnosis conditions was associated with increased activation in color processing (fusiform) areas of visual cortex for the color stimuli compared with grayscale stimuli on both sides of the brain. Comparable bilateral activations of fusiform areas were also seen in the hypnosis condition for hallucinated color compared with the hallucinated grayscale experience. In the no-hypnosis visual imagery condition, however, this differential effect was seen only in the right hemisphere. This outcome provides a further clear demonstration that specific suggestions following a

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hypnotic induction are associated with changes in activation in brain areas normally involved with processing the targeted experience. There is also an interesting parallel with the observation of Derbyshire et al. (2004) and Szechtman et al. (1998) that a hypnotically hallucinated experience is more similar in terms of brain activation to the corresponding physically produced experience than it is to imagining the same experience in hypnosis, though in the Kosslyn et al. (2000) study the imagination condition was conducted without a hypnotic induction. In terms of the distinction drawn earlier, this study does not allow any clear conclusion as to the role of the hypnotic state, or trance, in producing the differences observed in fusiform area activation in the hypnosis and no-hypnosis conditions as the cognitive demands were different in the two cases. Specifically, the participants’ task was to hallucinate color changes in the hypnosis condition and to imagine color changes in the no-hypnosis condition.

14.4.2. Conclusions on studies of

trance plus suggestion The studies in this section were not designed to identify any effects of a hypnotic induction procedure and any consequent hypnotic state or trance separately from the effects of suggestions or other ongoing cognitive tasks. They are, however, a very significant contribution in that they add further weight to the view that ‘hypnotic’ phenomena (i.e. phenomena produced by suggestion following a hypnotic induction procedure) are ‘real’ in the sense that I used the term in the discussion above. That is, they are not simply products of reporting bias, faking, etc. As in the case of the ‘instrumental’ studies reviewed earlier, the suggested effects are accompanied by clear neural activation changes that engage the same brain areas that are observed, or would be expected to be involved, in mediating the same phenomena produced by more naturalistic means. This clearly reinforces the potential effectiveness of hypnotically suggested effects as a neurocognitive tool. A limitation of these studies from the perspective of the earlier distinction between the possible effects of the hypnotic induction procedure itself (trance) and of suggestions that accompany

it is that the no-hypnosis conditions used for comparison have not only omitted the induction procedure but have also omitted the suggestions. The hypnosis conditions employed in these studies have included suggestions specifically to produce analgesia (Wik et al., 1999); catalepsy (Grond et al., 1995); color hallucinations (Maquet et al., 1999; Kosslyn et al., 2000); and revivification, reliving or guided imagery, all of which had an analgesic effect (Maquet et al., 1999; Faymonville et al., 2000, 2003; Schultz-Stubner et al., 2004). In contrast, no-hypnosis control conditions have involved resting (Grond et al., 1995; Wik et al., 1999; Faymonville et al., 2000, 2003); listening to autobiographical material plus mental imagery (Maquet et al., 1999); and mental imagery (Faymonville et al., 2000, 2003; Kosslyn et al., 2000; Schultz-Stubner et al., 2004). As already noted, there appear to be differences at the level of brain activation between ‘experiencing’ (or hallucinating) a suggested effect and ‘imagining’ the same experience even when these are both carried out in hypnosis. Using a mental imagery task without an induction procedure as a nohypnosis control for a hypnosis condition that includes both an induction procedure and suggested experiential change will produce differences that are as likely to be due to the different task demands as they are to the presence or absence of a hypnotic induction and any possible state change (trance) that might accompany it (Kirsch, 2005). One reason offered for making the task demands different in the two conditions is that the wording used in the hypnosis condition might lead the highly hypnotizable participants ‘to fall into a hypnotic state’ in the no-hypnosis condition (e.g. Kosslyn et al., 2000). This makes the assumption that there is a hypnotic state to ‘fall into’ and that it is inextricably linked to the execution of suggested effects (see also Barabasz and Barabasz, Chapter 13, this volume, on spontaneous hypnosis). The importance of addressing the distinction between hypnosis and suggestion that this assumption raises is highlighted in a recent study by Raz et al. (2006) in which the effects of suggestion given after a hypnotic induction to alter Stroop interference were compared with the effects of the same suggestion given without a hypnotic

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induction in a matched group of highly hypnotizable participants. Their finding was that the Stroop interference effect was reduced to the same extent in both groups irrespective of the use of a hypnotic induction procedure. Raz et al. (2006) concluded that ‘it is suggestion rather than hypnosis that reduces the Stroop effect’. A similar observation has been reported for pain by Milling et al. (2005) who found no significant differences in subjective pain reports when the same analgesia suggestion was given in a hypnosis or in a no-hypnosis condition. Neither the Raz et al. (2006) or the Milling et al. (2005) study included neuroimaging, and an important next step would be to compare brain activation patterns when the same suggestion is given with and without a hypnotic induction in high hypnotizables. There do not appear to be published reports of such a comparison using PET or fMRI neuroimaging procedures for the Stroop reduction effect, but there is some evidence for suggested alterations in pain from a study that I describe in the next section.

14.4.3. Suggestion with or

without trance In an ‘instrumental’ hypnosis study that investigated the brain mechanisms underlying clinically reported fibromyalgia pain, Derbyshire et al. (2007) used suggested ‘pain dial’ imagery in 13 hypnotized participants (HGSHS:A >8) to modulate their own fibromyalgia pain experience during fMRI scanning. Widespread areas of the brain (cerebellum, thalamus, midcingulate cortex, primary and secondary sensory cortex, inferior parietal cortex, prefrontal cortex and insula) showed changing levels of activation corresponding to the intensity of the subjectively reported pain experience. It seems clear from this that fibromyalgia pain involves activation of the traditionally identified ‘pain matrix’. Taken with the results of studies above in the section on instrumental hypnosis studies of pain, these data are consistent with the view that fibromyalgia pain could be functional in origin. But since the efficacy of hypnotic analgesia suggestions in modulating physically induced pain is well established (Montgomery et al., 2000), they are not definitive evidence for this. Derbyshire et al. (2007) also speculated that the activations seen in

‘supervisory neural structures’ (such as prefrontal cortex and medial ACC) when the fibromyalgia pain was being modulated by suggestion might reflect some of the cognitive processing that underlies the hypnotic alteration of pain experience. It is not possible to determine within this set of observations, however, whether these particular activations reflect changes in processes that are involved in the generation of fibromyalgia pain itself or the effects of suggestion per se rather than being specifically related to the ‘hypnosis’ condition. Fortunately some light can be shed on these and related questions raised in the previous section because the study also included a no-hypnosis condition in which the same pain dial-based suggestions were administered to the same participants without being preceded by a hypnotic induction. Subjective reports of the degree of change in pain experience in response to suggestion were not significantly different in the two conditions irrespective of the presence or absence of a preceding hypnotic induction procedure. This is similar to the lack of difference seen in response to suggestion between the hypnosis and the no-hypnosis conditions in the Raz et al. (2006) Stroop effect study and by Milling et al. (2005) for analgesia suggestions. In comparison with Raz et al. (2006), there are a number of differences, however, in that the reduced Stroop effect depends on over-riding what are believed to be automatic attentional processes, whereas reporting of subjective pain levels is voluntary and therefore open to reporting bias based on experimental demands, expectations, etc. Also the suggested effect in the Raz et al. (2006) study was achieved via a post-hypnotic suggestion whereas in the Derbyshire et al. (2007) and Milling et al. (2005) studies the suggestion was executed during hypnosis. Despite the similarity of the reports of pain experience in response to hypnotic and nonhypnotic suggestion in the Derbyshire et al. (2007) study, participants also reported that they experienced significantly more control over their pain in the hypnosis condition. Consistent with this, the brain activations were much weaker overall in the no-hypnosis condition, with significant attenuation of the suggested effects being seen in the thalamus and insula and in prefrontal and

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sensory cortices. This indicates that at the level of brain activity at least, there appear to be significant differences in the effectiveness of suggestions depending on whether or not they are administered after a hypnotic induction procedure, even when these differences are not evident at the level of subjective report. It is interesting that there are similar findings in the behavioral realm. McConkey et al. (2001), for example, found no differences in reported success of hypnotic and waking suggestions for gender change, but ‘dial ratings’, in which participants turned a dial to indicate the strength of their experience, showed that the highly hypnotizable participants achieved the experience sooner in hypnosis than in the no-hypnosis condition. It is also interesting that the neuroimaging evidence from Derbyshire et al. (2007) indicates that in this situation at least these highly hypnotizable participants did not seem to ‘slip into hypnosis’ when given the same suggestion in the no-hypnosis condition.

14.4.4. ‘Hypnosis’ as trance The Derbyshire et al. (2007) study just described indicated that engaging an individual in a hypnotic induction procedure (identified as such) results in a significant enhancement in the brain changes associated with a suggestion compared with the effects of the same suggestion without a hypnotic induction procedure. One possible implication of this is that the induction procedure itself, for whatever reason, creates a steady-state alteration in brain activity that mediates the observed changes in the effect of the suggestion. A first step in exploring this possibility is to investigate the effects of induction procedures independently of specific suggestions. The four studies that I describe in this section adopted this approach. That is, they have regarded ‘hypnosis’ as a background state of altered mental processing independent of specific suggestions—sometimes referred to as ‘neutral hypnosis’ (Edmonston, 1991; Kallio and Revonsuo, 2003) and corresponding to ‘trance’ in the definition adopted in this review. The further assumption is that there is an alteration in conscious experience that accompanies the hypnotic ‘state’ and that this alteration is what is generated by traditional hypnotic

induction procedures. Traditional procedures typically include suggestions for ‘relaxation’ alongside instructions for focused attention, and engagement with inner mental processes such as imagery. For this reason, ‘relaxation’, especially mental relaxation (or mental calm), will be included as a component of the hypnotic ‘state’ typically produced, though as noted earlier it is not evident that physical relaxation at least is an essential component of such a state (Banyai and Hilgard, 1976; Wark, 2006). All of the studies I review in this section have engaged the participants in the same mental task or activity in both the hypnosis (‘trance’) condition and the no-hypnosis condition. This has the effect of reducing individual variation in the incidental mental activity that the participants engage in, both across subjects and between conditions within subjects, which enhances the possibility of detecting differences that might be due to the induction procedure per se. The common tasks were experiencing warm and painfully hot stimuli (Rainville et al., 1999, 2002), watching a flashing checkerboard pattern (Deeley et al., 2007a) and engaging with a Stroop cognitive conflict task (Egner et al., 2005). The first of these studies (Rainville et al., 1999) provides a more direct evaluation of the effects of trance using data drawn from an earlier PET study that investigated the effect of suggestion on pain affect and pain intensity (Rainville et al., 1997). The data derive from eight participants screened for moderate to high hypnotic susceptibility defined as scores of 8 or more out of 11 on a shortened version of the SHSS:A (Weitzenhoffer and Hilgard, 1959) and their ability to modulate the affective component of heat pain in response to suggestion. The two conditions of interest here are pre-hypnosis condition (baseline) and a hypnosis-alone condition (hypnosis) in both of which the participant’s left hand was immersed in water that was ‘neutral’ or ‘painfully hot’. The baseline condition was one of restful wakefulness with eyes closed. The hypnotic induction procedure used to create the hypnosis condition was taken from the SHSS:A, which, in addition to trance-related instructions, includes eye closure and suggestions for relaxation. The task demands in the baseline and hypnosis condition were very similar however—sitting whilst feeling

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relaxed with eyes closed experiencing a heat stimulus—which leaves the presence or absence of the hypnotic induction procedure, and any induction-related trance state, as the major feature differentiating the two. Combining the two types of heat stimulus and comparing the hypnosis condition with the baseline revealed increased activations with hypnosis bilaterally in occipital regions (fusiform gyrus, middle occipital gyrus and lingual gyrus) and in inferior frontal gyrus; increases on the right in anterior cingulate gyrus (caudal part) and anterior superior temporal gyrus; increases in the left insula; and decreases in parietal cortex (right inferior parietal lobule, right medial precuneus and left posterior cingulate gyrus), left medial superior frontal gyrus and left posterior middle temporal gyrus. Of these changes, the widespread activation in occipital regions was the most striking hypnosis-related effect. This seems likely to be linked to the participants engaging in vivid visual imagery in the hypnosis condition. A number of the participants reported that they did in fact do this, though they had not been explicitly instructed to do so. In this context, it is also interesting that the pain stimulus appeared to inhibit the potentially trance-related occipital activations. This observation is consistent with the reports from some participants in the study that the painful stimulus interfered with their experience of ‘hypnosis’. Another interesting outcome from this study is the hypnosis-related activity increase in the right ACC compared with baseline activity that was seen for both neutral and painful stimuli. The earlier report based on these same scans by Rainville et al. (1997) also identified ACC as an area of activation associated with suggestion-based modulation of the affective component of the heat pain stimulus. However, the locus of the ‘hypnosis’ and the ‘pain’ areas within ACC were different. Another hypnosis-related change was the decrease in activation in posterior parietal sites. This is consistent with a decrease in attention to extraneous stimuli and general body-sense awareness that participants in hypnosis frequently report. In interpreting these differences, it is worth keeping in mind that some of them may be due to the presence of relaxation suggestions in the hypnosis condition, which may have

different brain effects compared with simple instructions to relax in the baseline condition. It is possible, for example, that the hypnosis suggestion may be more related to mental calming than to physical relaxation. In a subsequent report from the same group of investigators (Rainville et al., 2002), 10 volunteer participants of widely varying levels of hypnotic susceptibility (ranging from 1 to 10 out of 11 on a shortened SHSS:A) were tested while experiencing warm or painfully hot stimulation of the left hand under the same baseline and hypnosis conditions as in Rainville et al. (1999). As before, the hypnotic induction procedure involved trance instructions combined with relaxation suggestions, but again with no suggestion given relating to the experience of pain. A subtraction analysis (hypnosis minus baseline) confirmed hypnosis-related activations in both occipital lobes, right inferior frontal gyrus and right superior temporal gyrus, left insula and right ACC regions. Decreased activation associated with hypnosis was again seen in right parietal cortex (inferior parietal lobule and precuneus) and left posterior temporal cortex. Rainville et al. (2002) also took selfratings from their participants of relaxation and absorption after each scan. They found significant increases on both measures following the induction procedure, and both showed modest but significant correlations with hypnotizability. Looking at brain activations associated specifically with absorption, Rainville et al. (2002) identified a collection of areas showing increases in activation including upper pons, thalamus, rostral areas of right ACC, prefrontal cortex (especially right ventrolateral frontal cortex, right inferior frontal cortex and anterior insula) and right inferior parietal lobule. There was a negative correlation (reduced activation) between absorption and activity in the left inferior parietal lobule, right precuneus, posterior cingulate cortex and both occipital cortices. Increases in brain activation associated with the relaxation suggestion were reported in right precuneus, left inferior parietal lobule and bilateral occipital cortices. Reductions in activation associated with relaxation were found in mesencephalic brainstem, thalamus, prefrontal areas (in particular the superior frontal gyrus extending over rostral ACC, both temporal lobes, right

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parietal operculum and lobule, and somatosensory cortex). The absorption-related increases in activation in ponto-mesencephalic brainstem nuclei and thalamus may reflect attention-related activity of these areas and, in particular via pathways influencing activation in ACC, may serve to maintain focused attention and cortical arousal in hypnotized subjects. Absorptionrelated increases in activity were also found in the right anterior parietal lobule and bilaterally in prefrontal cortices, most strongly in ventrolateral frontal cortex, over the inferior frontal gyrus and in the anterior insula. Activation in these areas has been found in other studies to correlate with attentional processes in tasks associated with visual, auditory and somatosensory stimuli. Rainville et al. (2002) concluded that the co-ordinated pattern of activity in brainstem, thalamus, ACC, right inferior frontal gyrus and right inferior parietal lobule in particular provides very strong evidence that mental absorption is an experiential correlate of the activation of the brain’s executive attentional network and that this system plays a critical role in the production of hypnotic states. Negative absorption-related effects were found in right and left parietal cortices and in precuneus independently of thalamic activity. Right posterior parietal cortex has been identified as part of a vigilance/orientation system, and the observed decreases in this area may therefore reflect disengagement towards external sources of stimulation. More broadly, right and left posterior parietal cortices have been associated with monitoring external space and time. The absorption-related pattern of parietal activations are thus consistent with internal focusing of attention and alterations in spatio-temporal orientation frequently reported by individuals following an hypnotic induction. It is important to note here that the induction instructions used by Rainville et al. (2002) included specific directions to decrease orientation to ‘irrelevant’ external sources of information, which raises the possibility that the changes relate to the particular induction procedure used. A reduction in activity in both occipital lobes and an associated reduction in thalamic activity were also found to be linked with mental absorption. The authors

interpreted this in terms of the absorptionrelated engagement of the executive attentional network, which serves to reduce activity in unattended sensory channels. In contrast to absorption, negative correlations were reported with relaxation in mesencephalic brainstem and thalamus, which may reflect the contribution of these areas to cortical arousal and wakefulness. Rainville et al. (2002) suggested that relaxation-related decreases in right lateral posterior parietal cortex and in right prefrontal cortex may also reflect the experience of mental ease reported after traditional hypnotic induction procedures. Reflecting the heterogeneity of function that characterizes the ACC, a further distinction between the central correlates of absorption and relaxation is that though both are associated with increases in activity in this area, the peak observed with relaxation is more posteriorly located. Increases in activity in motor and premotor areas have previously been associated with voluntary muscular relaxation, and the Rainville et al. (2002) study also found strong relaxationrelated increases in the precentral gyrus, with reciprocal decreases in somatosensory areas (S1, S2 and insula). There were also relaxationrelated increases in activity in occipital areas. Similar increases in occipital activation have been reported previously with ‘hypnosis’ (e.g. Maquet et al., 1999; Rainville et al., 1999), and what the present study suggests is that this may be related to hypnotic relaxation, or other ongoing cognitive activity, rather than to absorption, which as I noted above is associated with a reduction in activation in occipital areas. A number of important general points emerge from this study. One is that though absorption and relaxation were significantly correlated, the variance in absorption was largely independent of relaxation, indicating that when a hypnotic induction procedure is used that includes suggestions for relaxation, the two processes co-exist but are potentially independent. This raises the question of whether either or both of these can be considered core features of ‘hypnosis’ as a state. The fact already noted that some hypnosis induction procedures do not involve physical relaxation (active alert hypnosis) clearly suggests that physical relaxation is not an essential component.

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This would also be indicated by the fact that individuals can become physically active even following a relaxation-based hypnotic induction without seeming to become de-hypnotized. This nevertheless leaves open the possibility that mental relaxation (or ‘mental calming’) is a component of the hypnotic state after an active alert induction as well as after a more traditional relaxation-based induction procedure. There appears to be no direct evidence to address this specific question, and the scale used by Rainville et al. (2002) did not overtly distinguish physical from mental relaxation, though it was probably biased towards mental relaxation or mental calming. Clinical observation, however, would suggest that hypnotized individuals can experience mental agitation without apparently becoming de-hypnotized. This may suggest that even mental calming is not an essential component of the hypnotic state. This leaves absorption as a prime contender. Whatever the final resolution of this particular question will be, it seems clear that following an induction procedure with relaxation instructions, the effects of relaxation and absorption seem in many ways to be in conflict. They appear to create an internal tension, requiring a balance between increased attention, arousal and mental focusing associated with absorption and decreases in these activities with relaxation. Nevertheless, it is reasonable to conclude that they may jointly or individually be precursors of other hypnosis-related changes such as a reduced tendency to judge, monitor and censor incoming information or mental events, the suspension of usual orientation to time, location and sense of self and, under some circumstances, the experience of responses as automatic or extra-volitional. Relevant to the last of these is the fact that in other studies a sense of agency has been associated with activity in right inferior parietal cortex, precuneus and somatosensory cortices, and these are also areas that show consistent changes in activity following hypnotic induction procedures. It is not clear whether these changes are the product of being hypnotized per se or are the results of suggestions embedded in the induction procedure, though it is clear that some of them at least can be produced by specific suggestions relating to

the experience of passive movement in hypnosis (Blakemore et al., 2003). In another study investigating the possibility of an altered background brain state following hypnotic induction, Deeley et al. (2007c) used fMRI to compare brain activity before hypnosis (pre-hypnosis), after a hypnotic induction (hypnosis) and following reversal of hypnosis (post-hypnosis) when participants were carrying out a nondemanding visual task (passively attending to a flashing checkerboard display). The participants were eight medium to high hypnotizable volunteers (HGSHS:A scores >7). The hypnotic induction procedure was based on Gruzelier’s three-step model (Gruzelier, 1998) of hypnotic induction and included both relaxation suggestions and special place imagery (Oakley et al., 2007). Subjective hypnotic depth measurements were taken from the participants on a 10-point scale (Oakley et al., 2007) before and after the checkerboard display in each of the three conditions (pre-hypnosis, hypnosis and post-hypnosis). These measures confirmed that hypnotic depth remained stable over the time that each display was presented and also that hypnotic depth was greater in the hypnosis condition compared with the pre-hypnosis and post-hypnosis conditions. There was no significant difference, however, between the pre- and post-hypnosis conditions, indicating that hypnosis had been effectively reversed following the hypnosis condition. Correlational analyses were conducted between brain activity and hypnotic depth. These showed that increasing hypnotic depth was associated with increased activity in lateral prefrontal regions previously shown to be involved in working memory and the maintenance of attention (bilateral middle prefrontal gyrus, bilateral inferior frontal gyrus and right precentral gyrus). Increasing depth of hypnosis was also associated with reduced activity in left medial frontal gyrus, bilateral parahippocampal gyri and left posterior cingulate gyrus. These areas have been identified across a variety of neuroimaging paradigms as components of a ‘default mode’ network of normal brain function that is active during ‘rest’ periods when task demands are low (Gusnard and Raichle, 2001). Subjectively, this normal default mode is characterized by spontaneous

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task-independent thought, episodic memory, semantic processing and self-awareness. The observed pattern of activations is consistent with a view that the ‘default mode’ in hypnosis is different from that in a nonhypnotized state, and in particular that it is characterized by a reduction in spontaneous conceptual thought. Increasing depth of hypnosis was also accompanied by reduced activity in thalamus, pons and medulla, which are areas associated with mediating arousal and alertness, possibly reflecting an increase in relaxation and ‘mental calmness’ in the hypnosis condition. Consistent with the observed changes in brain activation, visual analog scale (VAS) scores taken from the participants revealed that, compared with when they were not hypnotized, the hypnosis condition was associated with significant increases in both relaxation and absorption and significant decreases in distraction, the tendency to analytical thought and the feeling of their minds being ‘cluttered up’. From these observations it seems that ‘neutral’ hypnosis (or ‘trance’) is characterized by a default mode of brain functioning that is different from that encountered in individuals under the same conditions without a hypnotic induction and that the brain activity observed is congruent with subjective states typically reported by hypnotized individuals. One of the brain areas associated with both relaxation and absorption in the Rainville et al. (2002) study was ACC, which among other functions has been associated with ‘conflict resolution’. Egner et al. (2005) used a combination of fMRI and EEG (electroencephalogram) coherence to measure the effects of hypnotic induction on conflict monitoring and cognitive control processes using the Stroop procedure to manipulate levels of cognitive conflict in an ongoing task. In addition to ACC, interest was focused on left lateral frontal cortex, which has been identified as being involved in cognitive control processes that co-vary with conflict monitoring. The specific proposal Egner et al. (2005) were testing was that though highly hypnotizable individuals show good attentional capacities compared with low hypnotizables in no-hypnosis conditions, their attentional capacities, as evidenced by enhanced Stroop interference, are significantly altered following a

hypnotic induction procedure. In particular they hypothesized on the basis of earlier evidence that a hypnotic induction procedure in the absence of any suggestions aimed at altering attentional performance would result in a decoupling of conflict monitoring processes (mediated by ACC) without a compensatory increase in cognitive control (mediated by left lateral prefrontal cortical areas). To investigate this hypothesis, two groups of volunteer participants were selected on the basis of their HGSHS:A and SHSS:C scores as being of high (n = 11, scores on both scales 9 or higher) or low (n = 11, scores on both scales 3 or less) hypnotic susceptibility. Both groups were tested in the fMRI scanner before and after a hypnotic induction procedure (that excluded references to relaxation, heaviness or sleep) while performing a word/color Stroop task involving varying degrees of response conflict. Importantly, no suggestions were given that related to performance on the Stroop task. The main findings were that conflict-related activity during the Stroop task increased in ACC from baseline to hypnosis in the highly hypnotizables, but not in the low hypnotizables, resulting in higher overall levels of conflict-related activity in the high hypnotizables than the low hypnotizables following the hypnotic induction. Cognitive control-related activity in left frontal cortex, however, did not show any systematic changes due to either the hypnotic induction procedure or the hypnotic susceptibility of the participants. Given the well-established finding in other (nonhypnosis) studies that increased conflict-related ACC activation is normally associated with a compensatory increase in cognitive control, Egner et al. (2005) interpreted their own results as indicating a decoupling of the normal relationship between conflict monitoring (ACC) and cognitive control functions (left lateral frontal cortex) following a hypnotic induction procedure in highly hypnotizables. This interpretation was supported by EEG data collected in a parallel study that showed decreased gamma band coherence between frontal midline and left lateral scalp sites in the highly hypnotizables. Other than the taskrelated changes in ACC, it is interesting that they found no hypnosis-related changes in any other brain regions.

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Overall, Egner et al. (2005) concluded that their data were more compatible with the view that hypnosis per se (i.e. ‘trance’) in highly hypnotizable individuals is associated with impairment in some aspects of attentional processing rather than with the global increase in focusing of attention that has been commonly assumed. It remains to be seen whether the effects of hypnotic induction on the relationship between conflict monitoring and cognitive control functions are typical of all hypnosis inductions and test situations or are specific to this particular induction procedure or to being tested on a Stroop task. It is significant that the effects were produced using an induction procedure that did not include relaxation suggestions—which may indicate that it is the absorption (or at least nonrelaxation) component of ‘hypnosis’ that is responsible for the changes observed in attentional processing. This study is relevant to that of Raz et al. (2005), described in the instrumental hypnosis research section above, in that both clearly found changes in ACC activity that corresponded to hypnosis-related changes in conflict monitoring. The Raz et al. study, however, involved a reduction in Stroop interference in high hypnotizables after a hypnotic induction procedure. This was produced by a specific suggestion intended to reduce or to remove the cognitive conflict from the Stroop presentation rather than by over-riding any decoupling of the relationship between conflict monitoring and cognitive control functions. It is perhaps significant nevertheless that the effect in the Raz et al. (2005) study was achieved by a post-hypnotic suggestion and thus was demonstrated after the hypnosis condition had been terminated. It could be hypothesized on the basis of the evidence from the Egner et al. (2005) study that the reduction in Stroop interference would be easier to achieve by the use of post-hypnotic suggestion that operates when the individual is in a nonhypnotized state than it is when the suggestion is to be acted upon during the hypnotic condition when the individual’s susceptibility to Stroop interference has been increased by induction-related changes in attentional processing. There is at present no direct evidence that could answer this question as all of the hypnosis studies demonstrating a suggestion-related

reduction in Stroop interference, with the exception of a single case study reported by MacLeod and Sheehan (2003), appear to have used post-hypnotic suggestion to achieve the effect. Considering these studies as a whole, it is important to bear in mind that with the exception of Egner et al. (2005), the induction procedures used have included relaxation suggestions. Nevertheless, a growing case can be made that there is a distinct steady-state change attributable to a traditional hypnotic induction procedure, relating to alterations in attentional processes, spontaneous conceptual thought, feelings of absorption, relaxation and mental calm following a hypnotic induction procedure that might be considered to correspond to a state of ‘neutral’ hypnosis. The relationship between this mental state and suggestion is not clear, although the study reported by Derbyshire et al. (2007) in the previous section indicated that there is a difference in associated brain activity when the same suggestions are given following a hypnotic induction procedure and when they are given without it.

14.4.5. Effects of trance on sensory

and motor processes There is very substantial and convincing evidence from the studies reviewed above that specific suggestions given after a hypnotic induction have a significant effect on the processing of both sensory and motor information. If it is possible, as indicated in the previous section, to identify a mental state change (trance) that is produced by hypnotic induction procedures, a further question relates to the possibility that this change in turn affects sensory or motor processing in the absence of specific suggestions intended to alter these processes. This is a significant question, not least from the perspective of instrumental hypnosis studies where it is important for experimenters to know if the hypnosis condition itself alters brain processes over and above the effects of the specific suggestion they are using to manipulate the phenomenon of interest to them, particularly if they wish to extrapolate from the results observed in hypnosis to nonhypnotic contexts. There are a number of incidental observations from the

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neuroimaging studies already reviewed here that bear on this point and indicate that ‘neutral hypnosis’, or trance, does not affect normal sensory and motor brain processes. Rainville et al. (2002), for example, noted that of the two components of hypnosis they monitored, neither relaxation nor absorption correlated with pain ratings, and concluded that ‘pain was not altered by hypnosis alone’. This observation is also relevant to the interpretation of studies I reviewed above on the analgesic effects of ‘hypnosis’ (Faymonville et al., 2000, 2003; Schultz-Stubner et al., 2004) and reinforces the conclusion that the effects produced on pain processing depend on implicit suggestions or mental tasks embedded in the induction procedure rather than on ‘hypnosis’ per se. Kosslyn et al. (2000) noted in their PET color processing study that veridical viewing [of the visual stimuli] in both the hypnosis and no hypnosis conditions was associated with increased activation in color processing (fusiform) areas of visual cortex for the color stimuli compared to gray scale stimuli on both sides of the brain. More specifically, they noted that analysis of activity in these brain areas (left and right fusiform region) under veridical viewing conditions revealed no significant effects that could be attributed to ‘the state of being hypnotized’ and defined their areas of interest by pooling ‘veridical viewing’ data from the hypnosis and no-hypnosis conditions. Nonimaging studies involving hypnosis have similarly commented in passing on the absence of differences in sensory and motor processes in the absence of suggestions. In a study of hypnotically induced anomalous motor control experiences, for example, Haggard et al. (2004) included a comparison of perceived voluntariness of movement when the index finger of the participants’ right hand was either moved voluntarily or was passively moved by the apparatus both before and after a hypnotic induction procedure. They found no significant main effects of hypnosis for perceived voluntariness for either type of movement, and concluded that ‘hypnosis by itself did not therefore produce feelings of passivity’ (p. 650). It is also relevant to note here that though Egner et al. (2005) found spontaneous changes in some attentional control processes following their hypnotic induction procedure, they reported that ‘no background accompaniment of hypnosis was detected

elsewhere in the brain’ (p. 976). This latter observation is consistent with the conclusion that the basic sensory and linguistic processing associated with carrying out the ongoing Stroop task was not affected by the induction of hypnosis per se. In a recent study that has explored this issue directly, Deeley et al. (2007b) reported brain activity (fMRI) during the processing of an auditory stimulus (random spoken words) and a visual stimulus (a flashing checkerboard display) before hypnosis, following a hypnotic induction and after termination of hypnosis. There were eight participants (HGSHS:A >7) and the hypnosis procedure involved relaxation suggestions and special place imagery (Gruzelier, 1998; Oakley et al., 2007). No significant differences were found in brain activity associated with processing visual information in any of the three conditions. There were, however, increased activations in left-sided auditory cortical areas during hypnosis compared with the no-hypnosis conditions. The authors concluded that their data were consistent with the view that a hypnosis induction per se does not directly affect sensory processing but that implicit suggestions or task demands embedded in the particular hypnotic induction procedure employed could have such an effect, as appeared to be the case for their auditory processing task. It seems reasonable to conclude on the evidence available so far that trance or hypnosis per se in the absence of specific targeted suggestions (‘neutral’ hypnosis) does not alter the basic processing of sensory and motor events.

14.5. Future research

directions and implications for hypnosis The most comprehensive evidence to emerge from this review is that suggestions following a hypnotic induction procedure can produce profound changes in the reported experience of pain (Ersland et al., 1996; Rainville et al., 1997; Wik et al., 1999; Willoch et al., 2000; Derbyshire et al., 2004; Raij et al., 2005), volition and motor control (Halligan et al., 2000; Blakemore et al., 2003), conflict monitoring (Raz et al., 2005), catalepsy (Grond et al., 1995), color processing (Kosslyn et al., 2000) and auditory hallucinations

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(Szechtman et al., 1998), and that these are accompanied by corresponding changes in brain activity. Similarly, providing hypnotized participants with suggestions or instructions related to particular cognitive tasks such as the reliving of positive autobiographical events (Maquet et al., 1999; Faymonville et al., 2000, 2003) and guided imagery experiences (SchultzStubner et al., 2004) produces subjective effects, including spontaneous experiences of analgesia in some studies, that again are accompanied by congruent brain activation changes. There is also some preliminary evidence that the suggested effects are mediated differently in brain terms than when individuals are feigning the same phenomenon (Ward et al., 2003). Taken as a whole, these data confirm that suggested phenomena are in a very clear sense ‘real’. What remains unclear from all of these studies, however, is whether or not the induction of ‘hypnosis’ via a formal induction procedure is necessary to the production of the suggested phenomena in question. Indeed, as noted earlier, there is good evidence from the nonimaging literature to indicate that these suggested effects can be produced without a hypnotic induction. More specifically, even within the studies mentioned in this review there is evidence that at a subjective and behavioral level there appears to be no difference in the reported reduction in Stroop interference (Raz et al., 2006) or in fibromyalgia pain reduction (Derbyshire et al., 2007), irrespective of whether the suggestions were given with or without a hypnotic induction procedure. Interestingly, however, the Derbyshire et al. (2007) study indicated that despite the lack of reported differences in subjective pain levels produced by suggestion with and without hypnosis, there was a difference between the two conditions in the degree of control the participants felt they could exert over their pain and also in the accompanying brain activations. It is crucial for our understanding of what role, if any, the hypnotic induction procedure plays in mediating suggested changes to conduct neuroimaging studies that directly compare the effects of exactly the same suggestions with and without a hypnotic induction, ideally in the same session in the same individuals. It would be especially instructive to compare groups of low and high hypnotizables under these conditions. Irrespective of these

considerations, it remains the case that suggestion following a hypnotic induction procedure provides us with a valuable and reliable tool for the creation and removal of phenomena of interest in cognitive neuropsychology. There are few studies that have used neuroimaging to explore the possibility that a hypnotic induction procedure in the absence of specific suggestions may produce a stable background state (or ‘trance’) that may account for any unique effects on experience, brain function or subsequent responses to suggestion that may be attributable to hypnosis per se (or ‘neutral hypnosis’). Those that have attempted this have typically engaged the participants in both hypnosis and no-hypnosis conditions in a cognitively undemanding task such as passively experiencing levels of heat stimulation (Rainville et al., 1999, 2002) or patterned visual stimulation (Deeley et al., 2007a), though one study has involved the Stroop task to create a cognitive conflict in both conditions to explore predicted changes in attentional processing that should accompany the hypnosis condition but not the no-hypnosis condition (Egner et al., 2005). Rainville et al. (1999, 2002) found patterns of brain activation associated with the hypnosis condition that were consistent with increased visual imagery, engagement of attentional networks, increased internal focus of attention and reduction in general body sense awareness. More specifically, the second of these studies was able to determine which aspects of these activation patterns were attributable to an absorption component of the hypnotic experience and which were related to reported relaxation. Increased activations associated with absorption were seen in brain areas comprising an executive attentional network associated with alertness and with maintaining cortical arousal. In addition, there were absorption-related activation increases in brain areas involving more specialized executive attentional processes with a role in error detection and conflict monitoring. Reductions in activity associated with absorption were indicative of disengagement from external sources of stimulation, particularly vision and the monitoring of external space and time. The relaxation component was involved in decreases in activation in brain areas associated with cortical arousal and wakefulness,

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and increases in areas associated with voluntary muscle relaxation. Interestingly, the increase in activity in posterior visual cortical areas reported in other studies to be related to the ‘hypnosis’ condition (e.g. Maquet et al., 1999) was found to be associated with the relaxation component of the hypnotic experience. In another study intended to compare directly the brain activity associated with hypnosis with a matched no-hypnosis condition, Deeley et al. (2007a) described greater activation in the ‘hypnosis’ condition in areas associated with working memory and the maintenance of attention, similar to the absorption-related changes described by Rainville et al. (2002), and reductions in areas mediating arousal and alertness, corresponding to relaxation-related changes. In addition, Deeley et al. (2007a) described reductions in activity that have been claimed to characterize a ‘default mode’ of brain activity seen during rest periods in neuroimaging studies when task demands are low and the participant is engaged in spontaneous task-unrelated thought and other task-independent mental processes. This latter observation is consistent with participants’ reports that in addition to feelings of mental absorption and relaxation, they experienced a reduction in spontaneous conceptual thought in the hypnosis condition. The Rainville et al. (1999, 2002) and Deeley et al. (2007a) studies used traditional hypnotic induction procedures that incorporated instructions or suggestions for relaxation, and seem to indicate that these procedures are accompanied by consistent patterns of brain activation that are congruent with the subjective reports that participants typically give of their hypnotic experience. This provides support for the view that the effects of hypnotic induction procedures are ‘real’ though not outside what would be expected from what is known of normal brain functioning. In the latter sense, the hypnotic ‘state’, depending on the induction procedures used, appears to be a relatively mundane reflection of what would be expected in an individual experiencing attentional absorption, physical relaxation and/or mental calming and a reduced tendency to engage in spontaneous conceptual thought. A somewhat different approach was adopted by Egner et al. (2005), first in that their hypnosis

procedure did not include relaxation suggestions, and secondly in that they investigated the possibility of spontaneous changes within attention processes that had been hypothesized as the consequence of a hypnotic induction procedure in previous research using the Stroop task. Using a combination of fMRI and EEG techniques, they found that, as predicted, the hypnotic induction procedure in high hypnotizables created an apparent decoupling of the normal linkage between conflict monitoring and the normal cognitive control processes that provide a compensatory mechanism, with the result that Stroop performance deteriorated in their highly hypnotizable subjects following the induction procedure. This is a particularly interesting result in that it points to a change in mental processing, with corresponding alterations in brain activity, which would not be easily predictable simply from the subjective reports of participants of their hypnotic experience unless revealed by the particular cognitive probe. Aside from the question of whether the hypnotic induction procedure produces an identifiable mental ‘state’ independently of specific suggestions to alter particular mental processes is that of whether more basic aspects of information processing remain essentially ‘normal’ or are altered by the immediate consequences of the hypnotic induction procedure. The evidence summarized in the final section of this review indicates clearly that the perception of pain (Rainville et al., 2002), the processing of sensory information (Kosslyn et al., 2000; Egner et al., 2005; Deeley et al., 2007b) and the sense of agency over our action (Haggard et al., 2004) are not affected by the induction of ‘hypnosis’ per se. This again is important for those who wish to use suggestion following a hypnotic induction procedure alongside neuroimaging techniques as a means to produce discrete subjective and behavioral changes in a single cognitive capacity or function and to investigate the brain activity changes that are uniquely associated with it. This is an appropriate point to review the list of candidates for components of hypnotic states suggested by Price and Barrell (1990) and Rainville and Price (2003, 2004) in the light of the present review. The components they suggested were: focused attention, absorption,

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relaxation, a sense of automaticity and altered experiences of self-agency. Though as a personality trait absorption correlates only weakly with the trait of hypnotizability, especially when the effects of context are taken into account (see Milling et al., 2000), absorption remains a strong contender as a core feature of the experience of ‘hypnosis’ per se. There is some overlap between the notion of focused attention and absorption, and some aspects of focused attention, such as its inward focus, again seem to be central to the hypnotic experience. It is important, however, to recognize that the hypnotic induction procedure does not simply enhance attentional capacities, as some aspects of attention such as the linkage between conflict monitoring and cognitive control processes appear to be weakened. Relaxation is also a common feature of individual reports of trance experience, and there is good evidence to suggest that it is a distinctive component of the experience when it is present. It is less clear if relaxation is a core component of hypnosis per se, however, as the standard hypnotic induction routines typically include suggestions or instructions intended to produce relaxation. It seems well established in fact that physical relaxation is not essential for the induction of hypnosis, though it remains possible that mental relaxation (or mental calming) may be present, perhaps as a consequence of absorption and a more inward focus of attention, even when the induction procedure does not actively include relaxation instructions. Such evidence as there is in relation to the sense of involuntariness or loss of the sense of self-agency is that they can be created by suggestions following an induction procedure but may not occur spontaneously when, for example, motor actions are carried out in hypnosis. Nevertheless, a sense of lack of spontaneity, or reduction in feelings of self-agency, may characterize the feelings in resting states in hypnosis when task demands are low, much as the inclination to spontaneous conceptual thought also seems to diminish. A number of studies have identified enhanced visual imagery following an induction procedure, which was not on the original list of candidates, though this seems to be related to the relaxation component of the hypnotic experience rather than to absorption.

Apart from changes such as physical relaxation, mental calming, attentional absorption and a reduction in spontaneous conceptual thought that are associated with the experiential state of hypnotic ‘trance’, or the feeling of being ‘hypnotized’, the only fundamental change in mental processing that has been demonstrated so far in neuroimaging studies as a consequence of a hypnotic induction procedure per se is the apparently spontaneous disconnection of conflict monitoring and cognitive control described by Egner et al. (2005). There are a number of more general issues that arise from the studies I have considered. A major question concerning the very clear subjective and brain activity changes that have been shown to accompany specific suggestions following a hypnotic induction procedure is the extent to which these suggested changes are dependent on the induction of ‘hypnosis’ or whether the same effects would follow from the same suggestions given without a hypnotic induction. Relevant studies to address this question have only recently been initiated. The little evidence we have so far indicates that although the subjectively reported effects of suggestion under both conditions may be very similar (e.g. McConkey et al., 2001; Raz et al., 2006; Derbyshire et al., 2007), there may be differences in the time that the effect is experienced (McConkey et al., 2001) and in the way that these changes are represented at the level of brain activity (Derbyshire et al., 2007). A somewhat related issue is whether different types of suggestion are mediated in different ways and whether these differences may be accompanied by distinct brain processes over and above those associated with the execution of the particular suggested effect per se. For example, the 12 items on the HGSHS:A (Shor and Orne, 1962) have traditionally been divided into three distinct types (ideomotor, challenge and perceptual-cognitive), and more recent analyses have suggested four (Woody et al., 2005; see also Woody and Barnier, Chapter 10, this volume). That individuals vary in the number of suggestions they respond to in the various categories raises the question not only of whether hypnotizability itself is a unitary trait, or is composed of a series of component traits, but also of whether responding to the different types of suggestion contained in HGSHS:A may require

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different underlying cognitive strategies whether hypnosis is present or not (see Woody and Barnier, Chapter 10; Benham and Younger, Chapter 15, this volume). It seems clear that these areas deserve more extensive exploration. Another question alluded to above that has potential relevance to the mechanisms by which suggestions are mediated, but is particularly relevant to an understanding of the effects of the induction procedure itself, is the extent to which any of the changes that have been described as components of the ‘trance’ state are products of the particular hypnotic induction procedure used. The majority of neuroimaging studies to date have used a hypnotic induction procedure that includes instruction or suggestions for relaxation. As we noted earlier, there is ample evidence from outside the neuroimaging literature that physical relaxation at least is not a prerequisite for the demonstration of classic hypnotic phenomena—though mental calming may be a common attribute of both active-alert and relaxation-based hypnotic procedures. The one neuroimaging study that has separately analyzed the absorption and relaxation components of a classic ‘relaxation’ induction (Rainville et al., 2002) identified them as co-occurring but independent, and even in some sense opposing, elements of the hypnotic experience, which have distinct patterns of brain activity associated with them. It would be instructive to compare directly the brain activity following traditional relaxation-based induction procedures with matched active-alert procedures. There are other interesting questions that remain to be asked via neuroimaging techniques such as when we would expect the ‘hypnotic state’ to be manifest. The ‘trance’ effect of a hypnotic induction procedure, or ‘neutral hypnosis’, has been portrayed here as a ‘tonic’ change, a background state or ‘default mode’ shift that is created by the induction procedure. One question is whether this tonic change persists during enactment of specific suggestions. That is, do the effects of suggestion ‘over-ride’ the background hypnotic state or are they superimposed on it? Conversely, are there effects of the hypnotic induction procedure that are only manifest at the point at which a suggestion is acted upon? In this case, we might consider some components of the hypnotic state to be

‘phasic’. A further question is whether ‘latent’ suggestions alter the ‘tonic’ consequences of the induction procedure. That is, is the hypnotic ‘default mode’ itself altered once a suggestion (e.g. for limb paralysis) has been given or are the induction-related effects only manifest as the effect of the suggestion is tested by the individual (when they try to move the affected limb)? Do these suggestion-related effects vary according to the type of suggestion that is to be enacted (e.g. ideomotor versus challenge) over and above its specific content? These questions can only be answered by systematic comparison of activation in the relevant conditions. With the single exception of the Raz et al. (2005) study, all the hypnosis-related neuroimaging studies reviewed here have studied the effects of either hypnosis per se or hypnosis plus suggestion within the hypnotic state. Raz et al. (2005) studied an effect produced by posthypnotic suggestion; i.e. a suggestion that was given following a hypnotic induction for an effect to be observed after hypnosis had been terminated. This interesting strategy raises an immediate question as to whether a hypnotic state or some component of it is reinstated during the enactment of a post-hypnotic suggestion or does the ‘suggestion’ then act alone? In other words, does the brain state at the time a post-hypnotic suggestion is carried out correspond to that seen during the enactment of a suggestion given in a no-hypnosis condition— or does it still bear some trace of its ‘hypnotic’ ancestry? Again this raises a number of interesting questions that will need to be addressed by future studies. As a final general comment, the majority of the studies reviewed above used highly hypnotizable individuals as participants— this in itself is not a serious problem for instrumental studies though it may limit some of the generalizations that can be drawn from them. The use of participants across the whole range of hypnotizability or the use of low hypnotizables as control groups in intrinsic hypnosis studies using neuroimaging, however, would greatly extend our understanding of the mechanisms both of hypnosis per se and of suggestion. On the evidence so far it seems clear that suggestion given after a hypnotic induction is an effective and reliable tool for use in mainstream neuropsychological research, particularly in

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conjunction with neuroimaging techniques. There also seems to be clear evidence of its potential utility in the field of experimental psychopathology, in creating analogs of clinical conditions such as conversion disorders, chronic pain conditions and disorders of volition and motor control (Oakley, 2006). As hypnosis becomes more established as a research technique, this should enable more work to be carried out using neuroimaging to explore the nature of hypnosis itself and the mechanisms underlying suggestion effects both within and outside hypnosis. This in turn with have clear implications for the use of hypnosis and suggestion in clinical practice.

Acknowledgments I am grateful to Sarah-Jane Blakemore, Quinton Deeley, Stuart Derbyshire, Chris Frith, Ganesh Gandhi, Peter Halligan, Patrick Haggard, Val Walters, Mat Whalley and the many others I have had the pleasure of collaborating with in conducting research reported in this chapter. I would also like to thank Irving Kirsch and Pierre Rainville for their very positive comments on earlier versions of the manuscript. Finally, I extend my thanks and admiration to Amanda Barnier for her detailed, conscientious and helpful editing work in bringing the chapter to its present form.

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Milling, L. S., Kirsch, I., Allen, G. J. and Reutenauer, E. L. (2005) Effects of hypnotic and non-hypnotic imaginative suggestion on pain. Annals of Behavioral Medicine, 29: 116–127. Montgomery, G. H., DuHamel, K. and Redd, W. H. (2000) A meta-analysis of hypnotically induced analgesia: how effective is hypnosis? International Journal of Clinical and Experimental Hypnosis, 48: 138–152. Morgan, A. H. and Hilgard, J. R. (1978/79) Stanford Hypnotic Clinical Scale for Adults. American Journal of Clinical Hypnosis, 21: 134–147. Oakley, D. A. (1999) Hypnosis and conversion hysteria: a unifying model. Cognitive Neuropsychiatry, 4: 243–265. Oakley, D. A. (2001) Hypnosis and suggestion in the treatment of hysteria. In P. W. Halligan, C. Bass and J. C. Marshall (ed.) Contemporary Approaches to the Study of Hysteria, pp. 312–329. Oxford University Press, Oxford. Oakley, D. A. (2006) Hypnosis as a tool in research: experimental psychopathology. Contemporary Hypnosis, 23: 3–14. Oakley, D. A., Gracey Whitman, L. and Halligan, P. W. (2002) Hypnotic imagery as a treatment for phantom limb pain: two case reports and a review. Clinical Rehabilitation, 16: 368–377. Oakley, D. A. Ward, N. S., Halligan, P. W. and Frackowiak, R. S. J. (2003) Differential brain activations for malingered and subjectively ‘real’ paralysis. In P. W. Halligan, C. Bass and D. A. Oakley (ed.) Malingering and Illness Deception, pp. 267–284. Oxford University Press, Oxford. Oakley, D. A., Deeley, Q. and Halligan, P. W. (2007) Hypnotic depth and response to suggestion under standardized conditions and during fMRI scanning. International Journal of Clinical and Experimental Hypnosis, 55: 32–58. Orne, M. T. (1959) The nature of hypnosis: artifact and essence. Journal of Abnormal and Social Psychology, 58: 277–299. Price, D. D. and Barrell, J. J. (1990) The structure of the hypnotic state: a self-directed experiential study. In J. J. Barrell (ed.) The Experiential Method: Exploring the Human Experience, pp. 85–97. Copely Publishing Group, Acton, MA. Raij, T. T., Numminen, J., Narvarnen, S., Hiltunen, J. and Hari, R. (2005) Brain correlates of subjective reality of physically and psychologically induced pain. Proceedings of the National Academy of Sciences, USA, 102: 2147–2151. Rainville, P. and Price, D. D. (2003) Hypnosis phenomenology and the neurobiology of consciousness. International Journal of Clinical and Experimental Hypnosis, 51: 105–129. Rainville, P. and Price, D. D. (2004) Neurophenomenology of hypnosis and hypnotic analgesia. Progress in Pain Research and Management, 29: 235–267.

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Rainville, P., Duncan, G. H., Price, D. D., Carrier B. and Bushnell, M. C. (1997) Pain affect encoded in human anterior cingulate but not somatosensory cortex. Science, 277: 968–971. Rainville, P., Hofbauer, R. K., Paus, T., Duncan, G. H., Bushnell, M. C. and Price, D. D. (1999) Cerebral mechanisms of hypnotic induction and suggestion. Journal of Cognitive Neuroscience, 11: 110–125. Rainville, P., Hofbauer, R. K., Bushnell, M. C., Duncan, G. H. and Price, D. D. (2002) Hypnosis modulates activity in brain structures involved in the regulation of consciousness. Journal of Cognitive Neuroscience, 14: 887–901. Ramachandran, V. S. and Hirstein, W. (1998) The perception of phantom limbs. Brain, 121: 1603–1630. Ray, W. J. and Oathes, D. (2003) Brain imaging techniques. International Journal of Clinical and Experimental Hypnosis, 51: 97–104. Raz, A., Fan, J. and Posner, M. I. (2005) Hypnotic suggestion reduces conflict in the human brain. Proceedings of the National Academy of Sciences, USA, 102: 9978–9983. Raz, A., Kirsch, I., Pollard. and Nitkin-Kaner, Y. (2006) Suggestion reduces the Stroop effect. Psychological Science, 17: 91–95. Reyher, J. (1962) A paradigm for determining the clinical relevance of hypnotically induced psychopathology. Psychological Bulletin, 59: 344–352. Schultz-Stubner, S., Krings, T., Meister, I. G., Rex, S., Thron, A. and Rossaint, R. (2004) Clinical hypnosis modulates functional magnetic resonance imaging signal intensities and pain perception in a thermal stimulation paradigm. Regional Anaesthesia and Pain Medicine, 29: 594–556. Shor, R. E. and Orne, E. C. (1962) Harvard Group Scale of Hypnotic Susceptibility, Form A. Consulting Psychologists Press, Palo Alto, CA. Spiegel, H. and Spiegel, D. (1978) Trance and Treatment: Clinical Uses of Hypnosis. American Psychiatric Press, Washington, DC. Stone, J. and Zeman, A. (2001) Hysterical conversion—a view from clinical neurology. In P. W. Halligan, C. Bass and J. C. Marshall (ed.) Contemporary Approaches to the Study of Hysteria, pp. 102–125. Oxford University Press, Oxford.

Stroop, J. R. (1935) Studies of interference in serial verbal reactions. Journal of Experimental Psychology, 18: 643–661. Szechtman, H., Woody, E. Z., Bowers, K. S. and Nahmias, C. (1998) Where the imaginal appears real: a positron emission tomography study of auditory hallucinations. Proceedings of the National Academy of Sciences, USA, 95: 1956–1960. Tallabs, F. A. (2005) Functional correlates of conversion and hypnotic paralysis: a neuropsychological hypothesis. Contemporary Hypnosis, 22: 184–192. Walters, V. J. and Oakley, D. A. (2003) Does hypnosis make in vitro, in vivo? Hypnosis as a possible virtual reality context in cognitive behavioral therapy for an environmental phobia. Clinical Case Studies, 2: 295–305. Ward, N. S., Oakley, D. A., Frackowiak, R. S. J. and Halligan, P. W. (2003) Differential brain activations during intentionally simulated and subjectively experienced paralysis. Cognitive Neuropsychiatry, 8: 295–312. Wark, D. M. (2006) Alert hypnosis: a review and case report. American Journal of Clinical Hypnosis, 48: 293–303. Weitzenhoffer, A. M. and Hilgard, E. R. (1959) The Stanford Hypnotic Susceptibility Scale: Forms A and B. Consulting Psychologists Press, Palo Alto, CA. Weitzenhoffer, A. M. and Hilgard, E. R. (1962) Stanford Hypnotic Susceptibility Scale: Form C. Consulting Psychologists Press, Palo Alto, CA. Wik, G., Fischer, H., Bragee, B., Finer, B. and Fredrickson, M. (1999) Functional anatomy of hypnotic analgesia. European Journal of Pain, 3: 7–12. Willoch, F., Rosen, G., Tolle, T. R., Oye, I., Wester, H. J., Berner, N. et al. (2000) Phantom limb in the human brain: unravelling neural circuitries of phantom limb sensations using positron emission tomography. Annals of Neurology, 48: 842–849. Woody, E. Z., Barnier, A. J. and McConkey, K. M. (2005) Multiple hypnotizabilities: differentiating the building blocks of hypnotic response. Psychological Assessment, 17: 200–211.

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CHAPTER 15

Hypnosis and mind–body interactions Grant Benham and Jarred Younger

15.1. Introduction Truth is nothing but a path traced between errors. Franz Anton Mesmer (1799)

In 1784, the Royal Commission of King Louis XVI determined that claims of the healthenhancing properties of animal magnetism were not in and of themselves false (Franklin et al., 2002). Indeed, they recognized and specifically mentioned the potential for imagination and focusing one’s attention on internal processes to effect physiological change. What they challenged, as a result of numerous erudite experimental studies, was Mesmer’s claims about the mechanism by which these cures were achieved: the forces of animal magnetism (Mesmer, 1980). The Commission’s report dealt a devastating blow to Mesmer’s popularity and severely weakened this early construal of hypnosis. But it established the need for such extraordinary claims to be supported by level-headed empiricism. The history of hypnosis is rich in its examination of mind–body interactions. Early reports of mesmeric cures extolled its ability to heal physical illness, psychosomatic disorders were analyzed and treated through hypnotic sessions, and subsequent papers provided numerous examples of its promise for reducing surgical

and other forms of pain. As technology evolved, researchers also became increasingly well equipped to study the physiological concomitants of both the hypnotic state and hypnotic suggestions. The nature of the physiological basis of hypnosis has mutated over time, arguably as a result of the particular zeitgeist surrounding medical disease (animal magnetism, organ theories such as hysteria, nerves and electrical impulses). Today, researchers are increasingly aware of the complexity and interconnectedness of systems of the human body and have targeted the brain as the central player in understanding hypnotic phenomena. Throughout these changes, the notion that hypnosis is a powerful healing force has stood the test of time. In attempting to address the issue of hypnosis and mind–body interactions, we present a summary of research on the potential for hypnosis to alter physiological processes in response to hypnotic suggestions. Such research has been increasingly embraced by clinicians and researchers as ongoing investigations demonstrate the impact of psychological states on health. Even as psychodynamic interpretations were succeeded by biomedical models and psychoneuroimmunological or psychoneuroendocrinological explanations of these mind–body interactions, the notion of the inseparability of ‘mind’ and ‘body’ remained strong.

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As research programs demonstrate the negative impact of stress on the body, parallel lines of research have examined whether the potential exists to direct our own physiology in a positive way through techniques such as hypnosis, meditation, biofeedback, relaxation therapy or imagery. These approaches share a common goal of controlling biological processes through various psychological procedures. This notion of being able to self-direct physiology has been given the term ‘cyberphysiology’ from the Greek ‘Kybernan’ which means ‘to steer’ (e.g. Hall et al., 1992a; Culbert et al., 1994). A variety of cyberphysiological approaches exist, but there are many instances in which the boundaries between the various cyberphysiological strategies are ill-defined. As we will see later in this chapter, underlying commonalities between hypnotic and other cyberphysiological procedures can create problems for those wishing to ascribe exclusive benefits to hypnosis. In limiting our chapter to the above-mentioned focus, we have excluded certain topics that are arguably linked to the notion of hypnosis and mind–body interactions. First, while we do include some studies that reference treatment of ostensibly psychosomatic disorders, we do not specifically examine the role of hypnotizability in the development of somatic or psychosomatic disorders. Wickramasekera (1986) proposed a high risk model of threat perception in which individuals scoring at the extremes of hypnotizability (low and high hypnotizables) are more likely to develop illness than those with average hypnotizability. According to this model, high hypnotizables may reach this state of poor health through a process of amplification of symptoms, whereas low hypnotizables are more likely to postpone seeking treatment due to repression of explicit perception of their symptoms (thereby ultimately presenting with more serious psychophysiological disorders). More recent research (Younger et al., 2007) supports the notion that high hypnotizables are likely to report a greater number of psychosomatic complaints. Therefore, the trait that may enable these individuals to respond more effectively to hypnotic treatments may, ironically, make them more prone to develop the health conditions in the first place. Second, there is a large body of literature that has examined the physiological correlates of

the hypnotic state. Early investigations in this area were restricted by the limited technologies available such as cardiovascular, respiratory and electrodermal measures (e.g. Estabrooks, 1930; Wible and Jenness, 1936; Jenness and Wible, 1937; Nygard, 1939; Barber and Coules, 1959; Barber and Hahn, 1963; Fehr and Stern, 1967; Jana, 1967; Cade and Woolley Hart, 1971; Paradis, 1971; Mather and Degun, 1975; Tebecis and Provins, 1976). Development and refinement of the electroencephalogram enabled researchers to examine the brain states associated with hypnosis (Loomis et al., 1936; Barker and Burgwin, 1949; Rizzo et al., 1980; Sabourin, 1982; Meszaros and Szabo, 1999; Rainville et al., 1999; Williams and Gruzelier, 2001), and such research has continued as neuroimaging technologies evolved to include sophisticated positron emission tomography (PET) and functional magnetic resonance imaging (fMRI; e.g. Maquet et al., 1999). While the search for consistent alterations in cortical activity associated with the hypnotic state has proved unfruitful, recent studies have suggested some consistent alterations in regional cerebral blood flow following the hypnotic induction; changes that do not appear to be related to simple peripheral physiological relaxation (Rainville et al., 1999, 2002). A more comprehensive analysis of past and current research on cortical activity and the hypnotic state is provided by Barabasz and Barbarasz in Chapter 13 and by Oakley in Chapter 14 (this volume). Chapters 13 and 14 cover a third area of research that is also excluded from the current chapter, namely research on the brain states associated with specific hypnotic suggestions. Recent studies, for example, have demonstrated alterations in brain activity following hypnotic suggestions for visual and auditory hallucinations (Spiegel et al., 1985; Szechtman et al., 1998; Barabasz et al., 1999; Kosslyn et al., 2000), paralysis (Halligan et al., 2000; Ward et al., 2003) and analgesia (Crawford et al., 1993; Hofbauer et al., 2001). Lastly, we omit studies that examine the potential for hypnosis to influence perception, such as investigations of hypnotic deafness or blindness (Kramer and Tucker, 1967; Scheibe et al., 1968; Spanos et al., 1982a, 1991, 1992; Bryant and McConkey, 1989a,b, 1990a,b,c).

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While one can reasonably assume that alterations in perception are accompanied by a certain level of physiological shift, this assumption is not commonly put to the empirical test; studies in this area have generally relied on self-report of perceptual alterations without assessment of changes in physiology. We leave detailed coverage of these important areas (cortical activity associated with the hypnotic state and specific hypnotic suggestions and hypnotically produced perceptual alterations) to other chapters of this book. Instead, we focus on the use of hypnosis in cyberphysiological research; on the potential for hypnotic suggestions to ‘steer’ or direct physiology. Hypnotic cyberphysiological research has some advantages over other areas of hypnosis research. One of the critiques of studying hypnotic behavior is that it can be readily faked and that the observed changes in behaviors may therefore have nothing to do with hypnosis, per se. Around the 1930s there was increased focus on psychosomatic medicine, but researchers were progressively more aware that hypnotic phenomena such as catelepsies and posthypnotic suggestions could be elicited without hypnotic inductions (Sarbin, 2005). Researchers therefore began to focus their studies on the effects of hypnotic suggestions on physiological processes, processes that at face value could not be altered voluntarily. Although certain studies (Kinnunen et al., 1994) and methodologies (Orne, 1971) have attempted to invalidate the argument that subjective self-report or enacted behavior are intentionally faked, the study of alterations in physiology largely side-steps the issue. Given that the changes in physiology are not readily controlled, how could an individual ‘fake’ their response? Thus hypnotic cyberphysiological research avoids some of the social compliance critiques that still plague other areas of hypnosis research. However, as we will examine later in the chapter, establishing the central role of hypnosis in eliciting cyberphysiological changes faces its own share of challenges. Ours is not the first attempt to summarize the literature on this topic. In 1961, T. X. Barber published a paper detailing and discussing the findings from a number of studies examining the potential of hypnosis to alter physiological functioning (Barber, 1961). He followed up this review with an updated paper in 1965 and again

in 1984 (Barber, 1965, 1984). Similar summaries have been prepared by others (e.g. Sarbin, 1956), and more recent reviews have focused on the use of hypnosis in medicine or for psychosomatic disorders (e.g. Pinnell, 2000; Heap and Aravind, 2002; Stewart, 2005). Additionally, a number of review papers have been published on individual topics or conditions, such as immune function (Hall, 1982, 1989; Goldberg, 1985; Miller and Cohen, 2001; Gruzelier, 2002; Neumann, 2005), allergies (Wyler-Harper et al., 1994), asthma (Hackman et al., 2000), dermatology (Shenefelt, 2000, 2003), warts (DuBreuil and Spanos, 1993) and gastrointestinal disorders (Lackner et al., 2004; Soo et al., 2004; Gonsalkorale and Whorwell, 2005; Solloway, 2005). However, we believe the current chapter represents the most comprehensive and contemporary assessment of this important topic. A large proportion of published papers in this area have been single case reports which, while largely descriptive and lacking in generalizability, have served the field of hypnosis well: consistently supplying a rich supplement to empirical research and frequently acting as the catalyst for later experimentation. We begin the chapter by presenting a summary of core concepts and questions related to hypnotic cyberphysiological techniques. Following that, we review the literature on hypnosis and the body. This review covers the use of hypnosis both in changing physiological systems and in treating physical symptoms or conditions. We end the chapter with an assessment of the evidence as a whole and offer recommendations for future investigations.

15.2. Core concepts and

questions Hull (1933) observed that research on hypnosis is complicated by: . . . the inherent difficulty of the problems involved, the fundamental elusiveness of the phenomena, and the consequent subtlety in the experimental controls. These difficulties are so great that to enter seriously on a program of investigation in this field . . . is almost to court scientific disaster (p. 403).

In order to evade ‘scientific disaster’, researchers studying the cyberphysiologic potential of hypnosis

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must be particularly careful in employing adequate controls, though, as we will discuss, the lack of a solid definition of hypnosis makes this problematic. Even adopted definitions (Green et al., 2005) tend to become amorphous when one attempts to grasp them fully, slipping through the fingers of those who wish to apply scientific rigor to the study of hypnosis. In establishing the efficacy of hypnotic procedures for altering physiology one must: (1) demonstrate replicable effects in controlled studies; (2) demonstrate that the effects are due to hypnosis and relate to hypnotizability; and (3) demonstrate that the effects are at least as powerful as alternative psychological techniques, particularly those that require less training and/or time to administer. As concluded by Frankel (cited in Pinnell, 2000),‘How effective is the intervention and what part of it belongs to hypnosis’ (p. 233). At present, hypnosis researchers are still battling to satisfy the first criterion. While some areas have shown a number of positive findings (e.g. the modulation of delayed-type hypersensitivity (DTH) reactions), they are often challenged by reports of negative results. The lack of consistency may reflect the variety of methods used, particularly in terms of hypnotic procedures employed, the selection of outcome measures and the timing of interventions. As we will show later in this chapter, some treatments (such as the treatment of warts) have shown more consistency. But researchers are then faced with the second issue––establishing the relevance of hypnosis. Below, we examine various conditions for establishing the relevance of hypnosis and then introduce the issue of whether or not hypnosis is any more effective than other psychological techniques.

15.2.1. Establishing the relevance of

hypnosis and hypnotizability Contemporary hypnotic procedures generally incorporate suggestions for relaxation and provide suggestions for alterations in cognition, behavior or physiology. Thus, in order to establish the relevance of hypnosis to cyberphysiological change, one must determine whether or not hypnosis differs from the effects produced by relaxation alone and also examine whether suggestions given outside of hypnosis (‘waking suggestions’) produce similar changes to those

given during hypnosis. Lastly, if hypnosis is an important factor, it can be argued that hypnotizability should be associated with observed changes in physiology.

15.2.1.1. Differentiating the effects of hypnosis from those of relaxation The hypnotic induction produces a physiological state that cannot commonly be differentiated from relaxation. Both meditation (Walrath and Hamilton, 1975) and relaxation procedures (Mather and Degun, 1975) produce physiological profiles similar to hypnosis. An early example of the physiological similarity between hypnosis, meditation and relaxation is provided by Morse and colleagues (1977). Morse found no differences between the waking state, two types of meditation, hypnosis with or without suggestions, and relaxation in terms of various physiological measures (respiratory rate, pulse rate, blood pressure, skin conductance and muscle activity). Several researchers have also commented on the physiological similarity of hypnosis and the relaxation response (Edmonston, 1977; Benson et al., 1981). Both involve similar levels of decreased heart rate, respiratory rate and blood pressure. In a review of hypnosis and progressive muscular relaxation, Humphreys (1984) concluded that the two states are physiologically similar. Thus, in investigating the effects of a hypnotic procedure, it is important to establish that the physiological changes attributed to hypnosis (e.g. cardiovascular, immune and skin reactions) are not simply an effect of relaxation. As will be evident in this chapter’s literature review (Section 15.3), many hypnotic cyberphysiology studies do not control for the confound of relaxation. Suggestions for how to deal with this issue are provided toward the end of the chapter, but even when researchers can establish that specific suggestions themselves, not the relaxed state associated with hypnosis, are responsible for affecting the physiological change, they are faced with an additional issue: would the same suggestions, given outside of hypnosis, produce a similar effect? 15.2.1.2. Hypnotic versus nonhypnotic suggestions At present, there are few compelling data to support the notion of hypnosis as an altered physiological state. Thus, whether or not suggestions

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are considered hypnotic must be based on the process of hypnosis, hypnosis as a defined procedure. That is not to say that a person must be hypnotized if the process has been followed. As Nash makes clear (2005), hypnosis-as-product (state) ‘. . . is not achieved just because a hypnosis procedure has been administered’ (p. 268). However, suggestions can perhaps be considered hypnotic suggestions, as distinct from nonhypnotic suggestions, when they are part of the defined hypnotic procedure. Unfortunately, establishing an agreed on definition of hypnosis (even as a procedure) has been problematic. While Division 30 (Psychological Hypnosis) of the American Psychological Association recently offered a definition (Green et al., 2005), this definition has been criticized (Nash, 2005). It is of some importance how researchers define a hypnotic induction. The APA Division 30 definition speaks of the induction as ‘. . . an extended initial suggestion for using one’s own imagination, and may contain further elaborations of the introduction’ (p. 262). It has been argued that ‘. . . the first test suggestion . . . [of a scale] . . . becomes a functional induction’ if the scale’s standardized induction is removed (Nash, 2005, p. 270). For researchers wishing to study the effect of hypnotic suggestions on allergic skin reactions, could suggestions for reduced wheal size act as a functional induction if the standard (relaxation) induction is not used beforehand? If so, testing hypnotic suggestions against nonhypnotic suggestions would become difficult. And we are not helped by simply defining the situation to the subject as hypnotic. To argue that a process is or is not hypnotic based on whether the word ‘hypnosis’ is used seems somewhat unreasonable in light of the fact that the field of hypnosis was alive and well before Braid coined the term.1 While use of the term hypnosis may influence subsequent responsiveness (e.g. Barber and Calverley, 1964, 1965), failure to use the term does not de facto define the procedure as nonhypnotic.

1 The procedures for hypnotic induction have changed over the course of the history of hypnosis. Mesmer’s passes differ sharply from contemporary approaches. One study has even demonstrated that subjective and physiological measures change when mesmeric passes are added to a standard hypnotic induction (McGarry, 1987).

Comparison of hypnotic suggestions versus nonhypnotic suggestions has received some attention, particularly in the early reviews by Barber (e.g. Barber, 1965). A number of reports have examined this issue (e.g. Barber et al., 1964; Winer et al., 1965; Johnson and Barber, 1978; Clarke and Gibson, 1980) and there is no consistent evidence that procedures involving hypnotic inductions, or differentially defined as hypnotic, are more effective than ‘waking’ suggestions. As discussed above, whether or not this is a problem for hypnosis researchers depends on how hypnosis is defined. Young (as cited by Paul, 1963) argued that if causation is to be attributed to hypnosis, hypnotic behavior must be compared against waking behavior. Young proposed that changes demonstrated under hypnosis were likely to be due to subject peculiarities (individual differences) rather than hypnotic suggestions. Hull (1933) also argued that many autonomic functions should not be considered under ‘involuntary control’, but rather ‘indirect voluntary control’, which can be influenced in a nonhypnotized subject by talking (such as a discussion of eating leading to gastric secretions). Even Milton Erickson (1980) made it clear that he was ‘exceedingly suspicious’ (p. 180) of certain mind-over-body demonstrations, recognizing that certain individuals are able to exert voluntary control over physiological functions outside of hypnosis. In discussing the excellent results of a subject who demonstrated vasomotor changes in hypnotic trance, he stated that such results appear to be ‘an excellent demonstration of the proof of the possibility that hypnotic measures are bringing about physiological changes’ (p. 180) However, the subject later told Erickson how he could do the same thing ‘without being in a trance’ and he ‘. . . very neatly and carefully demonstrated it’ (p. 180). Thus, it is important to recognize that individual capability may be an important factor in successful elicitation of physiological change and that research examining group characteristics may fail to find effects due to large interindividual variability. One individual difference, which is potentially significant for establishing the importance of hypnosis in physiological control, is the measure of hypnotizability.

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15.2.1.3. Effects of hypnotizability Many hypnotic cyberphysiological investigations have worked exclusively with pre-screened highly hypnotizable subjects, presumably based on the assumption that it would increase the likelihood of finding significant effects for hypnotic interventions. For example, as we will see with Zachariae’s series of studies on allergic skin reactions (Zachariae et al., 1989; Zachariae and Bjerring, 1990, 1993), the effects of suggestions were only examined in highly hypnotizable subjects. The results of such studies do not allow us to determine whether hypnotizability really is a factor, for it is unclear whether low hypnotizables given the same hypnotic suggestions would have shown similar results. A number of studies, however, have directly examined whether or not hypnotizability is an important variable; the notion being that if a physiological change is produced via hypnosis, effects would be more apparent in highly hypnotizable individuals. The two methods commonly employed to test this are either to compare the results of pre-selected high and low hypnotizables or to test the correlation between hypnotizability and the dependent physiological variable. The measures used to assess hypnotizability have varied, making a comprehensive analysis of the findings additionally challenging. At various times, researchers have examined the association between physiological changes and the Creative Imagination Scale (CIS; Barber and Wilson, 1978; Wilson and Barber, 1978), the Stanford Hypnotic Clinical Scale (SHCS; Morgan and Hilgard, 1978), the Penn State Scale of Hypnotizability (PSSH; Pepe, 1985), the Harvard Group Scale of Hypnotic Susceptibility, Form A (HGSHS:A; Shor and Orne, 1963) and the Stanford Hypnotic Susceptibility Scale: Form C (SHSS:C; Weitzenhoffer and Hilgard, 1962). This is an important issue to keep in mind as one reads the ensuing literature review. A summary and discussion of this matter is presented toward the end of the chapter.

15.2.2. Relative efficacy of hypnosis versus other psychological techniques If consistent cyberphysiological effects can be attributed to hypnosis, it is important then to determine whether hypnotic techniques are of

equal or greater efficacy than alternative psychological procedures. This is a significant issue for both basic and translational research. A thorough comparison between hypnosis and other techniques, such as relaxation therapy, biofeedback, meditation and subtle energy therapies, is a Herculean task well beyond the scope of this chapter. Outside the field of hypnosis, there is growing evidence that nonhypnotic psychological techniques can influence physiology, including cardiovascular and immune function measures (e.g. Paul, 1969; Smith and McDaniel, 1983; Peavey et al., 1985; Smith et al., 1985; Green and Green, 1987; Hubert et al., 1993; Yung and Keltner, 1996; Amigo et al., 1997; Pawlow and Jones, 2002). Thus, while a study directly comparing relaxation and hypnotic suggestions may find no effect for relaxation, this information must be considered alongside positive evidence from nonhypnosis studies on relaxation. Analysis of effect sizes from independent studies may provide some clue as to the relative efficacy, but the variability in populations sampled, physiological measures assessed and the settings, timing or duration of interventions make this sort of analysis problematic. As evidenced from the following review of the literature, there are few studies that directly pit hypnosis against other techniques for altering physiology. Such an approach is necessary if we are to evaluate the relative efficacy of hypnosis adequately.

15.3. Reviewing the literature:

foundation studies and recent research A rich literature documents the use of hypnosis to modulate aspects of the human body. In reviewing the extensive history of this research, it is interesting to note how some topics that were once enthusiastically studied have not been revisited by contemporary researchers, while other early areas of inquiry have stood the test of time and still command the attention of researchers today. With increasing technological sophistication for assessing physiological parameters, new topics have also been introduced to the literature, particularly in relation to increasingly simple methods for assessing the

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immune system. There is no clear pattern to the waxing and waning of interest in the various topics. While some topics appear to have lost favor after failures to show replicable effects, other early studies, such as those dealing with hypnotic breast enlargement, showed consistent success, and yet no recent research in this area has been published. In attempting to cover this complex and varied area, particularly the multitude of varying terminologies, we have divided the following review into three major sections: (1) foundational studies on topics that no longer receive much attention; (2) topics that have stood the test of time and are still being actively researched; and (3) emerging interests that captured the attention of contemporary researchers. Using this basic structure, we cover a variety of topics––from vision improvement to wound healing––thus the literature review also provides a useful reference for examining the literature on circumscribed topics. We hope this organization allows the reader to digest the important points from a large and multifaceted literature.

15.3.1. The foundational studies As hypnosis became popularized as a powerful psychophysiological tool, many researchers set out to test its effects empirically. Many early studies of hypnosis and the body used developing psychophysiological monitoring equipment and provided the first attempts to separate the effects of hypnosis on self-reported experience from actual changes in the body. The areas covered in this section address those early attempts to associate hypnosis with physiological processes. While the studies are mostly dated, they do not represent ‘immature’ science. As will be seen, they present the same range of scientific rigor that is seen in contemporary research. These areas have in common the fact that they are no longer widely and actively researched.

15.3.1.1. Blood pressure and hypertension Hypnosis has been actively used in the literature as a nonpharmaceutical method for treating essential hypertension. Comparisons with other relaxation and biofeedback techniques are especially important. A well-controlled study was

conducted by Friedman and Taub (1977) in which 48 hypertensive individuals (diastolic blood pressure (DBP) >85 mmHg) were placed into one of four conditions: hypnosis only; biofeedback only; hypnosis and biofeedback combined; and measurement only (control group). Suggestions for the hypnosis-only group were simply to relax as much as possible. Subjects in the biofeedback groups were shown their DBP readings and were told to get that number as low as possible. Subjects were only ‘randomized’ into hypnotic groups if they scored seven or above on the SHSS:A. Followups were conducted at 1 week and 1 month. Only the biofeedback and hypnosis groups showed a significant reduction in DBP over baseline levels. Among these two groups, hypnosis was superior, with an average decrease in DBP of 7 mmHg at the 1-month follow-up. In another study (Deabler et al., 1973), hypnosis was found to be superior to both control (sitting with no instructions) and relaxation in reducing systolic blood pressure (SBP) and DBP. No attempt was made to screen or control for hypnotizability. The treatments worked whether or not individuals were taking antihypertensive medication. Hypnosis has also been used to manipulate blood pressure in normotensives (individuals within the normal or healthy range of blood pressure). Sletvold and colleagues (1986) examined blood pressure responses to hypnotic and nonhypnotic suggestions in 40 normotensive subjects. Subjects were randomly assigned to a hypnosis group, simple relaxation group or control group. Subjects in the hypnosis and relaxation group were given direct suggestions to raise their blood pressure. The control group was given no specific suggestions. The authors found no group differences in SBP or DBP, suggesting that hypnosis did not increase individual control over blood pressure. In a later study, the authors did show an ability of hypnotized subjects to increase and decrease blood pressure (Sletvold et al., 1990); however, an equivalent nonhypnotized group was not provided. In general, the literature suggests that hypnosis is one technique that can be used to lower blood pressure. The use of hypnosis may be most effective in lowering the blood pressure of individuals who are hypertensive. While limited

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clinical research is still carried out, hypnosis is often included in a broad, multidisciplinary approach to blood pressure control, involving other techniques such as relaxation and psychotherapy (e.g. Borckardt, 2002). Therefore, while evidence does suggest that hypnosis can be a useful tool for modifying blood pressure, it is not clear if hypnosis is any more powerful than other psychological approaches.

15.3.1.2. Breast enlargement The use of hypnosis for breast enlargement has a long tradition in the clinical field, with the first anecdotal reports emerging from Erickson’s (1960) work. More controlled work was conducted by LeCron (1969), who used a combination of suggested visualization and suggested greater physiological activity to increase breast size in 20 women aged 20–35. Breast size increased a moderate amount in most subjects (roughly 1.5 inches), with five showing an increase of 2 inches and three showing no change in breast size (although the authors did not indicate which dimension of the breast they measured). Willard (1977) also demonstrated breast enlargement in 22 women following hypnosis and imagery, with those most able to visualize the changes showing the largest increases. Staib and Logan (1977) looked at retained breast growth at a 3-month follow-up. Three women experienced slightly less than 2 inches growth after 12 weeks of treatment, using suggestions of visualization and sensations of growth. At the 3-month follow-up, an average 19 percent of the gains had been lost. The issue of whether or not hypnosis without suggestions could affect breast size was investigated in a small study by Williams (1974), in which three women were hypnotized once a week for 12 weeks. Three subjects were given suggestions to feel a sensation of breast growth, and visualize a larger breast size, while another three women were simply hypnotized with no further suggestions. At a 12-week test, individuals in the hypnosis-only condition experienced no change while the suggestion group exhibited an average of 1 and 5/8 inches of increase in breast size. Williams later explored the role of estrogen in hypnosis-induced breast growth (1979). While hypnosis with suggestions once again increased breast growth over a control

group, no changes in urinary estrogen levels were detected. Though a ‘file drawer’ phenomenon cannot be ruled out as an explanation for the lack of null findings in this area, the results of these early published studies uniformly support the use of hypnosis for breast growth. The studies vary in scientific rigor and many do not use a control group to assess naturally occurring increases or fluctuations of breast size over time. The topic does not seem to have been revisited in recent years, although it is unknown whether that phenomenon is related more to the lack of scientific interest, or a changing political and social climate. If further research in this field was to be conducted, it would be important to assess cardiovascular and endocrine components (such as progesterone and estrogen).

15.3.1.3. Improving vision Hypnosis has generated interest amongst some optometrists as a method for improving eyesight (Vaughn, 1964; Milkie, 1972). There have been various reports on the use of hypnosis for eye misalignment (Look et al., 1965), involuntary eye movement (Aschan et al., 1962), cataract symptoms (Schneck, 1967) and amblyopia, or ‘lazy eye’ (Smith, 1961, cited in Milkie, 1972). Research has also examined the application of hypnotic suggestions in improving visual acuity. Kelley (cited in Barber, 1965) found improvements in visual acuity for 12 of 14 subjects who were given indirect hypnotic suggestions, though similar results were demonstrated for those who were given the same suggestions without hypnosis. Early case studies and preliminary research demonstrating hypnotically improved visual acuity (e.g. Copeland, 1967; Davison and Singleton, 1967) were followed by a number of more carefully controlled studies including those by Graham and Leibowitz (1972) and Sheehan et al. (1982). Sheehan et al. matched two groups of subjects on suggestibility and acuity, provided one of the groups with direct suggestions for improved vision while the other group listened to classical music, then tested the subjects with a series of visual signal detection tasks. The increase in visual acuity for the hypnosis group, compared with baseline levels, was significantly greater than that of the music group. These results, supporting the hypothesis that visual

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acuity can be improved with hypnosis, were challenged by Wagstaff (1983), who argued that the apparent improvement was an artifact. In examining the changes in task performance, Wagstaff noted that while there was a difference between groups, this difference arose because subjects who listened to classical music showed decreased visual acuity, while the hypnosis group showed no real improvement (but see reply to Wagstaff by Smith et al., 1983). If additional research supports the effects of hypnotic suggestion on visual acuity, investigators will need to rule out the influence of increased motivation and begin to identify what, if any, physiological changes occur to produce improvements in vision. Although some have suggested that hypnosis produces observable physiological changes in the eye (Strosberg and Vics, 1962), there are, as yet, few convincing data to support such an effect, nor is there any evidence that improvements, even if consistently demonstrated, would persist for any length of time.

15.3.1.4. Blister formation The production of blisters through hypnotic suggestions is almost folkloric among the hypnosis community. A chronological review of early ‘experiments’ on hypnotic blister formation is provided by Pattie (1941), who summarized 16 reports on this topic dating back to 1886. It didn’t take long for people to realize that the blisters might be self-induced once the patients were no longer under the investigator’s watchful eye. Thereafter, the majority of researchers employed bandages, constant observation and even plaster casts to prevent any intentional or unintentional stimulation of the specified area. Pattie summarized his opinion on this topic as follows: The writer, after all this evidence, still finds himself in an attitude of suspended judgment, an attitude due mostly to his inability to understand by what physiological processes suggestion––or the central nervous system––could produce localized and circumscribed erythemas or blisters (p. 71).

The formation of blisters has been reviewed by others (Gorton, 1957; Paul, 1963; Johnson and Barber, 1976; Barber, 1978; Johnson, 1989; Gauld, 1990), though there have been very few

additional studies conducted since Pattie’s review. Paul (1963) suggested that one of the major limitations of a number of prior studies was the failure to consider the possibility of blister formation resulting from contact dermatitis. For example, where coins, particularly those containing nickel, had been pressed firmly against the skin as a marker for where the blister should form, the resultant skin reactions may have been more a result of allergic reaction than hypnotic suggestions. In the 1970s, Johnson and Barber (1976) conducted the first rigorous study that attempted to control for ‘the possibility that subsequent blister formation may have been due to self-injurious behavior, a preexisting labile skin condition, extraneous mechanical stimulation at the test site, contact dermatitis …’ (p. 177). After assessing hypnotizability, 40 student nurses were provided with a passage from a book (Weil, 1972) describing the powerful effects of hypnosis for blister formation. The effect of hypnotic suggestions (being burned by a frying pan) for blister formation was then examined within-subjects by comparing the skin of subjects’ ‘test hand’ with that of their control hand. In order to keep the investigator blind until after data collection, each nurse was provided with a ‘secret envelope’ on which the test hand (left or right) was identified. Although 27 of the 40 subjects reported subjectively feeling a blister developing during the 20 min of hypnotic suggestions, not one of the 40 subjects actually developed a blister, nor were any significant temperature differences shown between the control and test hand. Interestingly, one subject showed an irregular pattern of inflammation of the test site near the end of the session. The subject had been burned by hot grease on the same spot 6 years previously, suggesting that perhaps the ‘reliving’ of a prior event may be an important consideration in producing physiological changes in response to suggestion. However, subsequent research suggests that this is not the case. In a study in which 60 subjects who had been previously burned were hypnotically age regressed and given suggestions to relive the event and experience the sensation of blister formation (Spanos et al., 1982b), not one of the subjects developed blisters or showed changes in skin color. Like Johnson’s study, one subject showed an anomalous response, in that he

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demonstrated greater skin temperature differences between the test and control site during the hypnotic session. In both studies, however, the subjects demonstrating these atypical responses attained only moderate hypnotizability scores, strengthening the notion that the changes were due more to individual idiosyncratic responses than specific hypnotic suggestions. The effects of hypnotic suggestions on blister healing have also been investigated by applying noxious thermal stimulation (a heated rod) to the skin (Chapman et al., 1959). Thirteen subjects were used in a series of 40 tests in which comparisons were made between arms after suggestions of increased tissue vulnerability in one arm and suggestions of anesthesia or normality in the other arm. No statistical analyses were performed, but descriptive data indicated greater tissue damage for sites of suggested vulnerability. For example, in 20 of 27 tests, the inflammatory reaction was greater on the site of suggested vulnerability compared with the site of suggested anesthesia. More recently, research examining the potential for hypnotic suggestions to increase or decrease skin inflammation induced by ultraviolet-B radiation has shown that, while suggestions are associated with differences in cutaneous blood flow, they do not appear to influence inflammation (Zachariae et al., 1994). In summary, the notion that hypnotic suggestions can produce blisters does not appear to be reliably validated by controlled research. After correcting for potential confounds, such as selfinjurious behaviors or allergic reactions, there is seemingly little experimental evidence to support such claims. The potential for hypnotic suggestions to diminish skin inflammation generated by real external noxious stimuli (such as a heated rod or ultraviolet radiation) remains unclear, given the limited amount of research and conflicting findings.

15.3.1.5. Hypnosis and sexual dysfunction There are numerous reports of hypnosis for the treatment of sexual dysfunction such as impotence and frigidity (e.g. Watkins, 1947; Dittborn, 1957; Schneck, 1970a,b; Segel, 1970; Beigel, 1971; Levit, 1971; Deabler, 1976; Ward, 1977; Hall, 1978; Crasilneck, 1979, 1982, 1990, 1992; Sexton and

Maddock, 1979; de Shazer, 1980; Bateman, 1981; Diment, 1984; Matez, 1984; Fuchs, 1985; Goguen, 1985; Stanton, 1990; Frederick, 1991; Aydin et al., 1996, 1997), but such reports relied largely on case studies in which treatment for sexual dysfunction was integrated into a psychodynamic hypnotherapeutic context of uncovering unconscious conflicts, fears, guilt or anger. Only a handful of investigators have used direct suggestions for the alleviation of sexual dysfunction (Crasilneck, 1990; Aydin et al., 1997), where the hypnotic suggestions were targeted toward treating the symptoms (e.g. ‘You will have good, hard, solid, erections with good ejaculatory response’, Crasilneck, 1990, p. 153) rather than resolving the hypothesized (psychogenic) cause. In summary, while numerous reports in this area are generally positive, there appear to be no well-controlled studies on the topic. Thus, at present there is no solid foundation on which to support the notion of hypnosis as a central factor in reducing sexual dysfunction.

15.3.1.6. Urinary system Hypnosis has been used as a treatment for urinary retention (Werner, 1962; Chiasson, 1964; Patton and Sheehan, 1966; Allen, 1972; Goggins, 1983) and incontinence (Godec, 1980; Freeman and Baxby, 1982; Freeman, 1987). In the Freeman (1987) study, 63 incontinent women aged 17–74 years participated in a study which tested the effects of hypnotic suggestibility on disease and treatment response. These women were all diagnosed with idiopathic detrusor instability, indicating that no anatomical problem could be found (i.e. their condition was thought to be psychogenic). Women with an anatomically associated, unstable bladder were used as a control group. No differences in suggestibility were found between the idiopathic group and the control group, and it was not reported whether or not hypnotic susceptibility predicted response to the treatment. The author reported that 58 percent of the group were rendered symptom free at the end of 12 hypnosis sessions, which spanned 1 year. The majority of individuals, however, relapsed by the 2-year follow-up. The author suggested that significant life events often precipitated relapse. Hypnosis has also been used as a treatment for nocturnal enuresis in children. As reported

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in a review by Mellon and McGrath (2000), a total of four studies (Olness, 1975; Stanton, 1979; Edwards and van der Spuy, 1985; Banerjee et al., 1993) reported on average a cure rate of 71.2 percent. In the Banerjee et al. (1993) study, hypnosis was compared with imipramine treatment. While both groups had an equally successful cure rate immediately following treatment, the hypnosis group fared significantly better at a 6-month follow-up. The authors noted, however, that only one study was controlled and had a measurable outcome variable. Thus, the use of hypnosis to effect changes in the urinary system has been limited to treatment of existing urinary conditions. Studies have frequently suffered from methodological problems that limit the internal validity of the study findings. Given this, hypnosis remains a promising approach to treating urinary system disorders, but considerably more scientific validation is required before it can be considered an efficacious treatment.

15.3.1.7. Gastric motility A handful of early psychophysiology studies tested the relationship between hypnosis and gastrointestinal functioning. In one such study, Hall et al. (1967) examined the effects of hypnosis on gastric motility. After a night of fasting, subjects were intubated and infused with a ‘meal’ of 100 g/l of dextrose and 50 mg/l of phenol red in distilled water. Following the infusion, subjects were given the experimental manipulation, which differed on each of 5 days. Days 1 and 5 were controls, with no instructions given before or during data collection. Day 2 consisted of a hypnotic induction only. Days 3 and 4 included both a hypnotic induction and suggestions for either indigestion (day 3) or constipation (day 4). Following 30 min of the experimental protocol, gastric functioning was determined by aspirating stomach contents and measuring the volume of phenol red remaining in the stomach fluids. It was expected that hypnotically suggested experiences of indigestion and constipation would decrease gastric empting, thereby increasing residual amounts of phenol red. While six of the eight subjects did report increased gastric discomfort after the indigestion and constipation suggestions, objective markers of gastric functioning were not similarly affected. None of the hypnosis trials yielded physiological results (residual volume, volume passing

pylorus, acid, pepsin or chloride levels) different from those of the two control trials. Eichhorn and Tracktir (1955) found a significant effect for hypnotically suggested emotional experiences on gastrointestinal parameters. In their study, 24 students were given, in a counterbalanced fashion, suggestions for anger, fear and contentment. Following a rapid induction, subjects were told they would experience each emotion mentioned to them and would feel that way strongly until told otherwise. Free acid, total acid, volume of secretion and pepsin were measured during each experimental condition. As predicted, the authors found that all measures of gastric functioning were significantly higher (save for pepsin, which was significantly lower) in the contentment condition as compared with the anger and fear conditions. Without a hypnosisonly group or true control group, however, it is not possible to determine what effect hypnosis had over the simple, nonhypnotic concentration on an emotional state. The data do suggest, however, that suggestions to experience emotional states under hypnosis are potent enough to elicit measurable gastrointestinal effects. It is possible then, that hypnosis may serve to augment emotions, potentiating the physiological aspects of those states. It is possible that suggestion in general, rather than hypnosis per se, is responsible for suggestion effects on gastric functioning. In a small study (n = 7) conducted by Kehoe and Ironside (1964), subjects reported a high number of gastric complaints when told (under hypnosis) to experience whatever feelings they associated with the word ‘depression.’ No suggestions pertaining to the gastrointestional system were given. Secretory rate was assessed by continuous, manual gastric aspiration. Experiences such as nausea and vertigo were associated with significantly lower secretory rate of total acid, while experiences such as hunger were associated with higher secretory rate. As the authors observed a similar and equally significant relationship when subjects were not hypnotized, it seems unlikely that hypnosis was a critical factor in the observed results. This field, like many others, suffers from the lack of proper controls. The research suggests that it is not effective to suggest directly a change in gastric functioning. A more powerful

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approach seems to be suggesting a specific emotional state, such as depression or anger. Evoking such a state may cause physiological changes; however, these changes may also occur through nonhypnotic suggestion. The field of hypnosis and gastric motility has been largely forgotten in the recent literature. An important exception is irritable bowel syndrome (IBS), which will be discussed in Section 15.3.3.

15.3.2. Topics of enduring interest While some areas within the field of hypnosis and mind–body interactions have not persisted, others have continued to attract the attention of researchers. We now examine these enduring topics, topics that have been supported by ongoing research because the questions are important, the evidence has supported continued study, or because new technologies have allowed researchers to investigate the topic in novel or cost-effective ways.

15.3.2.1. Asthma and the respiratory system Hypnosis has been used to treat breathing problems such as vocal cord dysfunction (Anbar and Hehir, 2000), chronic dyspnea (Acosta-Austan, 1991) and asthma (Maher-Loughnan et al., 1962; Maher-Loughnan, 1970; Moorefield, 1971; Hanley, 1974; Aronoff et al., 1975; Ben-Zvi et al., 1982; Neinstein and Dash, 1982; Kohen, 1996). In an early randomly controlled trial (Anonymous, 1968), 252 asthmatic children and adults were randomized into a hypnosis group or a relaxation group. The hypnosis treatment group showed a statistically significant improvement in forced expiratory volume (FEV), a lung capacity test that is predictive of future asthma attacks. However, the subjects increased FEV by an average of only 4.3 percent, which is considered to be of little clinical value (Huntley et al., 2002). In an attempt to determine which asthmatic patients were most likely to respond favorably to hypnotic interventions, Collison (1975) examined 100 asthmatic individuals aged 8–69 years. Several factors were found to predict reductions in asthmatic attacks in response to the treatment, including: the ability to go into a deep trance, the youthfulness of the subject and the presence of psychological etiological factors.

Similarly, Ewer and Stewart (1986) found that responsiveness to hypnosis treatment was limited to high hypnotizables. Those responding positively to treatment evidenced lower asthma severity, fewer self-reported symptoms, greater peak expiratory flow and reduced use of bronchodilators. Low hypnotizables did not respond to the treatment. In addition to reducing the severity of asthmatic symptoms through hypnotic techniques, researchers have also demonstrated that asthma symptoms can be induced by hypnotic suggestions. In one such study (Thorne and Fisher, 1978), hypnotic susceptibility was a significant predictor of objective measures of asthmatic symptoms (FEV and vital capacity) following hypnotic suggestions for asthma. Additional research comparing hypnotic suggestions with waking suggestions (Clarke and Gibson, 1980) found that patients demonstrated significantly more signs of asthma attacks (measured by minute expiratory volume) under hypnosis when suggestions of relaxation, anger, fear, excitement and asthma symptoms were given. However, later research has demonstrated that such an effect can also be produced in normal individuals given waking suggestions (Kotses et al., 1987). There is some evidence that the effects of hypnotic suggestions are limited to those aspects of breathing over which individuals have voluntary control. Changes in respiration following suggested relaxation and suggested muscular effort were measured in both hypnotized and nonhypnotized subjects (Agosti and Camerota, 1965). Compared with baseline measures, relaxation suggestions decreased pulmonary ventilation in both groups, but only substantively so in the hypnosis group (though, as the authors note, this group started with higher baseline levels). Suggested muscular work increased ventilation, again especially so in the hypnosis group. However, in spite of the changes in ventilation, there was no change in uptake of oxygen, due to decreases in respiratory efficiency. A small number of additional studies have examined the effect of hypnotic suggestions on behavior related to the respiratory system. For example, Jana (1971) reported a case study in which respiratory rate decreases occurred after suggestions of smoking a cigarette (though

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similar suggestions without hypnosis were not tested), and other researchers have examined the influence of hypnosis for controlling coughs through case reports and descriptive analyses (Elkins and Carter, 1986; Anbar and Hall, 2004). However, there appear to be no well-controlled studies related to hypnotic treatment of cough, and other suggestive techniques outside of hypnosis have shown similar improvements (e.g. Cohlan and Stone, 1984). Overall, hypnosis appears to be a useful adjunct in the treatment of asthma. The technique is particularly effective when patients are highly hypnotizable, more sessions are used, sessions are reinforced with self-hypnosis and patients are younger (Hackman et al., 2000). While more recent randomized controlled trials are needed (Gyorik and Brutsche, 2004), the number of successful trials indicates the possible role of hypnosis in modulating the symptoms of asthma.

15.3.2.2. Allergic skin reactions There have been a handful of studies on the treatment of general allergies by hypnotic suggestion (e.g. Aston, 1959; Kroger, 1964; Perloff and Spiegelman, 1973; Langewitz et al., 2005),2 but by far the greatest focus regarding allergic reactions has centered on DTH. Discovered over 100 years ago, DTH is an immune reaction to an antigen, generally studied through either intradermal injection or skin contact with an antigen. In order to display the characteristic erythema and induration (reddening and hardening of the skin in the exposed area), an individual’s immune system must have been previously sensitized to the antigen, thus the DTH skin test is used to assess whether prior exposure to an antigen has occurred. Though the precise mechanism of the reaction is still

2 Aston reports a psychotherapeutic case study involving a female patient with food allergies, with successful treatment after a single session in which the hypnotist uncovered a deep-rooted embarrassment about being tall. The success was based on a follow-up session 2 years later in which the patient reported no allergic symptoms since the previous session. Interestingly, both therapist and patient were dentists, and the therapist in this study was the patient’s instructor in a hypnosis training session. Such a situation amplifies the potential confound of demand characteristics.

unclear, the process is believed to be mediated by T-cells (Black, 1999). An early case report of an asthmatic girl described the use of hypnosis to control the DTH response (Clarkson, 1937). Without hypnosis, the patient developed a large wheal to an intradermal test for egg sensitization. The next day, a suggestion that no reaction would occur was given during hypnosis and no wheal formed. Following hypnosis, the patient was again tested and the wheal was produced as before. There is some evidence that the nature of the specific suggestions for reducing DTH may be important. In a study of five hospitalized asthmatic patients described as ‘excellent hypnotic subjects’, a number of different allergens were tested intradermally (‘within the skin’) during both nonhypnotic and hypnotic conditions (Dennis and Philippus, 1965). Only one condition, in which specific hypnotic suggestions were given for nonreactivity and that the injected skin area would feel cold, resulted in reduced DTH reaction compared with a nonhypnotic no-suggestion control condition. Conditions in which specific suggestions for nonreactivity and anesthesia were given during hypnosis, hypnotic suggestions for nonreactivity to a specific allergen or suggestions for nonreactivity during the waking state failed to demonstrate any effect. The authors also found no effect for hypnotic suggestions to produce a reaction following the injection of a placebo substance. Specific versus general suggestions were also assessed by Mason and Black (1958) in their study of an allergic patient who showed skin reactions to three environmental allergens applied to the arm. Following hypnotic suggestions for the relief of hayfever (with no specific mention of skin reactions), the size3 of the DTH reaction progressively decreased over a period of 7 weeks. When the skin of the patient’s leg was tested, however, a large wheal appeared.

3 In a time before computer scanning technology, Mason and Black ingeniously assessed wheal size by tracing the area of the wheal and then transferring the traced area to a lead sheet (taken from the back of old dental X-ray films). The traced areas were cut out and the size of the area was calculated by weighing the lead (the sheet had been previously checked for consistency in thickness).

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The researchers then delivered direct hypnotic suggestions that the patient’s skin would be unresponsive to tests anywhere on her body and, tested immediately on waking, there was no subsequent allergic reaction to allergen testing on the leg. After 10 weeks of treatment, the patient was consistently showing no skin reactions (see Figure 15.1 for a graphical summary of results). To examine one potential mechanism for this change, a control subject with no skin reactions to allergens was subsequently tested for wheal reaction after having been intradermally injected with serum (blood plasma) from the allergic patient. After this sensitization, the control subject developed a wheal when allergens were applied to the skin. To Mason and Black, this test demonstrated that the blood of the cured patient still contained the ‘serological basis of her previous hypersensitivity’ (Mason and Black, 1958, p.879). Zachariae (1989) has shown that the type of hypersensitivity is a possible factor in hypnotic modulation of skin reactions. By comparing two types of allergic skin reactions, a rapid histamine skin prick reaction (Type I) versus the delayed Mantoux (Type IV) reaction, Zachariae showed that hypnotic suggestions to decrease

skin reactions resulted in a reduction in erythema (reddening) for both Type I and Type IV, but that reductions in induration (hardening) were only achieved for the Type IV reaction. Previous studies had shown positive effects of hypnotic suggestions on Type IV reactions (Black, 1963; Black et al., 1963; Black and Friedman, 1965), but Zachariae set out to compare the two reactions directly. The study used both within-subject and between-subject controls, and assessment of reactions was performed blindly. It is important to note that the Type I reaction was assessed after just 7 min of hypnotic suggestions, whereas the Type IV reaction was assessed after 72 h, following both an extended session of imagery suggestions immediately after the injection and repeated sessions of self-hypnosis using pre-recorded audiotapes. Within the same study, Zachariae tested the potential for hypnotic suggestions to increase both Type I and Type IV reactions––but found no increase in either erythema (redness) or induration (raised hardened area). Zachariae later demonstrated that a similar reduction in erythema to histamine prick tests could be achieved using hypnotic suggestions for analgesia of the tested arm (Zachariae and Bjerring,

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Fig. 15.1 Graphical summary of results from Mason and Black’s (1958) study of DTH reactions. From ‘Allergic skin responses abolished under treatment of asthma and hayfever by hypnosis’, by A. A. Mason and S. Black (1958), Lancet, 1: 877–879. Reprinted by permission from A. A. Mason.

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1990) and that hypnotically induced emotions could also influence skin reactions to histamine, with flare reactions being greater during induced sadness than during induced happiness (Zachariae et al., 2001). Other hypnosis research supports the mediating role of emotion in histamine skin reactions (Laidlaw et al., 1996), suggesting that while hypnotic suggestions may reduce histamine skin reactions, variability in efficacy may be partially explained by an individual’s feelings of tension and irritability. In an attempt to uncover the mechanisms by which hypnotic suggestions might alter DTH reactions, Zachariae also examined whether hypnotic suggestions can alter sensitization to allergens. In this study, rather than provide hypnotic suggestions for decreased skin reactions at the time of the skin tests, Zachariae administered two different experimental allergens to the skin of highly hypnotizable subjects to sensitize them for later allergic skin tests. After application of the sensitizing allergens, the subjects were hypnotized and given suggestions to increase their immunological reaction in one arm and decrease it in the other, using suggested perceptions of warmness/itchiness and coolness/numbness, respectively. Self-hypnosis was performed once a day for the subsequent 5 days using an audiotaped session to reinforce the suggestions, and subjects returned 6 weeks later for skin reaction tests to the sensitized allergens. The results again demonstrated an effect for erythema but no effect for induration, even though suggestions in this study had been given during the sensitization stage rather than the subsequent skin reaction test. Although the above reports provide encouraging evidence of the impact of hypnotic suggestions on allergic reactions, other case reports and controlled studies have shown no effects. Zeller (1944) published a series of studies examining the hypnotic modulation of allergic skin reactions in both allergic and nonallergic patients. Subjects in Zeller’s study were sensitized with serum obtained from a patient with ragweed allergies. Testing both intradermal injection and scratch methods for introducing the antigen, wheals were produced in both control sessions (no hypnosis) and following hypnotic suggestions that no skin response would occur. Additionally, Zeller failed to induce wheals hypnotically in nonsensitized

skin areas using hypnotic suggestions for skin reactivity. Similar failures to reduce or increase wheal formation size after specific hypnotic suggestions were reported by Levine et al. (1966) in a study that tested nonallergic individuals, those with ragweed allergies and those with chronic urticaria, and negative findings were also demonstrated by Beahrs (1970) using mumps antigen, trypsin and histamine. A randomized control study by Locke (1987) failed to show that hypnosis could enhance or suppress the DTH response. Locke (1994) later tackled a number of potential limitations of his 1987 study by carefully pre-screening subjects for both positive DTH reactions and their cyberphysiological potential (demonstrated by an ability to change fingertip temperature following hypnotic suggestions). To rule out an effect of hypnotist experience, Locke also enlisted Zachariae to act as the hypnotist in the study. Even with these issues addressed, Locke again found no effect of hypnosis on DTH response. An often cited reference regarding the potential for hypnosis to affect physiology is that of Ikemi and Nakagawa (cited in Barber, 1978). In their study, the researchers demonstrated that allergic reactions to the leaves of plants (similar to poison ivy) could be influenced by hypnotic suggestions. Five high-school students who were sensitive to the plants were told under hypnosis that they were being touched by the leaves from the poisonous trees. In actuality, they were being touched by leaves from a harmless tree. All five showed allergic skin reactions to the harmless leaf. The same subjects were later told under hypnosis that they were being touched by a harmless leaf, when in fact they were stimulated with the poisonous leaf. Four of the five subjects did not show the normal allergic reaction. Such findings demonstrate an impressive directionality of specific hypnotic suggestions and assist in excluding explanations based purely on relaxation. But there is more to the story. Ikemi and Nakagawa also provided the same suggestions to eight different students, without first providing a hypnotic induction. All of these students showed allergic reactions to the nonpoisonous leaf, and seven of the eight did not show the expected allergic reaction when a poisonous leaf was applied. The specific role of hypnosis in eliciting these changes

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therefore rests on how researchers define hypnosis, as discussed previously in Section 15.2. Thus, the potential for hypnosis to alter allergic responses is not yet clear. Although there are a number of studies supporting its efficacy, there are also well-controlled studies that fail to demonstrate an effect. Given that the mechanism underlying many allergic responses is still far from being fully understood, it is possible that these discrepancies are due to subtle differences in the timing and nature of the suggestions given and/or the specific allergens and reactions tested. While researchers still have their work cut out for them, there appears to be promise in this field of inquiry, as summarized in a 1992 committee report on allergy published by the Royal College of Physicians, London, who concluded that hypnosis deserved further evaluation (Kay and Lessof, 1992).

15.3.2.3. Peripheral skin temperature and blood flow Peripheral skin temperature is reflective of blood supply and, indirectly, vasodilation and vasoconstriction (expansion and narrowing of blood vessels). When vasoconstriction occurs (as with a stress response), blood supply decreases, lowering skin temperature. Skin temperature, then, is commonly used as a marker of stress and relaxation, the latter being associated with higher skin temperatures. Peripheral temperature provides a noninvasive and accurate measure of vasoconstriction and blood flow (Brock et al., 1975; Vincent et al., 1988). Attempts to use skin temperature as a biomarker of the hypnotic state have produced inconsistent results (Reid and Curtsinger, 1968; Grabowska, 1971; Peters and Stern, 1974; Piedmont, 1981; Bregman and McAllister, 1985). However, perhaps a more interesting question is whether or not hypnotic suggestions can be used to change skin temperature. Some studies have found that suggested pain (Hajek et al., 1992) and heat (Raynaud et al., 1984) can change peripheral temperature, while others have found that hypnosis does not confer any unique advantage for temperature control (Peters et al., 1973). In one study comparing the utility of hypnosis with other techniques for controlling temperature, 73 individuals were randomly assigned to one of four groups: (1) biofeedback; (2) false biofeedback;

(3) relaxation; and (4) hypnotically suggested hand warming with biofeedback (Barabasz and McGeorge, 1978). While all the groups showed temperature increases, only the hypnosis group produced increases significantly greater than the other three groups (note, however, that there was no waking suggestion group). Other controlled studies have shown hypnosis to be effective for changing skin temperature, but not more so than biofeedback. For example, Dikel and Olness (1980) measured children’s ability to control peripheral temperature voluntarily with selfhypnosis, hypnosis plus biofeedback and biofeedback alone. All groups significantly increased and decreased skin temperature in the suggested direction, but hypnosis did not increase the efficacy of biofeedback. Suggestions for temperature change, therefore, may not require hypnosis. The authors noted, however, that children may spontaneously use imagery even when not hypnotized. Children in the biofeedback group reported using vivid selfgenerated imagery during the session, and the authors raised the possibility that this imagery may be more potent than generic suggested imagery. The relevance of hypnosis to altering peripheral temperature is supported by research demonstrating a relationship between hypnotic susceptibility and biofeedback-assisted temperature change during hypnosis (Piedmont, 1983). Toward the end of a standard SHSS:C session, 30 subjects were instructed to open their eyes but remain hypnotized. Subjects then completed a 10-min biofeedback session while under hypnosis, with red and blue lights indicating increases or decreases in finger temperature. Subjects were instructed to lower their finger temperature but were given no further suggestions. A significant negative correlation was found between hypnotizability and skin temperature. Simply put, high hypnotizables were better able to lower their peripheral temperature. Hypnotizability has also been found to predict the ability of hypnosis to reduce stress-induced vasoconstriction (Jambrik et al., 2005). Self-reports of temperature change are a common occurrence during hypnosis. However, evidence suggests that this report reflects perceptual changes more than observable temperature change. Wallace and Kokoszka (1992) noted that many individuals report sensations of coldness when given suggestions of analgesia under hypnosis.

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The authors conducted three studies in order to determine whether or not experienced coldness was associated with actual decreases in skin temperature. In these studies, individuals (n = 104) with low and high hypnotizability were hypnotized and given suggestions for arm analgesia. Suggestions consisted of visualizing large doses of Novocain injected in the area and increased sensations of numbness (no suggestions specifically for cold). Highly hypnotizable individuals reported significantly greater analgesia in the suggested area as well as more sensations of coldness, but none of the experiments yielded a measurable temperature effect for suggestion or group (high/ low hypnotizable). Likewise, there were no skin temperature differences between those receiving analgesia suggestions and those given suggestions to relax. Thus, the perception of coldness accompanying hypnotically suggested analgesia appears to be the result of psychological, not physiological, changes. Other studies have also found behavioral responses to match temperature suggestions more closely than actual changes in peripheral temperature (Clark and Forgione, 1974). More recent studies have included invasive measures of hemodynamics (performance of the circulatory system). In one well-designed experiment, Casiglia and colleagues (1997) tested hemodynamics in healthy individuals following both real and hypnotically simulated phlebotomy (blood draw). One control group underwent a real 300 ml phlebotomy session while SBP, DBP, blood flow and vascular resistance were measured. Another group of sex- and age-matched individuals (selected for their high hypnotizability) completed each of three experimental sessions: (1) hypnosis-simulated phlebotomy; (2) hypnosis induction with no further suggestions; and (3) simple rest with no further instructions. In all cases, subjects lay in a hospital bed throughout the entire procedure, while cardiovascular measurements were collected. For the hypnosis-simulated phlebotomy group, imagery suggestions were used (e.g. ‘now the needle is being inserted into your arm …’). At baseline, there were no significant group differences in any cardiovascular parameter. During the protocol, both the real phlebotomy and hypnotically suggested phlebotomy groups showed the same hemodynamic response, with

no significant between-group cardiovascular differences. The hypnosis with no suggestion and simple bed resting groups showed no changes in cardiovascular parameters, leading the authors to conclude that hypnotically suggested blood draws evoke the same hemodynamic response as actual blood draws, but that hypnosis alone does not evoke such a response. Note that no waking suggestion group was included in the study, thus it is not clear whether or not the same hemodynamic response would have occurred with nonhypnotic suggestions. Weinstein and Au (1991) tested differences in hemodynamic response to hypnosis in 16 hypnotized individuals and 16 controls during angioplasty (artery widening). While hypnotized individuals were able to withstand angioplasty significantly longer than controls, no objective markers (ischemia, blood pressure, pulse or heart rhythm) distinguished the two groups. These results mirror those in the peripheral skin temperature literature: hypnosis may change perceptual factors related to cardiovascular experience but does not change physiological aspects of that system. Despite a lack of clear evidence for hypnosis as gaining any control over blood flow, hypnosis has been tested as a treatment for many cardiovascular conditions, including Raynaud’s disease (Conn and Mott, 1984) and erythromelagia, a painful condition associated with increased temperature in the extremities (Chakravarty et al., 1992). Hypnotically suggested hypothermia has been used to control cancer metastases (August, 1975). While some promising results have emerged from these reports, these approaches have not been studied with the scientific rigor required for claiming efficacy. The most recent use of hypnosis to alter blood flow has been in heart rate variability (HRV). In a basic sense, HRV is an indicator of sympathetic and parasympathetic balance. Too little variation may be indicative of excessive stress. There have been conflicting results regarding whether changes in heart rate variability are associated with the hypnotic state (De Benedittis et al., 1994; Ray et al., 2000). Interestingly, the most recent study of hypnotizability and HRV found that individuals of low hypnotizability may, paradoxically, be more susceptible to heart rate suggestions than highly hypnotizable individuals

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(Sebastiani et al., 2005). Low and high hypnotizables were given instructions to relax outside of hypnosis (in a normal state of wakefulness). There were no differences in HRV between groups before suggestions. After suggestions, both groups were able to decrease their heart rate, but only lows did so significantly. Furthermore, only lows increased parasympathetic aspects of HRV. Despite being studied for many years, there is no clear evidence that hypnosis can directly modulate blood flow or peripheral skin temperature. As noted throughout this section, hypnotic suggestions seem more effective in changing the experience of the subject than the peripheral physiology of those individuals.

15.3.2.4. Hypnosis and pain Perhaps one of the clearest examples of how identifiable physical mechanisms are influenced by psychological factors is the topic of pain. However, because of its general reliance on subjective reports rather than direct physiological changes, and because the topic is covered in more detail later in this book (Jensen and Patterson, Chapter 20, this volume), we have chosen to provide only a short summary of the issue within our own chapter. Hypnotically induced analgesia is arguably the arena in which hypnosis has proved itself most adequately, providing reduction of both chronic (e.g. cancer) and acute (e.g. surgical) pain (Holroyd, 1996). Hypnotic analgesia has a long history, with prominent figures such as the Scottish surgeon James Esdaile (1808–1859) demonstrating its apparent effectiveness for surgery (including 200 patients with massive scrotal tumors) during his time in India. The fervor surrounding this particular use of hypnosis declined shortly after the completion of Esdaile’s work, however, with discovery of the anesthetic qualities of ether and chloroform in the mid-1840s. Beginning around 1930, interest in the reduction of pain by hypnosis resumed and, today, from burn wound debridement (Patterson et al., 1989; Patterson, 1992) to childbirth (Harmon et al., 1990) to bone marrow aspirations (Liossi and Hatira, 1999) and cancer in children (Liossi and Hatira, 2003), hypnosis has found recognition as a dramatic method of producing analgesia, which in some cases has matched or exceeded that

derived from morphine. Additionally, research with naloxone, a drug that acts as a competitive antagonist at the opioid receptor, shows that hypnotic analgesia is not mediated by endogenous pain mechanisms involving endorphins (Spiegel and Albert, 1983). A National Institute of Health report (NIH Technology Assessment Panel, 1996) found ‘strong evidence for the use of hypnosis in alleviating the pain associated with cancer’ (p. 313) and other data ‘suggesting the effectiveness of hypnosis in other chronic pain conditions, which include irritable bowel syndrome, oral mucositis, temporomandibular disorders, and tension headaches’ (p. 315). A meta-analysis of studies of hypnotically suggested pain reduction, based on pain reports from 933 subjects, showed that such suggestions provided substantial pain relief for 75 percent of the population across different types of experienced pain (Montgomery et al., 2000). In one of the included studies, self-hypnotic techniques were used during interventional radiological procedures, in which intravenous pain medication was self-administered by patients by means of a push-button automated delivery system (Lang et al., 1996). Compared with hypnosis patients, the control patients as a whole used seven times more drug units and reported significantly more maximal pain. Not only was the pain reduction evidenced by subjective reports and behavioral response, but the reduction of drug use in the hypnosis group was associated with a significantly lower incidence of oxygen desaturation and significantly fewer procedural interruptions due to cardiopulmonary instability. Other research has shown that pain typically increases over the course of percutaneous medical procedures, but remains stable for patients using self-hypnosis techniques (Lang et al., 2000). However, the efficacy of self-hypnosis techniques is not assured. A recent investigation found hypnotic intervention to be effective in the reduction of pain, anxiety and distress behavior in children undergoing lumbar puncture procedures, but only when heterohypnosis (therapist-administered hypnosis) was used, not when children used self-hypnosis (Liossi and Hatira, 2003). It is clear that future research will need to address such disparities. For those interested in examining this topic further, a recent

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summary of review articles that deal in some fashion with hypnosis and pain (Hawkins, 2001) provides an impressive preliminary resource.

15.3.2.5. Treatment of dermatological disorders There have been a number of reviews supporting the potential for hypnosis to treat dermatological disorders (e.g. Shenefelt, 2000). Case studies have reported effective treatment of boils (Jabush, 1969), pruritis (Ament and Milgrom, 1967; Sampson, 1990; Rucklidge and Saunders, 2002), eczema (Twerski and Naar, 1974; Mirvish, 1978; Sokel et al., 1993; Stewart and Thomas, 1995) and psoriasis (Kline, 1954; Frankel and Misch, 1973). Tausk and Whitmore (1999) performed a randomized controlled trial with psoriasis patients to examine the relative efficacy of hypnosis with or without specific suggestions for skin healing. No significant differences were shown in improvement, suggesting that specific suggestions were no more effective in treating psoriasis than the neutral hypnotic procedures. The researchers did, however, find an effect for hypnotizability; high hypnotizables showed greater improvement than medium hypnotizables (but see also Zachariae et al., 1996, who failed to show a significant correlation between psoriasis improvement and hypnotizability in their study of the effects of relaxation and imagery suggestions). The role of hypnosis in dermatology has most frequently been demonstrated in the alleviation of warts (Sulzberger and Wolf, 1934; Vollmer, 1946; McDowell, 1949; Obermayer and Greenson, 1949; Sinclair-Gieben and Chalmers, 1959; Ullman and Dudek, 1960; Tenzel and Taylor, 1969; Surman et al., 1972, 1973, 1983; Ewin, 1974, 1992; Clawson and Swade; 1975; French, 1977; Tasini and Hackett, 1977; Dreaper, 1978; Johnson and Barber, 1978; Chandrasena, 1982; Straatmeyer and Rhodes, 1983; Morris, 1985; Noll, 1988, 1994; Spanos et al., 1988, 1990; O’Loughlan, 1995; Felt et al., 1998; Kohen et al., 1998; Goldstein, 2005). An excellent review of the psychological treatment of warts, with particular emphasis on hypnotic procedures, is provided by DuBreuil and Spanos (1993). In one study (Spanos et al., 1988), those who received hypnotic suggestions for wart removal demonstrated a 50 percent cure rate (as assessed by the number of warts lost and the

percentage of wart loss at a 6-week follow-up). This was significantly higher than the rate achieved by subjects who had been assigned to a waiting list control or who had received a cold laser placebo treatment. With reference to experimental research, DuBreuil and Spanos suggested that hypnosis-facilitated wart removal is not based on spontaneous remission and may be more effective than placebo techniques. However, they also concluded that suggestive treatments without a hypnotic induction appear to be equally effective. Johnson and Barber (1978) found remission of warts for three of 11 subjects in a hypnosis group, but for none of the subjects in a ‘focused contemplation’, nonhypnotic group. These findings led the authors to suggest that the ‘believedin efficacy’ of hypnosis may explain the observed differences. In other words, the hypnosis group may simply have had higher expectations about the effectiveness of their treatment. In attempting to define the role of expectancy in wart remission, research has shown that while subjects with low expectations of treatment efficacy do not lose warts, those with high expectations are not guaranteed positive results (Spanos et al., 1988). Thus high expectancies appear to be a necessary, but insufficient, factor in the cure of warts (for discussion of a similar relationship between expectancies and hypnotizability, see Barnier and McConkey, 2004). Additionally, while some early studies suggested a relationship between hypnotizability and wart remission, later investigations using standardized measures of hypnotic ability failed to show significant correlations. One of the most astonishing findings of the use of hypnosis in treating dermatological conditions was a report by the physician A. A. Mason of his treatment of a patient with congenital ichthyosiform erythrodermia of Brocq (‘fish skin disease’, Mason, 1952). The report, which appeared in the British Medical Journal in 1955, detailed the dramatic removal of the patient’s thick, scaly, inflexible, skin as it softened and fell off following hypnotic suggestions. In what would now be considered a multiple baseline design (Borckardt and Nash, 2002), Mason gave the 16-year-old patient suggestions that the left arm would clear. The suggestion was limited to the left arm ‘so as to exclude the possibility of spontaneous resolution’ (p. 422).

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Five days later, the thick horny layer ‘fell off ’ to reveal pink and soft skin, and within 10 days the arm was ‘completely clear from shoulder to wrist’ (p. 422). Suggestions were then given for the right arm, and 10 days later for the legs and trunk. By the end of treatment, 95 percent of the arms were clear, with other areas of the body demonstrating significant improvement (see Figure 15.2). At a 4-year follow-up visit, the improvement had progressed (Mason, 1960). Although carefully controlled studies are not viable due to the relatively infrequent occurrence of this particular condition, positive results were obtained with hypnosis in six other patients ranging from ages 7 to 34 (Bethune and Kidd, 1961; Wink, 1961; Kidd, 1966; Schneck, 1966), and for a patient with ichthyosis simplex, another type of fish skin disease (Schneck, 1954). While the nature of Mason’s methodology, and the speed with which changes were effected, reduces the likelihood of spontaneous

(a)

(b)

Fig. 15.2 Treatment of a patient with congenital ichthyosiform erythrodermia of Brocq (‘fishskin disease’, Mason, 1952). The top picture is prior to hypnotic treatment, and the bottom picture is after hypnotic suggestions that the skin would clear up. Pictures from ‘Hypnotism for medical and dental practitioners’, by A. A. Mason (1960, p. 65), published by Secker and Warburg, London. Reprinted by permission from A. A. Mason.

remission as an explanation, we are left with the question as to whether or not nonhypnotic suggestive techniques might be equally effective. With increasingly rigorous studies, researchers are beginning to identify the specific variables associated with successful outcome and to separate clinical anecdote from controlled experimentation. There is insufficient information at present to assert confidently that positive results are due exclusively to hypnosis (Pinnell, 2000). Understanding how ‘mere words’ might influence changes in skin is a formidable task, but researchers in dermatology are increasingly unearthing details about the complex nature of skin, developing a framework in which skin is ‘considered as an active neuroimmuno-endocrine interface’(Brazzini et al.,2003).

15.3.2.6. Biochemical changes in the blood A few studies have specifically examined biochemical changes in the blood following hypnosis and/or hypnotic suggestions. The approach to eliciting changes has generally relied on a procedure of hypnotically induced emotional states (Vandenbergh et al., 1966; Black and Friedman, 1968; Zachariae et al., 1991; Sobrinho et al., 2003), though other studies have suggested food ingestion (Goldfine et al., 1970), breastfeeding (Sobrinho et al., 2003) and memories of previously stressful events (Adlercreutz et al., 1982), or simply examined changes that result from the experience of hypnosis itself (Jana and Patel, 1965; Sachar et al., 1965, 1966). A number of studies have examined changes in blood biochemistry within the context of research on hypnotically elicited changes in immune functioning (e.g. Zachariae et al., 1991; Gruzelier et al., 2001a; Wood et al., 2003). The results of such studies vary, and an overall summary is confounded by variability in both the nature of hypnotic procedures and the statistical analyses employed. In examining the effect of hypnotically induced emotions, Sobrinho (2003) instructed subjects to associate freely with a feeling or actual scene of their past (the themes of which were nondirected), and then examined whether the number of ‘peaks’ of various hormones during the hypnosis session differed from those during a waking (nonhypnosis) baseline condition. The study showed significantly more

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surges in cortisol, prolactin and growth hormone levels during the free association periods than during the pre-hypnosis period, and specific themes of intimidation and shock elicited the greatest surges in cortisol. In another study of hypnotically elicited emotions, Zachariae (1991) induced specific emotional states under hypnosis, suggesting the vivid reliving of a prior episode in which the specified emotion (anger, depression or happiness) had been experienced. Zachariae then tested for statistical differences in hormone levels between the various emotional states and the pre-hypnosis state. Like Sobrinho, Zachariae found significant changes in cortisol as a result of induced emotions, but only during the induced emotion of happiness, which was lower than levels during anger, depression and pre-hypnosis. It should be noted that happiness was also the last emotion elicited in all subjects, introducing a potential order effect. Other specific differences were shown by Zachariae, such as decreased epinephrine during the depressive condition and decreased norepinephrine during all emotions relative to pre-hypnosis. In summary, there is currently only meager evidence for the potential of hypnosis to produce biochemical changes in the blood. Even assuming that further research can reveal consistent patterns of response to hypnotically induced emotions, the relevance of hypnosis to this effect is impossible to determine via the methodologies previously employed. In the realm of altering hormones, it is unclear whether hypnotic induction of emotion adds any benefit over simply asking individuals to imagine a previous emotion-laden event. Whether providing suggestions for breastfeeding, ingestion of food or the reliving of emotional events, a no-hypnosis control group is a necessary first step in elucidating the specific role played by hypnosis.

15.3.2.7. Induction of seizures Not all seizures are epileptic. Nonepileptic seizures are reported in 10–23 percent of patients referred to epilepsy centers. In most cases, distinguishing epileptic (caused by an electrical disturbance in the brain) from nonepileptic or psychogenic seizures requires constant video and electroencephalogram (EEG) monitoring, a process that is often prohibitively lengthy and expensive. Because of this, a number of physicians have

used suggestive techniques such as an injection of saline or a placebo ‘patch’ to precipitate an attack (Cohen and Suter, 1982; Flügel et al., 1996). However, the use of such ‘provocation’ methods to distinguish epileptic from nonepileptic seizures is surrounded by controversy, in large part because the necessary use of deception in such techniques presents certain ethical (and perhaps legal) dilemmas, especially in terms of informed consent (Stagno and Smith, 1996, 1997; Smith et al., 1997). In light of this, it has been suggested that hypnotically provoked pseudoseizures can be elicited without the need for deception, and preliminary reports have shown it to be an effective technique (Schwarz et al., 1955; Kuyk et al., 1995; Barry et al., 2000; Martínez-Taboas, 2002; Zalsman et al., 2002). Thus, identification of psychogenic seizures can aid in selecting proper treatment, and psychotherapeutic interventions including hypnosis (Gardner, 1973; Glenn and Simonds, 1977; Gross, 1980; Caldwell and Stewart, 1981; Miller, 1983) have been shown effective in the reduction or elimination of seizures in such patients (Aboukasm et al., 1998). Regardless of the provocation method used, the induction of a psychogenic seizure does not rule out the possibility of epileptic seizures. Research has shown that between 10 and 20 percent of psychogenic seizure patients also have epileptic seizures, and there is some evidence that hypnosis-induced seizures produce epileptic-like EEG patterns (Ravitz, 1982; Bryant and Somerville, 1995). Bryant and Somerville successfully induced an epileptic seizure in a patient, with characteristic EEG seizure patterns, following hypnotic suggestions for age regression to a previous seizure episode and the accompanying experience of prodromal symptoms (symptoms indicating the onset of a seizure). In the broader realm of neuromuscular and neurological disorders, hypnosis has been reported as an effective adjunctive treatment for organic brain damage (Sullivan et al., 1974), Parkinson’s disease (Wain et al., 1990), stroke (Holroyd and Hill, 1989), peripheral nerve lesions (Pajntar et al., 1980), cases of organic paralysis (Yensen, 1963; Vodovnik et al., 1979; Lucas et al., 1981), various types of dystonia (De Benedittis, 1996; Medd, 1997) and multiple sclerosis (MS; Dane, 1996; Medd, 1996). These reports, based on case studies with individual patients, provide a

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first step in demonstrating the usefulness of integrating hypnotherapeutic procedures into treatment of neurological conditions. For example, with MS, various symptoms have been ameliorated via hypnosis, including spasticity (Shapiro and Kline, 1956; Brunn, 1966) and MS-associated pain (Medd, 1992; Sutcher, 1997). In summary, hypnosis may be a useful method for inducing epileptic seizures on demand and reducing the hospitalization time required for diagnosis. Case studies of hypnosis for neuromuscular and neurological disorders identify potentially useful applications of hypnosis that can be more closely examined through appropriate scientific experimentation. However, to date, hypnotic provocation research and neurological case studies have not adequately controlled for treatment effects due to increased motivation, attention or relaxation, thus the specificity of hypnosis remains uncertain.

15.3.3. Emerging interests The last few years have produced great developments in imaging internal systems. New technologies often lead to the revisiting of old studies, in the hopes that new modes of investigation will reveal patterns that were not observable using earlier methods. In the field of hypnosis, this change is most centrally tied to increased neuroimaging capabilities. It is not surprising, then, that new directions in hypnosis research involve many questions regarding effects in the brain (see Barabasz and Barabasz, Chapter 13, this volume, for a review of neurophysiological aspects of hypnosis). New research may also be spurred by new clinical syndromes or a new understanding of those syndromes. In this section, we review the areas of hypnosis and the body that have generated a good number of publications in recent years.

15.3.3.1. Immune system functioning With increasing evidence that psychological stress negatively affects the immune system (Kiecolt-Glaser and Glaser, 1992; Ader and Cohen, 1993; Herbert and Cohen, 1993; Cohen and Herbert, 1996; Miller and Cohen, 2001; Kiecolt-Glaser et al., 2002; Segerstrom and Miller, 2004), a number of researchers have examined whether psychological techniques

such as hypnosis might be able to ‘improve’ immune system functioning (for a review of hypnosis and immune functioning, see Hall, 1982; Goldberg, 1985; Hannigan, 1999; Gruzelier, 2002; Solloway, 2004). Some studies have indirectly indexed immune changes through self-report of symptoms or outwardly observable physiological changes that are linked to immune functioning, such as the reduction of allergic skin reactions. Increasingly, however, researchers are directly quantifying changes in humoral and cellular immunity, examining both acute changes in immune function as a result of single-session hypnotic suggestions and the potential for extended hypnotic treatments to produce longer lasting, more clinically significant, effects. The impact of hypnosis on immune function can be broadly divided into acute intervention and extended intervention studies. While some research on acute interventions has examined the potential for hypnotically elicited emotions to influence immune function (Zachariae et al., 1991), the majority of studies have examined the effect of specific suggestions or imagery. Hall (1989) reported case studies on voluntary immunomodulation involving members of his research group. Using self-induced hypnosis and imagery for increasing neutrophil adherence (a marker of white blood cell immune activity), one person was able to increase adherence by 243 percent within 7 min. Another person increased adherence after 30 min, and Hall himself increased adherence after 45 min, though two other team members did not show any increase. Recognizing the limitations of such an approach, Hall conducted further research on hypnotic-like procedures with imagery. In one study (Hall et al., 1992b), a 45 min ‘hypnosis-like procedure’ (p. 277) with imagery of white blood cells as ‘. . . strong, powerful sharks with teeth that are attacking and destroying weak, confused germ cells . . .’ (p. 277) produced significant increases in two of seven blood measures (pokeweed mitogen and white blood cell count). Hypnotizability was not independently correlated with these immune changes but, when examining both age and hypnotizability simultaneously, the factors were a significant predictor of some of the immune measures.

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The lack of a control group makes interpretation of Hall’s results problematic, but he was able to address the limitation in a study examining whether prior cyberphysiological training would influence voluntary immunomodulation (Hall et al., 1992a). Subjects in one group received 2 weeks of training (four sessions) in which they attempted to decrease levels of an immune component found in the saliva, secretory immunoglobulin A (S-IgA), using a hypnosis-like induction and imagery. Following the training sessions, these subjects then were given information about neutrophils and the process of adherence, and completed a 30-min session involving the ‘. . . induction of a hypnosis-like altered state and the manipulation of mental imagery’ (p. 289). Blood samples were taken both pre- and post-intervention, and the 30-min session was repeated a week later. A second group received the same intervention, but without the prior S-IgA training, and a third (control) group simply rested in a bed for the 30-min sessions. Analysis of eight immunological measures revealed that only neutrophil adherence showed an increase, suggesting that the imagery specifically activated the targeted cells. This increase was only apparent during the second session, and only for the subjects with prior cyberphysiological (S-IgA) training. Indeed, subjects in both intervention groups showed decreases in neutrophil adherence during the first 30-min session, and this decrease was also observed during the second session (a week later) for subjects that had not received prior cyberphysiological training. The researchers summarized their findings: ‘Until the trainees have experience and feedback, they will often experience a physiologic change opposite to that intended. This is usually a transitory phenomenon which is eliminated with practice’. This assertion, while perhaps premature, raises an issue that is rarely addressed in cyberphysiological research: whether individuals can be trained to improve their ability to modulate physiology using hypnotic suggestions. In an attempt to separate the effect of an hypnotic induction in general from that of specific suggestions following hypnotic induction, Olness et al. (1989) showed that only children given specific suggestions to increase immune functioning showed subsequent increases. Those who were administered hypnosis without

specific suggestions, and those who simply conversed with the experimenter for the same amount of time, showed no increases. In light of these findings, and given that nonhypnotic relaxation interventions have also been shown to increase S-IgA, Hewson-Bower and Drummond (1996) examined the influence of relaxation with and without imagery suggestions. Studying both healthy children and those with recurrent upper respiratory tract infections (illness linked to deficiencies in S-IgA), Hewson-Bower and Drummond (1996) found significant increases in S-IgA for both (imagery and no imagery) relaxation groups but not for a conversation control group. However, another measure, the S-IgA/albumin ratio, increased only for the relaxation group that received imagery suggestions. To complicate matters further, subjective ratings of relaxation correlated with increases in both S-IgA concentration and S-IgA/albumin ratio. While the previously mentioned studies attempted to alter immune measures within short periods of time (acute intervention), other researchers have examined the effects of multiple hypnosis sessions spread out over time (extended intervention). In one such study (Ruzyla-Smith et al., 1995), subjects were assigned to one of three groups. Subjects in a hypnosis groups were given direct hypnotic suggestions to ‘imagine your white blood cells attacking and destroying germ cells in your body’, suggestions that the subjects then used during self-hypnosis for the following week. Subjects in a relaxation group participated in flotation restricted environmental stimulation therapy (REST) sessions, in which they floated effortlessly in a solution of Epsom salts in a fiberglass tank after having been given the same suggestions as the hypnosis group. Finally, subjects in a third (control) group were given the same suggestions without hypnosis or REST. Analysis of blood samples showed significant immunomodulation for highly hypnotizable subjects given hypnotic suggestions, based on B-cell and T-cell counts, but not for subjects in the relaxation or control groups (see also Wood et al., 2003). Extended intervention studies have more commonly focused on the usefulness of hypnosis to counteract ‘downregulation’ of the immune system, particularly to examine whether hypnotic

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procedures can buffer the negative effects of stress on immune function. One such study demonstrated that 3 weeks of relaxation training with hypnosis can decrease lymphocyte responsiveness to a laboratory stressor (Johnson et al., 1996). In addition, a number of studies have tested the effectiveness of hypnotic relaxation training in modulating the effects of exam stress on the immune system (Kiecolt-Glaser, 1986; Whitehouse et al., 1996; Gruzelier et al., 2001a,b; Kiecolt-Glaser et al., 2001; Naito et al., 2003). In one of these studies (Kiecolt-Glaser, 1986), medical students in a hypnosis group practiced hypnosis-relaxation procedures frequently for two and a half weeks prior to examinations, while medical students in a control group did not engage in hypnosis-relaxation sessions prior to the exams. After 3 days of exams, subjects in the hypnosis group showed a higher percentage of specific T-lymphocytes than subjects in the control group who did not practice the hypnosis-relaxation. These T-cell findings were replicated in a subsequent study, in which subjects trained in hypnosis-relaxation for 8 days before impending exams and were then tested for immune functioning 3 days prior to the actual exams (Kiecolt-Glaser et al., 2001). However, while hypnosis-relaxation appeared to influence T-cell levels, the investigators found no effect for the training on natural killer (NK) cell activity (NK cells help to protect against cancer cells and virus-infected cells; low NK activity is associated with reduced immunocompetency). Around the same time, Gruzelier et al. (2001b) demonstrated hypnotic intervention effects in a group of medical students for both T-cells and NK cells. Additionally, in order to determine whether certain types of hypnotic suggestions might be more effective than others in sustaining healthy immune functioning, Gruzelier et al. (2001a) subsequently compared an active imagery hypnosis approach with a relaxationbased hypnosis approach. Subjects in the active visualization group were given specific hypnotic suggestions for ‘envisaging increases in NK cells and lymphocytes and surveillance by white blood cells in the form of sharks or dolphins devouring germ cells’ (p. 76) while subjects in the hypnotic relaxation group were given hypnotic suggestions for relaxation, ‘. . . peace, happiness, and tranquility’ (p. 76). Although this

second study failed to show the same beneficial effects for NK cells, hypnotic immune imagery suggestions appeared to be more effective in buffering the effects of stress on certain specific lymphocytes than hypnotic relaxation suggestions. The effect of stress on CD8 cells was buffered by both hypnosis interventions, compared with a control group, and was associated with hypnotizability. In addition, those with immune-specific imagery reported less illness during the exam period compared with the hypnotic relaxation group, suggesting that the buffering effect of hypnotic suggestions on immune function translates into clinically significant health measures. The benefits of hypnosis have been supported in a more recent study of medical students during exam time (Naito et al., 2003), and also in studies with HIV patients (Laidlaw et al., 2004) and patients being treated for breast cancer (Bakke et al., 2002). In Laidlaw’s research with HIV patients, high hypnotizables were able to maintain their CD4+ T-cell count over the 4-week hypnosis training period, while those scoring lower in hypnotizability showed a decline in T-cell count (unfortunately, a control group was not included in the study). In a separate study (Bakke et al., 2002), a group of 25 breast cancer patients showed an increase in NK cell number (but not NK cell activity) following 8 weeks of hypnotic-guided imagery, though the increases were not maintained at a 3-month follow-up. Additionally, as the authors themselves indicated, it was not possible to separate the effects of hypnotic-guided imagery from the psychological benefit of personal support resulting from the sessions. There is some evidence that hypnosis may be effective in the treatment of herpes simplex. Case studies demonstrating reductions in outbreak recurrence (Gould and Tissler, 1984) have been bolstered by research that also assessed changes in related immune components (Fox et al., 1999; Gruzelier et al., 2002). Following a 6-week baseline assessment period, patients in Gruzelier’s study spent 6 weeks listening to audiotaped hypnotic suggestions to enhance immune function. Recurrence of genital herpes was reduced by 40 percent and in 65 percent of patients, but Gruzelier was also able to demonstrate an increase in NK cell numbers

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and function in patients that responded well to the treatment. Furthermore, those who responded also showed a significant increase in herpes simplex virus-specific NK cell cytotoxicity (the ability of the NK cells to destroy the viruscontaining cells and the enclosed virus particles). With few exceptions, the clinical significance of hypnotically produced increases in immune function is limited. For example, although one would implicitly assume that increasing immunoglobulins is a ‘good thing’, research on the effects of acute physical and mental stress have shown similar increases in S-IgA levels. Recent research from our own laboratory (Benham et al., 2001) demonstrated that subjects could produce significant increases in S-IgA both after a short hypnosis session and after an acute mental stress (math) task. In the hypnosis condition (lasting 16 min total), subjects listened to a standardized hypnotic induction followed by specific suggestions for increasing S-IgA in the saliva. In the acute stress condition, subjects completed an 8-min stressful math task. Subjects experienced the hypnosis session as relaxing and the stress task as stressful, and these subjective reports were validated by significant differences in heart rate during the two conditions. While both tasks resulted in significant increases in S-IgA, it is important to note that the increases were short-lived; for both the stress task and the hypnosis intervention, the increased S-IgA levels returned to pre-task baseline levels within 8 min. Thus, it is not clear that such acute intervention practices confer any long-term immunological benefit; the clinical relevance of hypnotic immunomodulation will only be suitably assessed after additional longterm outcome studies have demonstrated its impact on health.

15.3.3.2. Accelerated wound healing While some studies have shown hypnosis to be effective in reducing surgical recovery time or the length of hospitalization following medical procedures (Blankfield, 1991; Rapkin et al., 1991; Enqvist et al., 1995a,b; Mauer et al., 1999), there are also a limited number of studies that have examined the potential for hypnosis to increase healing times using directly measurable indices of physiological recovery. These studies, although diverse, all surround the central topic

of whether hypnosis can expedite the process of physiological healing. The potential for hypnosis to accelerate bone healing was examined in a pilot study by Ginandes and Rosenthal (1999). Twelve patients with ankle fractures were randomly assigned to a control or hypnosis group, with the six hypnosis subjects receiving suggestions for accelerated bone healing via individual sessions and self-hypnosis audiotapes over a period of 12 weeks. Assessment of fracture healing by a radiologist blind to group assignment indicated greater bone healing in the hypnosis group, with significant differences at 6 weeks (based on an alpha of 0.25). Various components of burn pain appear to be reduced by hypnotic suggestions (Hammond et al., 1983; Van der Does et al., 1988; Patterson et al., 1992; Patterson and Ptacek, 1997), but there is limited research supporting the use of hypnosis for increasing recovery from burn wounds. In a study of five burn patients with symmetrical or bilaterally equivalent burns (Moore and Kaplan, 1983), patients served as their own controls with hypnotic suggestions for increased blood flow to a randomly selected side of the body. Four of the five patients had ‘clearly accelerated healing’ (p. 18) of the targeted side of the body (estimated as advanced by about 2 days over the control side), while the remaining subject achieved ‘relatively rapid healing’ (p. 18) for both of his hands. In two additional studies, research examining the effect of hypnotherapeutic interventions on physiological parameters in burn patients found little benefit other than elevated urine output in those patients who were successfully hypnotized (Margolis et al., 1983; May and DeClement, 1983). There are a few reports of hypnotic control of bleeding in hemophiliac patients (LaBaw, 1975, 1992; Fung and Lazar, 1983; LeBaron and Zeltzer, 1984; Swirsky-Sacchetti and Margolis, 1986), but little experimental evidence for its effect on healing wounds. One study, utilizing both high and low hypnotizables found no effect for hypnotic suggestion on the healing time of 5 mm cuts made in the forearms of subjects during the experimental session (Hopkins et al., 1991). In summary, while there are some interesting case studies and preliminary findings related

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to hypnotically accelerated wound healing, we are far from the critical mass of evidence needed to corroborate claims of clinical efficacy. Though Ginandes and Rosenthal’s (1999) study of bone healing was intriguing, its impact is lessened by a limited sample size, high alpha and lack of a task-motivated control group, and there is conflicting research on the hypnotic treatment of burns, bleeding and superficial wounds. Thus, while some support the use of hypnosis in burn healing based on positive case studies (Ewin, 1986a,b, 1996), reviews of this issue have generally have been less positive (Van der Does and Van Dyck, 1989; Weir, 1990; Patterson et al., 1996) and claims as to the effectiveness of hypnosis in reducing bleeding time are at present insufficiently substantiated.

15.3.3.3. Vomiting and irritable bowel syndrome Hypnosis has seen a resurgence recently in the clinical treatment of gastric problems. These efforts have focused mostly on the treatment of nausea and vomiting in cancer patients (Zeltzer et al., 1983, 1984, 1991; Syrjala et al., 1992; Jacknow et al., 1994). As Pinnell and Covino (2000) observed in their evaluation of hypnosis for nausea and vomiting, research in this area is inconsistent, and support for the effectiveness of hypnotic techniques is limited by factors such as small sample sizes and lack of hypnotizability ratings. As a newer diagnosis, IBS has received a considerable amount of attention in the hypnosis literature. The condition is marked by abdominal pain, bloating, and alternative constipation and diarrhea. A number of case studies support the use of hypnosis in IBS. Galovski and Blanchard (2002) reported on a man suffering from 30 years of IBS. After six sessions, the authors reported a 53 percent reduction of symptoms. Six-month and 2-year follow-up revealed continued reduction in symptoms of 70 and 38 percent, respectively. Anxiety and depression were also relieved. Zimmerman (2003) suggested utilizing a metaphor of a smooth, flowing river to assist in restoring proper gut functioning in IBS. A female patient, who had experienced IBS for 1 year, reported immediate relief of symptoms after a single hypnosis session. Associated mood problems were also improved. Follow-up at 1 year showed a continued relief in symptoms.

More controlled studies similarly support the use of hypnosis in IBS treatment (Whorwell et al., 1987), using suggestions of increased control over gut function. Imagery of a flowing river, coupled with sensations of warmth and relaxation in the abdomen, has been used in clinical trials of IBS. One such study, carried out by Harvey and colleagues (1989), was conducted on 33 patients with refractory IBS. Patients received four 40-min hypnosis sessions. Sixty percent of the patients responded positively to the treatment and 33 percent experienced full relief from symptoms. Progress persisted during 7-week and 3-month follow-ups. Efficacy of the hypnosis intervention was not affected by patient gender, the hypnotherapist or whether sessions were group or individual. The last point is particularly important, as the use of group hypnosis programs could be significantly more cost-effective. A quasi-experimental design by Houghton et al. (1996) found significant effects of hypnosis on both physical and psychological aspects of IBS. Significant improvements were attained over a waiting list control group. As with other IBS studies, the hypnotic suggestions centered on increased control over gut functioning. IBS has also been the subject of a small number of randomized controlled trials. Thirty patients, all with severe, refractory IBS, were randomly assigned to either a psychotherapy group with a placebo or a hypnotherapy group (Whorwell et al., 1984). The hypnotherapy intervention (7 sessions of 30 min) consisted of imagery (warmth in the gut) and increased control over gastric functioning. While both groups improved over baseline symptom levels, the hypnotherapy group improved to a degree significantly greater than that of the psychotherapy/placebo group. Those in the hypnosis group experienced drastic reductions in pain/distension and markedly improved well-being, as contrasted to the very slight changes observed in the placebo group. Tan and colleagues (2005) reviewed the empirical literature on hypnotherapy for IBS and concluded that the approach met the highest qualifications of efficaciousness and specificity, according to the efficacy guidelines of the Clinical Psychology Division of the American Psychological Association. More recently, Whitehead (2006) reviewed 11 clinical studies, four of which were randomized trials.

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Hypnosis was found to be highly effective (87 percent average response rate), with therapeutic gains lasting for years. Very few studies have distinguished psychological from physiological effects in IBS treatment. Given that hypnotherapy also consistently relieves IBS-associated psychological complaints, it is possible that hypnosis works by modifying attention to gastrointestinal sensations and by changing associations and meanings attached to those perceptions. This hypothesis that hypnotherapy works via psychological, rather than physiological, mechanisms was directly tested in a study by Palsson and colleagues (2002). Rectal pain thresholds, rectal smooth muscle tone and autonomic functioning were unchanged by hypnosis, while self-reported markers of illness severity (pain, bloating, etc.) were all significantly reduced. Despite the lack of evidence for physiological change, evidence does support hypnosis for IBS, in that quality of life does seem to be improved by the treatment.

15.4. Revisiting core concepts

and suggestions for future research At the beginning of this chapter, we argued that the efficacy of hypnotic procedures for altering physiology can only be proven by: (1) demonstrating replicable effects in controlled studies; (2) demonstrating that the effects are due to hypnosis and related to hypotizability; and (3) demonstrating that the effects are at least as powerful as alternative psychological techniques, particularly those that require less training and/or time to administer. While some areas have shown more consistency than others, hypnotic cyberphysiology research has yet to establish reliably the relevance of hypnosis. As discussed previously, the relevance of hypnosis can be more convincingly argued by demonstrating that effects are not produced simply by relaxation or by the same suggestions given in a waking state. While many studies have simply ignored the confound of relaxation, there are a number of tactics that can be used to separate the effects of hypnosis from the effects due to relaxation. One approach, as exemplified by Olness et al. (1989),

is to compare the effects of specific suggestions under hypnosis with a hypnotic relaxation condition without specific suggestions for alterations in physiology. Olness found that only the group with specific hypnotic suggestions showed an increase in immune measures; no increase was shown for the hypnosis group without specific suggestions. A similar approach was used by Gruzelier et al. (2001a) who showed that specific hypnotic suggestions for immune imagery were more effective in moderating the effects of stress on immune function than hypnotic suggestions for relaxation, and Williams (1974) found an increase in breast size following specific suggestions, but not after hypnosis without specific suggestions. Demonstrating consistency in these sorts of studies will be a first step toward challenging the notion that physiological effects are simply due to relaxation. Another technique to separate hypnotic effects from relaxation effects, admirably employed in Mason’s early study of the skin disorder congenital ichthyosiform erythroderma (1952), is to demonstrate site-specific changes due to hypnotic suggestions. Given that the physiological effects of relaxation are systemic, multiple baseline designs such as Mason’s (in which the progression of skin healing coincided with specific suggestions) allow the researcher to differentiate relaxation effects from the effects of specific suggestions under hypnosis. If the resultant changes are limited to the suggested site and not the entire body, one can rule out relaxation as the sole cause. Similar approaches have been used in the treatment of warts, though with mixed results. Site-specific changes can also be directed at simultaneously increasing some measure at one site and decreasing it at another, such as temperature or DTH skin reactions. Indeed, the approach of differentially increasing or decreasing some physiological measure can be used in a variety of designs, whether they be time-series, independent groups or repeated-measures, to help in differentiating the effects of hypnosis from those of relaxation (Chapman et al., 1959; Ikemi and Nakagawa, cited in Barber, 1978; Zachariae et al., 1989; Zachariae and Bjerring, 1993). Although most studies have used relaxationbased inductions, the confound of relaxation can also be eliminated by using alternative

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nonrelaxation-based inductions such as the activealert hypnotic induction (Banyai and Hilgard, 1976). However, while this certainly would rule out relaxation effects and has been examined in this regard in relation to hypnotic analgesia (Miller et al., 1991), psychophysiological studies generally rely on stable baselines obtained during quiet rest, and thus the active-alert approach may not be the most practical technique. An alternative option is a frequent sampling technique that examines the pattern of changes during the various stages of a hypnosis protocol. The applicability of the technique rests on two conditions: (1) that frequent physiological measures can be obtained; and (2) that the measured physiological variable is anticipated to change within a short period of time. Data collection and presentation using this method have traditionally relied upon physiological variables that can be measured continuously, such as temperature, skin conductance, respiration or EEG (e.g. Dikel and Olness, 1980; Raynaud et al., 1984; Mück-Weymann et al., 1997), though it is possible to obtain multiple measures from physiological variables that must be sampled independently at discrete time intervals, such as blood or saliva samples. As an example, consider the measurement of S-IgA, an immunoglobulin found in saliva.

While researchers commonly rely on pre- and post-measures of immune functioning, one of the authors (G. B.) has shown that frequent sampling of saliva can reveal the ‘pattern’ of changes in S-IgA following an acute stress task (Benham, in press). The frequent sampling method could be applied to a protocol in which individuals sit quietly for 10 min, then undergo a hypnotic induction, are provided with specific suggestions for alterations in S-IgA, followed by the deinduction and another 10 min of quiet rest. By obtaining saliva samples every 2 min, the pattern and timing of changes during each phase can be examined. Such a technique would provide a data set far richer than those generated by pre- and post-treatment designs and would enable researchers to determine whether the hypnotic induction, the specific suggestions or perhaps even the deinduction led to changes in the dependent measure. Measures during the recovery phase would also enable researchers to examine the rate at which changes returned to baseline levels. Two alternative outcomes are shown below to illustrate possible results from such a study. In the first scenario, Figure 15.3a, the results suggest that S-IgA increased as a result of the hypnotic induction and were not influenced by the specific suggestions. Figure 15. 3b suggests

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Fig. 15.3 Hypothetical results for frequent sampling methodology. (a) Changes in secretory IgA occurring as a result of the hypnotic induction. (b) Changes occurring as a result of specific suggestions.

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that the hypnotic induction had little effect on the immune measure, but that specific suggestions caused a rapid increase. However, as addressed in the introductory sections of this chapter, excluding the influence of simple relaxation is not sufficient to prove the specific role of hypnosis in effecting change. The proposal to compare waking suggestions with those given after a formal hypnotic induction is complicated by an inadequate definition of hypnosis, thus one alternative approach to support the specific role of hypnosis in effecting change is to examine whether observed changes are related to an individual’s level of hypnotizability.

15.4.1. Hypnotizability and

physiological change A small number of studies have provided some support for the role of hypnosis and hypnotizability in effecting physiological change. Piedmont (1983) found an association between hypnotizability and the hypnotic control of peripheral temperature (Piedmont, 1983), Johnson et al. (1996) demonstrated a correlation between the Creative Imagination Scale and changes in immune function, and Gruzelier et al. (2001a) found an association between the HGSHS:A and immune function (hypnosis buffered the effects of stress on immune cells). In his study of herpes simplex, Gruzelier also showed an association between hypnotizability and increases in immune function, though it should be mentioned that improvements in health were not restricted to patients with high hypnotic ability. Following 4 weeks of self-hypnosis, highly hypnotizable HIV patients showed significantly higher T-cell counts than low hypnotizables (Laidlaw et al., 2004). Tausk and Whitmore (1999) failed to find any differences between hypnosis with and without specific suggestions for improvement in psoriasis, but high hypnotizables showed significantly greater improvement. High hypnotizables also showed less stress-induced vasoconstriction than lows following hypnotic relaxation procedures (Jambrik et al., 2005). While there is some support for the association between hypnotizability and the extent of physiological change following hypnotic suggestions, there are also numerous studies that have

failed to find such a relationship. Hypnotizability was found not to be associated with cardiovascular changes (Forbes and Pekala, 1993), wart loss (Spanos et al., 1988), reductions in skin reactions to histamine (Laidlaw et al., 1996) or changes in S-IgA (Olness et al., 1989). Hypnotizability was not correlated with the buffering effect of hypnotic relaxation prior to exams on T-cells (Kiecolt-Glaser et al., 2001), nor with increases in neutrophil adhesiveness in either of two studies by Hall et al. (1992a,b), though an age by hypnotizability interaction was predictive of change in immune measures in one of the studies (Hall et al., 1992b). Holroyd and colleagues (1982) found no effect for hypnotizability on hypnosis or biofeedback lowering of blood pressure and skin conductance, nor reductions in bleeding following hypnotic suggestions (Hopkins et al., 1991) or response to hypnotherapy treatment of incontinence (Freeman, 1987). Thus there is no clear association between hypnotizability and hypnotic cyberphysiological success, not even when singularly focusing on specific changes such as research on warts or DTH. While this may at first glance weaken the claim that hypnosis is a central factor for eliciting physiological change, it is important to consider the nature of hypnotizability scales. Scales are commonly built around suggestions for alterations in cognition and behavior and, while some have proposed hypnotic ability is best understood as a single factor, others have suggested two-factor, three-factor and, more recently, four-factor conceptualizations (Peters et al., 1974; McConkey et al., 1980; Balthazard, 1993; Sadler and Woody, 2004; Woody et al., 2005; see also Woody and Barnier, Chapter 10, this volume). Additionally, these factors are based on analysis of the responses to items included in the scale which, to reiterate, are behavioral and cognitive suggestions. If hypnotizability is not a unitary factor underlying all aspects of hypnotic response, it is not unreasonable to propose that hypnotic cyberphysiological ability may be an additional hypnotic factor, unrelated to the capacity to respond to behavioral and cognitive suggestions and thus untapped by traditional scales. This echoes the notion that some individuals may be predisposed to respond to cyberphysiological suggestions, but whether or not such an individual

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ability is ‘hypnotic’ is an independent question, inseparably linked to the definition of hypnosis. In sum, hypnotic cyberphysiological ability may show little relationship with current measures of hypnotizability.

the field of cyberphysiological hypnosis by addressing various important questions raised by prior research and thus eliminating potential confounds. Using the healing of an experimentally induced cut to the skin as an example, there are a number of questions that arise:

15.4.2. Relative efficacy of hypnosis versus other psychological techniques

1. Does the addition of a hypnotic induction increase the rate of healing above and beyond the effects of specific suggestions without an induction?

As we noted at the beginning of this chapter, if consistent cyberphysiological effects can be attributed to hypnosis, it is important then to determine whether hypnotic techniques are of equal or greater efficacy than alternative psychological procedures. As we also noted, and as highlighted in our review, few studies have directly compared the ability of hypnotic techniques and alternative techniques––whether relaxation, biofeedback, mediation or subtle energy therapies––to alter physiology. There is growing evidence from outside the field of hypnosis that nonhypnotic psychological techniques can influence physiology. The relative efficacy of hypnotic and nonhypnotic techniques remains to be addressed. This can be accomplished most effectively through designs in which one or more nonhypnotic techniques are directly tested against hypnotic techniques. At a minimum, future research must use comparable populations, designs and measures.

15.5. Summary and

recommendations In delineating the rich history of studies in hypnotic alterations of physiology, one is struck by the diversity of processes and conditions investigated; a factor that simultaneously represents the greatest strength and the greatest weakness in this field of research. For, while hypnosis has been examined in relation to immune, cardiovascular, integumentary, digestive, nervous and endocrine systems, the scope of questions asked and the array of methodologies used to investigate them have resulted in an assortment of studies that fail to advance the field systematically. This lack of logical progression has resulted in a failure to address some of the most fundamental questions adequately, as suggested in the previous section. While a practicable definition of hypnosis may prove challenging, it is possible to advance

2. If so, can believed-in efficacy (potentially heightened by the hypnotic context) be ruled out by either providing the same suggestions in association with an equally convincing context or assessing subjective ratings of believed-in efficacy? 3. Can suggestions be used to increase healing rates or decrease healing rates in a direction determined by the specific suggestions used? 4. Can targeted hypnotic suggestions produce localized (nonsystemic) changes, such as increasing wound healing on the right arm while not affecting healing on the left arm? 5. Does the nature of hypnotic suggestions (direct suggestions for blood clotting versus indirect suggestions for imagining the arm in an ice bath) have a differential effect? 6. Does individualizing suggestions/imagery have a greater effect than using standardized imagery? 7. Do established measures of hypnotizability correlate with healing time? 8. Are there reliable individual differences, outside of hypnotizability, in the way people respond to the suggestions (i.e. personal cyberphysiological propensities)? 9. Do the effects translate into clinically significant results? 10. Can any biochemical or physiological (e.g. cardiovascular) markers be identified that suggest a mechanism for observed changes? 11. Does hypnosis produce greater effects than meditation, biofeedback, relaxation, subtle energy therapies, etc? Such questions could be addressed in controlled studies, while what have traditionally been handled as descriptive case studies could

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be improved by better integrating objective dependent measures and by using time-series methodologies (Borckardt and Nash, 2002). If the Royal Commission of King Louis XVI were charged with investigating the claims of hypnotists today, what verdict would they render? Contemporary researchers are more cautious in their proposition of the mechanism by which physiological changes occur––beyond the fields of psychoneuroimmunology and psychoneuroendocrinology, we do not propose a system of physics (animal magnetism) to explain these changes. Thus, a test of hypnosis would be based not on mechanism, but on method. We would need to demonstrate that the procedure of hypnotic suggestions is the important element in creating physiological change. And yet, our definition of hypnosis is still not settled. If a formal hypnotic induction is not required, how do we differentiate hypnosis from waking suggestions? How do we adequately control for methods that are not hypnosis? What would the Royal Commission conclude? Given that hypnotic interventions are often used as a component of a more complex treatment and that certain studies use hypnotic techniques that are not explicitly defined as such, a clear picture has not yet emerged as to the importance of hypnosis as a primary component in producing physiological changes. However, with the encouraging preliminary results of well-designed studies, researchers remain optimistic about demonstrating the usefulness of hypnotic techniques, above and beyond that of other psychological interventions. Alongside these efforts at validating efficacy, future research will have to elucidate the mechanism by which verbal suggestions during hypnosis might affect physiological changes. Summarizing the nature of experimental designs in many psychoneuroimmunological studies, Gruzelier acknowledged limitations that arguably apply equally to other areas of cyberphysiological research, suggesting that ‘. . . investigations have been carried out with meagre resources by dedicated pioneers’ (p. 161, Gruzelier, 2002). As the Royal Commission warned over 200 years ago, ‘Man seizes, abandons, takes up again the error that gratifies him’ (Franklin et al., 2002, p. 359). If, as Mesmer stated, truth is a path traced between errors, the duty of these dedicated

pioneers is to develop and apply a systematic approach based on standardized methodological designs so we can avoid repeating the errors of the past.

Acknowledgments We are grateful to Amanda Barnier for her constructive feedback during the writing of this chapter, and to Dr A. A. Mason for permission to print the photographs of hypnotic treatment of congenital ichthyosiform erythrodermia of Brocq.

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SECTION IV

Clinical hypnosis: treatment and consultation

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CHAPTER 16

Psychoanalytic approaches to clinical hypnosis Elgan L. Baker and Michael R. Nash

16.1. Introduction Throughout his life, Freud was quick to acknowledge his intellectual debt to hypnosis, especially the work of Charcot (1890) and Bernheim (1889). However as a young Freud sought to formulate a distinctive clinical theory to guide technique, it was important, even necessary, for him to define what psychoanalysis is not—and from the latter years of the nineteenthth century Freud was very clear that psychoanalysis is not hypnosis, nor should hypnosis be used in psychoanalysis. Most importantly, for Freud, psychoanalytic patients improved because the unconscious was made conscious, not because they were responding to suggestion. It was natural enough that hypnosis came to be the all-purpose foil for psychoanalysis because when psychoanalysis was born, hypnosis dominated the landscape of clinical and experimental psychiatry. If psychoanalysis was to have its own identity, hypnosis as technique had to be jettisoned. After all, to the extent that suggestion is unexamined transference, it is anathema to the uncovering ethos of analysis. Indeed Freud was fond of labeling the successes of nonanalytic therapies as the product of ‘mere suggestion’; for him the only alternative to the ‘gold of analysis’

was the ‘copper of suggestion’ (sometimes he mentioned the possibility of an ‘alloy’, Freud, 1918, p. 168). But by categorically rejecting hypnosis, the psychoanalytic community lost a tool which, when employed judiciously, can support the working alliance, soften defenses and enable patients to examine their emotional life productively. In this chapter we discuss the ways in which hypnosis can be used in psychoanalytically informed therapies across a range of therapeutic aims and patient diagnoses.

16.2. The nature of hypnosis

and its applicability to therapy The most current psychoanalytic models of hypnosis (Nash, Chapter 8, this volume) rely on two aspects of psychoanalytic metapsychology: early analytic constructs rooted in drive theory, conflict and insight; and later developmental principles grounded in attachment, identity and the therapeutic relationship.

16.2.1. Hypnosis as topographic regression Well before the publication of ‘Interpretation of Dreams’ (1900), Freud construed the hypnotic

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state as a form of a topographic regression, a construct rooted in the notion of homeostasis, conflict and compromise. Freud’s topographic regression (Freud, 1917) was based on his understanding of the reflex arc in neurology and physiology. Freud described topographic regression as a reverse movement along a path ‘from the region of thought-structures to that of sensory perceptions’ (Freud, 1905/1960, p. 162); ‘in this process thoughts are transformed into images’ (Freud, 1917, p. 227)—a backward course that results in a transformation of thoughts into visual imagery (Freud, 1933). Freud noted that the regressive shift from thought to imagery carries with it a shift in form, from secondary process to primary process thinking (Freud, 1916–1917, 1917). Indeed a cornerstone of psychoanalytic theory is that the topographic regression we observe in pathological conditions is similar to the mentation we encounter among normal individuals when they dream or are in a hypnotic state. Hence when we use hypnosis in psychotherapy, we induce a topographic regression that (when applied wisely) supports a number of cognitive, affective and relational shifts that are fully congruent with the aims of psychoanalytic work: 1. Thought processes shift in the direction of symbolic, primary process mentation, which can soften defenses and lead to productive expression of repressed material. 2. Primary process content is typically more affect-laden and emotionally compelling, which can support therapeutic abreaction and mastery of difficult material. 3. The relaxation of ego functioning sometimes involves dramatic shifts in somatic experience involving boundary, image and permeability. Attention to this material can help patients become more attuned to routinely disavowed body experience. 4. The displacement and condensation inherent in primary process mentation can be used to help patients encounter transferential material in a supportive environment without being overwhelmed. 5. To the extent that the hypnosis is managed as a regression in service of the ego, the patient becomes more able to identify neurotic

deployment of defenses and to examine ongoing emotional experience productively.

16.2.2. Hypnosis as supporting shifts in the experience of identity and self In his later writings on metapsychology and the clinical technique of psychoanalysis, Freud (1923, 1926) began to focus on the organization/maturation of the ego, the formation of identity and the developmental unfolding of attachment. These ideas formed the foundation of contemporary ego psychology and object relations theories that have contributed to a fundamental change from concern with the management of instincts and their vicissitudes to primary concern with the maturity, stability and structural integrity of the ego. This shift in the metapsychological understanding of psychopathology has also produced changes in our view of the hypnotic state and how it is utilized in psychoanalytically informed treatments. These changes include an increased emphasis on the contemporary, nontransferential aspects of the therapeutic relationship and an appreciation for how hypnosis can support: (1) the emergence of adaptive interpersonal involvement; (2) the use of therapeutic process to support adaptation and mastery rather than primarily being in service of regression and uncovering; (3) an emphasis on affective containment, modulation and neutralization rather than abreaction and catharsis; and (4) increased technical attention to the facilitation of identification and introjective process during treatment. An integration of the drive-based (i.e. topographic) notion of hypnosis with the more relationally based developmental model, extends the therapeutic reach of clinical hypnosis (Baker, 1981, 1983a,1983b). This integrative approach emphasizes the potential of hypnosis to facilitate structural maturation and mastery, as well as its usefulness in expression of affect. Below is an outline of how hypnosis can be used in psychodynamic therapies from an integrative psychoanalytic perspective. I. Hypnosis is typically utilized in an auxiliary fashion and is indicated for introduction as a therapeutic technique at several junctures in psychotherapy.

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1. Management of specific resistance. 2. Enhancement transference.

or

modification

of

3. Structuralization of the contemporary therapeutic alliance. 4. Modulation of affective intensity, especially when it is disruptive 5. To support therapeutic process and the patient’s ego functioning. 6. Support of specific ego functions during regression (rehearsal in fantasy; gratifying imagery; reinforcement of boundaries). 7. Management of dysphoric or disruptive rumination. 8. Uncovering and remembering (dream work; age regression; projective techniques; automatic writing). 9. Symptom management and specific suggestion. II. The dynamics of the hypnotherapeutic process unfold along several interactional dimensions and focus on symptom resolution, intrapsychic structural alteration, developmental maturation and the integration of a mature, adaptive and realistic self-representation. The phenomenological arenas of this interactive process include the following: 1. The relationship: the development of a safe, gratifying, dependable and facilitating emotional climate ◆ Relaxation supports comfort and a sense of security in relational connectedness. ◆ The hypnotic experience narrows the gap between the ‘all-powerful’ other and the ‘helpless victim’ patient by establishing neutrality, equanimity and shared controls of the trance and by structuring selfmastery and success experiences in hypnosis. ◆ Hypnosis evokes intense archaic and primary process material with associated affect which the patient experiences in a structured and supportive environment without being overwhelmed. ◆ Structured and modulated transferential experience brings intrapsychic reconstruction and regrowth.

2. Cognitive understanding—insight and control is fostered via interpretation, suggestion and the specific uses of conscious and pre-conscious imagery. 3. The incorporation of the contemporary experience with the therapist and the introjection of representations of the therapeutic alliance, serve a mending, integrative function and foster developmental maturation (‘analytic introject’) 4. The enhancement’ control and direction of motivational forces supports a positive sense of self and the development of a sense of mastery. III. Specific goals of hypnotherapy for insightoriented treatment include: 1. Ego support—the identification and enhancement of the boundaries and adaptive functions of the person. 2. Ego mastery—the development and supportive maturation of the person’s defensive functions, including the differentiation and modulation of affect and impulse. 3. Verbalization, ventilation, catharsis and abreaction—the discharge and development of strategies for managing conflict and tension, as well as the support of secondary process and observing ego functions. 4. Neutralization—the freeing of energy for adaptive functioning. 5. Enhancement of relatedness—the development of mature capacities for meaningful and reciprocal interpersonal intimacy with resolution of conflicts relating to the developmental tasks of attachment, separation and individuation. 6. Confrontation—the correction of distortions in the representation of self, others and internal and external reality, and the resolution of destructive and repetitious behavioral reactions to these distortions. 7. Internalization—support of an integrated, gratifying internal representational of the world.

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8. Regulatory processes—enhancement of affect regulation. 9. Autonomy—the support of self-control, independence and secure separateness. 10. Integration—the internal integration of insight and change, as well as the experience and process of change, with subsequent growth, maturation and creative productivity.

and engagement of emotion, albeit within the context of a safe holding environment. All three types of therapies incorporate supportive and expressive processes; however, the balance shifts across treatment types. We now discuss how hypnosis can be used in each type of therapy, illustrating with case examples.

16.3.1. Short-term problem-focused

therapy

16.3. Utilization of hypnosis

in three types of psychoanalytically informed therapies How hypnosis is used in an applied setting depends on the nature of the presenting problem, the patient’s characterological maturity, the therapeutic aim and a host of contextual factors (e.g. health, family, financial, temporal, geographic). Hence no categorization scheme can capture the richness and complexity of psychotherapy as it is delivered in practice. However, for pedagogic reasons, we here impose a pragmatic typology of therapeutic scenarios that we believe will help readers decide whether, when and how they might use hypnosis in a psychoanalytic psychotherapy. Table 16.1 summarizes three types of psychoanalytically informed treatments for which hypnosis might be used adjunctively: short-term problem-focused therapy; insight-oriented therapy; and intensive long-term therapy. Note that each treatment type is associated with typical patient characteristics, treatment aim and duration (column 1). In addition, how hypnosis is used in the therapeutic process is broken down into its supportive and expressive aspects (columns 2 and 3). Supportive processes refer to (1) those aspects of the therapy that reflect the quality of the patient’s experience of the therapist; and (2) a focus on strengthening adaptive copying strategies. For supportive processes the emphasis is on relationship and containment, albeit with the expectation of change. Expressive processes set the stage for the patient to experience previously disavowed emotional material which is unwittingly enacted within and outside the therapy. Here the emphasis is on interpretation of defense

Regardless of theoretical orientation, when a clinician is identified in the community as someone who uses hypnosis, referrals for hypnosis will be predominantly of this type: shortterm problem focused, with relatively intact patients who seek to control some aspect of their physical, behavioral or emotional life. The presenting problems might be pain (chronic or acute), nicotine addiction, dental anxiety, irritable bowel syndrome, asthma or skin disorders. Other clinical chapters in this book cover this clinical terrain thoroughly and admirably from a nonanalytic perspective. Here we describe how these problems can be treated from a psychoanalytic-informed position. As per Table 16.1, supportive strategies are used with these problems, assuming patients are relatively free of complicating psychiatric disorders. Further, the supportive techniques in these short-term approaches are almost exclusively designed to strengthen intact defenses and to reinforce extant coping strategies. This is in contrast to the supportive techniques of structural repair used with the regressed patients encountered in intensive long-term therapy. Short-term problem-focused hypnotherapy requires the patient to have a relatively stable sense of identity, and a workable capacity to regulate affect. The task of the therapist then is to discern the patient’s defensive style and to enable the patient to deploy these defenses more effectively, usually via a self-hypnosis procedure which can be used as needed. In general the aim is symptom removal, symptom substitution or symptom amelioration (decreased severity, intensity or frequency of the symptom). Generically speaking, these treatments move through three intervention phases: enhanced self-efficacy; tension reduction; and establishment/rehearsal of ‘better alternatives.’

Aim: insight and working-through of significant arenas of conflict with patients who have pervasive impairment of self-representation and capacity for intimate attachment Patients: severe neurotic to psychotic spectrum Duration: long-term

Intensive long-term therapy Predominantly supportive strategies designed to enable the patient to gradually develop a capacity to tolerate the therapeutic relationship, to sustain an internal representation of the therapist, and to locate emotional experience in the context of therapeutic interaction. Techniques support structural maturation, boundary demarcation, and mature attachment.

Focus on positive aspects of the working alliance and transference. Provide enough containment to support expressive aspects, re-enforcing of positive expectations and attributions. Softening and relaxation of defenses

Expressive interventions are titrated carefully. Regressive aspects of hypnosis (e.g. topographical regression) are rarely used. Instead hypnosis is used to demonstrate that ongoing sensations or emotions can be tolerable, and even gratifying, when shared in the context of a safe interpersonal environment.

Predominantly expressive techniques designed to provide insight and working-through of significant arenas of conflict. Involves the use of hypnosis within the context of a traditional transference-mediated psychotherapy. Hypnosis is used to facilitate uncovering, regression, working through and integration. Discharge of disruptive affect and related conflict or trauma via affect bridge. Alternated with suggestions for containment and mastery

Typically limited to the initial exploratory phase of brief hypnotic intervention to determine patient’s relational and defensive style. Can address and utilize core conflictual material in crafting an intervention optimally congruent with the patient’s characterological maturity (e.g. some types of psychogenic pain, physiological and other medical conditions).

Expressive aspects

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Aim: resolve and ameliorate clearly delimited and/or encapsulated neurotic symptoms in a focused therapy Patients: neurotic spectrum Duration: intermediate

Predominantly supportive techniques designed to strengthen intact defenses and to reinforce ego-syntonic adaptive coping strategies. Rehearsal in fantasy; gratifying imagery; reinforcement of boundaries; management of dysphoric or disruptive rumination; direct suggestion; self-hypnosis; supports mastery and more effective use of pre-existing defenses

Supportive aspects

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Insight-oriented

Aim: modulate disruptive sensation/ affect, support mastery (e.g. acute pain, chronic pain, anxiety, smoking cessation, physiological conditions) Patients: normal to neurotic Duration: Brief

Short-term problem focused

Type of treatment

Table 16.1 Hypnosis in the therapeutic process

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To enhance self-efficacy the therapist initially uses hypnosis to support relaxation, imagery and ideomotor or sensory focusing. This is usually accomplished via techniques described in Nash (Chapter 8, this volume). During or soon after the patient’s first experience with hypnotic induction and suggestion, the therapist then focuses on developing the patient’s capacity for self-observation, self-awareness and selfregulation, elaborating experiences of success and developing related increases in self-esteem. Within the first two or three sessions, the work moves to the tension reduction phase where relaxation and imagery are used to reduce the level of stress and anxiety and to dilate (and reveal) related defenses. The functional value of the symptoms usually begins to emerge during this phase. Up to this point, the intervention is exploratory. The core challenge of this work is to establish a more adaptive coping strategy to replace the symptom, and then to rehearse this ‘better alternative’ via self-hypnosis. Over a period of several hypnosis sessions, the patient and therapist craft imagery and suggestions that are congruent with the patient’s defensive style and are emotionally compelling to the patient. In framing an optimal ‘better alternative’, the therapist is mindful of six principles: 1. Principle of syntonicity: choose strategies consistent with the patient’s defensive style (e.g. hysterical, depressive, obsessive–compulsive, paranoid). 2. Principle of alternation: alternate suggestions and rehearsal with relaxation and deepening techniques. Repeat the work several times across the course of a single session. 3. Principle of dynamic equivalence: choose a strategy rooted in developmental tasks similar to the target symptom. 4. Principle of linguistic equivalence: elaborate the new strategy using the symbolic language of the patient and related primary process themes. 5. Principle of integration: in order to facilitate maintenance and generalizability of the behavior change, integrate this into the patient’s conscious self-representation via imagery, suggestion and ‘time projection’ (hypnotic suggestion to imagine oneself in the future).

6. Follow-up: offer ‘booster sessions’ after the treatment is completed

16.3.1.1 Short-term problem-focused psychotherapy: case 1, a cystoscopy Todd was a single 25-year-old male patient who was referred to the senior author’s office following diagnosis and treatment for bladder cancer. Two months prior to referral he observed blood in his urine and promptly consulted his physician. Eventually he was examined by a urologist and underwent an in-office cystoscopic procedure. Cystoscopy (passing a tube-like instrument through the urethra and into the bladder) is quite painful for most men, and for some exceedingly so. Todd found the procedure to be an excruciating ordeal which at one point involved two nurses holding him down with considerable force. A malignant tumor was discovered, and eventually removed. As the prognosis for this particular type of bladder cancer is quite good, Todd was relieved to hear that radiation therapy and chemotherapy were not necessary. He was, however, profoundly alarmed when he was informed that he must adhere to an intensive monitoring protocol that requires he undergo one cystoscopy every 3 months for the next 5 years. Todd was not pleased. He was in fact so distressed that the urologist suspected he might not comply. As repetitive general anesthesia was out of the question, Todd was referred by the physician to E. L. B. to determine options for pain management. Following a brief history and evaluation, the therapist considered Todd to be a good candidate for a brief intervention. The next cystoscopy was scheduled 8 weeks after our first session. Todd was receptive to the notion of using hypnosis to control pain, so the therapist administered a trial hypnotic procedure as described in Nash (Chapter 8, this volume). Todd was quite responsive to hypnosis, especially to suggestions requiring him to alter the experience of his body. Todd’s defense style was flexible, but primarily histrionic. His defenses were organized around body-based themes of supply, with repressed material expressed somatically. During the first three sessions, Todd became quite accomplished in displacing his somatic sensations (e.g. tingling, heaviness, warmth, cold)

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from one part of his body to another. During hypnosis he would imagine his father’s hand on his shoulder. The warmth would move down his arm to his hand. By the fourth session Todd was able to experience complete anesthesia in his left hand, and he found he could transfer this ‘numbness’ from his left hand to his right. During the therapy hour he would rehearse this effect many times: going into hypnosis, experiencing the anesthesia in his hands, and being brought out of hypnosis. During the fifth session, he began gradually to expand the anesthetic effect across a large but unarticulated portion of his lower body (about from his ribs down to his knees), and he was instructed to use a relatively rapid self-hypnosis procedure (see Nash, Chapter 8, this volume) on a twice-daily basis, 5 min each time. Sessions 6 and 7 began with a review of his practice experiences during the week, and eventually moved to hypnosis proper, with Todd using his self-hypnosis procedure and signaling to the therapist when the numbness was consolidated. Interestingly, Todd always began his hypnosis with the feeling of his father’s hand on his shoulder. Session 8 was scheduled 2o days after the cystoscopy. Todd reported that when he arrived at the physician’s office the staff were prepared, with two burly male nurses at the ready. He informed the physician that he wanted to use self-hypnosis, and asked if he would give Todd about 60 s notice before starting the procedure. The physician did so, Todd used his self-hypnosis, and the 10-min cystoscopy went without a hitch, with no observed lesions. Todd reported he felt nothing, other than the pressure as the probe ‘popped into my bladder’. When the procedure was complete, Todd brought himself out of hypnosis, feeling particularly satisfied that the nurses had had nothing to do. E. L. B. offered follow-up sessions if Todd wanted them. Todd politely declined.

16.3.1.2. Short-problem-focused psychotherapy: case 2, trichotillomania A 29-year-old married female accountant consulted the junior author (M. R. N.) regarding a life-long habit of pulling out her eyelashes (always with her right hand and always rolling the hair between her forefinger and thumb). Kristi was otherwise asymptomatic, with no

indication of a broader psychiatric disorder, and no generalization of the hair-pulling to other areas of her body. She never knew a time when she did not pull her eyelashes. As is often the case with trichotillomania, the patient’s defenses were obsessive, with recurrent interpersonal themes of defiance and submission. Much, though not all, of her life was organized around undoing, counter-dependency and a considerable interest in orderliness and parsimony. Interestingly, Kristi’s defiance indirectly led to her seeking therapy. To the distress of her upper middle-class family, Kristi had embraced a pentecostal denomination which encouraged speaking in tongues (i.e. glossolalia). Her highchurch, professional parents were mortified. Indeed Kristi was so proficient at glossolalia that she wondered whether she might be a good candidate for hypnosis. She wanted to find out whether someone could use hypnosis to make her hair-pulling go away. The therapist detected the invitation to become part of yet another defiance-submission enactment, and responded ‘its interesting that in church you discovered you possessed something good and powerful all along, and you wonder if there is more’. Kristi’s glossolalia experiences served as a template for her experience of hypnosis. The initial hypnotic procedure revealed her to be highly responsive. Although her behavioral responses were idiosyncratic (e.g. arm lowering suggestions resulted in her arm actually rising), Kristi reported being profoundly relaxed, keenly attuned to her sensations and ‘bathed in light’. Following termination of this first hypnotic procedure, Kristi again likened hypnosis to the way she felt before speaking in tongues, i.e. ‘receptive to whatever I am feeling. Just waiting’. It occurred to the therapist that Kristi’s eyelash compulsion was almost certainly a desperate attempt to self-sooth—a muted version of the self-abuse behaviors we see with borderline patients. However, Kristi’s counter-dependent style seemed to leave few avenues for expression of her disavowaled passive dependent yearnings. Her glossolalia was the most notable exception. In the religious context she could encounter her need for comfort and allow that need to be satisfied. Could we fashion a self-hypnosis procedure for Kristi which would serve as an alternative to lash pulling;

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one which would satisfy her passive dependent needs without overwhelming her defenses? In subsequent hypnosis sessions, the therapist consciously chose to avoid direct suggestion in favor of grounding the intervention in sensation. For instance, during hypnosis: Now, I would like you to focus your attention on your right hand [this is the hand she uses to pull], every sensation that the right hand is experiencing at this moment…you find yourself paying close attention to everything your right hand is feeling right now. Becoming keenly aware of every nuance of sensation that is happening in the right hand…how the air feels against the skin of the hand . Tell me, what sensations are you having in your hand right now . That’s right, rub your fingers together and feel the surfaces of your skin…the sensation of how one surface feels as it moves across another…. As you become even more clearly aware of the surfaces, you also become mindful of how the hand feels itself…the width and length of its fingers…the way part of the hand is just slightly at a different temperature than another part…. What are you feeling…. What are you feeling now?

Kristi describes, not only the sensations in her right hand, but the emotions she is having: sad and anxious. The therapist then says: Yes that is right, you are doing quite well, your experiencing so much more because you are hypnotized. Now you can be curious about whether there might be an eyelash in your right hand, right on the tip of your fore finger. Let’s be curious about how that feels. Let’s wait and see. Tell me when you first feel the eyelash on your finger [patient signals the lash is present, and described how it feels]. I know that you do not just pull an eyelash out and then throw it away, but that you pull it out and then, with your right hand, you carefully roll the hair and feel it in a very special way. Now, let’s find out what that really feels like. And what you feel when you roll this lash back and forth between your index finger and your thumb. Go ahead. Go ahead and roll this lash back and forth.

Kristi describes that she can feel the lash, but she does not want to roll it. The therapist encourages her: Feel the lash on your finger. It is there, and moving around just a little bit. You can feel the air moving it

ever so slightly. Feel its texture against the tip of your finger.

Kristi rubs her thumb and forefinger together and smiles. She describes how good it feels, and how much more relaxed she is becoming. As you continue to roll the hair over and over again between your fingers, you are becoming more fully aware of your feelings, your emotions … how do you feel right now [patient answers that she feels wonderfully secure] fine, now allow this wonderful feeling of safety to be center stage right now … how good it feels … there is something so familiar, so safe, so wonderful

As the patient reports feeling more and more fully secure and safe: Now, focus on the safety and goodness. In a little while I will count to 5. Meanwhile stay very, very focused on this wonder safety and goodness. When I reach the count of 5 you will drop your lash without knowing it, and immediately go back to a place and a time when you first felt this wonderful feeling of goodness. So safe, so good. When I reach the count of 5 you will drop the lash and go right back to that place. A time and a place of goodness. You will be touching something, and you will be able to tell me all about it. 1…2…3…4…at the next count you will drop the lash and you will go back to the first time you felt this wonderful safety…5…where are you?

Given her defensive structure and these suggestions, it is not surprising that Kristi reported soothingly embracing her transitional object after an oft-repeated episode of leavetaking by her father during childhood. The regression was compellingly real for Kristi, and the tactile richness of the embrace with her teddy bear was figural. What was once experienced as an exclusively ego-alien visitation of self-mutilating behavior becomes associated with loss, and consolation. Over a period of seven subsequent sessions, Kristi and the therapist worked to consolidate this material, incorporate it into a concise self-hypnosis protocol, and rehearse it in and out of session. At termination, Kristi had a reliable means of self-soothing which she successfully used on a routine basis, and when she became aware that she was stressed.

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16.3.2. Insight-oriented therapy Here we describe how hypnosis can be used adjunctively in expressive therapies with patients functioning within the neurotic spectrum (see row 2 of Table 16.1). These therapies are typically intermediate in length (e.g. 6–18 months), and focus on providing insight and working through of significant arenas of conflict. However, it is assumed that the clinical picture does not involve broad developmental deficits in the patient’s capacity for attachment and identity. There is a solid base of clinical and research evidence to support the claim that hypnosis is well suited to the aims and process of uncovering therapies. Because hypnosis involves a topographic regression (Nash, Chapter 8, this volume), when used adjunctively it can promote emotional articulation of conflictual material, enhance access to symbolic processes and encourage de-automatization of ingrained, maladaptive defensive operations. But the flesh and blood of psychoanalytic therapy is the therapeutic relationship itself. Here hypnosis can be used to highlight the patient’s transference distortions, thereby making them more immediately available for examination by patient and therapist. These intense transference reactions underlie the enormous clinical potential of hypnosis, but at the same time present special challenges in pacing and dosage of interpretative work. Hence, insight-oriented therapies are predominantly expressive. Hypnosis is used within the context of traditional transference-mediated psychotherapy to facilitate uncovering, regression, working through and integration. The regressive aspects of hypnosis encourage discharge of disruptive affect and related conflict or trauma. However, these expressive aspects must be alternated with support and containment. Supportive hypnotic strategies (described above Section 16.3.1) strengthen intact defenses, reinforce ego-syntonic adaptive coping strategies, support boundaries and generally summon secondary process mental processes to help the patient smoothly integrate what he has learned about his emotional life. Here the therapist focuses on positive aspects of the working alliance, providing enough containment to support the expressive work, alternated with

suggestions for containment and mastery. Below we illustrate this work with case material.

16.3.2.1. Insight-oriented: case 1, clarifying the transference Hypnosis may be used to bring into focus important transference reactions in a timely fashion, but with less attendant threat to the working alliance. Among patients who are responsive, hypnosis can facilitate productive attention on the ongoing transferential material in a way that accesses unconscious conflicts and affect, but does not challenge the defenses so acutely. The relative suspension of secondary process in favor of more imagistic modes of experiencing during hypnosis enables the ego to bind intolerable manifestations of the transference to images which are sufficiently vague or disguised that their implications are sufficiently unrecognizable for the time being. Nevertheless, important uncovering work can proceed. Perhaps even more critically in the beginning phases of the therapy, the patient is extended a gentle invitation to reflect on his/her own experience of the therapist in a context which communicates, not pressured confrontation, but earnest curiosity. During the second intake session with a perfectionist single heterosexual depressed woman in her early 30s, I (M. R. N.) listened without comment as the patient described three upsetting situations, all of them involving a man requiring more ‘attention and care’ than she can deliver: a teacher, her father and a co-worker. The strained quality of these stories seemed to suggest that they might be references to the transference, i.e. she had experienced me as demanding and critical in our previous session. My invitations to consider whether she might harbor similar feelings about me were met with suspiciously sachrin denials In a later session, hypnosis was attempted, in part to challenge and highlight her resistance to the awareness that she was having important feelings about me. Accordingly, after an initial induction and series of ideomotor suggestions, the patient was instructed to have a dream about ‘hypnosis and me’. ‘You will have a dream about me doing hypnosis with you and what it means. This might be directly evident from what

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you dream, or you may dream about this quiet indirectly, but you will have a dream about me doing hypnosis with you, and what it means’. The patient reported that she is in the classroom where she had seen me teach. I am lecturing to her and the other students, but I never ask anyone else questions, only her. Soon she is unable to hear my questions or make sense of what I am saying. But I look angry with her because she does not know the answers. She feels humiliated. This work with hypnosis proved pivotal. As we explored the meaning of this dream outside of hypnosis, it became evident that her perfectionism is a desperate defense against intrusive fears of being shamed and humiliated by those she loves. When it came to men, the only thing good enough is perfection. This young woman’s emotional life was organized around sacrifice versus defiance. We could now explore this dynamic material as it unfolded in the therapeutic relationship.

16.3.2.2. Insight-oriented: case 2, catharsis and the silent abreaction Abreaction is not a stand-alone technique as Freud learned very early in his work with patients. However, in certain cases involving trauma, it can prepare the ground for interpretive work by giving the patient a sense of conviction about the reality of a remote event which might otherwise remain vague and unavailable. A hypnotic technique that can assist with this process is the ‘silent abreaction’ as first articulated by Helen Watkins (1980). What follows is a case example of how this technique can be used for insight-oriented work. A 28-year-old female patient with three children was referred for depression. It became plain that she expected men, including the male therapist, to be controlling and in charge, hopefully in a benign manner. When this wish was frustrated in therapy, she attempted to solicit this response by being seductive. Interpretation of this dynamic was secured without recourse to hypnosis. With the resistance thus illuminated, the patient began to revisit incidents of early sexual abuse (aged 6) by the maternal grandfather. She always remembered these incidents, but rarely thought or spoke of them. These erotic and sometimes violent memories were clear.

Feelings were not. In fact she wrote off the matter as being ‘ugly but over’. Still, she found herself being visited by the memories more often now. About this time, the patient also began to experience unusually intense anger: uncharacteristic irritability at family members, conversion reactions and motor agitation. As connecting the current angry episodes to her seductiveness with me and to her history of trauma proved difficult, the therapist employed a hypnotic technique, silent abreaction, designed to bring emotion into the foreground of her awareness. During hypnosis the therapist suggested that the patient imagine going back to the bedroom where the attacks took place. No one would be there but her. The door is closed and she would not make a sound…‘not a peep’. It was suggested that she ‘examine the bed very, very carefully, telling me every detail’. She carried this out with her usual precision. The therapist mentioned that soon she would find a very sturdy new oak baseball bat, and as she and the therapist explored her feelings she began quietly, silently, but thoroughly to demolish the bed with the baseball bat. And as she did the tears streamed down her face as she whispered through her clenched teeth how she hated him, his ‘ugly body’, and his ‘sick mind’. With every word, she struck the bed. There is nothing about insight here. Instead the work of this hour was restricted to elaboration and expression of affect. The patient reported some initial confusion followed by a quite sense of exhaustion—a relief which seemed to persist for several days. What was mutative occurred during sessions subsequent to the hypnosis as the patient discovered words that could meaningfully articulate the enormity of her rage, not just at her grandfather, but at all figures who she construed as maliciously dominating (for quite some time this included the therapist). Tracing and retracing contemporary manifestations of this recurrent interpersonal scenario of being controlled by men eventually revealed her own desperate attempts to achieve mastery over her passive dependent yearnings via seduction.

16.3.2.3. Insight-oriented: case 3, revealing neurotic relational patterns Following the affect, pursuing its displacements and condensations, and re-tracing its course

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across objects remains the most rewarding avenue for elucidation and resolution of core conflictual material. What follows is a case that illustrates how hypnosis can be employed in support of this process. A 37-year-old married female patient presented with a long-standing untreated depression with recent acute suicidal features. This woman also suffered from chronic pain for which she had undergone several courses of surgery over the past 5 years, with little improvement. The patient was a bright, but emotionally constricted woman who had little capacity to be directly angry with her husband. She over-idealized her husband and strove to be his ‘perfect little girl’. During the initial intake session, she reported that the previous evening she had placed a loaded pistol in her mouth: she had played with the idea of pulling the trigger. She was hospitalized for 9 days. While in the hospital the patient was seen daily for psychotherapy. The initial focus of therapy was the relief of her pain, since this was her only conscious reason for wanting to commit suicide. The therapy proceeded quickly in two phases: her conversion of anger to somatic pain; and the emergence of the original interpersonal matrix in which this anger was embedded. During the third session in the hospital, the patient was hypnotized and found to be highly responsive. Accordingly she was asked to have a dream about ‘what your pain means’. She vividly described a beautiful day on a beach in the Caribbean. She was alone, sunning herself on a white-sand beach. The noise of the surf and the gulls was soothing and peaceful. As she visually scanned the scene she glanced at her own body. There she notices that coming out of the right side of her abdomen is ‘a white cloth, half in and half out’. When asked to describe this white cloth, she said that it is white cotton; it emerges about 7 or 8 inches from her side, and it is gently waving in the breeze. She was bewildered by this, but certain that the cloth had something to do with her pain. Mindful of the patient’s unconscious resentment of her submissive posture in important relationships, and mindful that premature interpretation of the phallic aspects of this imagery might be counter-productive, the therapist queried whether this white cloth might be ‘a flag of

surrender’. Stunned for a moment, she wondered aloud whether she could ever stop wearing ‘this thing’. For several subsequent sessions which did not employ hypnosis the patient productively considered whether surrender and pain might be connected for her. Interestingly, her pain began to recede as she articulated her husband’s oppressive insistence on her having a recent abortion. During a later hypnosis session the ‘white cloth’ gradually emerged entirely from her abdomen. She could now examine it much more closely. Interestingly, her examination of the ‘white flag’ was attended by angry fantasies of wanting to strangle her husband with it (now ironically it had become a weapon). While she was entirely pain free for the first time in months, she was left with a raw anger at her husband which was quiet frightening to her. She reported ‘blowing up’ at her husband for seemingly trivial oversights. The second phase of this therapy began as the patient was invited to examine this anger more closely—to follow its course to the very source. Hypnosis was used on only one occasion in which the therapist employed the ‘affect bridge’ (J. G. Watkins, 1971). Here hypnosis was used to magnify and intensify an important emotion (in this case anger). When the patient was experiencing the emotion with vivid intensity, an age regression was quickly suggested: an age regression to an important time when this same intense feeling was in play. This turned out to be an incident she had always remembered. However the response of the patient was a bit unusual for two reasons. First, the age regression settled on a relatively recent, but no less important incident at the age of 19. Second, there was practically no conscious experience of anger as she described the incident. As the patient regressed to age 19, she coolly reported walking down the steps of her parents’ home (where she lived at the time she was age 19). She is thinking about a very attractive young man she has met during the summer. A brief romance had developed that summer but he had to leave town for 3 months. He left, but promised he would write. As the patient imagines walking down the stairs of her parents’ home to the living room, she is wondering why he has never written. It has been over 2 months and she has not received a single letter. As she somewhat glumly and silently

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enters the living room, she notices her mother standing by the fireplace with a sealed letter in her hand, about to pitch it into the flames. The patient realizes that she has caught her mother in the act of destroying what turned out to be the seventh or eighth letter from the young man. Again one particularly noteworthy aspect of the patient’s story is that she was not in the least bit consciously aware of being angry at her mother. She numbly submits to her mother’s explanation that the boy is ‘not really suited for you’. She returns to her room feeling that what her mother did is probably wrong, ‘but she really is just trying to look out for me’. The therapy now traced the demoralizing and humiliating surrenders she had made to the pathogenically intrusive mother: a mother who interpreted even the most innocent manifestation of separation/individuation as literally ‘sin’. Of course the patient was remarkably persistent in her attempts to enact this same scenario with the therapist (e.g. ‘Is it sinful to feel this way about her?’; ‘Isn’t it horrible/sick that I have these feelings?’). This patient’s will had been crushed by her beloved mother. As she began consciously to experience anger at a previously over-idealized mother, her depression lifted markedly. Just as importantly, a neurotic burden was lifted from her marital relationship. Couples therapy could now began in earnest.

16.3.3. Intensive long-term therapy with borderline and psychotic patients While insight-oriented therapies with neurotic spectrum patients emphasize the regressive aspects of hypnosis and its importance for uncovering and abreaction, intensive work with borderline and psychotic spectrum patients emphasizes the integrative potential of hypnosis and its importance for structural maturation and master. Hypnotic technique allows for the direction of a specific experience in external sensory reality to be elaborated, given meaning and internally integrated, facilitating the resolution of unfinished developmental work. The experience of hypnosis involves repeated experience with the boundaries of reality and the self through the unfolding of regression and dissociate processes. Within the context of the

therapeutic alliance, hypnosis can be used to stabilize the demarcations and functions of boundaries and reinforce the patient’s sense of efficacy and security in autonomous control. The experience of hypnosis also involves a series of experiences of ‘being with the other’ with varying degrees of intensity in object relatedness. The interpersonal qualities of the hypnotic experience demonstrate that the interpersonal connections can be tolerable, safe and even gratifying, while providing secure opportunities to intensify or to dilute the degree of interpersonal interaction. Meaningful psychotherapy with these patients is frequently very difficult because of problems in establishing a consistent and valid therapeutic alliance. These patients resist interpersonal involvement due to fears of merger, rejection or malevolent destruction. Further, attempts at alliance are disrupted by: labile shifts in affect, with the intrusion of primitive aggression; shifts in the experience of self and other due to the absence of an integrated internal representational world; and erratic and transient regressions with increases in autistic involvement and the use of primitive defenses such as splitting, denial and projective identification. The lack of structural integrity is a core aspect of these patients’ psychopathology and becomes a crucial focus in any hypnotic intervention. Experience with a consistent and facilitative environment is a cornerstone of this work. However, consistent experience with the environment is limited by the fragmentation, disorganization, liability and regressive propensity of these patients. Therefore, therapeutic intervention must: establish clear and reliable boundaries; provide a consistent and secure experiential environment with those boundaries; develop a capacity to titrate engagement with the environment at a level tolerable to the patient; establish avenues to represent, process and integrate that experience internally; and contain episodic disengagement and regression without disruption, abandonment or retaliation. The capacity of hypnosis to delineate experience differentially, to modulate the intensity and locus of experiential involvemen, and to process this experience in an interactive/interpersonal fashion renders it a useful technical adjunct to the strategic management of these parameters in intensive treatment. The therapeutic relationship

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and the therapeutic process then can evolve in a form conducive to structural mutation and psychological maturation. A number of technical alterations are important in applying hypnosis to patients organized at this primitive level of development. A clear demarcation of the boundaries of hypnosis and specific cues and sensory referents helps to contain the experience of altered consciousness without the undue regression, and to anchor this experience to a dependable external reality. The clarity of these boundaries also serves to stabilize the patient’s own ego boundaries of the self. Formal and structured hypnotic procedures, the comparison of experience in and out of hypnosis, ‘open-eyed’ hypnosis to check episodically the permanence and continuity of external reality, limits on undirected association during trance and specific ideomotor signals to alter trance involvement and to maintain interactive connectedness with the therapist are useful and important technical considerations in structuring hypnosis. The touch of the therapist’s hand, focused sensory awareness of the weight of the feet on the floor or the clenching or unclenching of a fist can provide sensory anchors for images. The ‘grounding’ of intervention in sensory experience parallels the way in which internal concepts are grounded in sensori-perceptual exploration and experience during childhood, and supports the evolution of a consistent internal organizing structure for experience. As the patient learns to enhance body awareness or to use body experiences to control tension, to recapture a soothing image, to restore a sense of security rooted in the relaxation of hypnosis or to access attention or problem-solving processes, he or she also develops a sense of mastery and a sense of self as master. This emerging sense of self as one with the physical reality of the body, comfortable with awareness of the body and in control of body experience is fundamental to the development of a stable self-concept fueled by a sense of self-efficacy and self-esteem. Hypnosis provides opportunities to direct specific experiences with and of the external world including the therapist, and to elaborate these as building blocks of the internal selfstructure. The relaxation of hypnosis, the soothing and gratifying attention of the therapist and

the calm security of the office provide an experiential referent for the perception of self as comfortable (and comforted), safe (and securable) and gratified (and therefore deserving of gratification). Simultaneously, such experience can be utilized to demonstrate the security and goodness of involvement with the world. Altered attention in hypnosis, muscle tension discharge and motor control during hypnosis can enhance awareness of the integrity of the body (and self as strong) and control over motor and sensory processes (and self as efficacious and/or autonomous). Such experiences can be elaborated with internal symbols and structured fantasies to expand the certainty and integrity of identity and the consistency and safety of others in the eternal world. Hypnotic images are often useful for these patients in creating a sense of self as a whole, as attractive, or as lovable. Problems with object performance—the continuity of object and self across time and space—can be addressed by images that evoke a single consistency of the self or object representation elaborated or focused across imagined situations. One of the senior author’s patients had a favorite yellow scarf that we regularly included in images of self in varying situations and temporal frames. Another focused on a characteristic birthmark to assure himself that he was able to exist unchanged across time. Difficulties with object constancy— the integrity of self and object across situations with changing affective valences—can also be treated with hypnotic imagery and sensorimotor experience. Images of blending and mixing can support the working through of splitting defenses without overwhelming anxiety. Images that emphasize the integration of parts, the uniqueness of parts that remain securely anchored to a whole and fantasies about the ability of relationships to continue despite changes in self and other are all evocative of emerging representational constancy and structural stability. With another patient, the senior author would ask him to imagine that one hand was becoming very, very heavy while the other hand became very, very light, and then to focus these sensations while simultaneously experiencing that both hands were part of his body, that both sensations were a part of his experience of himself, and that he could move

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both hands together or apart. We then reversed the sensory experience so that the light hand became heavy and the heavy hand began to feel light. This experience became a sensory focus for his work on the constancy of his identity across varying feeling states and his ability to tolerate and manage opposing feelings simultaneously in anticipation of an emerging capacity for neurotic ambivalence rather than primitive and discontinuous affective lability.

16.3.3.1. Intensive long-term therapy: case 1, psychosis From the beginning of treatment, the primary focus of therapy is helping the psychotic patient relate to the therapist as someone who can nurture and protect him in a consistent and dependable fashion. In a manner which is felt generally to recapitulate the developmental process of self/other differentiation followed by object introjection and integration, hypnotic visual imagery and fantasy are developed in the following progressive sequence: 1. While maintaining relaxed feelings of comfort and calm, the patient is helped to visualize an image of self involved in some pleasant activity alone. Feelings of relaxation and well-being are suggested intermittently. 2. The patient is instructed to open his eyes and see the therapist, then close his eyes and return to an image of self. This process is repeated several times with suggestions for relaxation and comfort. This process helps to reassure the patient that the therapist continues to exist when he cannot be seen, and begins to pave the way for the development of evocative object constancy. 3. The patient is helped to develop visual images of the therapist associated with continued feelings of relaxation and well-being. It is not unusual for patients to experience difficulty in visualizing the therapist. If this is the case, images of the therapist’s name written on a blackboard, or his initials, or an object selected from his office desk are substituted. With any feeling of discomfort, the image is discontinued and an experience of calm relaxation is redeveloped. This use of inanimate representations or symbolizations of the therapist is useful in controlling the anxiety associated with

attaching to a real, whole object so characteristic of schizophrenic patients. Their usefulness as transitional phenomena appears to parallel the developmental occurrence of transitional objects (Winnicott, 1965) and the emergence of similar fantasies in psychoanalysis. 4. The patient is instructed to alternate between developing visual images of the therapist and images of self; then to picture the two together. The proximity of ‘togetherness’ may be defined by the patient. It may involve being in the same room, passing on a highway in separate cars or viewing each other across a chasm with telescopes. Gradually, the distance in the images is decreased in concordance with the maintenance of calm and comfort. 5. Next, treatment moves to develop fantasies involving the patient and therapist in parallel activity and then in interaction. Interactional fantasies are developed to emphasize the nurturing, supporting and protecting role of the therapist, and move from concrete to symbolic representations of these functions. The fantasy reflects the level of dependence/independence appropriate to the patient’s level of functioning. This internalization of positive visual images of the therapist provides a cognitive–affective paring which facilitates the introjection of the therapist as a good (gratifying) object and the experience of self in relation as a positive, ‘good me’. These images may then be used as cues to induce or deepen the trance, reduce anxiety and increase feelings of positive self-regard. Once the object introject is well established, it may be used as a focus to gain control over hallucinations and delusions by altering the patient’s cognitive set, decreasing anxiety and reducing the patient’s need for compensatory, autistic self-stimulation through providing a more gratifying yet safe connection with the real world and its consensually validated internal representation. 6. Controlled externalization of distorted self and object representations is facilitated through helping the patient develop visual representations of voices, threatening delusional figures, the infant self who provoked mother’s anger and deprivation, the crazy self who cut her wrist, etc. These images may be managed in fantasy or hypnotic dreams in

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one of two ways. Elements which need to be made increasingly ego-dystonic or repressed may be elaborated in terms of their destructive effect on the patient and relegated to ‘an old truck’, ‘stored in the attic’ or ‘buried for later excavation’ via fantasy. Elements which represent aspects of defensive object splitting may be moved towards integration through emphasis on their similarity, alteration of their symbolization in terms of shared significant dynamic issues, and various fantasy representations emphasizing temporal and spatial pairing or revivification of common historical roots for the split images. Often this results in marked abreaction. 7. With increasing stability of ego-functioning, hypnotic fantasy may begin to include other significant objects, and work may move to examine significant interpersonal experiences with an emphasis on integrating both positive and negative images. As dynamic issues emerge, they are examined and worked through external to the trance state. A vignette from a case illustrating the various stages of this treatment approach may help to clarify its application. John was a 23-year-old white, single male who was seen on the inpatient psychiatric unit of a teaching hospital. This was his second psychiatric admission in 2 years with a diagnosis of paranoid schizophrenia. The patient presented with classical symptoms, including auditory hallucination, religious and persecutory delusions, ideas of reference, progressive withdrawal, and a guarded and suspicious interpersonal stance. The patient agreed to work with the therapist, and asked for hypnosis after learning of its helpfulness from a fellow patient. During the first session, a light trance was induced utilizing progressive relaxation. The following exchange occurred: Therapist: Now John, as you continue to relax and feel how good it is to control your own muscles and control your own body and be in charge on your own thoughts and feelings, if you wish you can imagine seeing an image of yourself in your mind’s eye. Just imagine that you can see your reflection in a mirror. Patient: I can’t, it’s too dark. Therapist: Well, let’s just turn on a light.

Patient: The light of the world is Jesus, not you. Therapist: Jesus wouldn’t want you to hide your light under a bushel basket, so just let it shine for yourself and see how warm and calm it can feel, like sunshine on a summer day. Patient: It is warm. Therapist: Good. That warmth is a good feeling that can help you become more and more relaxed. Now perhaps you can find that mirror. Patient: I see it, but I can’t look. Therapist: You’re afraid of what you’ll see? Patient: (nods yes). Therapist: If you look closer, you’ll notice that you can see your face there smiling, looking calm and relaxed and happy. It feels good to see yourself up close…just your face with two eyes and a nose… Patient: I can’t look! Therapist: Can you tell me what’s happening? Patient: My face is melting. It’s running and oozing and isn’t one face but like vomit that has lots of cut-up faces in it. Therapist: Then let’s just turn that mirror upside down and bring your face back together again. Everything just returning to it’s right place. Together … together … there, now. Patient: It worked! Therapist: Let’s just let it rest there, together now. It’s all one face; your face. It’s together like you can move your hands together if you wish. There. Just grasp one hand with the other. Feel the touch, the pressure, the strength, the warmth. You can move them together, grip them tightly, or move them apart. Whatever you want. Each hand is still a hand, separate, But they can come together; work together, just like you and me. We’re together and that can fell safe and warm and secure. You’re still you, and I’m still me. But we can work together…. Patient: I can see you. [He opens his eyes.] And you’re still here. Therapist: That’s right. I’m here when you have your eyes shut, too. So just relax and remember that you can control togetherness. Can you see your face?

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Patient: Yes. Therapist: That’s good. Sometimes your face may want to vomit, to vomit up all the poisons that are inside. But it’s still your face and that won’t scare me away. And maybe it won’t scare you when we’re together.

[In the third session with this patient, efforts are focused on helping him visualize himself together with the therapist.] Patient: You aren’t there. Therapist: Sure I am. Do you want to check? Patient: [Opens eyes, smiles, then closes them.] Therapist: Can you see us together now? Patient: [He giggles.] Yeh. You’re on a mountain in California, and I’m not there. I’m on the top of a mountain in New York. It’s windy up here. Therapist: But the winds can gradually slow down. And we can see each other. Patient: Through telescopes. Therapist: You look far away but you look like you belong there for awhile. Maybe we could send messages across the distance that separates us to keep in touch. Patient: Probably smoke signals. I’ll say,‘I’m hungry’. Therapist: Then I’ll just send you a meal now and then, and we both can stay strong and safe. But someday we may build a bridge and find that we can be together and neither of us will be destroyed. Patient: Like the Golden Gate Bridge? San Francisco is for queers. Therapist: Coming together has many scary feelings doesn’t it? John. We won’t build that bridge until you’re ready. Patient: I’m sending another signal. It says, puff, puff, ‘puffection’ takes time. Therapist: I can give you time too. We’ll wait together, but apart. Patient: You’re the doctor.

16.3.3.2. Intensive long-term therapy: case 2, borderline personality disorder Just as the integrity and stability of the psychotic patient’s self-structure emerge from secure and

gratifying experiences of the other and the world during hypnosis, similar technical maneuvers can help borderline patients to internalize representations of permanence and constancy. Hypnotically elaborated images can move from partial representation to whole pictures (part objects to whole objects) to support structural cohesion. Experiences with being ‘together but apart’ can be developed through hypnotic interactions involving alternating sharing/no sharing of experience such as dreams retold or kept private during hypnosis, sensory alterations that involve hearing the therapist’s voice as coming from near or far away, or alternately feeling and being anesthetic to pressure on the back of a hand. Such experiences reinforce the patient’s ability to maintain a secure sense of self in interaction with others and to control the privacy of internal experience and the regulation of stimulus barriers requisite for social involvement. Hypnotic fantasy may also be utilized to help the patient imagine an expanding world of parallel and interactive object involvement and to profit from the gratification and rehearsal functions such fantasy can serve. A brief clinical vignette from a hypnosis session with a borderline patient illustrates this approach. Sophia was a 27-year-old single woman who presented with classic borderline features of impaired impulse control, emotional liability, dissociative symptoms and identity diffusion. In one therapy, session utilizing hypnosis, the therapist gave the following suggestion: While remaining relaxed and quiet, focus your attention on the feeling in your feet. Notice if they feel warm … or heavy … or tingly. Compare the sensations in your right foot to your left. Good. Now picture an image of your feet in your mind’s eye; each foot firmly connected to the rest of you. Can you imagine them there? [Patient nods.] Good. Now I want you to move your attention back and forth from the sensations in your feet to the image in your mind while focusing on how my voice sounds just the same and my presence feels just as near regardless of the focus of your attention. Some aspects of your experience will change while others stay the same, and that can feel comforting, soothing and secured. Just focus heavy … picture your feet … warm … picture the right and the left … tingly … a feeling in your body and an image in your mind can

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be experienced together just as you and I continue to be together in this room.

Here the therapist is working to integrate body wholeness, body sensory awareness and identity integrity by helping the patient to practice the experience of connecting and integrating transitions in sensation, perception and cognitive representation within the holding context of the therapeutic alliance and the continuity of the therapist’s empathic and observational presence. Such work provides an experiential anchor for maturation to object and self constancy and the ability to evoke this sense of integrity in the face on anxiety, producing shifts in sensation, affects and self-awareness. This perspective emphasizes the interactive phenomenological matrix of hypnotherapy and the enhanced ego-receptivity of trance involvement as a crucible for recapitulation developmental work through directed trance experience that is internalized and integrated via the transitional functions of the hypnotherapist and the structuralizing representations of the therapist as a transitional object. By forging developmentally focused experiential bridges, such hypnotherapeutic interventions help to build internal structures which potentiate internal stability and psychic integrity and which help our patients to grow in structural maturity.

16.4. Conclusion The integration of hypnosis into psychoanalytically informed treatment offers opportunities for the creative facilitation of the therapeutic process. For patients in the normal to neurotic spectrum, hypnosis can be used supportively to strengthen already intact defenses, in service of managing pain (acute and chronic), anxiety, stress and some somatic symptoms. These therapies are of relatively brief duration, with an emphasis on patients using self-hypnosis strategies to achieve the goals they have set for themselves. For patients in the neurotic spectrum who suffer from delimited and/or encapsulated symptoms, the regressive aspects of hypnosis can be used to facilitate emotional expression, broaden insight and permit discharge of disruptive affect

and related conflict or trauma. These therapies are typically of intermediate length. Finally, hypnosis can be useful in work with borderline and psychotic spectrum patients who lack a consistent capacity to engage and to modulate emotional processes via verbal and introspective activity alone. Here hypnosis can help to direct experience, to contain and to modulate the process, and to facilitate its internal representation and integration in a fairly direct fashion not typically available in waking, verbal psychotherapy. This aspect of hypnosis is especially helpful in treating patients with structural pathology who otherwise demonstrate significant problems in engaging and tolerating the process central to the work of psychotherapy.

References Baker, E. L. (1981) An hypnotherapeutic approach to enhance object relatedness in psychotic patients. International Journal of Clinical and Experimental Hypnosis, 29: 136–147. Baker, E. L. (1983a) Resistance in hypnotherapy of primitive states: its meaning and management. International Journal of Clinical and Experimental Hypnosis, 31: 82–89. Baker, E. L. (1983b) The use of hypnotic dreaming in the treatment of the borderline patient: some thoughts on resistance and transitional phenomena. International Journal of Clinical and Experimental Hypnosis, 31: 19–27. Bernheim, H. (1889) Suggestive Therapeutics: A Treatise on the Nature and Uses of Hypnotism (C. A. Herter, transl.). G.P. Putnam’s Sons, New York. (Original work published 1886.) Charcot, J. (1890) Œuvres Complètes, Leçons sur les Maladies du Système Nerveux. Paris, Progress Medical, III: 299–359. Freud, S. (1900) The Interpretation of Dreams. Standard Edition, 4 and 5. Hogarth Press, London, 1953. Freud, S. (1905) Three Essays on the Theory of Sexuality. Standard Edition, 7: 130–243. Hogarth Press, London, 1953. Freud, S. (1916–1917) Introductory Lectures on Psychoanalysis (Part III). Standard Edition, 16, Hogarth Press, London, 1962. Freud, S. (1917) A Metapsychological Supplement to the Theory of Dreams. Standard Edition, 14: 222–235. Hogarth Press, London, 1957. Freud, S. (1918) Lines of Advance in Psycho-analytic Therapy. Standard Edition, 17, 157–168. Hogarth Press, London. Freud, S. (1923) The Ego and the Id. Standard Edition, 19: 12–59. Hogarth Press, London, 1961.

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Freud, S. (1926) Inhibitions, Symptoms, and Anxiety. Standard Edition, 20: 20–178. Hogarth Press, London, 1957. Freud, S. (1933) New Introductory Lectures on Psycho-analysis. Standard Edition, 22: 7–182. Hogarth Press, London, 1964. Watkins, H. H. (1980) The silent abreaction. International Journal of Clinical and Experimental Hypnosis, 28: 101–113.

Watkins, J. G. (1971) The affect bridge: a hypnoanalytic technique. International Journal of Clinical and Experimental Hypnosis, 19: 21–27. Winnicott, D. W. (1965) The maturational processes and the facilitating environment: studies in the theory of emotional development. New York: International Universities Press.

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CHAPTER 17

Reclaiming the cognitive unconscious: integrating hypnotic methods and cognitive-behavioral therapy Joseph Barber

17.1. Unrealistic expectations Hypnosis is not a type of therapy, like psychoanalysis or behavior therapy. Instead, it is a procedure that can be used to facilitate therapy. American Psychological Association (1993, p. 7)

A review of the titles in the clinical hypnosis literature over the past 75 years suggests a charming but curiously naïve optimism about the efficacy of hypnotic intervention. Compared with other psychological methods, clinicians and patients alike often have expected hypnotic treatment to be magical in its effect. These methods have been believed to be curative— and quickly—of virtually all psychological ills—and a variety of medical ailments, as well. Psychological symptoms might include amnesia,1 drug abuse, marital discord, heightened libido and lowered libido. The wide range of medical syndromes includes chronic pain, speech disorders, fibromyalgia, chronic fatigue syndrome, gastrointestinal distress, hypertension,

obesity, skin disorders, alcohol or drug addiction and a range of endocrine disorders. With the advent of the Internet, the capacity to spread such expectations has grown suddenly and enormously. Persuaded by the claims of advertisements and popular literature, the general public has developed expectations that hypnosis can achieve almost anything. We should not be surprised, then, that the public view of hypnosis is so ambivalent, ranging from credulousness to ridicule. Deepening the problem further, this unusual set of expectations is reflected in the hypnotic training of health practitioners. When, for example, a dentist or a gynecologist undertakes hypnotic training relevant to dentistry or

1 The distinction between documented traumatic memory loss and the undocumented report of amnesia for traumatic events is an important one. The perils of hypnotic treatment for the latter are described elsewhere (Barber, 1998b)

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gynecology, the specific admonition is given that the practitioner should confine hypnotic treatment to his or her specialty. This caution recognizes that, because these practitioners are being trained in the use of a psychological method, they are likely to be tempted to treat problems beyond their training and, in particular, they are more likely to treat problems that are essentially psychological in nature.2 Is there any other clinical method, taught to dentists, physicians and psychotherapists, alike, which tends to promote such inappropriate use? A further influence on the unrealistic expectation of hypnotic effect is the use of hypnotic methods by those who are otherwise not clinically trained. A review of Yellow Page listings reveals that the number of ‘certified hypnotherapists’ exceeds the number of clinically trained professionals.3 Is there another clinical method that does not require basic clinical training for its legitimate practice? This is a curious state of affairs. However, even the hypnotic training of otherwise well-trained clinicians may not be sufficiently different from that of ‘certified hyp- notherapists’. Observing the clinical training of hypnotic methods for professionals, one might reasonably conclude that these methods somehow allow us to dispense with our usual clinical considerations, most notably the necessity for thorough evaluation prior to intervention. It is as if the magical thinking sometimes evoked by hypnotic suggestion in the minds of patients has a similar effect in the minds of practitioners—even when their names begin with ‘Doctor’. Clinicians who do not practice hypnotic methods are also vulnerable to the magical belief in the efficacy of such treatment. This is often revealed when they make an inappropriate referral for hypnotic treatment. It would be 2 A typical example is the case of a surgeon who uses ‘hypnotherapy’ to treat a case of hysterical muteness, though not effectively, evidently unaware of more appropriate treatment (BBC, 1981). 3 The training of a ‘certified hypnotherapist’ (sometimes called a lay hypnotist) ordinarily consists of a set of weekend workshops on the use of hypnotic techniques—without any other training in the principles or techniques of medicine, dentistry or psychotherapy.

highly unlikely that such patients would be referred for cognitive-behavioral therapy (CBT) —or any other psychological intervention—for the range of problems listed earlier, and certainly not with the concomitant expectation of rapid success. Not to put too fine a point on it, but we suffer from highly unrealistic expectations of hypnotic methods. Let us assume that the use of these methods depends upon the same psychological principles that apply to any other intervention. We should employ the same clinical assessment procedures we would use prior to undertaking nonhypnotic clinical interventions. In addition, we must expand the assessment process to include evaluation of the specific appropriateness of hypnotic methods. For example, if, upon evaluation, I determine that the patient’s aversion to riding in an airliner is the result of a concatenation of events that conditioned the patient to feel anxious about flying, then I think that a relatively conservative, simple CBT approach is likely to be effective. If I judge that hypnotic suggestion will facilitate a heightened, vivid focus on the treatment, then I will add this component to the intervention. If, however, I judge that the patient’s aversion to riding in an airliner is the result of the trauma he experienced as a pre-adolescent when his father died in the crash of an airliner (a trauma he does not want to visit upon his own son), then I think it improbable that CBT will be effective in reducing this patient’s aversion to flying. Upon further exploration with the patient, he is able to say, ‘Unless there is a guarantee that the plane won’t crash, I’d rather not take the chance. Period’. When I suggest that his aversion seems the natural reaction of a caring father, the patient expresses relief. He now accepts that avoiding airliners is a healthy (if sometimes inconvenient) choice, rather than a neurotic limitation. In a strictly narrow discussion of using hypnotic methods with CBT, there is little to say beyond elaborating the ways that hypnotic methods can increase the patient’s focus, highlighting the vividness of the treatment, and thereby substantially increase the effectiveness of the intervention. However, I think that treatment effectiveness will be further enhanced if

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the clinician’s conceptual grasp is broader. Accordingly, we will explore the larger context in which hypnotic methods are used in psychotherapy. Like hypnotic techniques, CBT is not conducted in a psychological vacuum. It is the human interaction, however extraneous it may be to the clinician’s intent while using CBT, which may either facilitate or thwart the otherwise appropriate application of hypnotic methods.

17.2. Integrating hypnosis into

psychotherapy 17.2.1. Initial clinical assessment We will assume that a usual assessment when undertaking psychotherapeutic treatment includes a diagnostic interview, MMPI (Minnesota Multiphasic Personality Inventory), discussion of the treatment plan and then an initial treatment trial. If the treatment will be hypnotic in nature, there are additional considerations which ought to be made. I will want to be confident, for instance, that the patient can tolerate the sometimes unusual cognitive and affective qualities, as well as the heightened interpersonal qualities that tend to accompany the hypnotic experience. A patient whose psychological boundaries are confused or vague, or who expects that interpersonal relationships will be threatening or harmful, is more likely to experience difficulties (Barber, 1998a) as a consequence of this treatment. A patient whose sense of reality is tenuous is more likely to have difficulty tolerating the experience of an altered state. However, a patient who is vulnerable to dissociative episodes is likely to find the hypnotic experience a familiar and, probably, nonthreatening one. For such a patient, one of the initial goals of hypnotic treatment might include identification and understanding of the dissociative experience, which can support the patient’s conscious control of the phenomenon. Exerting such control can reduce the automatic activation of dissociation as a defense but allow it as an aid to hypnotic treatment.

dissociate fully, this readiness is unlikely to be important. Nonetheless, it can be useful to the clinician to have a sense of the patient’s readiness to respond. Many clinicians utilize one of the wellknown measures of hypnotic responsiveness, perhaps the most widely used being Morgan and J. Hilgard’s Stanford Hypnotic Clinical Scales (SHCS; Morgan and Hilgard, 1975, 1979). However, other clinicians may be concerned about the potential for the patient’s experience of failure to respond to the scale and the consequent limiting effect on the therapeutic relationship.4 For these clinicians, the Tellegen Absorption Scale (TAS; Tellegen and Atkinson, 1974; Tellegen, 1982) offers a useful and comparatively nonintrusive alternative to the responsiveness scales. Though the correlation between the TAS and the Stanford Scales is small (0.20–0.40), unlike the more quantifiable scales of hypnotic responsiveness, administration of the TAS can readily be done within the context of preparation for hypnotic induction, using ordinary, respectful, nonthreatening language. Moreover, the patient’s responses to the TAS items provide the attentive clinician with more than a mere score; they create a meaningful impression of the patient’s comfort with the experience of imaginative absorption. Josephine Hilgard (1970) first identified the relationship between absorption and hypnotic responsiveness. The special relationship between an individual’s ability to become absorbed in imagination and that individual’s readiness to respond to hypnotic suggestion has been well investigated (Quall and Sheehan, 1979; Hilgard and Hilgard, 1994; Glisky et al., 1995). Imaginative involvements may be in reading, in dramatic viewing or acting, in music listening or performing, or in some forms of adventure. The person who becomes involved temporarily sets ordinary reality aside to become totally absorbed in the imaginative experience; he finds this absorption refreshing and wholly satisfying. … Those who habitually had such experiences proved to be among the most hypnotizable, while those who could report none of them were among the least hypnotizable (Hilgard and Hilgard, 1994, p. 11).

17.2.2. Hypnotic assessment It is well documented that readiness to respond to hypnotic methods is variable. If the clinical goals do not depend upon the patient’s ability to

4

It is important to remember, when considering the use of any of the hypnotic responsiveness scales that, at best, the administration of the scale can yield only a probabilistic assessment of the patient’s ability to respond (Hilgard, 1994, p. 68).

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17.2.3. Introducing hypnotic methods to the patient How should the patient be informed about the use of hypnotic methods? Since we are operating under the assumption that psychological principles (and principles of good treatment) are unchanged by the introduction of hypnotic methods, we do not want to encourage the patient’s probably misguided expectations about hypnosis. I find it useful to describe the treatment in terms that describe the process. For instance, the patient might be told, ‘Your imagination will be helpful to this phase of treatment’. Or, ‘Mental rehearsal is usually more effective if you can become deeply absorbed in the process’. Or, ‘We can best proceed if you will close your eyes, relaxing and allowing the external world to recede while we focus on your inner experience’. In each example, the patient is being informed about the experience or the process that will be undertaken; there is no intent (nor necessity) to mislead. However, by not saying, ‘Now I will hypnotize you’, most people’s misunderstanding about hypnosis will not be activated.

17.2.4. Crafting the induction as

part of the therapy The history of hypnosis has left in its wake a troublesome taxonomy, in which terms are often more metaphoric than descriptive, more confusing than clarifying. ‘Induction’ is the unfortunate term5 given to denote the process whereby the clinician helps the patient begin the process of making cognitive and affective shifts, from ordinary waking attention to functioning from a more narrow, internally oriented focus. It is within this latter frame that perception and memory may be modified, and which facilitates greater access to internal experience. In this respect, the induction is a process of altering consciousness (Kihlstrom and Hoyt, 1990; Kihlstrom et al., 1992; Kihlstrom and Eich, 1994). The hypnotic induction is the means whereby the clinician moves, either abruptly or gradually, from usual conversation with the 5 I say, ‘unfortunate,’ because ‘induction’ supports the misguided belief that the clinician is ‘doing something to the patient’, rather than, for instance, inviting the patient to participate in a meaningful imaginal process.

patient to a monologue that contains suggestions intended to facilitate the turning inward of the patient’s attention, and then narrowing the range of the patient’s attention toward what Braid (1960) once called ‘mono-ideism’ to indicate the single-mindedness that can be characteristic of the hypnotic experience. This initial stage of the hypnotic method constitutes an invitation to the patient to ‘lay aside the cares of the day’, as Hilgard would say, and focus attention on the thoughts and feelings and images evoked by the words of the clinician. However, although the induction is important for helping the patient to establish the dissociative qualities necessary to some hypnotic phenomena, we may have paid too much attention to this part of treatment at the expense of the actual clinical plan. More about this later.

17.3. What hypnotic methods

can achieve Suggestions are not the unique province of hypnotic treatment. Effective psychotherapists who do not employ hypnotic methods are familiar with the usefulness of nonhypnotic suggestions. Why should a clinician take the time and effort to induce a hypnotic experience? In what circumstances are hypnotic suggestions more effective than nonhypnotic suggestions? What are features of the hypnotic experience that can inform us about realistic expectations we might have for clinical hypnotic methods? Attention to these questions will facilitate our effective use of these methods. The psychological quality that is the hallmark of the hypnotic experience is dissociation (Orne, 1959, 1966; Bowers, 1976; Frankel 1976; Hilgard 1986; Hilgard and Hilgard, 1993). Although dissociation is essential for some clinical applications, perhaps most notably in the treatment of pain, it is not essential for most psychological interventions. In the course of psychotherapy, this dissociative quality may be facilitative, but, of course, it is not necessary for effective treatment. This is not to say that the hypnotic process is not useful. Applied deftly, even if the hypnotic induction may not necessarily result in dissociation, it may convey to the patient that this is a special circumstance of

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deep focus and greater emotional contact with the clinician. More, the induction can be used to convey that this is a safe and secure context in which to become more aware of deep internal experience and profound psychological content. In this context, then, let us review the three categories for which hypnotic methods have been shown to be effective when integrated with CBT.

17.3.1. Symptom amelioration Following the theoretical foundations of CBT, we assume that the hypnotic amelioration of symptoms is primarily conditioning in nature, that the hypnotic experience serves to accelerate the conditioning process, and hence we are guided by principles of learning. Although single-treatment reduction of a symptom may occasionally occur, as does single-trial conditioning, such a result is not likely, and we need not expect such a miracle to result from our interventions, no matter how cunningly crafted they may be. As with almost all conditioning, repetition is necessary, although the integration of hypnotic methods may serve to abbreviate the usual number of repetitions and, consequently, may reduce the length of treatment. While hypnotic methods may be used directly and expressly to suggest alteration of symptoms, they may also be used to support and amplify the effects of more conventional CBT. In each of the following examples, familiar CBT methods may be made more effective by the patient’s hypnotic experience of comfort, security, greater receptivity and greater access to imagery.

17.3.1.1 Facilitating identification of intrusive thoughts If the patient is initially unable to identify the thoughts which precede, say, feelings of anxiety, the addition of the hypnotic experience may be sufficient to focus the patient’s attention and clarify thinking. In this fashion, the hypnotic intervention can highlight triggering events, while simultaneously providing the patient with a better means to manage emotional reactions better. 17.3.1.2. Reframing While reframing may be helpful in a nonhypnotic context, the additional alteration of the patient’s consciousness, with the increased sense

of comfort and receptivity that usually characterize the hypnotic process, may amplify the effectiveness of such reframing. That is, when a patient has the hypnotically enhanced qualities of a fresh or expanded understanding of a problem, the patient also benefits from the emotionally supported experience of positively modifying perspective.

17.3.1.3. Using post-hypnotic suggestion to facilitate thought stopping ‘Whenever you notice [the target thought], you will immediately and automatically find yourself saying, “Stop!” and your attention will immediately and automatically turn to [the preferred thought]’. The effectiveness of thought stopping can be enhanced by the contribution of post-hypnotic suggestion—the automatic quality of the desired behavior. 17.3.1.4. Using post-hypnotic suggestion to facilitate behavioral change Case example: compulsion: Erika—overeating and regretting it Trigger: stress and anxiety. Treatment plan: identify triggers. Post-hypnotic suggestions are offered to enhance control over behavior. These include: ‘Whenever you notice that impulse to snack, stop what you’re doing, take a deep, satisfying breath, hold it for a moment, and then, as you let it all the way out, these feelings of comfort and satisfied wellbeing will automatically come washing over you. You will then listen to music that pleases you [or initiate one of two other stress-reducing behaviors the patient has identified]’. Case example: phobia: Erik—fear of flying Trigger: thinking about flying. Treatment plan: conventional CBT exposure is made to the hierarchy of anxiety stimuli within the hypnotic context, plus post-hypnotic suggestions for managing anxiety when it emerges. These suggestions include:‘Whenever the thought of flying occurs to you, take a deep breath, hold it for a moment, and then, as you let it all the way out, notice how naturally these feelings of comfort and well-being come washing over you…’

17.3.2. Exploration or problem solving Clinical example: Erika (same patient as above): compulsion: overeating

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Prior to developing the CBT plan, Erika discussed her experience of overeating. Initially, she identified her problem as ‘habitual overeating’ and she had no awareness of what stimulated the habit nor of what role the habit might play in her life. During the conversation, suggestions were made for her to close her eyes and become increasingly aware of her inner experience. Since she readily responded, hypnotic suggestions were used to heighten her awareness of her eating habit. ‘As you sit quietly, you’ll begin to notice the feeling you’ve described. You’ll begin to want to snack. Let me know when that happens’. After a moment, Erika smiles and says, ‘I feel embarrassed, but I think I want to eat a cookie’. That’s right, you want to eat a cookie. And, as you let that feeling continue to be with you, tell me what you see in your imagination. I’m in my kitchen. You’re in your kitchen. (Note: the echoing of Erika’s statements is intended to heighten her awareness. This process must be done with finesse, of course, lest it seem robotic and disingenuous.) Mhm. I’ve just gotten home from work. [She sighs] God, I feel exhausted. You feel exhausted. And what else are you aware of right now?

Erika is quiet for a moment and looks puzzled. ‘I think this reminds me of coming home from school when I was a kid. My mom would always be there, in the kitchen’. She laughs. ‘I have the feeling that she was always baking, but I know that can’t be true’. You have the feeling that she was always baking. Mhm. And what else do you notice? She always sat me down with a glass of milk and two cookies. And the same for my sister. She always sat you down with a glass of milk and two cookies. As you remember this, what do you feel?

Erika smiles. ‘I feel sort of … sort of bittersweet, you know? It’s nice to remember my mom in this way, but…’

It’s nice to remember your mom in this way, but… ?

She sighs. ‘I realize, now, that, when I get home from work, I wish my mom were here to give me milk and cookies’. She laughs. ‘It’s nice, but sort of sad, because … well, she’s not here, is she?’ It’s sort of sad, because she’s not here.

Within a short time, the conversation led to Erika’s growing awareness that, at least partly, her daily snacking was a self-soothing attempt to recreate the comfort her mother afforded her. We were then free to begin attending to the lack of comfort in her life and to explore more productive, satisfying and healthy ways to obtain the comfort she needed.

17.3.3. Development of the

therapeutic relationship Shor (1962) identified archaic involvement as an essential feature of the hypnotic experience. Archaic involvement refers to the rapidly developed sense of closeness the patient feels to the clinician who employs hypnotic methods and, by extension, it refers to the heightened sense of power and import the patient attributes to that clinician. For Shor, this reflected a psychological revivification of feelings and the re-enactment of the relationship the patient had with early care-givers. The clinical significance of this archaic involvement merits special attention. Any alert practitioner of hypnotic methods has observed the sometimes sudden alteration in the quality of the therapeutic relationship. This phenomenon has been explored elsewhere (Bowers, 1976, p. 113; Diamond, 1984; Frederick, 1994; Barber, 1998a). This quality of the hypnotic experience lends itself to utilization in the clinical circumstance, of course, but, even if the clinician does not have this purpose in mind, the phenomenon will occur. That is, even if one is strictly focused upon the utilization of hypnotic methods as an adjunct to CBT, the patient is likely to experience archaic involvement. Thus, the hypnotic experience tends to cause the patient to feel attended to, comforted by and emotionally closer to the clinician. Because the experience of being hypnotized tends to promote trusting, affectionate feelings toward the clinician and tends to incline the patient toward compliance with the clinician’s

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suggestions, experienced clinicians use this feature to facilitate the patient’s sense of comfort and security in the clinical situation. It may be that this experience promotes a lowering of defenses toward the clinician, and is central to the sometimes rapid effects often engendered by hypnotic treatment. The process of building the relationship is more complex, of course, than the process of providing CBT. The process of building the relationship is also more complex and more lengthy than reflected in the clinical examples described above. Most clinicians are familiar, though, with the salutary effects of a patient’s developing trust and openness to the treatment.

17.4. Troubleshooting Treatment does not always go well. Sometimes the treatment, however well validated, is ineffective. Or sometimes the treatment may result in reduction of symptoms, but only transitorily. Though it is rare, occasionally a patient may experience untoward complications resulting from the hypnotic experience. We do well to be prepared for these eventualities, however uncommon they may be.

17.4.1. When the intervention is not

effective Case example: anxiety: Bart, a pilot afraid to fly Trigger: intrusive thoughts about a near-accident. Treatment plan: Anxiety hierarchy in the context of hypnosis. Bart is a private pilot who was frightened by a potentially catastrophic ‘near-miss’ of a collision with another aircraft. The resulting anxiety has kept him from flying. He responded readily to a hierarchy of imagined stressors, beginning with imagining the airport, which he could do with no anxiety, through being at the controls of the airplane, which, initially, he could not tolerate. Through hypnotic suggestions to reduce anxiety, and with two repetitions, Bart was able to experience the full hierarchy, including the highest level, piloting the airplane, with no unpleasant affect. Within a few days, he went to the airport to fly. He was able to approach the airplane,

performed the pre-flight inspection, executed the checklist and started the engine. However, he felt increased anxiety and felt he should not fly. The treatment was repeated within a week, with results similar to the previous occasion. Bart said he felt confident, now, that he would be able to fly. A return to the airport the next day resulted in a similar aborted attempt to fly. At our next appointment, when we discussed the treatment ineffectiveness, I suggested it meant that perhaps I was missing the meaning of the flying anxiety or its role in his life. He disagreed, and concluded, ‘Maybe I’m safer here on the ground’. He discontinued treatment.6 Two years later, Bart sought treatment again, saying, ‘You were probably right about missing something. I hadn’t told you about my marital troubles, and that’s what I’d like your help with now’. As Bart freed himself from a very unhappy marriage, he reported that his general level of anxiety decreased and he had begun flying again, though with an instructor. The lesson this case taught me is to be wary of being too narrowly focused. If I had had broader understanding of Bart’s circumstance, I might have been better able to integrate that knowledge with his anxiety about flying. For example, if I had understood the stress he felt from his unhappy home life, I might have been able to look beyond the apparent root of his flying anxiety (the near-accident), as I was subsequently able to do. (It eventuated, as you may have guessed, that Bart’s unhappy home life generated an undercurrent of apprehension and anxiety about which he remained only distantly aware. One might say that this anxiety cathected to his sense of the danger of flying. Since the source of his anxiety—his conflicted marriage—was not given adequate attention, his anxiety was not reduced and, so, his fear of flying was not affected.)

17.4.2. When there are complications Case example: Genevieve, painful cysts Treatment plan: establish hypnotic analgesia to reduce awareness of pain. 6 I must admit that this reduced my own anxiety. What if, after successfully reducing Bart’s anxiety about flying, he is involved in an aircraft accident?

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Genevieve is a 36-year-old oral surgeon who suffered from painful mammary cysts. Her physician had no effective solution to offer, so Genevieve has sought hypnotic treatment. Contrary to her expectations, she is unusually responsive to hypnotic suggestion. At the conclusion of the first hypnotic experience, she expresses surprise that 40 min seem to have passed in no more than ‘four or five minutes’. She is very surprised to notice that she has no pain. We make a follow-up appointment. That night, Genevieve reaches me through my answering service. She is obviously distressed as she recounts the events following our appointment. I walked down the stairs and then, when I reached the sidewalk, I didn’t remember where I was or where I should go next. I wasn’t really troubled by this, but I knew that it was very unusual. I always know where I am and where I’m going!

She went on to describe becoming oriented sufficiently to remember that she was supposed to return to her office. She then walked three blocks to the location of an office where she had practiced prior to moving to her current location more than a year ago. She was more agitated when she realized her error. She then hurried back toward my office where she had parked her car. ‘Then I just sat in my car for … a couple of minutes, I think … just sort of “blissed out”, I guess you’d say’. She then seemed to ‘wake up’ and the rest of her day was uneventful. She was calling now, however, because she was increasingly worried about her experience. ‘Am I going crazy, or something?’ After reassuring her, we agreed to meet as we had previously arranged. At our appointment, 2 days later, she reported that she had experienced no pain since the previous treatment. ‘I should be happy about that, I guess, but I feel too worried about what’s happening to me’. I describe my belief that she is far more deeply responsive to hypnotic suggestion than she (or I) had imagined and that the residual confusion she experienced was a result of the depth of her altered state. She accepted this explanation. However, she declined further treatment, saying, ‘I can’t believe you cured my pain so quickly, but I’m glad, anyway’.

Genevieve’s experience was significant to me, alerting me to the possibility that a patient may not be fully oriented just because she and I expect her to be. Subsequently, I have give more time and attention to assuring that a patient is fully oriented before leaving my office. I have previously presented a more thorough discussion of cases that involve unintended complications (Barber, 1998a). The mindfulness that we wish for our patients is required of us to manage such unintended consequences of our treatment.

17.5. Summary The effectiveness of psychotherapeutic treatment, in general, and CBT, specifically, may be accelerated and otherwise enhanced by the thoughtful integration of hypnotic methods. The experience of hypnosis may serve to heighten the patient’s focus and concentrate attention on the therapeutic experience. Additionally, the relatively rapid development of the therapeutic relationship that results from the hypnotic experience supports the effectiveness of the treatment. While clearly advantageous, such gains are accompanied by potential difficulties. Clinicians who employ hypnotic methods are obligated to be especially alert to complications and other unintended consequences of the hypnotic experience. Even if a symptom-based emphasis (rather than a relationally rich psychotherapeutic alliance) is the expressed goal of treatment, clinicians who employ hypnotic techniques must be psychologically prepared for the kinds of emotional experiences and attachments that may develop. Be realistic about expected outcomes. Be a clinician first. Remember to integrate hypnotic methods with sound psychological theory and practice. Utilize effective assessment and be prepared for whatever surprises your patient may bring to you. For you can be sure they will.

Acknowledgments I am fortunate to have had the indispensable advice of Mary Pepping, PhD, ABPP, and Sam LeBaron MD, PhD while writing this chapter.

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References American Psychological Association (1993) Psychological Hypnosis: A Bulletin of Division 30, 2. Division of Psychological Hypnosis, Executive Committee, American Psychological Association, Wahington, DC. Barber, J. (1998a) When hypnosis causes trouble. International Journal of Clinical and Experimental Hypnosis, 46: 157–170. Barber, J. (1998b) Hypnosis and memory: a hazardous connection. Journal of Mental Health Counseling, 19: 305–318. BBC Television, Michael Barnes, producer (1981) Hypnosis. BBC, London. Bowers, K. (1976) Hypnosis for the Seriously Curious. Norton, New York. Braid, J. (1960) Braid on Hypnotism. Julian Press, New York. Diamond, M. J. (1984) It takes two to tango: some thoughts on the neglected importance of the hypnotist in an interactive hypnotherapeutic relationship. American Journal of Clinical Hypnosis, 27: 3–13. Frankel, F. H. (1976) Hypnosis: Trance as a Coping Mechanism. Plenum Medical Book Co., New York. Frederick, C. (1994) Silent partners: the hypnotherapeutic relationship with non-verbal ego states. Hypnos, 21: 141–149. Glisky, M. L., Tataryn, D. J. and Kihlstrom, J. F. (1995) Hypnotizability and mental imagery. International Journal of Clinical and Experimental Hypnosis, 43: 34–54. Hilgard, E. R. (1986) Divided Consciousness, expanded edn. Wiley, New York. Hilgard, E. and Hilgard, J. (1994) Hypnosis in the Relief of Pain, revised edn. Brunner/Mazel, New York Hilgard, J. R. (1970) Personality and Hypnosis: A Study of Imaginative Involvement. University of Chicago Press, Chicago. Kihlstrom, J. F. and Eich, E. (1994) Altering states of consciousness. In D. Druckman and R. A. Bjork (ed.) Learning, Remembering, and Believing: Enhancing Performance, pp. 207–248. National Academy Press, Washington, DC.

Kihlstrom, J. F. and Hoyt, I.P. (1990) Repression, dissociation, and hypnosis. In J. L. Singer (ed.) Repression and Dissociation: Implications for Personality Theory, Psychopathology, and Health, pp. 181–208. University of Chicago Press, Chicago. Kihlstrom, J. F., Barnhardt, T. M. and Tataryn, D. J. (1992) The psychological unconscious: found, lost, and regained. American Psychologist, 47: 788–791. Morgan, A. H. and Hilgard, J. R. (1975) The Stanford Hypnotic Clinical Scale (SHCS). In E. R. Hilgard, and J. R. Hilgard (ed.) Hypnosis in the Relief of Pain, pp. 209–221. Kaufmann, Los Altos, CA. Morgan, A. H. and Hilgard, J. R. (1979) Stanford Hypnotic Clinical Scale for Children. American Journal of Clinical Hypnosis, 21: 148–169. Orne, M. T. (1959) The nature of hypnosis: artifact and essence. Journal of Abnormal and Social Psychology, 58: 277–299. Orne, M. T. (1966) On the mechanisms of posthypnotic amnesia. International Journal of Clinical and Experimental Hypnosis, 2: 121–134. Quall, P. J. and Sheehan, P. W. (1979) Capacity for absorption and relaxation during electromyograph biofeedback and no-feedback conditions. Journal of Abnormal Psychology, 88: 652–662. Shor, R. E. (1962) Three dimensions of hypnotic depth. International Journal of Clinical and Experimental Hypnosis, 10: 23–28. Tellegen, A. (1982) A brief manual for the multidimensional personal questionnaire. Unpublished manuscript, University of Minnesota. Tellegen, A. and Atkinson, G. (1974) Openness to absorbing and self-altering experiences (‘absorption’), a trait related to hypnotic susceptibility. Journal of Abnormal Psychology, 83: 268–277.

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CHAPTER 18

An Ericksonian approach to clinical hypnosis Stephen Lankton

18.1. Introduction Milton H. Erickson, M.D. (1901–1980) is largely considered an architect of innovations in clinical hypnosis and in psychotherapy; some have labeled his contributions as being parallel in scope to those of Freud. However, where Freud was a major contributor to the theory of personality structure, Erickson’s contributions involved methods and techniques of intervention and change. One can measure his contributions in many ways. He advanced clinical hypnosis, family therapy and the general approach to problem solving in all therapies. He was said to have hypnotized more than 30,000 people during the course of his career (Lankton and Lankton, 1983). He wrote the entries on hypnosis for three encyclopedias, including the Brittanica from 1954 to 1973, the Americana for 7 years, and Colliers Encyclopedia from 1952 to 1962 (Lankton, 1979). He published more than 300 scientific papers, has had more than 100 books written about him, and there are 124 institutes attempting to promote his approach worldwide. His creative and pioneering contributions to therapy inspired works by Bateson (1972, 1979), Haley (1973, 1985a,b), Watzlawick (1976), Bandler et al. (1976), Fisch (1990), Fisch et al. (1982), Ritterman (1983), Rosen (1982), Erickson and Rossi (1979) Rossi (1980a,b,c,d, 1981),

Lankton (2004), Lankton and Lankton (1983, 1986), Zeig (1980, 1982, 1985a,b), Zeig and Lankton (1988) and others. Erickson himself, however, never offered a formal theoretical formulation of his work. There are no entries entitled ‘theory’ in the indexes of Erickson’s collected writings (Erickson, 1980a,b,c,d,e,f,g), nor in Erickson’s collected lectures and seminars (Rossi et al., 1983; Rossi and Ryan, 1985), nor in any book written by him (Cooper and Erickson, 1954; Erickson et al., 1961, 1976; Erickson and Rossi, 1979, 1981). This is primarily due to Erickson’s desire to avoid structural theories for working with individuals and families in favor of formulations about the process of change itself. A great deal of confusion surrounds the work of Milton Erickson, and a great deal of diversity marks the true legacy of his career. It is difficult to characterize Dr Erickson’s approach to therapy, and his work is too novel and varied to outline the approach which he most commonly used. For example, there are a wide range of case examples given by Erickson wherein the applied technique was never repeated and never empirically tested. He provides details of successful work with patients whose symptoms or diagnoses range from pain, post-traumatic stress, general anxiety disorders, depression, childhood sexual abuse, phobias, borderline personality and dissociative disorders, catatonia, active psychosis, and beyond (Haley, 1973, 1985a,b;

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Rossi, 1980a,b,c,d). Looking just at the interventions he used, we again see a wide diversity; a few of these fall under the category of intentionally producing ‘shock’ (via an unexpected delivery), which caused a moment of pause or confusion in which clients had an inability to mobilize a response that, for them, would correctly articulate their reaction; in that moment more therapeutic progress was made. On the other hand, there are interventions which Erickson used repeatedly and which can be employed thoughtfully by modern therapists to enhance their repertoire of interventions. These would include the use of therapeutic stories such as Erickson’s repeated use of the February man technique delivered by a lengthy story within hypnosis (Erickson and Rossi, 1989). In addition, several other unique interventions arose as hallmarks of Erickson’s work. These include, for example, his use of cognitive reframing, varieties of indirect suggestion to induce hypnosis or retrieve trance phenomena, confusion techniques, structured amnesia and the use of goal-directed rehearsals in hypnosis, and visual multiple-dissociation technique, to name just a few. In addition to this dizzying array of work that students must synthesize, many myths and false assumptions have appeared both by word of mouth and in print about so-called ‘Ericksonian hypnosis’. In an attempt to clear the confusion, I will begin naming and dispelling some of these false assumptions.

18.2. Four common myths 18.2.1. Myth #1: there is some

special sort of hypnosis called ‘Ericksonian hypnosis’ After carefully studying this topic for 30 years I am confident that the hypnosis achieved by Erickson is not different from that done by other therapists. However, the term ‘Ericksonian hypnosis’ became a convenient way of referring to an approach to change that is uniquely Erickson’s. The proper phrase ought to be an ‘Ericksonian approach to change and hypnosis’. That said, it might be important to speculate on the definition of hypnosis that I am embracing.

I consider hypnosis to be a heightened state of internal concentration. In such a state, the subject may spontaneously demonstrate all the classical trance phenomena to varying degrees, depending on variables such as duration of the episode, previous learning experiences and the stimuli provided to them. Erickson described hypnotic trance ‘as a special psychological state which effects a similar break in the patient’s conscious and habitual associations so that creative learning can take place’ (Erickson and Rossi, 1979, p. 6). And at other times Erickson stated, ‘hypnosis [is] a modality of communication of ideas, understandings, and useful unrealized self-knowledge contained in what is popularly called the unconscious’ (Erickson, 1980d, p. 74). In other words, it is therapeutically communicating with the client who is experiencing that heightened state of internal concentration which facilitates a reduction of the normal conscious framework and its imposed limits. The unique manner in which Erickson communicated and facilitated change is our focus of interest, but not the hypnotic trance per se.

18.2.2. Myth #2: Erickson’s work was all about using indirect suggestion There has been some controversy over the years between those who insist that Erickson used direct suggestion and those who claim that he relied on indirect suggestion. The controversy is easily resolved when we look at the evolution of his work over time. In a 1957 (Haley, 1967) transcript of Erickson conducting an induction, we hear the direct suggestions and the redundant use of the word ‘sleep’ as found in the following quotes, ‘As you go deeper and deeper asleep…’ (p. 53), ‘Now I want you to go deeper and deeper asleep’ (p. 54), and ‘I want you to go deeper and deeper asleep’ (p. 54), and so on. However, by 1976, Erickson believed indirect suggestion to be a ‘significant factor’ in his work (Erickson et al., 1976, p. 452). Furthermore, by 1981, Erickson clearly stated that he ‘offers’ ideas and suggestions (Erickson and Rossi, 1981, p. 1) and explicitly added, ‘I don’t like this matter of telling a patient I want you to get tired and sleepy’ [italics mine]—a complete reversal from his position regarding direct suggestion two decades earlier (Erickson and Rossi, 1981, p. 4).

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With regard to his use of indirect approaches, there is clear evidence that Erickson’s practice evolved to a point in the late 1970s where he had all but abandoned his earlier techniques of redundancy and authoritarianism during induction. In the course of his career, Erickson demonstrated the use of both direct and indirect suggestion during hypnosis. He stated, ‘indirect suggestion tends to bypass conscious criticism and because of this can be more effective than direct suggestion’ [italics mine] (Erickson and Rossi, 1980b, p. 455). His later writing indicated that by the end of his career he preferred using indirection so as to reduce compliance and to have a stimulating effect on the client’s active mental processes. He explains that the effectiveness of therapy is the result of this inner activity stimulated by indirection when he writes: Direct suggestion is based primarily, if unwittingly, upon the assumption that whatever develops in hypnosis derives from the suggestions given. It implies that the therapist has the miraculous power of effecting therapeutic changes in the patient, and disregards the fact that therapy results from an inner resynthesis of the patient’s behavior achieved by the patient himself. It is true that direct suggestion can effect an alteration in the patient’s behavior and result in a symptomatic cure, at least temporarily. However, such a ‘cure’ is simply a response to the suggestion and does not entail that reassociation and reorganization of ideas, understandings and memories so essential for an actual cure. It is this experience of reassociating and reorganizing his own experiential life that eventuates in a cure, not the manifestation of responsive behavior which can, at best, satisfy only the observer (Erickson and Rossi, 1979, p. 9).

18.2.3. Myth #3: the Ericksonian

approach does not require preparation—just trust your unconscious to do the right thing This false assumption amounts to having a subject enter trance and then telling them whichever story happens to come to mind. This is a dangerous false assumption that has been promoted in many communication training workshops for nonprofessionals. I am not sure of the degree to which it is an opinion held by

any trained professionals. However, there is an appeal in this belief for inexperienced clinicians because it dictates that formal education, professional training and supervision, restraint and ethical wisdom are unnecessary for the therapist. As a consequence, we might expect clinicians with less experience to embrace such an idea. While this is not the proper context in which to expound on the subject of counter-transference, it is simply sufficient to illustrate that this idea does not arise from Erickson’s work. While Erickson was keen on having clients trust themselves and elevate their own sense of capability, to trust their unconscious experiences, he did not mean for one to conduct therapy in the absence of professionalism, conscious knowledge or unexamined conduct. He was well known for taking great effort in preparation of his interventions. There is an often told tale of his laborious reworking of a 20-page induction until it became reduced to a one and a half-page induction after many drafts. This process of careful preparation was repeated for many recorded cases (Erickson and Rossi, 1989). However, while Erickson formulated treatment plans, made ongoing assessments and took wellcrafted action as much as possible, his intent to allow and utilize the client’s unique responses would leave moments where he had to act without fully understanding the situation. Some confusion may arise from comments Erickson has made regarding these moments. ‘I know that in the situation of dealing with patients I often wish I knew exactly what I was doing and why, instead of feeling, as I know I did with both patients, that I was acting blindly and intuitively to elicit an as yet undetermined response with which, whatever it was, I would deal’ (Erickson, 1966, p. 62). While this seems to contradict earlier remarks, it is merely a careful introspective analysis of the moment to moment, here and now contact Erickson made with clients. This did not define his overall approach. He sometimes referred to the myth of the Procrustean Bed to illustrate that a therapist should not cut off the client’s experiences to make them fit into the therapist’s favorite theoretical stance. While he had an overall map of where therapy was going, he was able to take detours along the way that would accommodate unique client responses.

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18.2.4. Myth #4: anyone who claims to work with an Ericksonian approach is an Ericksonian There has been no standard set to credential or in any way certify a clinician as ‘Ericksonian’. One would assume the proper organization to undertake such a task would be the Milton H. Erickson Foundation, Inc., and its 120 plus institutes established around the world. However, the American Society of Clinical Hypnosis was established by Erickson in 1957 and it provides a competency certification for clinicians who use hypnosis. Mrs Elizabeth Erickson remains steadfast in her belief that there should not be a competing organization, collection of dues and provision of certification. This wish is regarded as a valid position by the Milton H. Erickson Foundation, Inc., and such standards and credentialing will not occur. As a result, there are no controls regulating an individual’s claims of working with an Ericksonian approach. There is a related problem. Just what is an Ericksonian approach? This chapter will outline my standards for the principle to which a therapist should adhere and the defining basic footprint of an Ericksonian approach. Readers should keep in mind that other notable authors may place emphasis elsewhere and offer an alternative schema; however, none has done so to date.

18.3. Fundamental principles

of Erickson’s approach Understanding or describing Dr Erickson’s work has two major difficulties. One is that Dr Erickson himself avoiding using theoretical trappings to create concepts for a human being or his or her problems. He often found it unnecessary to describe his approach with other than folksy or common understandings. However, his approach has been looked at carefully by a number of his students who are skillful practitioners and psycho-theoreticians. In combining the ideas purported by these individuals with Dr Erickson’s work, we can draw a framework of Ericksonian approaches to therapy. It should be mentioned that the clinical work of Dr Erickson done in waking state psychotherapy bears the same fingerprint as that

done under hypnosis. As previously mentioned, there is no such thing as ‘Ericksonian hypnotherapy’, but rather there is an Ericksonian approach to hypnosis. We can, therefore, examine the larger body of his clinical and psychotherapy work, and from this derive a richer pool of examples from which to sketch what constitutes the basic footprint of the Ericksonian approach in hypnosis as well as in waking state.

18.3.1. Speaking the client’s

language One of the most compelling features about Dr Erickson’s approach was his ability to speak to anyone. He referred to this as ‘speaking the client’s experiential language’. This meant that it was possible for Erickson to speak comfortably with a wide range of clients—from physicians and physicists to farmers, unemployed individuals, musicians, Native Americans, etc. One might question how Dr Erickson’s approach of speaking the client’s experiential language differed from that of the Rogerian approach of empathic and active listening. The answer lies in the adaptation, by Dr Erickson, of the client’s language and gestures. That is to say that there was an acculturation that quickly occurred where Dr Erickson’s approach allowed him rapidly to obtain and reflect the culture of the client who was speaking. This varies from the Rogerian approach in which the therapist merely tries actually to reflect or accelerate the emotional content for the client to indicate that the therapist understands. This has often been referred to as pacing, and sometimes ‘pacing and leading’. Leading in therapy, as done by the therapist, is the ability to blend with the client’s experience and offer ideas that change the direction of the conversation.

18.3.2. Taking a nonpathological approach Erickson was keen on reducing the degree of stigma attached to a client by the mental health or medical community. He commented that an unsightly gap between a woman’s teeth was an extraordinary way to direct a flow of water that she could ‘spit’ at a man who followed her to the water cooler at work; he convinced a girl with

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severe acne that it was like ginger cookies fell on her face; he got an autistic young man to take dance lessons and then self-evaluate that he was better off than the wallflowers at the barn dance; he convinced a young girl obsessed with her large feet that her feet were too small, etc. In none of these cases did he need to resort to clinical labels or a focus on the client that emphasized deficiency. Instead, he emphasized a nonpathological approach that continually identified personal and interpersonal strengths that empowered his clients.

18.3.3. Conceptualization of

symptoms: positive and individualistic From his earliest years as a psychiatrist up to at least 1954, Erickson took a traditional analytic view of neurosis and various symptoms. He said the development of neurotic symptoms ‘constitutes behavior of a defensive, protective character’ (Erickson, 1980c, p. 149). By the mid-1960s his view had become much more interactional. Perhaps this was a result of his collaboration with Jay Haley, Gregory Bateson, John Weakland and the Palo Alto Communication Project. In any case Erickson writes, in 1966, ‘Mental disease is the breaking down of communication between people’ (Erickson, 1980d, p. 75). However, by the end of his career, he had moved even further from the analytic and the communications/systems theory of disease. He stated that symptoms are ‘forms of communication’ and ‘cues of developmental problems that are in the process of becoming conscious’ (Erickson and Rossi, 1979, p. 143). In summary, his evolution of thought concerning the nature of problems became less oriented to a pathological explanation until, in the end, symptoms could be seen as communication signals of desired directions of growth. Erickson took such signals to be a request for change and even unconscious contracts for therapeutic engagement. Erickson attempted to take a unique approach with each client. He mentioned this unusual approach in nearly every training session I attended in the mid- to late 1970s. His personal contact and nonpathological view of clients led to a strong resource- or strength-oriented approach to all problems. He did not espouse

a personality theory and did not, therefore, posit the existence of a negative or harmful personality part (such as Thanatos principle, Superego, negative Adaptive Child Ego State, bad-mother, shadow, etc.). It appeared that for Erickson, all behaviors, thoughts, feelings, perceptions, and so on were resources that could be used in a manner that was positive for the client. This view gave rise to the logic behind reframing and utilization.

18.3.4. A strategic approach Erickson was fully engaged in the sessions to the extent that he orchestrated the direction of therapy whenever possible. This active approach, wherein the hypnotist introduces the next issue, experience or idea, is the key factor in a strategic approach. While Erickson’s speaking the client’s language seems Rogerian in principle, his strategic approach is clearly a departure from anything Rogerian. There is a fine line between controlling a session and being strategic in such a fashion that, at the same time the client is contributing to the therapeutic movement, the therapist is introducing control into the material. Yet this type of blending is exactly what Erickson attempted and achieved in his best cases.

18.3.5. Solution oriented Erickson was interested in moving clients from their current problem state to one of health and adjustment as soon as possible. He inquired selectively about a client’s past and placed the emphasis of therapy on the goals and future direction of outcomes that might be achieved. He did not take elaborate psychosocial histories, but derived an understanding of a client’s limiting past from the limitations he or she demonstrated in accessing resources in the present. Since the goal was to help clients have the resources they needed in the contexts in which they needed them, an analysis of past limitations was only counter-productive. I speculate that this approach was refreshing to most clients and reduced the possible defensiveness and stigma attached to seeking professional help. The ‘bottom line’ is that therapy is about retrieving experiences. It is not about insight, or changing reinforcers, nor is it about cognition and imagery, per se. It is about any or all of these aspects, providing the central concern is to reorganize the

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client’s experiences.‘It is this experience of reassociating and reorganizing his own experiential life that eventuates in a cure…’ (Erickson, 1980e, p. 38).

18.3.6. System oriented Erickson did not fall victim to the notion that a person could be treated in isolation. When he saw a child or one member of a couple, he knew he was helping to create change in the entire system. Granted, his way of viewing interventions made his actions or interventions seem similar for individuals, couples or families. For example, a paradoxical intervention could be requested for an individual’s behavior in trance, a couple’s behavior in couple’s therapy or an entire family’s behavior in family therapy. Indeed, the interventions he typically used have even been expanded into organizational and corporate change (Lankton and Lankton, 1997; Lankton, 1998).

the basic minimum work that got them active. He would ask for a very small change as a precursor to a larger change. Once a client was in action, greater action could continue. Erickson thought that insight was a cognitive understanding that did not lead to action. Rather, he thought that action would be followed by insight (and not the other way around). Erickson writes, ‘In other words, hypnotic psychotherapy is a learning process for the patient, a procedure of reeducation. Effective results in hypnotic psychotherapy, or hypnotherapy, derive only from the patient’s activities. The therapist merely stimulates the patient into activity, often not knowing what that activity may be, and then he guides the patient and exercises clinical judgment in determining the amount of work to be done to achieve the desired results’ Erickson and Rossi, 1979, p. 9).

18.3.7. The use of ambiguity

18.3.9. Utilization

Perhaps the most intriguing aspects about Dr Erickson’s work were his use of various forms of ambiguity in his interventions. He has written about the use of ambiguity as forms of indirect suggestion (Erickson and Rossi, 1980b), varieties of double binds (Erickson and Rossi, 1980a), confusion techniques (Erickson, 1980f) and the use of complex stories or therapeutic metaphors (Erickson, 1980b). These will be discussed in greater detail below. Furthermore, his use of humor and interactive questioning during sessions was still another way in which he introduced ambiguity. If the client arrives at an idea by his or her own active thinking, sorting through otherwise ambiguous content, then the client will not resist it. It was the client’s discovery and not compliance that evoked the new thought, idea, goal or experience. Therein lies the true value of using a controlled elaboration of ambiguity in trance.

The principle of utilization, sometimes called utilization technique, is a pivotal aspect of Erickson’s work. Utilization refers to using, rather than challenging or inhibiting, what the client presents. If a client is adamant that he or must continue to pace the floor and cannot sit in a chair, then hypnosis is done asking the man to continue pacing. In one case, Erickson asked if a client would be ‘willing to cooperate with me by continuing to pace the floor, even as you are doing now?’ (Erickson, 1980g, p. 181). Each time the man passed the chair, Erickson would comment how nice it might be to sit in it and relax but, since he could not, to keep pacing. Eventually, he was permitted to sit for increasingly longer periods and then continue pacing. Finally, of course, he remained in the chair and in hypnosis. Summarizing this process, Erickson wrote, ‘These techniques are in essence no more than a simple reversal of the usual procedure of inducing hypnosis. Ordinarily trance induction is based upon securing from the patients some form of initial acceptance and cooperation with the operator. In Techniques of Utilization the usual procedure is reversed to an initial acceptance of the patients’ presenting behaviors and a ready cooperation by the operator however seemingly adverse the presenting behaviors may appear to be in the clinical situation’ (Erickson, 1980g, p. 178).

18.3.8. Action versus insight In addition to these verbal methods, Dr Erickson also used a number of extramural activities that have been called ordeal assignments, ambiguous function assignments, and task and symbolic assignments. In addition, Erickson felt that the mental effort made by the client in hypnosis was

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18.3.10. Close observation Erickson’s students were often surprised at the degree of observational skill displayed by him in training classes and while they witnessed his interactions with clients. These tales have included his keen eye for a client’s arm movement, calluses on a client’s hand when they shook hands, and other reported unique behaviors that revealed telltale aspects that helped build a diagnosis or assessment. The following is a rare report of the degree of concentration Erickson would bring to a session. Upon the arrival of my patient I immediately became intensely absorbed in the task confronting me … Now and then I became aware that I had been so attentive to my patient that I had forgotten where I was, but I would comfortably and instantly reorient myself… To begin, my first procedure was to make a visual and auditory survey of the interview situation. I wanted to know what my patient could see and hear and how a shift of his gaze or a change of his position would change the object content of his visual field. I was also interested in the various sounds, probable, possible, and inclusive of street noises, that could intrude upon the situation. I inquired about the age, height, weight, and sex of my patient, and I tested various possible seating arrangements to check relative physical comfort, the possibilities of adequate recording, and the predominant content of the patient’s general field of vision (Erickson, 1966, pp. 62–63).

These reports are indicative of Erickson’s attempt to truly understand the client’s experiential world and blend with it. In his folksy way

he would urge therapists to ‘put one foot in the client’s world and keep one foot in (their) own’ (Erickson, personal communication, August 18, 1975). I address the importance of this position in the next section that deals with the components that will define the basic ‘footprint’ of Erickson’s work.

18.4. The basic footprint Identifying the modern Ericksonian approach to change can be accomplished by looking for the signs of what I call the basic footprint of Erickson’s approach to change. It identifies the approach that Erickson taught and that was reflected in the cases detailed in his collected works (Rossi, 1980a,b,c,d). Many have suggested that clinical hypnosis typifies his approach. Others believe that techniques such as metaphor, paradoxical intention and indirect suggestion are the crucial signs (Zeig, 1985a,b). But techniques are not the essence of Erickson’s work. His is instead a theory of change, and a process of contact with clients that embodies the unique aspects of his approach. The basic footprint is a model of change that represents and identifies Erickson’s method for change. It is a general umbrella under which we should be able to place any step of change or intervention. Encounters that follow the basic footprint create change, and any therapy that steps through these stages reflects his approach and echoes Dr Erickson’s legacy. A brief description of the basic footprint may be helpful. The steps are: matching, blending, utilizing, introducing ambiguity (disrupting stasis), reframing and co-creating outcomes (see Table 18.1).

Table 18.1 The basic footprint Stage

Summary statement about the general goal for each stage

Matching

Understanding client’s experience, increasing rapport

Blending

Reducing resistance to new ideas

Utilizing

Allowing client to extend energy of conflict and exhaust it

Introducing ambiguity

Unbalancing, creating a search for ‘ground’, stimulating client’s involvement

Reframing

Increasing cognitive or perceptual options or changing the meaning first discovered

Co-creating outcomes or twist

Including unique client needs and resources; allowing it to end with the client’s unique slant

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Since each area of the basic footprint track is represented by a single word or phrase for convenience, some degree of greater explanation is offered here to provide a better grasp of what occurs and what sorts of interventions, activities, strategies, tactics, etc. are encompassed within each step. Rather than a list, these phases might best be considered as a wheel. It is the entire gestalt of that wheel that, once set in motion, facilitates unique change.

18.4.1. Matching The goal for matching is to understand the client’s situation and begin to build rapport, and to experience the world from the client’s perspective. ◆ Becoming complementary or symmetrical, depending upon the situation. ◆ Responding, if possible, to all messages sent by clients (verbal and nonverbal). ◆ Responding in same system in which system message was sent when feasible. ◆ Packaging communication in the unique manner each client uses. ◆ Speakinge the client’s experiential language. ◆ Beginning to see, feel, hear and experience the world as clients do. ‘There should be a constant minimization of the role of the hypnotist and a constant enlargement of the subject’s role’ (Erickson, 1967, p. 18). Typical interventions or activities include careful observation, speaking the client’s language, entering into the client’s world, verbal and nonverbal interpersonal matching behavior, responding to the client in the manner the client expressed him or herself, responding to all channels of communication used by the client, accurately reading ‘between the lines’ and contextualizing to the same degree the client does.

18.4.2. Blending The goal is to maximize the client’s ability to express, free of tension, and to introduce ideas to the client free of resistance. ◆ ◆ ◆ ◆

Reducing resistance. Minimizing interference by the therapist. Resonating with the client system. Keeping pace with the dynamic speed and energy.

◆

◆

◆

Blurring the boundary or reducing the difference between self and the other person, Removing the line between following and leading clients, Introducing change only at the client’s speed,

Often matching and blending have been lumped together as if they were one and the same. The important difference is that an ongoing adjustment to the dynamic motion of the client is not the same as matching communication channels or seeing the world from the client’s perspective. The goal of matching is to experience the client’s perspective on the world—the goal of blending is to blur the line between therapist and client and to reduce resistance. Matching and blending need to remain separate aspects to emphasize (and ensure) the importance of the continued use of both. Typical interventions or activities include accepting what clients present as they present it, extramural contracts for increasing trust, using silence, allowing clients to move first and emit fantasy, thought, words and behavior as they emerge.

18.4.3. Utilizing Using or exhausting clients’ efforts, energy and direction. Accepting, enjoying and not resisting the other person’s offering. ◆ Using client energy with gentle guidance. ◆ Continuing client behavior and requesting more of it. ◆ Introducing minimum guidance or control in the direction or expression. ◆ Allowing clients to extend the use of ineffectual problem-solving efforts. ◆ Allowing clients to extend any energy of conflict until they exhaust it. Typical interventions or activities include the ‘classical’ use of clients’ presented behaviors, extending clients’ energy in the manner they wish to extend it, bringing clients’ energy and behavior into the service of therapy, using latent experiential potentials and behavior, reducing the effort of the therapist, encouraging clients to continue certain thoughts or behaviors with directed goals, or helping clients tap latent ◆

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potentials that have shown some sign of existence (such as talents, or feelings, curiosity, etc.).

18.4.4. Elaborating ambiguity or

specificity Elaborating ambiguity or specificity helps facilitate clients’ searching for experience. ◆ Facilitating search for understanding or new behavior. ◆

Unbalancing, creating a search for ‘ground’.

◆

Personalizing a learning by making sense of it.

◆

Seeking a different, or greater experience to their problem solving.

◆

Introducing material that is ambiguous but which is apparently meaningful.

Requesting more specificity so clients seeking meaning try to find a foot-hold or balance in reference experience. Techniques include using metaphors and stories, using anecdote for understanding and experiencing retrieval, using verbal confusion, formulating and using indirect suggestion, unbalancing the client system with ambiguous function assignments, and using detailed confrontational and specifying questions that help clients search for their own unique meaning and grounding. ◆

18.4.5. Reframing or relabeling Reframing or relabeling assists with sculpting cognitive and experiential understanding. ◆

Using freshly discovered footing or ‘sense’ of balance.

◆

Changing the meaning or ‘size’ of discovered ideas and experience.

◆

Magnifying or diminishing understandings, explanations, reports of history, experimental material, etc., to suit clients’ desired and contracted outcomes.

Making understandings and experience more or less important, more or less inclusive, ‘bigger’, ‘smaller’, ‘softer’, ‘harder’, etc. Techniques include carefully choosing each label and explanation, using techniques of reframing which include a global use of the term reframing as in ‘life reframing’, conceiving and formulating what is reframed content from the client, reframing experience, etc. ◆

18.4.6. Co-creating outcomes Being sensitive to the desires, limitations and skills of clients as used by therapists to help determine maximum achievement implementing therapeutic outcomes. ◆ Including the client’s unique needs and skills. ◆ Implementing understanding of all the labeled and ‘reframed’ resources that have occurred in therapy. ◆ Helping clients take credit for achievements. ◆ Knowing when to let clients ‘go it’ alone. ◆ ‘Backward framing’ the meaning and accomplishments of the therapy. ◆ Handling termination and follow-up decisions and issues. Techniques include initial contracting with clients, changing contracts in the course of therapy, allowing clients’ a unique ‘take’ on performance or insight about their accomplishments, learning from and being influenced by the client, compromising goals and understandings, post-hypnotic suggestion, emanated imagery, self-image thinking, setting expectations, etc. There are some complications in this model as mentioned; some interventions operate across several phases simultaneously. Also, therapists should continue to conduct the activities of the preliminary phases as they advance through the others. Finally, any phase can be omitted, depending on various factors of the case. However, when too many are omitted, one can no longer identify the overall approach as something that is exclusively or uniquely Erickson’s basic footprint for change. Some of Erickson’s techniques seem to cover more than one area of the basic footprint at once. Techniques auch as storytelling may be seen at times as fulfilling almost every part of the basic footprint. Similarly, reframing may at times be seen as involving at least three aspects of the basic footprint: matching part of a client’s understanding; introducing a view that is temporarily disrupting; and finally achieving its end as a different understanding or label. How is this sort of overlap to be addressed? Occasionally, it appears that these steps proceed in a sequential fashion, and at other times it appears that they proceed simultaneously throughout the change process and to some

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degree with each technique. Personally, I think they always proceed throughout the entire change process independently of the technique being used. However, some aspects tend to be more noticeable in the early stages of engagement and contracting, and others become more obvious near the end of treatment; hence, the apparent sequential aspect of the stages or steps. For the sake of teaching any particular technique, it is fine to acknowledge this rich aspect of certain interventions and yet emphasize one relevant angle of a technique’s capability. For instance, in a section for matching, therapeutic metaphors can be taught as a way to match, or in a section emphasizing ambiguity, it can be taught as a contribution stimulating new understandings and options. Similarly, there is a point to be made that some of Erickson’s cases seem to emphasize three or four of the steps, but not all of them— indeed, in some cases maybe fewer still. (Erickson’s case of the parents hoping to talk a daughter into giving a child up for adoption, for instance, seems to only emphasize reframing.) In these truncated cases we will not see sufficient signs actually to identify it as Erickson’s unique approach, his fingerprint, or, as I am calling it, his basic footprint. But, in the cases where all or nearly all of these stages occur (whether done by Erickson or others), we can recognize his unique approach and credit Erickson. Certain therapists have explored Erickson’s contribution from the standpoint of an almost exclusive use of one or another intervention. For instance, some therapists almost exclusively employ the use of paradoxical intervention to create change, while others may have relied almost entirely on the use of skill building homework assignments. The success of such mere techniques (which will be listed below in detail) is a testimony to their power, but by themselves do not really ‘mark’ the approach that uniquely identifies Erickson’s contribution to problem solving and change. In fact, it is somewhat of a detriment when less knowledgeable therapists try a technique, fail and then incorrectly proclaim that they ‘tried the Erickson approach and it doesn’t work’. For that reason, my theme is an attempt to paint Erickson’s approach to change with the broadest brush strokes.

In considering the aspects of the basic footprint in the context of research, a main issue is that of research related to treatment outcomes. It may appear to be a paradox that research in treatment outcomes asks the question: is this set of interventions likely to create the requested improvement? That is, a success in predictability means that the interaction has, in some way, caused or forced the desired outcome. Considered in this manner, not many therapists would be proud to say there is predictably or hence ‘manipulative’ and ‘controlling’ aspects to their approach. If we can answer affirmatively that we know our approach to change will eliminate a problem, then we must conclude that therapy is ultimately very controlling and manipulative instead of being interactive in a mutually respectful or client-centered manner. If we examine the steps of an Ericksonian approach we can say that ‘matching’ or ‘speaking the clients’ language’ is not designed to create the therapy change—it is not designed to create the outcome. Nor is ‘blending’ a step to create the outcome. These are designed to maximize contact, understanding, rapport, lower resistance, etc. ‘Utilization’ is not designed to create a changed outcome either. It is intended to use the client’s energy or exhaust client energy, and from a habitual and unproductive problem-solving approach. In the same way,‘destabilizing’ and introducing the various types of ‘ambiguity’ in therapy (confusion, metaphor, indirect suggestion, antidote, etc.) are not designed to create an outcome in and of themselves. But as part of the interpersonal process, they create a context in which clients search for meaning. The same is true for ‘reframing’ and ‘relabeling’ as they are not designed to solve the problem. They are designed to help clients sculpt and change the meanings and experiences they discover and know in the most useful and therapeutic manner toward reaching a goal. In other words, research for therapy outcomes may need to be rethought in light of the steps of the basic footprint. Strategic and tactical therapy attempts to maximize an interpersonal relationship by increasing rapport, reducing resistance, disrupting ineffectual problem-solving efforts, changing the interpretation of experience and arriving at a suitable implementation of goals. Research needs to be done to measure

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the use of interventions to achieve the goals at each step, on the one hand, and the effectiveness of sequencing these steps for efficient problem solving, on the other hand. Of course, there are more research issues that we may have helped clarify by marking out the basic footprint for change.

18.5. Ericksonian approach to

retrieving experiences in trance The most difficult and confusing aspect of Erickson’s work is his use of indirection. Several works have published a more comprehensive overview of Erickson’s interventions (Lankton and Lankton, 1983, 1986, 1989; Lankton, 2004). This section is not a comprehensive overview of the techniques used by Erickson but is dedicated to developing a deeper understanding of the structure of interventions such as metaphor, indirect suggestion and therapeutic binds in hypnosis.

18.5.1. The use of metaphor as

indirect intervention In 1944, Erickson reluctantly published ‘The method employed to formulate a complex story for the induction of the experimental neurosis’ (Erickson, 1980b). His understanding at that point was that a complex story that paralleled a client’s problem could actually heighten the client’s discomfort and bring the neurosis closer to the surface. Within a decade, in 1954, Erickson was using many ‘fabricated case histories’ of fleeting symptomatology (Erickson, 1980c, p. 152). Still, almost two decades later in 1973, we see that Erickson provided several examples of case stories for making a therapeutic point (Haley, 1973), and by 1979 Erickson and Rossi actually used the heading of ‘metaphor’ as a class of interventions (Erickson and Rossi, 1979, p. 49). Again, this movement corresponds to his movement from direct and authoritarian therapy to indirect and permissive therapy. There are two major categories of metaphor: those which are parallel to the client’s problem and those which are parallel to the anticipated goal. Stories which are parallel to the client’s current state or problem are far easier to construct and were the first type of metaphors

noticed in the process of modeling the therapeutic work of experts such as Milton Erickson (Gordon, 1978; Lankton, 1980). The basic idea of the metaphoric stories that are parallel to the problem can be summarized in the understanding of the term ‘isomorphism’. Metaphors that are isomorphic have the body of their content in a one-to-one correspondence with the experience of the client. A simple way of understanding this is that for every major player and situation in the client’s problem, and for every major relationship and activity in the client’s problem that connects these players and situations, a corresponding part is created in the story told to the client. Again, the degree of distance or vagueness between the elements in the metaphor and the elements in the client’s life will regulate the degree of ambiguity that is introduced. For example, consider the following variation of isomorphic metaphor that matches the problem. Here the husband seeks affection from a wife who ignores him unless blaming him for a fault. The pattern then unfolds as the husband withdraws into depression and the wife becomes angry with him. Table 18.2 lists the situation’s components as related by the client, and the two columns show the elements of a story that can be told with varying degrees of ambiguity. It should be obvious that despite the similar isomorphic relationship between parts of the story and the problem, the more ambiguous references may not be an apparent match to the listener for some time (if at all). The solution to the dilemma is not shown in Table 18.2, and contains only the match to the problem. However, the sketching of a part (or all) of the solution would be the next step for the therapist. The therapeutic value of an isomorphic metaphor exists in two places. The first is that it outlines the context or heightens the client’s awareness for the problem situation in which the solution will be fitted, just as Erickson demonstrated in his original article. Second, isomorphic metaphors need to have resolution that provides some metaphoric solution. It is in this second aspect of isomorphic metaphors that beginning therapists may encounter difficulty. There are a few major ways for isomorphic metaphors to be terminated so that they provide a therapeutic conclusion for the problem they

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Table 18.2 Varying degrees of ambiguity Situation

Less ambiguous

More ambiguous

husband

lovebird

electric drill

(husband) asks

chirps

(drill) freezes up

needs affection

needs touching

needs oil

wife

girl

mechanic

(wife) ignores

(girl) locks up

throws down

(wife) blames faults

(girl) shouts at bird

worries it will burn

(wife) defensive

(girl) recalls messes

brags of skill

(husband) withdraws

(bird) chews cage

(drill) overheats

(husband) depression

(bird) gets ill

(drill) emits smoke

(wife) angry

(girl) sells bird

throws it out

have highlighted. The most elegant manner is that which involves the continued and often creative behavior of the protagonist through whose behavior a solution is modeled. A second, less practical method is for the therapist to introduce into the story the direct instructions that represent words spoken to the protagonist. This second option fails to meet the criteria of retrieving experiences for a client, and often fails to meet the ambiguity element that prevents resistance in the client. However, it is very practical for clear guidelines, instructions or directives to be delivered to a client in a fashion which reduces confrontation. The third and least elegant method to create a goal in an isomorphic metaphor is to introduce a break in the normal flow of the protagonist’s behavior due to some unexpected element, such as the protagonist going to therapy, having a dream or having some sudden sort of epiphany. While this device within a story will allow the speaker to jump to a solution set, it does so at the expense of the logical flow of the metaphoric content, although it still provides an opportunity for experiences to be retrieved which will help alter perception, behavior, emotion or attitude. The second major category of metaphor is a story constructed to become parallel to the goal rather than parallel to the problem (Lankton and Lankton, 1989). It is essential that a basic protocol be followed for specific goals of cognition, emotion and behavior, and that experiences be

so ordered that the metaphor retrieves a specific goal for the listener. This movement can be maximized to facilitate, if not ensure, that the listener’s experience will be one of cognitive alteration, emotional alteration or behavioral sensitizing. In order to illustrate this, the three self-explanatory protocols for emotion, attitude and behavior metaphors will be listed.

18.5.1.1. Affect and emotion protocol 1. Establish a relationship between the protagonist and a person, place or thing which involves emotion or affect (e.g. tenderness, anxiety, mastery, confusion, love, longing, etc.). 2. Detail movement in the relationship (e.g. moving with, moving toward, moving away, orbiting, etc.). 3. Focus on some of the physiological changes that coincide with the protagonist’s emotion (be sure to overlap with the client’s facial behavior).

18.5.1.2. Attitude change protocol 1. Describe a protagonist’s behavior or perception so it exemplifies the maladaptive attitude. Bias this belief to appear positive or desirable. 2. Describe another protagonist’s behavior or perception so it exemplifies the adaptive attitude (the goal). Bias this belief to appear negative or undesirable.

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3. Reveal the unexpected outcome achieved by both protagonists which resulted from the beliefs they held and their related actions. Be sure the payoff received by the second protagonist is of value to the client.

18.5.1.3. Behavior change protocol 1. Illustrate the protagonist’s observable behavior similar to the desired behavior to be acquired by the client. There is no need to mention motives. List about six specific observable behaviors. 2. Detail the protagonist’s internal attention or nonobservable behavior which shows the protagonist to be congruent with his or her observable behavior.

Conscious/unconscious bind. Use the form: ‘Your conscious mind is/may (some form of awareness) while your unconscious is/may (retrieval of the goal). Double dissociative bind. Use the form above and then reverse: Your conscious mind __A__ as your unconscious mind __B__, or perhaps your conscious mind __B__ while your unconscious __A__. Pseudo nonsequitir. State the goal: ‘A’; and then restate it with a rewording that sounds different: ‘A(alt)’.

18.5.3. A case example

Truism. Use ‘every person’ or ‘every company’, etc., and state the goal in some manner.

The case example that follows has been truncated for brevity. The goal of providing a partial case example is to illustrate the principles, basic footprint and interventions mentioned above. The client is a 28-year-old woman who is experiencing a great deal of self-criticism and thinks she might be too sensitive to the opinions of others. She feels that she does not know how to pull together being the mother of two and keep her husband happy. She is hiding this feeling and trying to be strong on the outside because she believes she and her friends will find her to be without value if she cannot perform for them. She is the mother of a 5-year-old and is 3 months pregnant with another child. She does not know if her sensitivity is a ‘plus thing or a curse’. She speculated that she might be able to use hypnosis to become less sensitive. The initial treatment goals were to help her retrieve a feeling of acceptance and belonging, help her reduce her negative self-talk, assist her in altering her self-concept to imagine herself with these emotional options, and rehearse using them in a few common daily situations. The transcript begins at the end of our initial assessment phrase.

All possible alternatives. Use a, or b, or c, or d, or ‘not’ as different ways of reaching the goal.

Client: That’s the thing I don’t know if it is a plus thing or a curse.

Apposition of opposites. Contrast a desired change toward a goal with some presenting change or process that remained in opposition to the goal.

S. L.: [Sitting in the same posture as the client and speaking at the same rate of speed] Until you find out I think that you should keep your sensitivities and your ability to be moved by moving things, that is a real precious gift. It would be a shame if you were as stiff as Alexander Haig and so I think you should keep those things. I think that you should be

3. Change the setting within the story so as to provide an opportunity for repeating all the behavioral descriptions several (three) times.

18.5.2. The use of indirect suggestion As mentioned earlier, Erickson’s reliance on indirect forms of suggestion and therapeutic binds increased in his later years. I have reduced the large number of possible indirect forms of suggestions and binds to 10. Each sentence presupposes a goal has been formulated. Then a simple formula for rephrasing the goal can be applied and the resulting sentence will sufficiently accomplish creating the form. These categories and formulae can be summarized as follows: Open-ended suggestion. Increase elements of the sentence to one higher level of vagueness. Simple pre-supposition. Use a pre-supposition and state the goal. Focusing attention. Use ‘wonder’ or ‘doubt’ about the goal.

Bind of comparable alternatives. Use ‘A’ or ‘B’ where both contain a form of the goal by pre-supposition.

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able to keep your reactions, being moved to tears by things that are happy and sad. And it’s a joy sometimes too, but I don’t think that you need to let it chip away your self esteem. So perhaps that’s what we should work on, how you can continue to keep your sensitivity and not let it chip away your self esteem, because you’re at the stage of having your second baby, shortly you’ll be enjoying the security of a nest.

In this excerpt we can see how the client’s experience is being matched, responded to and taken in a positive and nonpathological framework. The contact is sufficiently high for a new idea to be introduced without resistance. So, the discussion that preceded this as well as the above comment have accomplished the matching and blending stages of the basic footprint. These processes will need to continue throughout the session. The new idea of reducing the selfesteem problems was accepted along with the reframing of the positive aspects of her sensitivity. In the induction that follows, the indirect suggestions and binds are indicated in brackets. S. L.: So, I wonder if you can uncross your legs and put your hands on your lap [focus awareness]. I don’t know how you normally go into trance, do you know you can do that by taking off your glasses or by closing your eyes, or concentrating on something [all possible alternatives]. You could concentrate on your hands and maybe they will rise up to your face [focus awareness and pre-supposition]. One of them can rise up to your face as your eyes close [bind of alternatives]. Sooner or later everyone goes into trance in a way that’s right for them [truism]. As I talk about things that may remind you of the ways that you can put yourself into trance, and the ways that you’ve put yourself into trance before, you will of course find that your conscious mind goes from idea to idea or from perception to perception, but your unconscious should be regulating the depth of trance so that the taking of information is useful [conscious/unconscious bind]. And disregard information that is confusing or unnecessary, because everyone needs to know that you are in control when you go into trance by the very fact that you hypnotized yourself and that you used my words as a stimulus for you own induction [open ended]. All your life you’ve known how to concentrate on an idea to get more awareness [open ended]. And your conscious mind can’t just say how you do that

[focus awareness]. And with or without your conscious awareness, that hand again can move up off of your lap [focus awareness]. Your conscious mind doesn’t begin to explain how your unconscious actually moves those small muscles gradually, even using those little jerking movements [conscious/ unconscious bind]. It ought to bring you a sense of hope and a sense of comfort to realize that your unconscious does have the capability to move appendages and move ideas in a way that you didn’t think possible [conscious/unconscious bind]. And maybe it’s useful to find out that it is your left hand that is up in the air [focus awareness]. Because it is nice to know that you can be comfortable when you’re left up in the air sometimes and maybe it will go all the way to your face, half way to your face, maybe it will float out to the side, maybe it will stay right there, and for some people it gets heavier and drops [all possible alternatives]. Everyone has their own way of having their hand indicate to them that they’ve achieved the kind of trance that they can learn from [truism]. And how you learn from the trance may parallel how your hand rises when it does, moved half way up to your face [pre-supposition]. So I wonder if there is a dissociation in your arm and shoulder that allows it to be comfortable [focus awareness]. And then some sense of solving your problem is already half way forming in your unconscious [pre-supposition]. While I was talking, your cheek muscles flattened, your breathing became slower, your hand moved half way to your face, your eyes closed, skin color became more pale [focus awareness]. And I think that you will discover that you can ignore things that are irrelevant and that your conscious mind will be decidedly interested in those things that are relevant and useful [open ended]. And I bet that you’ll be glad to discover how much your unconscious learns about how hypnosis can be applied to the ease of child birth [referring to a relevant topic she did not request], even though you may have consciously been thinking about other things while I’m speaking today [conscious/unconscious bind].

In the course of this session several stories were told. The first story, omitted in this chapter, was structured to help Anna realize she would not lose her husband’s love or friend’s support if she told them about her true feelings of inadequacy. The first story following the induction was an attitude protocol with the goal of coming

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to believe that she could have more resources and problem-solving skills than she had believed were available to her. It juxtaposed two individuals who were trying to solve a riddle since extremely important personal gains or losses were at stake: ‘How can I be myself when I don’t know who I am?’ One protagonist gave the impression of confidence in her success because she thought she could do anything (a position the opposite of Anna’s). The other protagonist appeared to be on a path of failure because she knew that nothing she could think or do would solve the riddle and she was afraid that if she admitted her helplessness no one would like her (a position matching Anna’s). In the end, the confident protagonist failed because success required recognizing that she had simply to be herself with an honest admission of ‘not knowing’ how to proceed. In having that skill, the second protagonist happened upon the solution to the riddle: ‘by not trying to be somebody else’. In the attitude protocol, the clients are led to the surprising conclusion that what they feared would not come to pass but actually brought a resource they needed. Note, that the client comes to this conclusion, as it is the only one that fits the facts of the story and provides some sense of this ambiguous phase of the basic footprint of change. The second story, found here in its entirety, is an affect protocol for belonging. That is, the experience of belonging and acceptance should be retrieved by the listener in order to make sense of the ambiguity. The value of indirection is clear in that the client’s own meaning and experience is brought into play as the listener makes sense of the action, but at no time was the feeling requested by the therapist. Note that the process of the story is to make it clear that two positive protagonists are defined and then brought together. Finally, the physiological state of one of them is described and it is, of course, the same as that of the listening client, Anna. S. L.: [Illustrate each action that defines each protagonist as positive] Jane had developed a very good friendship with her girlfriend. They flew kites together, they made sail boats, they jumped rope, they collected pretty stones that they would wash off and put in boxes. And they knew, they absolutely knew that they’d never be carrying briefcases with

credit cards in them down the streets, and they just hated people like that. Those people didn’t have any fun at all, they thought, but then again they were only children. One of the things they liked to do involved bending over the bottom of those nails. They would take a bottle of nails in a sack up to the limb of a tree and they’d haul some boards up there, maybe use a rope, and then they would start pounding those nails into the boards to hold them together on the tree limbs. And the part that they liked the best was bending those nails over at the bottom when they were done so those boards wouldn’t come out, making a nice comfortable, safe, little tree house. They would swing from the ropes on cloudy days and on sunny days. And every day Jane’s friend would be there. It was just like God had supplied them with one another over the summer vacation. And then they understood that school was going to start. Jane thought that she was going to lose her friend. And with two little feet under her desk, inside two little shoes with two little pennies, Jane sat and looked around the classroom only to discover that her friend was seated right beside her, and at recess they were able to play with each other, and after school they could do their homework together. And it continued for some time. Then one night when she was hoping that the telephone call would come to invite her to go to the ninth grade dance and no little boy called, the phone rang and it was Jane’s friend. She wanted to go to the ninth grade dance too, so they went together. And a lot of girls went with other girls, and a lot of boys went with other boys. Finally Jane’s family moved away and Jane went to other high schools, but she never forgot that special friend. Some time after that, things were really looking their worst for Jane. She didn’t know if she would ever graduate because she was having a heck of a time passing even her driver’s-ed class. She wasn’t yet aware, of course, of the fact that she was going to grow up and walk down some street with a briefcase and credit cards, because she didn’t even know if she would graduate. She walked dismally to the mailbox and opened it up and there was a letter from her special friend. It was just enough to give her the strength to continue another attempt to study those insurance policies and write an adequate report for driver’s ed. She went to Disney World after graduation and before college. She was working there because it seemed like a nice place, and a lot of activity and

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a lot of friendly people, including the biggest friend of all—Mickey Mouse. And when she checked into the underground dormitories where the people lived, how surprised do you think that she was to find out that her best friend of long ago was also living in the dormitory, also working at Disney World. They had a second childhood together. It was such a hoot to work together at Disney World, she said. And having matured more she wasn’t really that sad when they went off in separate directions. And although she wished that she had discussed her plans for college with her friend, it totally slipped her mind. Michigan State University is a long way away from Disney World and Justin Hall is a very big dormitory. And it is only half way across the campus from Bessey Hall but it is a long way across the campus from Acres Hall. And so it took three or four weeks on campus before Jane found out while she was staying in Justin her best friend was staying in Acres Hall. Walking down the sidewalk that day across Bessey Hall bridge leading to the American literature class, it seemed like everybody she saw looked like someone from her past, and that guy over there looked like somebody she knew, that guy looked like somebody she wished she knew from her high school, and that guy looked like somebody from home town, and that guy looked liked somebody from Disney World, so did that girl. In fact, that girl looked just like her best friend. And so she convinced herself that it wasn’t her best friend and kept on walking. [This step moves the protagonists toward each other] From down the bridge she didn’t know that the girl with the little ponytail who was walking towards her was having the same thoughts, and was unable to shake the thought. And that little shaking ponytail sure shook like her best friend. She thought, isn’t it funny that you keep seeing things that aren’t there when you feel lonely. And when they were only three feet apart she realized that it WAS her best friend and they ran towards each other and they embraced, giving out the loudest giggle of glee that Bessey Hall has ever had. As they hugged each other, tears of joy ran down their cheeks. Neither one of them could finish the sentence about how they were so happy that they had ended up at Michigan State and they hadn’t even talked to each other. They couldn’t believe that they were really enrolled here and how much fun it was to find a friend.

And they just hugged on that bridge for more minutes than you should if you want to get to class on time. [This step is to focus on physiological signs of protagonist that match the client] Signs of strain went out of their lips and foreheads, and they just closed their eyes and touched each other and patted each others back, sometimes they laughed. Jane’s mouth was slightly turned up at the corner. Her skin was pink, muscle tonus had returned to her cheeks, a certain glitter returned to her eyes. You never know how your conscious mind is going to be surprised with the feeling of joy, a little wetness around the eyes, and they weren’t embarrassed at all. They were happy they knew out loud how they cared for each other, they had lumps in their throats, they realized how fate had brought them together again. What a precious feeling to memorize and to know that you have with you forever. And Jane was probably thinking that that feeling would be with her for ever and now she knew she’d never have to give up that feeling. There was no way she could do anything but remember this moment and that feeling inside. Nobody had to tell her that that was the feeling of being wanted and worthy of fun and loving. I think that the conscious mind never even cared, and it was the unconscious feeling of warmth, and openness and acceptance, breathing a little more deeply, standing a little taller, shoulders relaxed from the tension, the conscious mind never even knew it had … expanding the rib cage while realizing that the tongue is relaxed. She didn’t know that the job she had to do was to memorize that feeling. People don’t know how you memorize something, how you find it in your chest, or your neck, your face, or it’s an idea, a picture in your mind. Now let that feeling radiate until all parts of your body know it. You earned it and you deserve it. Jane had to get to lit class before she was too late to get the lesson for the day. They exchanged phone numbers and ran off, but that wouldn’t be the end of it. She held onto that feeling.

A third story was now introduced. This story dealt with ways people can reduce the behavior of self-criticism. The story provided examples of the protagonist identifying a self-criticism and then exaggerating it to a humorous extreme. Then, the context is changed and the process is repeated. In each instance, Anna’s face would reflect a seriousness with the identification of each of the protagonist’s criticism and then

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would reflect humor, and she often laughed as the criticism became ludicrous. It can be speculated that this associating of humor with previously feared self-criticism will continue to take the ‘bite’ out her self-critical behavior. Furthermore, the process of applying this cognitive behavior was taught repeatedly in the behavior protocol metaphor. Finally, a self-image rehearsal metaphor was presented. This story begins where an earlier metaphor, that for affect protocol, ended. In this manner the session creates a multiple embedded metaphor effect discussed elsewhere (Lankton and Lankton, 1983). This metaphor is presented in partial form so as to illustrate the basic parts of the steps involved. Jane had been sitting there with that feeling all through American literature class of having embraced her friend on the Bessie Hall Bridge. She still felt the warmth, she still felt the smile, her face still had a glow on it, and her heart was still pounding like she was in love, because she had her best friend. She couldn’t see what the professor could see through his eyes. Or she’d be able to see a sweet delicate little swallow; her head perched vertically between her horizontal shoulders, back relaxed somewhat as she leaned forward with her elbows on the desk. Her eyes were closed and not twitching. It was too bad that she didn’t have a mirror so that, while she had that feeling of relaxation, she could see her face with that feeling of joy and the acceptance and love, because you should be able to see your face when you have that feeling of joy, acceptance and love. And, you can see a smooth forehead, and relaxation of the little lips slightly curled at the side, pink color of the skin, easy breathing, and the warmth around the body that seems to come because the shoulders are rolled forward just like the embrace is still happening. And she wasn’t thinking of lit class at all, of course. Every time the professor said something about somebody’s life and literature, the scene changed, and it wasn’t just her face she saw. She was seeing herself conducting various activities that she’d never dreamed about before, while she saw herself have the feeling of acceptance and joy, and comfort. Some noise happened and she saw the scene change and there she was going through the shops with that feeling of comfort and joy, window shopping and buying clothes. She hadn’t realized how her

unconscious had been capable to memorize that feeling and give it to her conscious mind, so that on the outskirts of her conscious mind, she could form a visual picture of herself walking down the street and feeling that sense that she had gotten and seeing it on her face. She saw it again when the scene changed and she watched herself talking to strangers. Her face said ‘everyone likes me’, and that is what she thought. And when she saw herself with that feeling, there was another change and another posture as she saw herself sitting in class with that same feeling, studying with that same feeling. And he must h\ve said something about family, and life and America because she imagined herself in her home in her living room, with that same feeling. She chuckled to think that she had cleaned the house while she had that good feeling. It might be a little uncommon, but she couldn’t see why not. In fact she could see herself have that same feeling and the same thoughts about how nice it was to know that her sense of being liked went so deep.

It should be apparent in the above transcription that three components were used to create this feeling-enriched visual rehearsal: desired feeling resources were retrieved, a visual image of the self was formed reflecting these feelings, and the enhanced visual image of the self was rehearsed through several realistic scenarios. In each story the continued use of indirect suggestions and binds can be found, as using them will enrich the mental search process and increase the experiential involvement of the clients. While a large portion of this case session has been presented, the entire case session is too lengthy to recreate in the context of this chapter. However, Anna was in trance for nearly 1 hour and she heard the metaphoric stories dealing with accepting her particular emotional life as being tolerable, reducing her self-criticism and rehearsing her self in different contexts with feelings of acceptance and without self-criticism. Finally, a reorientation was suggested: S. L.: Sooner or later a dissociation that developed in your hand will leave your hand [truism] and help you realize a lot of other things your conscious mind was paying attention to [focus awareness]. Maybe your unconscious also learns how to apply that dissociation to matters that are imminent and your unconscious mind doesn’t even have to know how [conscious/unconscious bind].

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I hope that when you open your eyes and come out of trance, that you only remember as much as is useful to you [focus awareness], like my client Diana did when she remembered only a riddle and a feeling, eventually only a feeling, richer than a riddle [anecdote]. But know that your unconscious can take those suggestions that are relevant and build on them for your own betterment and comfort even while your conscious mind may not fully understand what your unconscious will do with them, or maybe you’ll consciously understand only small bits from time to time as necessary, so that you gain an appreciation for the wisdom of your unconscious working for your own betterment, as you or your children learn things that you can be glad to teach them [double dissociate bind]. So pretty soon you’ll probably be wanting to reorient the rest of your body like your fingers begin to do, and the skin color will probably come back here and there [focus awareness]. And then your eyes will open eventually [pre-supposition]. Sooner or later you will reorient yourself back into the room [truism].

she call me for further sessions rather than schedule one immediately. Letting this learning and alteration of mood stand as a success conveys the meaning that she has accomplished something by her trance work. On the other hand, scheduling another session immediately conveys the meaning that she has much more work to do before she has accomplished something substantial. Weighing the factors in this case, I opted for the former choice, letting her use her own unique way of unfolding this (at least temporary) new attitude and feeling in her real life. This final act of goodbye was an act of co-creating the outcome with trust that Anna would do a responsible and competent job sculpting her life with only these new resources to begin the task. Anna contacted me a year and 3 months later to say that a baby girl was born and that she and her husband and children were all doing fine. They were taking their first vacation on a family cruise ship.

Anna: Gee. I mean wow! I feel like I am still thinking a lot about, um, well I don’t really know what I’m thinking about … I mean stuff you said … I was just thinking that … maybe life isn’t really so hard, you know, like … I feel sort of like [begins crying] crying in relief. [drying her tears] You know, it’s like something that scared you is over and you can cry—like that sort of tears. [closes her eyes and sits quietly—looking almost tearful].

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S. L.: You can expect a lifetime of relief, I bet! Anna: [nodding her head slowly and then gradually building a smile and opening her eyes]. Thanks.

My comment that she may ‘expect a lifetime of relief’ was intended to go to the next phase of the basic footprint for change—reframing. That is, Anna had begun to resolve the ambiguity stage by concluding that she felt relief. However, she suggested it was a here and now relief for things in the past. If she stayed with that conclusion, the future would remain to be ‘solved’ with relief, so to speak. I chose to offer a reframing comment that implied this relief was not over, but in fact was just the beginning of much more success and relief. Her response indicated that she did not challenge that reframing, and this phase of the basic footprint was successfully concluded, at least for this session. Anna gathered her possessions and stood, extending her hand to shake my hand. I suggested

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Erickson, M. (1980e) Hypnotic psychotherapy. In E. L. Rossi (ed.) The Collected Papers of Milton H. Erickson on Hypnosis, Vol. 4: Innovative Hypnotherapy, pp. 35–48. Irvington, New York. Erickson, M. (1980f) The confusion technique in hypnosis. In E. L. Rossi (ed.) The Collected Papers of Milton H. Erickson on Hypnosis: Vol. 1 The Nature of Hypnosis and Suggestion, pp. 258–291. Irvington, New York. Erickson, M. (1980g) Further clinical techniques of hypnosis’ utilization thechniques. In E. L. Rossi (ed.) The Collected Papers of Milton H. Erickson on Hypnosis: Vol. 1 The Nature of Hypnosis and Suggestion, pp. 177–205. Irvington, New York. Erickson, M. and Rossi, E. (1979) Hypnotherapy: An Exploratory Casebook. Irvington, New York. Erickson, M. and Rossi, E. (1980a) Varieties of double mind. In E. L. Rossi (ed.) The Collected Papers of Milton H. Erickson on Hypnosis: Vol. 1 The Nature of Hypnosis and Suggestion, pp. 412–429. Irvington, New York. Erickson, M. and Rossi, E. (1980b) Indirect forms of suggestion. In E. L. Rossi (ed.) The Collected Papers of Milton H. Erickson on Hypnosis: Vol. 1 The Nature of Hypnosis and Suggestion, pp. 452–477. Irvington, New York. Erickson, M. and Rossi, E. (1981) Experiencing Hypnosis: Therapeutic Approaches to Altered state. Irvington, New York. Erickson, M. and Rossi, E. (1989) The February Man: Evolving Consciousness and Identity in Hypnotherapy. Brunner/Mazel, New York. Erickson, M., Hershman, S. and Secter, I. (1961) The Practical Application of Medical and Dental Hypnosis. Julian Press, New York. Erickson, M. H., Rossi, E. L. and Rossi, S. I. (1976) Hypnotic Realities: The Induction of Clinical Hypnosis and Forms of Indirect Suggest. Irvington, New York. Fisch, R. (1990) The broader interpretation of Milton H. Erickson’s work. in S. Lankton (ed.) The Ericksonian Monographs, Number 7: The Issue of Broader Implications of Ericksonian Therapy, pp. 1–5. Brunner/Mazel, New York. Fisch, R., Weakland, J. and Segal, L. (1982) The Tactics of Change: Doing Therapy Briefly. Jossey-Bass, San Francisco. Gordon, D. (1978) Therapeutic Metaphors: Helping Others Through the Looking Glass. Meta Publications, Cupertino, CA. Haley, J. (ed.) (1967) Advanced Techniques of Hypnosis and Therapy: Selected Papers of Milton H. Erickson, M.D. Grune and Stratton, New York. Haley, J. (1973) Uncommon Therapy: The Psychiatric Techniques of Milton H. Erickson, M.D. Norton, New York. Haley, J. (1985a) Conversations with Milton H. Erickson, M.D.: Changing Individuals. Norton, New York. Haley, J. (1985b) Conversations with Milton H. Erickson, M.D.: Changing Vol. 2: Changing Couples. Norton, New York. Lankton, C. and Lankton, S. (1989) Tales of Enchantment: Goal-oriented Metaphors for Adults and Children in Therapy. Brunner/Mazel, New York. Lankton, S. (1980) Practical Magic: A Translation of Basic Neurolinguistic Programming into Clinical Psychotherapy. Meta Publications, Cupertino, CA.

Lankton, S. (1998) Document engineering knowledge white paper. Go Inside. Retreived January 31, 1998, from http://goinside.com/98/1/kirk-1.html. Lankton, S. (2004) Assembling Ericksonian Therapy: Selected Papers of Stephen Lankton, Vol. 1, pp.1985–2200. Zeig and Tucker, Phoenix, AZ. Lankton, S. and Lankton, C. (1983) The Answer Within: A Clinical Framework of Ericksonian Hypnotherapy. Brunner/Mazel, New York. Lankton, S. and Lankton, C. (1986) Enchantment and Intervention in Family Therapy: Training in Ericksonian Approaches. Brunner/Mazel, New York. Lankton, S. and Lankton, C. (1997) Application of Ericksonian principles to larger systems. In W. Matthews and J. Edgette (ed.) Current Thinking and Research in Brief Therapy: Solutions, Strategies, Narratives, Vol. 1, pp. 215–238. Brunner/Mazel, New York. Ritterman, M. (1983) Using Hypnosis in Family Therapy. Jossey-Bass, San Francisco. Rossi, E. L. (ed.) (1980a) The Collected Papers of Milton H. Erickson on Hypnosis, Volume 1: The Nature of Hypnosis and Suggestion. Irvington, New York. Rossi, E. L. (ed.) (1980b) The Collected Papers of Milton H. Erickson on Hypnosis, Volume 2: Hypnotic Alteration of Sensory, Perceptual and Psychophysical Processes. Irvington, New York. Rossi, E. L. (ed.) (1980c) The Collected Papers of Milton H. Erickson on Hypnosis, Volume 3: Hypnotic Investigation of Psychodynamic Processes. Irvington, New York. Rossi, E. L. (ed.) (1980d) The Collected Papers of Milton H. Erickson on Hypnosis, Volume 4: Innovative Hypnotherapy. Irvington, New York. Rossi, E. L. and Ryan, M. O. (ed.) (1985) Life Reframing in Hypnosis: The Seminars, Workshops, and Lectures of Milton H. Erickson, Vol. 2. Irvington, New York. Rossi, E. L., Ryan, M. O. and Sharp F. A. (ed.) (1983) Healing in Hypnosis: The Seminars, Workshops, and Lectures of Milton H. Erickson, Vol. 1. Irvington, New York. Rosen, S. (1982) My Voice Will Go With You: The Teaching Tales of Milton H. Erickson. Norton, New York. Watzlawick, P. (1976) How Real is Real? Confusion, Disinformation, Communication. Vintage Books, New York. Zeig, J. (ed.) (1980) A Teaching Seminar with Milton H. Erickson. Brunner/Mazel, New York. Zeig, J. (ed.) (1982) Ericksonian Approaches to Hypnosis and Psychotherapy. Brunner/Mazel, New York. Zeig, J. (ed.) (1985a) Ericksonian Approaches to Psychotherapy, Vol. 1: Structures. Brunner/Mazel, New York. Zeig, J. (ed.) (1985b) Ericksonian Approaches to Psychotherapy, Vol. 2: Application. New York: Brunner/Mazel. Zeig, J. (1985c) Experiencing Erickson: An Introduction to the Man and His Work. Brunner/Mazel, New York. Zeig, J. and Lankton, S. (ed.) (1988) Developing Ericksonian Psychotherapy: State of the Arts. Proceedings of the third international congress on Ericksonian psychotherapy. Brunner/Mazel, New York.

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CHAPTER 19

Foundations of clinical hypnosis Michael R. Nash

19.1. Introduction This chapter is for those readers who are unfamiliar with the technical aspects of clinical hypnosis. In introducing the practitioner to the techniques of hypnotic induction and clinical hypnosis in general, it must be emphasized that the pre-eminent factor determining how fully a patient experiences hypnosis has almost nothing to do with therapist technique or any other therapist-related factor for that matter. The extent to which a patient experiences hypnosis is primarily determined by his/her pre-existing trait-like capacity to experience the perceptual, behavioral and experiential shifts we associate with hypnosis—in short, hypnotizability. This ability is stable over time, and is unrelated to any personality characteristics, at least in any simple linear fashion. A highly hypnotizable subject will become hypnotized under a host of therapist conditions and therapeutic settings. In fact, formal induction is often not necessary. For all patients then, the extent to which patients become hypnotized has more to do with what ability they bring to the session, than with what the therapist does or says. Learning to hypnotize someone per se is fairly easy. It is an elementary skill that can involve little more than reading a standardized script to someone else. However, learning to do hypnosis therapeutically is another matter entirely.

Here the therapist must marshal all of his/her clinical abilities: empathy, disciplined compassion, conceptual rigor, theoretical sophistication and technical savvy, to use hypnosis maximally in service of the therapeutic goal—whether it be symptom removal or insight. The analogy to surgery seems apt: anyone can wield a scalpel so as to cut. Cutting therapeutically involves years of training and experience. Use of hypnosis does not, and cannot, make a poor therapist better. Its use in no way compensates for limitations that the therapist brings to the consulting room. If anything, therapist limitations may be writ larger in sessions when hypnosis is used precisely because the pace and emotional intensity of the interaction can be accelerated. Thus, the two necessary pre-conditions to therapeutic use of hypnosis are: (1) a patient who is at least minimally hypnotically susceptible, (about 80–90 percent of the population); and (2) a therapist who has solid diagnostic and clinical skills. One does not really become a better clinical hypnotist by learning new things to say during hypnosis. One becomes a better clinical hypnotist by sharpening and refining ones clinical skills in general, and applying those general clinical skills to the environment of hypnosis. Nothing happens with hypnosis that does not also happen without hypnosis. Nevertheless, there are certain parameters and techniques specific to hypnosis and suggestion

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that constitute a helpful body of knowledge for clinicians wishing to employ hypnosis. Below we describe the pre-hypnosis interview, and then move to the six phases of hypnotic procedure. We then give an example of how to instruct patients in self-hypnosis.

values that come into play? Does the patient seem motivated? The therapist then seeks to shape the patient’s expectations and attitudes in terms of what we know about hypnosis and what will be effective during the ensuing treatment. Depending on the patient’s attitudes and expectations about hypnosis, typical points that might be mentioned are:

19.2. The pre-hypnosis interview

1. Setting the tone for the first hypnotic procedure.

As in many forms of psychotherapeutic intervention, it is helpful to provide the patient with some expectations about what the hypnotic procedure will be like. There is a modest but informative nonhypnosis literature on the advantages of preparing patients for the psychotherapy process (Strupp and Bloxom, 1973; Heitler, 1976; Marquardt et al., 1975). It is especially important to do when planning to introduce hypnosis into the treatment. I call this preparation the ‘pre-hypnosis interview’. There are several reasons for doing such an interview: first, the therapist needs to be very clear on the patient’s expectations and motivations regarding hypnosis. Second, the lay literature and the mass media are saturated with misinformation about hypnosis. Hence there is often a need to disabuse patients of some of these misconceptions. Third, the therapist needs to clearly articulate the reasons for doing a hypnotic procedure, underscoring that it is not necessary for the patient to ‘do well’ during hypnosis, but merely to experience whatever happens. This pre-hypnosis interview is typically of 10–20 min duration, and is really an interactive process in which the therapist carefully listens to the patients construction of hypnosis (the inquiry phase), but then more actively shapes the therapeutic frame in light of the aim and nature of the intervention Usually during the first part of the interview, the therapist asks the patient open-ended questions pertaining to their attitude about hypnosis. If fears are verbalized, the therapist inquires about them. Are there unrealistic expectations about treatment results? Is the patient inclined to an excessively passive stance in regards to hypnosis? Are issues of control figural for this patient? Does the patient anticipate a wildly abreactive experience involving emergence of ‘long-buried’ trauma? Are there religious

When I see you next week, we will be doing a hypnotic procedure which will take about 30 minutes. It will have nothing to do with your problem … I simply want you to become familiar with hypnosis and I want to understand more about how you experience it. You do not need to be an extraordinary hypnotic subject to gain benefit from hypnosis. In fact, even people who at first do not experience hypnosis much can be helped with hypnosis nonetheless. Almost everyone can experience hypnosis to some extent, and I just want to know what hypnosis is like for you … and I want you to become more familiar with it as well.

2. People do not lose consciousness when hypnotized. You will know what is going on around you, you will be attentive, and you will remember what we did during hypnosis just as you would if you were not hypnotized. In fact, this is especially important in our work because I want you to tell me what you are experiencing so that I know what works best for you. Remember, your responses are fully under your control.

3. Hypnosis is different from sleeping. You may find it to be a somewhat dreamy state in which your attention can be fixed on some particular thing, while other things fade into the background. You will probably find that you can become absorbed and focused on interesting events with greater ease.

4. Discouraging excessive self-monitoring. It would be most helpful not to try to make experiences happen, but instead just let things happen by themselves. If you find yourself wondering whether or not you are hypnotized, remember that what we are most interested in is how you experience what we do, not if you experience one thing or another.

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5. Establishing mutuality. Hypnosis is not something that I do to you. Nor is it something that you do by yourself (although that may come later in our work). But for now hypnosis is something that we do together. And we can be curious about how you will experience hypnosis.

6. Emphasis on the nature of the hypnotic experience. People differ in the way they respond to hypnosis. It is not necessary that you experience everything I suggest for us to work productively together. No one experiences everything in hypnosis.

7. Contextualizing the hypnotic experience. Responding to hypnosis is a perfectly natural ability. It is just that in working together in this way we can use your ability in a more systematic and productive way to help you with your problem.

Disabusing patients of gross misconceptions about hypnosis can be helpful. However, since imparting information is de facto delivering a suggestion, one must be careful not to ‘overdo’ the disabusing process. Below is a list of typical misconceptions about hypnosis. 1. The hypnotist can make me do things that I will not remember later. 2. In hypnosis people can be made to do immoral things that they would not otherwise do. 3. Hypnosis means losing control of my behavior. 4. Hypnosis is a form of brainwashing or an X-ray of the mind. 5. I will tell the hypnotist secrets about myself without wanting to. 6. I will be passive and under the complete control of the hypnotist. 7. The therapist will hypnotize me, and when the hypnosis is over, my problem will be solved.

19.3. The initial hypnotic

procedure In this section I give specific examples as to how to proceed during the first hypnosis session. I make two assumptions: first, that the clinician and the patient are relatively inexperienced with

hypnosis; second, that the pre-hypnosis interview has been properly completed as per above. Typically there are six phases of the initial hypnotic session: induction; deepening; exploration of hypnotic experience; preparation for subsequent hypnosis; termination; and post-hypnotic interview. Of course, in later therapeutic work a utilization phase (employing hypnosis in service of therapeutic movement) figures prominently. But the goal of the initial hypnotic session is not therapeutic per se. It is to introduce the subject to the experience of hypnosis and to inform the therapist about the patient’s responsiveness.

19.3.1. Phase I: inductions As per the American Psychological Association Division 30 definition: Hypnosis typically involves an introduction to the procedure during which the subject is told that suggestions for imaginative experiences will be presented. The hypnotic induction is an extended initial suggestion for using one’s imagination, and may contain further elaborations of the introduction (Green et al., 2005, p. 262).

Our ‘pre-hypnosis interview’ serves as the ‘introduction’ mentioned in the above definition. As we see, the second component of the hypnotic procedure, the ‘induction’, is in fact nothing more than the first suggestion. The choice of what suggestion to use as the ‘induction’ is unimportant. Typically though, this first suggestion is slowly paced to allow the novice subject time to be unrushed. Below, I provide a word-for-word script of four different hypnotic inductions: eye fixation/relaxation; arm drop; arm levitation; and coin drop.

19.3.1.1. The eye fixation/relaxation induction Perhaps the most common type of hypnotic induction is one that incorporates suggestions for eye fixation, eye closure and relaxation. This is the approach I detail below. The eye fixation/ relaxation suggestion is popular clinically because it soothingly invites the patient’s participation in a manner consistent with the tenor and aims of psychotherapy. What follows is a procedure that owes much to the family of Stanford

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Hypnotic Susceptibility scales (Weitzenhoffer and Hilgard, 1959, 1962, 1967). Now I would like you to find a spot or an object on the wall or the ceiling, any spot will do. Perhaps it will be a spot on one of the paintings or perhaps a spot on the wall or an area where the sun strikes the wall or the ceiling in some particularly interesting manner. I would like you to find a spot and focus your eyes on that spot. I am going to call that spot the target. I would like you to focus your eyes on the target and listen to my words By doing so you will find out what it is like to experience hypnosis. I assure you that no matter how deeply hypnotized you become you will remain in complete control. Hypnosis is really something that you and I do together. Eyes comfortable and heavy, focus on the target, continue focusing your eyes on the target and listening to my words. There is nothing particularly mysterious or other worldly about hypnosis. It really is a quite natural ability that almost everyone has to some extent. In a way hypnosis is like being absorbed in a movie that you are watching and forgetting that you are part of the audience but instead you become part of the story, or perhaps you are one of those people who enjoys listening to music and can be transported by that music so that everything else fades into the background and the music becomes figural, center stage. Continue to focus on the target, if your eyes should wander away from the target, that’s fine but just bring them back to the target. You may notice that the target moves about or again changes color, and if that should happen you can let it take place Just concentrate on the target and listen to my words, allowing yourself to relax more and more. As you relax more and more you become aware of a certain kind of drowsiness, a relaxation coming across your entire body. Pretty soon you will notice that the object that you are staring at is changing a bit, perhaps it is becoming nebulous or perhaps changing colors … you find that the eyelids are beginning to get heavier and heavier and you are looking forward to finding out what it is like for your eyelids to grow heavy and close in this way … what it is like to go into hypnosis. What do you notice?

It is a strain to look at a single object for so long and it would be so nice to relax completely. Allow yourself to relax completely. As your eyelids become heavier and heavier you may notice that your eyes become wet from straining … so tired and wet from straining. Your eyes may soon close by themselves and when they do you can let that happen … and drift into a comfortable state of relaxation because you will gradually, and at your own pace, be drifting into hypnosis. Soon your eyes will close themselves and when they do, you can really allow yourself to relax completely. As your eyes become heavier and your body becomes more and more limp and relaxed. Your eyes and your body drifting together into hypnosis. Your eyelids become heavier [patient’s eyes being to blink], blinking, blinking [patient closes eyes]. That’s right, your eyes are closed now and they will remain closed for the duration of our work together but if you would wish to open your eyes while remaining deeply hypnotized, you could do so, but you would do so only for a moment and then close them again. But most likely your eyes will remain comfortably closed as you continue to listen effortlessly to my voice. Now that your eyes are closed you can really settle into a deep state of relaxation and hypnosis. In a moment I’m going to touch the very top of your head with my hand and, when I do, I would like you to notice these warm waves of relaxation that begin to emanate from the very top of your head and pass through your entire body. In a little while I will touch the top of your head and when I do you will notice these wonderfully warm waves of relaxation that pass from the top of your head through your entire body. And you will become even more comfortably hypnotized. I am touching your head now. [therapist touches head for 2 s]. Allow those warm waves of relaxation to radiate down, down through your entire body. Where do you feel these waves of relaxation right now? [patient responds ‘at the top of my head’]. Good, I am going to count from 1 to 20 and as I do you will become more and more relaxed and continue to enter a comfortable state of hypnosis in which you can experience many different things. 1. Allowing those warm comfortably warm waves of relaxation to pass down through the top of your

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head, across your facial muscles so that the muscles of your forehead, your eyes, your face become limp and relaxed, limp and relaxed … 2. Allowing these warm waves of relaxation to pass down through the back of your head and into your neck, you know how tense your neck can become during the day but as these warm waves of relaxation pass through it, your neck becomes limp and relaxed, limp and relaxed. 3, 4. Allowing these warm waves of relaxation now to pass down through your shoulders, your shoulders now dropping limp and relaxed, limp and relaxed as you effortlessly listen to my voice and allow yourself to drift into comfortable state of relaxation and hypnosis … 5–6. Allowing these warm waves of relaxation to pass down through your shoulders and into your arms down toward your elbows and down toward your wrists, your arms are now limp and relaxed as these warm waves of relaxation pass down through your hands pushing any excess energy in your arms and hands out through the ends of your finger tips. 7–8. Now letting these warm waves of relaxation pass down through your chest and your upper back and you can be aware, perhaps not for the first that your breathing is becoming more and more slow and regular, slow and regular as these warm waves of relaxation pass down through your chest, down your back, limp and relaxed, beginning to become more and more sleepy and drowsy as your breathing becomes more and more slow and regular … 9 – 10, Letting these warm waves of relaxation pass through your stomach muscles and your lower back. How good it feels to be so completely relaxed, how good it feels to feel the support of the couch and these wonderful waves of relaxation that transform the relationship between your body and your mind because you are comfortably drifting into hypnosis at your own pace. 11–12. And you can be aware of how these warm waves of relaxation passed down through and beyond your waist, down your legs towards your knees and your thighs … relaxed, legs comfortably relaxed, allowing these warm waves of relaxation to continue to pass through your legs, over and through your legs … 13–14. Down beyond your knees … 15. Down towards your ankles and pushing any excess energy out through your toes. 16. More and more sleepy and drowsy, drifting along, sleepy and drowsier, and as your listen to my

voice, you can be aware that no matter how deeply hypnotized you become, you will always be able to hear my voice, you will always be able to hear my voice no matter how deeply hypnotized you become. 17. And you are now becoming more and more aware of how really relaxed and sleepy and dreamy you have become. More and more relaxed and, as you are aware of how these warm waves of relaxation continue to permeate through your entire body, you can continue to listen effortlessly to my voice going deeper and deeper into hypnosis. 18. More and more deeply relaxed, more and more sleepy, more and more drowsy. You are curious about how your mind and body work together in this hypnotic state … it is so comfortable, so pleasurable to be so deeply hypnotized and relaxed as your are now, with each breath it seems that you go deeper, more and more sleepy, more and more drowsy, yet listening effortlessly to my voice. We are working together to find out more about what hypnosis is like for you. 19. It feels good to be drowsy, to be hypnotized … as we find out what hypnosis is like for you. 20. Deeply relaxed and deeply hypnotized.

19.3.1.2. The arm drop induction There is some merit in using a suggestion for an ideomotor response as an induction: it affords the therapist the opportunity to observe the patient’s responsiveness throughout the procedure. I would like for you to sit comfortably in your chair and close your eyes, that’s right, and I would like for you to hold your right hand and arm straight out in front of you, palm facing down, that’s right, hold your right arm straight out in front of you, palm facing down. I would like you be concentrate on this right hand and arm and be aware of every feeling that you are having in your right hand and arm right now at this very moment. As you know, a person is not usually aware of all the sensations he [use ‘she’ if the patient is female] is having in his body because he is not paying attention to the particular parts of the body where these sensations are taking place. But if you pay attention to a particular part of your body as you are now paying attention to your right arm and hand, then you become aware of many different things.

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As I have been talking, perhaps you have noticed a feeling of tension in your hand or in your arm or maybe you have noticed a tingling sensation … or a tendency for your fingers to twitch ever so slightly … or you have noticed something I have not mentioned … There may be a feeling of warmth or coolness in your hand or your arm or in both…. Pay very close attention to your hand and arm and tell me now, what are you experiencing? [Patient responds] That’s good. Now, I would like you to continue to pay very close attention to your arm because something interesting is about to happen to it. It is beginning to get heavy … heavier, and heavier and as I continue to talk you can be aware that thinking about this heaviness creates a tendency for your arm to become heavy, very heavy and you will find that in a moment your right hand and arm will become so heavy like lead, so heavy that your hand and arm will gradually very slowly begin to move down, more and more down. Notice what it feels like. The heaviness in your right hand and arm grows. And as it does you can be curious about this heaviness because as the heaviness in your arm grows more and more it is a sign that you are becoming more and more deeply relaxed and more and more hypnotized. Allow the heaviness in your arm to grow more and more and as the heaviness grows you become more and more relaxed and sleepy, sleepy and dreamy. Notice how as your arm moves—just as it is now, gradually moving down, that’s right, your arm gradually moving down,—you can learn what it is like to be profoundly relaxed and comfortably hypnotized. Deeply relaxed, deeply hypnotized as your arm moves down, you go deeper into this comfortable state of relaxation. That’s right, your arm is moving down and you are becoming more and more deeply relaxed … hypnotized … drifting down … more and more deeply, more and more comfortably, relaxed. Notice how your breathing is changing and how as your arm moves down more and more, you can continue to listen to my voice effortlessly letting everything else fade into the background. It is as though your arm, as it moves down towards your lap, signals to you and to me how deeply relaxed and hypnotized you are. [if patient’s arm has not moved much the following component might be added] Your arm is more and

more heavy and you are becoming more and more relaxed and hypnotized. Now as I continue to talk, you can imagine holding a bucket in your right hand it is empty right now, holding a bucket in your right hand, holding a bucket out in front of you in your right hand. You can sense its color and its weight right now … What color is it? [patient answers]. I am going to count from 1 to 10 and with each count I will silently pour a quart of water in the bucket and your hand and arm will grow heavier and heavier, moving down more and more. 1. I am adding a quart of water, can you picture the water right now. That’s right, you can picture the water right now. I have added a quart and your hand and arm are feeling much heavier. 2. I am pouring another quart of water in, you can hear the water pouring in the bucket and your arm getting heavier and heavier, moving down more and more … 3. The third quart … 4. Another quart as we continue to work together to help you go deeper and deeper … 5. More water … Moving down more and more and as your arm moves down you become more sleepy, more drowsy, more and more deeply relaxed, breathing slowly and regularly, letting everything else fade into the background as your arm continues to become heavier and heavier and you continue to go more and more deeply and completely into hypnosis. 6–7. More water … More and more down, more and more deeply relaxed, more and more hypnotized … 8 – 9. Almost there. Your hand is almost in your lap and when it reaches your lap you will be completely relaxed, deeply hypnotized, listening without effort to my voice … 10 [hand reaches lap] That’s right, your hand has reached your lap now. You are relaxed, dreamily hypnotized … your right hand is in your lap, and while you drift along comfortably and deeply hypnotized, your hand returns to normal. No longer heavy. Now let’s move on to something else.

19.3.1.3. The arm levitation induction Another induction is an ideomotor suggestion for arm levitation. Please put your right hand on the table, I want you to concentrate all your attention on that hand. As you look at it, be aware of all the sensations and feelings in the hand. For example, you are aware that it is sitting on the table. There is a weight there.

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You are aware of the texture of the table. You can keenly sense the position every finger has toward every other finger. And there is the temperature of the fingers, which ones are a little warmer and which ones are a little cooler than the others. As you look at that hand with great concentration, you are going to notice that one of the fingers of that hand will feel especially different from the others. Now, it might be the thumb or the little finger or perhaps the index finger or the big finger or the ring finger, but one of them will feel distinctly different from the other, and that feeling may be that it is a little more warm or that it is a little cold. It could be that it kind of tingles a little bit or that it is numb, it could feel lighter but if you concentrate well you will be able to find out which finger it is that has the different sensation from the others. And as you pay close attention to that particular finger, that finger will lift itself a little bit from the table over the others. Now concentrate on that, and you will notice that one of the fingers will tend to lift itself up from the table a little. [patient’s index finger lifts slightly] Oh yes, it’s your index finger. We can be curious about how light the finger must be to rise in this way. And as you think about this lightness, the lightness in your finger grows even more…. moving up more and more and as you concentrate on this lightness this pleasant lightness in your finger, you will notice that lightness spreads to your other fingers. One by one your fingers and your thumb will rise to the level of your index finger. One by one, that’s right, one by one your fingers, the feeling of lightness spreading from one finger to another. That’s right, there is a light feeling as though your fingers were corks, just very light and buoyant, floating and buoyant. Now go ahead and close your eyes as you drift along in this relaxed and comfortable state, curious about how becoming more relaxed will enable your hand and arm to experience even more. Now what I would like to do is, I’m going to touch your wrist, imagine that I am tying a string loosely to your wrist, here … I am doing it now [therapist touches writs as though tying a string loosely around wrists] and on the other end of that string is a balloon, a balloon of a particular color, it is not filled yet with helium but it soon will be….

and that string is loosely tied to your wrist and when the balloon is filled with helium, your hand, not just your fingers, your entire hand and arm will begin to feel lighter and lighter. The balloon is not yet filled with helium, but soon it will be. What color is the balloon? [patient responds that the balloon is blue] That’s right it is just lying there on the ground now, it’s a dark blue color. Now imagine the balloon is being filled with helium, the balloon is getting bigger and you can hear the balloon filling, filling up with helium and you know the way balloons become brighter and lighter when they are filled with helium until the rubber is taut and you can almost see through this beautiful blue balloon filled with helium and rising off the ground and this string around your wrist becomes taut. You can be curious about what is beginning to happen to your right hand and arm as the balloon begins to tug, tug and pull at your wrist, that’s right, your hand and arm are beginning to lift higher and higher and as your hand and arm raise higher, higher and higher, becoming lighter and lighter as the helium balloon tugs on your wrist, your hand and arm began to move up and toward your nose and when your hand touches your nose, you will know you are deeply relaxed and hypnotized. [patient’s hand and arm begin to slowly move upward] That’s right, higher and higher and as your hand moves higher and closer to your nose, a gentle breeze can blow the balloon in such a way that your hand and arm move toward your face, closer and closer to your nose, gently pulling, tugging, moving, lighter and lighter and as your hand is moved and pulled and made lighter and lighter by this balloon, you drift more and more comfortable into hypnosis. More knowledgeable, finding out more about how your mind affects your body in this very relaxed, deeply hypnotized state. That’s fine, the hand has now touched your nose, and settles there, now I am going to touch your wrist as I untie the balloon … [therapist gently takes wrist between thumb and forefinger and holds it for a moment] … as I touch your wrist, I will hold your wrist while I release the string … and as I do you can watch the balloon go high in the sky and I will place your wrist back in its resting position as you remain deeply relaxed and hypnotized. Deeply relaxed, deeper and deeper, deeper into hypnosis. Your hand and arm are comfortable

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again, relaxed in their resting position, normal and comfortable as you continue, deeply relaxed and deeply hypnotized.

Now I am going to gently touch the top of your right hand and, as I do so, you will notice that the warmth grows even more on the inside of your hand and the balloon-coin expands even more.

19.3.1.4. The coin drop induction The coin drop technique can be used in a number of ways. If the patient is situated over a noncarpeted floor the sound of the coin dropping can be incorporated in the procedure in the form of a suggestion that ‘when you hear the coin drop to the floor you will know that you are deeply relaxed and hypnotized’

I am going to count to 10, each time that I touch your hand, I will count, and as I do your hand will become warmer and warmer and the balloon will swell more and more. This is a very special ballooncoin so that by the time I reach the count of 10 your fingers will be opened and the balloon-coin will fall upon the floor and you will hear it and when it does fall on the floor you will know that you are deeply and comfortably hypnotized.

Now I would like for you to seat yourself comfortably and close your eyes. I am going to put a coin into your right hand like this [puts coin in patients right hand] … and perhaps you would like to hold your arm straight out and make a fist around this coin, I would like you to make a fist around this coin. Be aware now of the warmth in your right hand and the warmth that surrounds this coin. As you concentrate on the warmth in your hand at this very moment, you can be aware of how the coin is warming up as well. I would like you to imagine now that this is a very special coin because it has the characteristics of a coin and it has the characteristics of a balloon. Imagine this coin as a balloon, your hand is surrounding a balloon, this coin balloon, and the warmth of your hand surrounds the balloon, warming it, warmer … And as you know, the warmth of a balloon determines how large it is. The air in a balloon expands when it is warmed and as the balloon-coin becomes warmer and warmer it begins to expand, it expands inside your hand. Warmer and beginning to expand. Eventually as the balloon gets warmer and warmer, it will press against the inside of your hand until your hand gradually opens as it presses against your fingers and your hand. Imagine the balloon filling with air in your hand, pushing against the inside of your hand, trying to force the fist open. Warmer and warmer now, gradually, very gradually forcing your fingers open, warmer and warmer, soon your fingers will begin to open of themselves, you can feel the fingers beginning to move by themselves. [patient’s fingers move, but only very slightly] That is right, your fingers are just now beginning to move. Your fingers are responding, and moving … the pressure from the balloon-coin is having an effect.

[therapist gently strokes back of hand at each count] Now I will begin to count 1, beginning to press more and more against the inside of your hand, 2. Warmer and warmer, let the warmth flow through your hand. 3. Warmer and warmer, the comfortable warmth increases in the inside of your hand. 4–5, Warmer and warmer your fingers beginning to move more and more, that’s right, moving of themselves, you can find your fingers moving of themselves. 6–7. That’s right, fingers beginning to open. 8–9. Soon you will hear the coin drop and when you do you will be deeply relaxed and deeply hypnotized listening effortlessly to my voice. 10. There, that’s right, the coin is dropped and you are deeply relaxed and deeply hypnotized. You can be curious about what the hypnotic state is like as you become more and more deeply relaxed and hypnotized with each breath with each passing moment.

19.3.2. Phase II: deepening procedures Here I offer two types of techniques that can be used to ‘deepen’ the patient’s experience of hypnosis further. The same structural principles apply for these techniques as apply for the inductions. In fact, any induction technique can also be used as a deepening technique. The two general categories of deepening techniques are: fantasy/imagery techniques and somato-attentional techniques.

19.3.2.1. Fantasy/imagery deepening technique #1: the spiral staircase In a little while I am going to stop talking for a bit and, when I do, I would like you to imagine yourself

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walking down a very beautiful and quiet spiral staircase. The kind that winds down and around, down and around, down and around. Imagine, if you will, a spiral staircase now as I am talking. It is a very beautiful and quiet spiral staircase with an interesting carpet, plush and soft, your favorite color, and as you look further down, the stairs seem to fade out into a soft, warm darkness. As you walk down this beautiful staircase you slide your hand along the smooth hardwood banister. In a little while I will ask you to walk down this beautiful spiral staircase at your own pace … and you will note that with each step you take with each slow step you take down this beautiful … spiral staircase, you will go deeper and deeper into hypnosis. [with some more fragile patients the therapist might suggest that they both walk down the stairs together] In a little while I will stop talking for a bit and when I do I would like you to imagine yourself walking down this beautiful spiral staircase. The kind that goes down and around, down and around, down and around, and you will note that with each step you take, with each slow step you take down this beautiful spiral staircase you will go deeper and deeper into hypnosis. You can go at your own pace, going deeper and deeper as you like until when I speak again you will be much more deeply relaxed and deeply hypnotized. Go ahead and imagine yourself walking down this beautiful spiral staircase with each step going deeper and deeper into hypnosis. [Therapist is silent for 1 min]. That’s right … no longer walking down the spiral staircase now … deeply relaxed and deeply hypnotized.

19.3.2.2. Fantasy/imagery deepening technique #2: the beach Now as you drift along comfortably, deeply relaxed and deeply hypnotized listen carefully to what I have to say. In a little while I am going to count from 1 to 5, and when I reach the count of 5 you will find yourself at that special ocean beach about which you told me today. I am going to count from 1 to 5 and when I reach the count of 5 you will be there, relaxed and comfortable, with each passing moment going deeper and deeper into hypnosis. Now I will begin to count and when I reach the count of 5 you will be there and you will be able to tell me the things that you see and the things that you hear and smell and feel.

1–2. You are going to the beach, soon you will be there. 3 … and you will be able to tell me all about it. 4 … once there at the beach you will find yourself going more completely and deeply into hypnosis … at the next count, you will be there … at the beach. 5. Where are you? [patient responds]. What are you doing? [Patient responds], What do you see, hear, feel. [the Patient responds] that’s good, this is a very special place which means relaxation. As you lie back on the sand and feel the comfortable warmth of the sun, the comfortable warmth of the sun surrounds you. As you have already noted, you can hear the waves and the sea gulls … feel the support of the sand, how good it is to be supported in this way. I would like you to pay even closer attention now to the sounds of the surf … as you know if you listen to the surf you can hear every individual gentle wave breaking on the shore and if you listen another way, the waves all seem to blend together into a kind of rolling, gentle cascade. Listen to the surf so that you can hear different waves breaking at different times, rhythmic waves, one wave after another …. How do you hear them? [patient indicates that waves can be heard separately]. And you discover that as you listen, it is almost as though the waves seem to break every time you exhale … there is a certain rhythm, a timing and pacing to our work together. And as you listen to the waves breaking on the shore, you can note that with each wave, with each breath … you go deeper and deeper into hypnosis. A very special rhythm of your breathing and of the waves begin to move together, as you go deeper and deeper. I am going to stop talking now for a bit and you can continue to listen to the waves breaking on the shore gently. With each wave that breaks gently on the shore you go deeper and deeper asleep. [Therapist is silent for 1 min]. Good, deeply relaxed and deeply hypnotized.

19.3.2.3. Fantasy/imagery deepening technique #3: diving under the water A particularly useful technique to prepare patient’s for expressive, insight-oriented applications of hypnosis employs a metaphor of going beneath the surface for the sake of discovery. This example is adapted from Brown and Fromm (1986).

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Imagine that we are going on a deep sea exploring trip down in the warm waters off the Caribbean. We have come to a beautiful reef where a group of young deep sea explorers is preparing a trip in an enclosed capsule into the depth of the ocean. The capsule can be lowered from a ship on a steel cable. You can safely make a decent of hundreds of feet down into the ocean. Imagine a spacious metal sphere with four port holes, thick plate glass, two or three people can go inside the capsule and sit in it and observe. They are supplied with oxygen lines and a telephone line to the boat on the surface. Imagine yourself for several days watching the young ocean divers on the beach carefully preparing the capsule for their next trip. They have fitted it out with food and with a number of scientific instruments. You have made friends with them and several of them have invited you to join them on their trip to see the wondrous sites of the deep sea. You have accepted the invitation and you are intrigued, delighted and curious. Now imagine yourself and the deep sea explorers standing on the deck of the ship that will take you out to the sea. You are going out to sea now, you see the long, low swell of the sea and hear the waves rolling in on this calm sunny comfortably warm spring day. You can feel a light breeze on your face. Imagine yourself with two of the explorers who have descended deep into the ocean many times before, we are going into one of the capsules lying on the deck. The portals are being screwed tight so that no water can penetrate, strong cranes swing out your capsule over the side of the ship and you can hear it splash and descend beneath the surface of the water. Notice the sudden shift from the gold and yellow light above the sea to a turquoise green all around you. You see the foam and bubbles from the splash. Look upwards, you see the strong steel cable from which your capsule is being lowered down close to the ship’s side, now we are being lowered. Peer up, you can see the watery ceiling crinkling and slowly lifting and settling while here and there pinned to the ceiling are tufts of seaweed. Notice small dots moving just below the weed and you try successfully to focus a pair of binoculars that one of the explorers has handed to you on these moving dots. You have no trouble recognizing a flying fish trailing its half-spread wings as it swims. You can feel the capsule revolving slightly and the bottom of the ship’s hull comes into view. It is encrusted with

corals and shells. Great streamers of plant and animal life float from it. There is something unreal and at the same time rather amusing about a port view of a slowly rolling bottom of an unanchored boat. The people on the deck of the boat phone down to tell you that the sun keeps blazing over the ocean, the surface is unusually quiet and conditions are ideal for going down further. You are being lowered further, the green of the water fades as you go further down and at 200 feet it is impossible to say whether the water is greenish blue or bluish green. You make your eyes focus in mid-water and see a lovely colony of jelly fish drift past. Gracefully floating in the deep water, they are beautiful. They sweep slowly along, alive and in constant motion. A bit lower a beautifully colored fish looks in on you, two deep-sea turtles go by, several silvery squid balance for a moment in front of your port hole then shoot past. Now you can take control of how deep you go, which way your capsule turns, and what you see. There are the rich colors of a reef … observe with interest the texture and colors as the fish gently swim between and around the reef. Slowly, steadily, you guide your vessel … then there are lobsters and some crabs. You are less and less concerned with the upper world, you feel restful, quiet and happy, removed from it while you plunge into new, interesting and predictably beautiful sites. Your attention is relaxed, very relaxed and you keep on going down as far as you like.

Some patients do not posses vivid imaginations. For these patients suggestions to imagine can prove quite frustrating, potentially leading to problems with compliance and discouragement. In these cases other deepening techniques can be employed which do not emphasize imaging ability, but instead invite absorption in internally generated sensation. Two of these are breathing and the kinesthetic sense of heaviness.

19.3.2.4. Somato-attentional deepening technique #1: breathing Now that you are relaxed and deeply hypnotized, I would like you to be aware of your breathing for a moment. One way to go more deeply into hypnosis is to pay attention to your breathing for awhile.

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Notice, as you breath slowly and normally, how good it feels to exhale … inhale and exhale [the therapist may time the words ‘inhale’ and ‘exhale’ to the patient’s actual breathing pattern] and as you continue to feel all these sensations the way your muscles move quite naturally and effortlessly to facilitate your slow and normal breathing, you become more and more relaxed with each passing breath. More and more hypnotized. It’s as though every time you exhale, you purge your body of the stress and tension of the day. Every time you exhale, while you are hypnotized, every time you exhale, without even thinking about it, you become more and more deeply and comfortably hypnotized as you wish. Now I am going to count from 1 to 25 … and, as I do, you will go more deeply and comfortably into hypnosis … because every time you exhale, your body will become more and more limp and relaxed … your mind will become more and more clear, and you will find yourself curious about how your mind and your body work together in this relaxed and interesting state [the therapist might choose to time the counts with the patient’s breathing]. 1. More and more relaxed, 2, 3, etc.

19.3.2.5. Somato-attentional deepening technique #2: progressive heaviness As you remain deeply hypnotized you will notice that there is a warm numb feeling beginning to form all over your body. A comfortable feeling of heaviness and warmth spreading from the very, very top of your head down through your face, jaw, neck and shoulders … becoming more and more limp and relaxed, all the muscles of your body, as this comfortable warmth, heaviness and relaxation move down through your neck and your arms and chest and stomach muscles, down through your whole body, more and more comfortably heavy. Muscles limp and relaxed, feel this warmth … wonderful warmth, almost as though you were in a hot tub, so relaxed. Now in a moment I am going to place my hands on your shoulders and this will allow you to go even more deeply into hypnosis, you will feel the heaviness coming over your entire body … as I press down gently on your shoulders, you will go deeper into hypnosis, comfortable and relaxed. [Therapist places a hand on each of the patient’s shoulders and very gently applies modest pressure].

19.3.3. Phase III: introductory suggestions In the initial hypnosis experience it is useful to follow the induction and deepening procedures with three very simple suggestions which serve a 2-fold purpose. First, the patient gains further experience with the hypnosis, gauging if, and how, this state is different from their normal state of consciousness. Second, by noting the response to suggestions, the therapist makes a determination of the patient’s general hypnotic ability which may be important in treatment planning. We offer three examples of relatively neutral suggestions which can serve the purpose of educating patient and therapist about how hypnosis is being experienced.

19.3.3.1. Arm lowering or levitation Here the procedures are almost identical to the arm lowering and arm levitation inductions, but with the difference that they are dramatically shortened. For instance, an arm lowering suggestion might consist of: Now that you are deeply hypnotized, I would like you to hold out your right hand up in the air, straight out in front of you, palm facing down. As I have been talking, perhaps you have noticed a feeling of tension in your hand or in your arm or maybe you have noticed a tingling sensation … or a tendency for your fingers to twitch ever so slightly … or you have noticed something I have not mentioned…. There may be a feeling of warmth or coolness in your hand or your arm, or in both. Now, I would like you to continue to pay very close attention to your arm because something interesting is about to happen to it. It is beginning to get heavy … heavier, and as I continue to talk you can be aware that thinking about this heaviness creates a tendency for your arm to become heavy, very heavy and you will find that in a moment your right hand and arm will become so heavy … like lead, so heavy that your hand and arm will gradually very slowly begin to move down more and more down. As it becomes heavier and heavier, like lead. I am going to count from 1 to 10 and the hand and arm will become increasingly heavy and move down more and more. 1 … down … 2 down more and more … 3 … down … 4–5 down more and more … 6 down, 7–8 down more and more … like lead. 9–10 more and more down.

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[allow about 10 s of silence, then note if hand and arm have moved, and how much].

This is a relatively easy item which about 75 percent of people pass to some extent. Of course if the hand and arm have reached the patient’s lap or the side of the chair before the count of 10, the therapist simply says: ‘that’s fine, just relax, let your hand feel normal once again… as we move on to something else’. If the patient’s hand and arm move very little, the therapist might say at the end of the procedure: ‘you are doing fine, you felt the heaviness in your hand and arm…now you can put them back in their resting place and we will move on to something else’.

19.3.3.2. Hands together Another relatively innocuous suggestion is the hands together item from the Stanford Hypnotic Susceptibility Scale: Form A. Now what I would like you to do is hold both hands straight out in front of you, palms facing toward each other. That’s right arms out in front of you, palms facing inward … about a foot apart. [if the patient has difficulty with these instructions the therapist positions the hands accordingly]. Now, I would like you to imagine a very strong force attracting your hands together. And as you think of this force attracting you hands together, they begin to move together … it is a powerful force, like powerful magnets or maybe very very thick rubber bands around your hands … pulling and moving your hands closer and closer. Moving, more and more closely together, that’s right … moving … moving … closer and closer. The force is so powerful, that your hands begin to move more and more … moving … moving … closer and closer [allow about 10 s of silence].

Here again, the procedure is terminated if the hands come together at some point: ‘good, your hands have come together and are now touching … now let the force dissipate’. If the patient fails to respond to the suggestion, gentle reassurance is given as above. About 65 percent of patients will respond positively to this procedure.

19.3.3.3. The hypnotic dream Another item fashioned from the Stanford family of susceptibility scales is the hypnotic dream. This item has the advantage of probing for the patient’s ability to regress more substantially

than the other items, but has the disadvantage of having an abreactive pull. Nevertheless, the item does merit inclusion for most patients. As you continue to remain very deeply hypnotized, I am going to count from 1 to 5, and as I do you will become sleepier and sleepier … and when I reach the count of ‘5’ you will sleep and have a dream … but a special and pleasant dream … you will have a dream about what hypnosis means … you will have a dream, just like you might have when you sleep, and it will be a dream about hypnosis. You may dream directly about hypnosis, or you may have a dream which does not seem outwardly to be about hypnosis, but may very well be. Now I am going to count from 1 to 5 and you will get sleepier and sleepier … when I reach the count of ‘5’ you will have a dream about hypnosis. After a while I will speak again to ask you about the dream that you had, and you will remember everything very clearly … and you will be able to tell me all about it without it disturbing your relaxed state of hypnosis. Now, 1 … more and more sleepy … 2 … sleepier and sleepier, you are going to have a dream about hypnosis … 3 … 4 … 5 … sleep and dream … deep asleep. [therapist waits about a minute, noting any eye movements, or other bodily indications of private experience]… That’s fine, deeply relaxed and hypnotized, but no longer dreaming …tell me about your dream … tell me all about it [therapist listens, asks open-ended question etc.]

19.3.4. Phase IV: abbreviated hypnotic inductions for subsequent sessions A simple but exceedingly important therapeutic maneuver during the latter portion of the initial hypnotic session is to structure a constellation of cues that will enable the patient to enter hypnosis quickly and easily on subsequent sessions. It is entirely unnecessary to employ lengthy hypnotic inductions each time hypnosis is used in therapy. Indeed, after one or two sessions of using the full induction, there is normally no reason for the patient to take more than a minute to enter hypnosis Normally instructions for rapid reinstatement of hypnosis are administered during the latter portion of the first or second hypnotic session. They are given in hypnosis as a post-hypnotic

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suggestion. Here there is a premium on establishing salient cues (both verbal and nonverbal) which have become associated with being hypnotized. What follows is one example of such a procedure:

count of ‘1’ you will be fully alert. 10, 9 … less and less hypnotized … 8, 7 … less hypnotized, more awake … 6, 5, 4 … more and more awake … 3, 2, 1 … EYES OPEN, WIDE AWAKE … Are you awake? [the therapist then proceeds with the post-hypnotic interview].

As you remain deeply hypnotized I will now help you to learn how to enter hypnosis easily and quickly. Whenever you are in this room, and in your chair, and whenever we want to use hypnosis in our work together, all you need do is to close your eyes and listen to me count from 1 to 5 … and when we do this together you will find that by the count of ‘5’ you will be as deeply relaxed and hypnotized as you are now … perhaps even more so. When I reach the count of ‘5’ you will be deeply relaxed, finding yourself walking down the spiral staircase that you liked so much today. Whenever we are in this room together, and we wish to use hypnosis in our work together, all you need do is close your eyes and listen comfortably to me count from 1 to 5. And by the time I reach the count of ‘5’ you will be deeply relaxed and hypnotized … walking down that very special spiral staircase.

For subsequent sessions in which hypnosis is used, the patient can be instructed: ‘Soon you will be ready to come out of hypnosis … when you are ready, take a deep breath in, open your eyes and you will be wide awake [patient opens eyes]. That’s it, wide awake’. That termination of hypnosis is an emotionally charged event is evidenced by the widespread, but completely inaccurate, belief that patients can ‘get stuck’ in hypnosis. Patient’s are no more likely to ‘get stuck’ in hypnosis than they are to ‘get stuck’ in a traditional, intensive nonhypnotic therapy session. In both instances themes of separation and loss can make termination evocative. Sometimes hypnosis patients enjoy their experience so much that they are reluctant to ‘come out’ of hypnosis because it is so pleasant. On the exceedingly rare occasion when a hypnosis subject does not easily come ‘out’ of hypnosis, the therapist can simply note: ‘I notice that you have chosen to remain in hypnosis for awhile … tell me what is happening…’. In my experience, the mere act of asking for information provides the solution. Sometimes patients claim to have not heard the termination instructions; sometimes they are so wonderfully relaxed that they do not want to interrupt the experience; sometimes there is something they wish to share with the therapist before hypnosis ends; sometimes they are in fact asleep. Attention to any unfinished material along with gentle and reassuringly direct suggestion for termination will suffice. It may be helpful for therapists to keep in mind that in research where the hypnotist willfully and abruptly left the room while the subject was still hypnotized, subjects were found to arouse themselves gradually and spontaneously from the hypnotic state, no worse for wear (Evans, 1966; Orne and Evans, 1966).

When hypnosis is terminated, and after the post-hypnotic interview, the therapist and patient might ‘practice’ this abbreviated counting procedure. A second termination then follows. In the next session when hypnosis is used, the patient and therapist can repeat the procedure. Sometimes it is helpful to follow the abbreviated induction with a brief and familiar deepening technique. In any event, subsequent induction of experienced hypnotic subjects need take no longer than 1 or 2 min.

19.3.5. Phase V: termination of

hypnosis The termination of hypnosis is very straightforward. For patients who have never before experienced hypnosis, the therapist simply states: In a little while I am going to count backwards from 10 to 1. And as I do you will become less and less hypnotized. When I reach the count of ‘1’ your eyes will open and you will be fully awake and alert, in your normal state of awareness. When I reach the count of ‘1’ you will be fully awake, and you will feel refreshed and relaxed, remembering everything you wish to remember. That’s right, now I will begin to count backwards from 10 to 1, and you will become more and more awake and alert, and when I reach the

19.3.6. Phase VI: the post-hypnotic interview It is helpful, especially in the initial hypnosis session, to allow 5 or 10 min to discuss the

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patient’s experience of hypnosis. While the therapist has had an opportunity to observe the patient’s behavioral response to hypnosis, it is important to assess the patient’s subjective experience, and the patient’s attitude about that experience. As in any such semi-structured interview, the therapist begins with open-ended, neutral questions, and then moves through a series of increasingly specific queries regarding the patient’s experience. The therapist may begin with ‘What was that like?’ ‘What else did you experience?’ ‘What was it like being hypnotized’. Then moves to questions regarding the patient’s general phenomenological experience: ‘How deeply hypnotized did you feel?’ ‘How did you experience my voice?’ ‘How did time seem to go by?’ ‘Did you feel hypnotized more deeply at some times than at others?’ ‘How did your body feel during hypnosis?’ Another series of questions addresses responses to specific suggestions. Here the therapist can listen for evidence of topographic regression, especially nonconscious involvement: ‘What was the staircase like?’ ‘What was it like for your arm to move down and get heavy?’ ‘What was it like when your hands moved together as they did?’. The therapist can assess whether movement seemed to ‘happen by itself ’ or whether there was a more conscious participation (‘I helped it along quite a bit’). The therapist can probe for the vividness of imagery and richness of fantasy: ‘What was the dream like?’‘Was it like a real dream?’ Finally the therapist can invite a frank discussion of technique: ‘Tell me, was there anything I did that helped you go more deeply into hypnosis, or anything I did that seem to get in the way?’. Typically patients will be quite forthcoming about their experience, diminishing the need for formal questioning. Further, patients can be expected to be understandably curious about what the therapist thinks of their response and what that means about subsequent treatment. As we will discuss later, there are times when the patient’s response is so problematic, or their hypnotic ability is so very limited, that nonhypnotic interventions are indicated. If this is the case, the therapist should discuss this with the patient in a way that avoids implying failure or poor prognosis. But since most patients will be moderately to highly hypnotizable and, since for some problems even low hypnotizables benefit

from hypnotic intervention, the therapist can be justifiably encouraging about the patient’s performance. In short, the post-hypnosis interview is a time for the patient to de-brief the therapist on how he/she experienced hypnosis. The information derived from this interview period is easily as valuable as any information the therapist gleans from the hypnosis phases proper. Similarly, the therapist informs the patient about treatment implications of this initial hypnotic experience, and in so doing underscores the joint nature of the therapeutic enterprise.

19.4. Instruction on self-

hypnosis In the course of supportive hypnotherapy with an aim of symptom alleviation, it is often quite essential for the therapist to teach the patient how to perform self-hypnosis, so that coping techniques developed in the consulting room can be transferred to the patient’s day-to-day life. Of course, patients should not be encouraged to use self-hypnosis for uncovering or expressive purposes, but only for self-soothing and symptom containment. Instructing patients on how to do self-hypnosis is straightforward. Assuming the therapist has introduced the patient to the role of self-hypnosis in the treatment plan, the topic is addressed during a subsequent hypnosis session. When the patient is sufficiently hypnotized, and the supportive effect is obtained, the therapist may directly instruct the patient as follows (this example is taken from a pain patient): Now that you are deeply relaxed and hypnotized, once again on your tranquil beach where no discomfort of any sort can reach you, listen to my words carefully. Whenever you wish to go into hypnosis, whenever you wish to take control of the sensations you have in this way, all you need to do is to find a reasonably comfortable place to be, shut your eyes, and count slowly to yourself from 1 to 5. As you count you will note that your breathing changes, the way your body feels changes, and you become transported once again onto this wonderful beach. So that by the time you reach the count of ‘5’ you will always be deeply hypnotized, and in the wonderfully relaxed state you are now in. You may find that you actually go even more completely and deeply into hypnosis with practice.

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Whenever you wish to go into hypnosis, all you need do is find a comfortable place, close your eyes, and count silently to yourself from 1 to 5. You will find that your mind and body are effortlessly transformed back into this peaceful state of hypnosis. A state in which you have a different kind of control over your sensations. At the count of ‘5’ you will always be right there on the beach, calm, tranquil, free of all discomfort. Once you are thus hypnotized, once you are once again at the beach, you can stay for as long as you like. You need only stay there one or two minutes to obtain the benefit of hypnosis, or you may chose to stay longer. But whenever you wish to bring yourself out of self-hypnosis, all you need to do is take a deep breath in, and open your eyes, and you will be wide awake … refreshed … alert and … completely comfortable. You can be surprised how far this refreshed, comfortable, and alert feeling will extend in the remainder of the day. You will practice self-hypnosis in this way at least twice a day. For now, just remain hypnotized, as you listen to my voice.

[Therapist repeats the general instructions of the second paragraph] Now, in a little while you will come out of hypnosis. Soon you will take a deep breath … open your eyes … and you will be wide awake. You will remember everything we did today. You will find you are especially clear on how to do self-hypnosis. After you have a chance to talk a bit about your experience today I will ask you to practice self-hypnosis right here in the office.

After termination of the hypnosis, the patient and therapist discuss the work of the day. The therapist then reminds the patient of the selfhypnosis instructions, and asks the patient to practice hypnosis in the consulting room: ‘Now what I would like you to do is to go ahead and use self-hypnosis right now with me here. [Therapist reminds patient of instructions]. When you are there on the island, comfortably hypnotized, just say the word ‘Now’, so that I know you are there. When you do, I will speak to you, and help you go even more deeply into hypnosis. Now I will be quiet for a while … go ahead and go into hypnosis … just say ‘Now’ when you are on the island.’ When the patient signals that he/she is hypnotized, the therapist probes for the patient’s experience, and repeats by now familiar phrases

associated with increased depth and/or symptom alleviation. It is once again suggested that the patient will employ self-hypnosis at least twice a day, more if needed. The sessions need be no more than 1 or 2 min each, but they can be longer if the patient so wishes. The patient is then asked to come out of hypnosis as he/she would when doing self-hypnosis alone. The therapist then queries the patient about the selfhypnosis experience, again reiterating the instruction to practice self-hypnosis at least twice a day. The first order of business on the subsequent session is to discuss how the patient found self-hypnosis to be. For the most part, patients who respond well to traditional heterohypnosis respond well to self-hypnosis. Patients who struggle with conflicts around autonomy will sometimes actually report that they go deeper into hypnosis when they do it alone. On the other hand, strikingly dependent patients may resist self-hypnosis initially, but this is rarely unmanageable. There is of course utterly nothing special about any of the specifics contained in the above example: providing a cue is helpful, but whether it is counting, a subtle motor gesture or some particular word is not important. Instructions on practice are probably important, but the specifics are less so. Two authoritative texts on self-hypnosis are: Fromm and Kahn (1990) and Fromm et al. (1981).

References Brown, D. P. and Fromm, E. (1986) Hypnotherapy and Hypnoanalysis. Erlbaum, Hillsdale, NJ. Evans, F. J. (1966) The case of the disappearing hypnotist. Paper presented at the American Psychological Association convention, New York. Fromm, E. and Kahn, S. (1990) Self-hypnosis: The Chicago Paradigm. Guilford Press, New York. Fromm, E., Brown, D. P., Hurt, S. W., Oberlander, J. Z., Boxer, A. M. and Pfeifer, G. (1981) The phenomena and characteristics of self-hypnosis. International Journal of Clinical and Experimental Hypnosis, 29: 189–246. Green, J., Barabasz, A., Barrett, D. and Montgomery, G. H. (2005) Forging ahead: the 2003 APA Division 30 Definition of Hypnosis. International Journal of Clinical and Experimental Hypnosis, 53: 259–264. Heitler, J. B. (1976) Preparatory techniques in initiating expressive psychotherapy with lower-class unsophisticated patients. Psychological Bulletin, 83: 339–352.

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Marquardt, K., Sicheneder, L. and Seidenstucker, G. (1975) The influence of role induction on the success of systematic desensitization of socially anxious students. Archiv fur Psychiatrie-und Nervenkrankheiten, 221: 123–137. Orne, M. T. and Evans, F. (1966) Inadvertant termination of hypnosis with hypnotized and simulating subjects. International Journal of Clinical and Experimental Hypnosis, 14: 61–78. Strupp, H. H. and Bloxom, A. L. (1973) Preparing lowerclass patients for group psychotherapy: development

and evaluation of a role-induction film. Journal of Consulting and Clinical Psychology, 41: 373–384. Weitzenhoffer, A. M. and Hilgard, E. R. (1959) Stanford Hypnotic Susceptibility Scale, Forms A and B. Consulting Psychologists Press, Palo Alto, CA. Weitzenhoffer, A. M. and Hilgard, E. R. (1962) Stanford Hypnotic Susceptibility Scale, Form C. Consulting Psychologists Press, Palo Alto, CA. Weitzenhoffer, A. M. and Hilgard, E. R. (1967) Revised Stanford Profile Scales of Hypnotic Susceptibility, Forms I and II. Consulting Psychologists Press, Palo Alto, CA.

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CHAPTER 20

Hypnosis in the relief of pain and pain disorders Mark P. Jensen and David R. Patterson

20.1. The problem of unrelieved

acute and chronic pain Acute pain refers to pain associated with tissue damage, or that is experienced with noxious stimulation that would produce tissue damage if it continued. Examples include minor injuries that quickly resolve, such as paper cuts or stubbed toes. More serious examples of acute pain include pain associated with diagnostic procedures and medical treatments that themselves produce tissue damage, such as lumbar punctures or bone marrow aspirations. During lumbar punctures, a needle is inserted into the spinal canal between vertebrae to obtain spinal fluid, and during bone marrow aspirations, a needle is inserted directly into bone (often the pelvic bone), to suction out bone marrow. Both of these diagnostic procedures produce significant pain and anxiety in many patients that is only minimally helped by biomedical interventions. In addition to painful diagnostic procedures, there are a host of invasive medical interventions that can result in severe acute pain. These include the hundreds of thousands of minor and major surgeries performed every year. Other examples include burn wound debridement, childbirth and that pain associated with dental care. Although opioid analgesics and

brief anesthetic procedures (e.g. nitrous oxide) can reduce the acute pain associated with some procedures, they seldom control all pain, have little efficacy for some patients and can be costly and dangerous (Patterson and Sharar, 2001). Unlike acute pain, which usually resolves once healing is complete, chronic pain, by definition, remains or worsens over months and years. It is often precipitated by trauma, such as a motor vehicle accident or fall, but can also result from an ongoing disease process (e.g. arthritis, cancer, sickle cell disease). Other sources of chronic pain include severe headaches, back problems or disabilities (e.g. amputations, spinal cord or traumatic brain injury, multiple sclerosis, neuromuscular diseases such as muscular dystrophy, and cerebral palsy). There are also a number of specific chronic conditions that have moderate to severe pain as a primary symptom (e.g. complex regional pain syndrome, previously known as reflex sympathetic dystrophy, diabetic neuropathy, post-herpetic neuralgia). For many people with these chronic pain conditions, the experience of severe disabling pain is a central, if not the single most important, feature of their lives. Biomedically focused interventions for chronic pain such as nerve blocks, surgeries or medications, some of which themselves can put

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patients at risk for more pain or uncomfortable side effects, are often the first and sometimes only treatments offered to patients with chronic pain. Unfortunately, by their very nature, chronic pain problems tend to be refractory to biomedical interventions, leaving patients who are offered only biomedical pain treatments little recourse for managing pain once these treatments fail or produce only limited pain relief. As a result, there remain millions of individuals who suffer from severe unrelieved chronic pain (Jacobson and Mariano, 2001). Hypnotic treatments are among a number of nonbiomedically focused treatments [others include cognitive-behavioral therapy, operant treatment, motivational enhancement therapies, biofeedback, graded exposure therapy, group therapy and family therapy, as well as some relatively new approaches such as acceptance-based therapy (McCracken et al., 2005) and Motivational Interviewing (Jensen, 2002)] that have been shown to result in significant reductions in pain and improvement in overall quality of life in persons with acute and chronic pain (Turk and Gatchel, 2002). Although more research is needed to identify the rates of positive response and the effective components of hypnotic analgesic interventions, enough controlled trials have been performed to conclude that hypnosis is effective for a large number of acute and chronic pain conditions (Montgomery et al., 2000; Patterson and Jensen, 2003). As such, we believe that hypnosis should be a treatment option offered to any patient suffering from pain. This chapter is written for the clinician who is interested in helping patients better manage acute or chronic pain with hypnosis. It begins with an overview of pain, and presents the essential components of modern biopsychosocial models of pain; models that we believe should be clearly understood by health care professionals who work with patients with pain. This is then followed by a discussion of strategies that can be used to assess and treat acute and chronic pain, and how hypnosis can be integrated into the treatment plans. Because the key issues important to the management of acute and chronic pain differ, we present the strategies for assessing and treating patients with each pain type separately.

20.2. Understanding pain 20.2.1. The Gate Control Theory and

the development of biopsychosocial pain models Traditionally, and perhaps as recently as the late 1960s, pain was viewed by many health care providers primarily from a biomedical perspective. On the basis of a simple biomedical model, the severity of pain was thought to be directly related to the amount of tissue damage or injury; more tissue damage should result in more pain, and more pain should be indicative of more tissue damage. Patients who presented with significant pain in the absence of clear signs of tissue damage were viewed as suspect. They were often thought either to be malingering or to have significant psychopathology that was being expressed using the language of pain and suffering. Such patients were told indirectly, and sometimes even directly, that they were imagining or exaggerating their pain experience, and did not need to take the pain seriously. They might have been told that ‘nothing can be done’ and that they must ‘learn to live with’ their pain.1 Such patients would often seek repeated medical consultations. Some even ended up undergoing repeated invasive medical interventions (surgeries, spinal blocks) that provided at best only temporary relief and, at worst, produced significant tissue damage that contributed to the overall pain problem. The publication of the Gate Control Theory of pain in the 1960s (Melzack and Wall, 1965) marked a significant turning point in the understanding of pain. This model pointed out what many clinicians observe every day; that patients who are neither exaggerating nor have significant psychopathology can experience severe pain in the absence of identifiable tissue damage, and that this pain can persist for months, years and decades long after tissue healing occurs. The model described how pain can be modulated at the level of the spinal cord (specifically, in the dorsal horn of the spinal cord,

1 Indeed, if one views pain from a purely biomedical perspective, nothing more could be done for such patients, and acceptance of pain was the only option left.

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where the axons of sensory neurons from the periphery enter the spine). This modulation was hypothesized to be influenced by ‘ascending’ (towards the brain from the periphery) activity from peripheral nerves, as well as by ‘descending’ (down to the spinal column from the brain) activity from the brain. Ascending influences on pain experience include the effects of stimulation of nerve fibers by massage or by movement. For example, most people are aware that when they rub or shake a body area that has recently been injured, their experience of pain decreases. An example of a descending influence would be the effects of anxiety or the meaning given to the sensory information transmitted to the brain, which can then ‘open’ or ‘close’ the gate through descending fibers, and subsequently influence the amount of painful signals that enter the central nervous system for processing. The Gate Control Theory provided a compelling and specific physiological model for how pain can be influenced by both biological and psychological factors, inspired a profound increase in pain research (Cervero, 2005) and increased acceptance for the development of more complex biopsychosocial models of pain (Novy et al., 1995).

20.2.2. Biopsychosocial models Biopsychosocial models of pain acknowledge that biological components and mechanisms can play a significant role in the perception of pain. However, these models also posit an important role for psychological and social factors on pain intensity, overall suffering and the effects of pain on day-to-day life. Clinically, the model emphasizes that all three (biological, psychological and social) factors should be considered when evaluating pain and developing effective treatment plans. As we will discuss, hypnosis can play a positive role in most of these treatment plans. The complex biological factors that contribute to pain vary significantly between patients and their conditions, and are only now beginning to be better understood. They include, but by no means are limited to, the amount of ongoing inflammation in the areas associated with pain (in general, more inflammation means more pain), the relative strength and mobility of the

muscles and tendons in the areas associated with pain (in general, muscles and tendons that are stronger and better stretched hurt less), the amount and nature of any ongoing nerve damage (patients with nerves that are being compressed, that have been damaged or that are deteriorating due to genetic neuromuscular conditions tend to report more pain) or even the amount and nature of immune cell activity in the spinal cord [recent evidence suggests that immune cell activity in the spinal cord can increase pain sensitivity (Wieseler-Frank et al., 2005)]. The extent to which any patient’s pain experience is related to any one or more of these factors, and the development of an appropriate biomedical treatment plan, requires a thorough evaluation from a trained pain physician. Appropriate biomedical treatments might include medication management (often discontinuing or decreasing medications, but sometimes also initiating or increasing others), graded reactivation or exercise and, for some pain problems, specific invasive procedures. One important decision that should result from a medical evaluation of a pain problem is the extent to which neuropathic (factors associated with nerve damage or irritation) or nociceptive (factors associated with the transmission of pain messages along otherwise healthy nerve fibers, often due to musculoskeletal problems) are contributing to a patient’s pain. As a rule, many neuropathic problems do not tend to respond well to physical exercise and reactivation.2 Recommendations for first-line interventions for most neuropathic pain problems usually include trials of appropriate medications [e.g. anti-seizure medications such as gabapentin or pregabolin, or tricyclic antidepressants (Dworkin et al., 2003)] with a primary goal of reducing the intensity and unpleasantness of pain. Because of its proven efficacy (cf. Patterson and Jensen, 2003), we believe that hypnosis for pain reduction should be added to the list of first-line treatments offered to patients with neuropathic pain.

2 One important exception to this is complex regional pain syndrome, for which appropriately structured movement and activity of the affected limb, while painful in the short run, can provide important benefits in the long run.

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The suggestions that medication management and self-hypnosis training be considered first-line treatments for neuropathic pain, and the fact that such pain often has a clear biomedical cause, do not mean that psychosocial factors do not impact the severity and impact of neuropathic pain; in fact, evidence suggests just the opposite (e.g. Haythornthwaite and Benrud-Larson, 2000; Hanley et al., 2004). However, the reduction of perceived pain intensity and associated suffering remains appropriate as a primary treatment goal that should be strongly considered in persons with severe neuropathic pain. Patients with a nociceptive source of their pain, especially when this pain appears to be related to a history of trauma to muscles and tendons, tend to have more variable treatment outcome goals, depending on the patient’s particular situation. For patients with such pain problems, the prognosis is good for improvements in pain and functioning, as long as the patient is willing and ready to make the significant personal efforts required for adaptive pain management. For musculoskeletal pain problems, in particular, what the patient does (e.g. avoidance of inactivity, maintaining a moderately active lifestyle, practicing self-hypnosis for pain management) is much more important than what is done to them; invasive medical procedures tend to provide little long-term benefit, and can even make things worse for such patients. Psychological factors that impact pain and its effects on function in persons with chronic pain include such variables as beliefs and attributions about the pain (including its specific meaning to the patient), coping strategies used to manage pain, and psychosocial history (e.g. learning, developmental and abuse history). Social factors include such variables as overall level of social support available to the patient, how the important people in the patient’s life respond to the patient when he or she communicates pain (via ‘pain behaviors’, such as groaning, limping, etc.), and the patient’s work (or lack of work) environment. A great deal of research now supports the utility of biopsychosocial models of pain. Such research findings often include significant associations between biological variables and pain, but usually even stronger associations between psychological and social variables and

measures of pain severity and patient functioning. Evidence that treatments designed to have an impact on biological (e.g. medications, rehabilitation and exercise programs), psychological (self-hypnosis training, cognitive restructuring) and social (e.g. treatments that alter social contingencies of pain behaviors) components all influence pain and adjustment provides even stronger support for these models. The primary clinical implication of modern biopsychosocial models of pain is that the treatment of pain requires a thorough understanding of the biological, psychological and social factors that may be contributing to an individual patient’s pain and suffering before a treatment plan is developed. The goals of treatment, and the patient’s readiness to participate in treatment, will have a profound impact on whether hypnosis should even be offered, and, if offered, on the specific suggestions that should be used during hypnosis. In the sections that follow, we discuss the strategies we use to evaluate patients with acute and chronic pain, and how these can be used to design a treatment plan that uses hypnosis. We then follow each section with case reports that provide examples of how we have applied the approaches in real patients.

20.3. Acute pain 20.3.1. Evaluation of the patient with acute pain When performing the initial psychosocial and medical history of the patient with acute pain, the evaluating clinician should determine if the patient has a history of psychological issues that might influence his or her ability to cope with pain. For example, because anxiety has a cyclical relationship with acute pain, and patients with depression may show withdrawal and other maladaptive coping behaviors, the clinician should determine the presence and extent of any anxiety and depression symptoms. It is also useful to assess whether the patient has had any previous episodes of acute pain or trauma, and, if so, how they reacted to these. The manner in which patients have coped with acute pain in the past is a strong predictor of how they will respond to future similar events, and obtaining such information can be very helpful when developing a treatment plan.

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One important domain to assess when evaluating the patient’s coping style is the extent to which he or she responds to threatening medical procedures by avoidance or by sensitizing. Patients who use avoidance will typically cope by minimizing the amount of information they seek and gather about the medical procedure, and make efforts to shift attention away from a procedure (Patterson, 1992). They tend to do well with interventions that encourage distraction, imagery and/or dissociation. For these patients, hypnosis that includes suggestions for dissociation (see Appendix) can be particularly helpful. On the other hand, patients who sensitize tend to request a great deal of information about a procedure, and tend not to do well with coping strategies that encourage them to withdraw their attention from the procedure (Everett et al., 1990). Such patients will often remain hypervigilant, and want to know exactly what is going on during the procedure. These patients tend to benefit more from strategies that focus their attention on the intervention rather than away from it. They might be told, for instance, that by focusing on sensations that they experience, they will be more able to change (and therefore control) them. In some instances, the patient will already be experiencing acute pain at the time of evaluation. In this situation, it is obviously important to assess the intensity and bothersomeness of this pain if possible. In fact, by asking patients to rate both (we use 0–10 scales, with 0 = ‘No pain’ or ‘Not bothersome’ and 10 = ‘As much pain …’ or ‘As bothersome as you can imagine’), and explaining the difference between the two, the clinician can begin to help the patient separate these two aspects of the pain experience; a skill that may prove useful for patients who are able to reduce one of these aspects of pain more than the other using hypnosis. The clinician should also assess how well the patient is able to respond and concentrate. Patients experiencing intense pain may not be able to hold a conversation long enough for hypnosis to be introduced. Hypnosis can be of particular use when the patient is in a crisis state, but the magnitude of the pain and the threat to the patient should be determined as a first step. Whether the acute pain is anticipated because of an upcoming medical event, or is a current

problem, it is often important to treat anxiety with both hypnosis and nonhypnotic (e.g. anxiolytic drugs, cognitive-behavioral approaches) strategies. For some patients, particularly children, anticipatory anxiety may be a more serious issue than the pain itself. Also, it is important to remember that some patients may not recognize or acknowledge that they are anxious, so careful observation of the patient (e.g. for avoidance behavior, physiological indications of anxiety such as perspiration or increased heart rate when discussing the medical procedure, sleep difficulties) is necessary when evaluating the presence and severity of anxiety. There are a number of environmental and logistical factors associated with medical procedures that influence how painful and threatening the patient finds them. For example, it is well known in the pediatric literature that the patient’s room should be regarded as a ‘safe’ place, and medical procedures should not be performed there; it would also make sense to extend this approach with adult patients whenever possible. Also, people experience less pain and anxiety when they feel as if they have some control over the procedures. The presence of a supportive person (spouse or parent) can reduce pain and suffering further, particularly if they act as calm role models (McGrath et al., 1994). For children, restructuring medical procedures so that the child sees them as a game can also be of great benefit. For example, a child may be unwilling to walk on injured legs but might be willing to do so (or even run) if the therapy or activity is presented as a game. The specific questions that assess the factors discussed above that we have found particularly helpful during the evaluation of a patient for acute pain management, are listed in Table 20.1.

20.3.2. Acute pain treatment plan development Table 20.2 lists the primary treatment targets of patients who have experienced, or who are scheduled to experience, significant acute pain. It is important to keep in mind, as a first consideration, that the pain associated with many medical procedures can be severe. Although this chapter focuses on hypnosis, we wish to emphasize that

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Table 20.1 Questions to ask during an acute pain evaluation, and the problems/issues these can be used Question

Responses can be used to evaluate…

On a scale of 0 to 10, with 0 being ‘No pain’ and 10 being ‘The most intense pain you can imagine,’ how would you rate your pain intensity [now/with the procedure]?

Current (or predicted) pain intensity associated with the procedure

On a scale of 0 to 10, with 0 being ‘Not at all unpleasant or bothersome’ and 10 being ‘The most intense unpleasant and bothersome pain you can imagine’, how would you rate the unpleasantness or bothersomeness of your pain [now/with the procedure]?

Current (or predicted) pain unpleasantness/bothersomeness

Are you generally more an anxious person or relaxed person? Have you been diagnosed with an anxiety or nervous disorder? Do you find that you worry a lot?

Trait anxiety

In the past 2 weeks, on how many days would you say you felt sad or blue more of the day? What has really brought you pleasure in the past couple of weeks? Have you had a big change in your weight in the past month? Have you noticed any problems with your appetite? Any problems with sleep? On how many days in the past 2 weeks did you feel tired most of the day? Do you feel that you are worthless or no good? Have you noticed problems with your memory or ability to concentrate? Have you had thoughts of your own death recently?

Symptoms of depression

Once you are in bed and ready to go to sleep, how long does it usually take you to get to sleep? About how many times a night do you wake up, on average, and how long does it usually take you to get back to sleep when you do wake up? What time do you usually wake up in the morning? Do you usually feel rested when you wake up in the morning?

Sleep problems, including sleep onset latency, nocturnal awakenings, early morning awakening and extent of restful sleep

As you think about the upcoming procedure, do you want a lot of information about it, or would you rather just ignore it and think about something else?

Avoidance versus sensitizing style

As you think about the upcoming procedure, how would you rate your anxiety about it on a 0 to 10 scale, with 0 being ‘Not at all anxious’ and 10 being ‘The most intense anxiety I could ever imagine’?

State anxiety

What treatments have you ever had for pain associated with medical procedures in the past? How have these worked for you?

History of use and efficacy of procedural pain treatments

analgesics should almost always be considered as a first-line treatment for acute pain management. Morphine and its derivatives are often very effective and safe for treating acute pain. Concerns about patient addiction when such medications are given to treat acute pain are largely unwarranted, and usually reflect irrational

concerns from health professionals (Melzack, 1990). Combining opioid analgesics with anxiolytic medications such as benzodiazepines (e.g. lorazepam, diazepam) has been shown to reduce pain ratings (Patterson et al. 1997). Anesthetic agents, such as ketamine, propofol or nitrous oxide, can also be of great value,

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Table 20.2 Specific problems or issues associated with acute pain, treatment options and hypnotic suggestions that can be of benefit Problem/issue

Treatment options

Hypnotic suggestions for

High pain intensity and/or bothersomeness

Pharmacological analgesia/anesthesia, decreasing adversity of procedures, hypnosis

Relaxation, comfort, amnesia (for pain and for procedure), dissociation (from pain), time distortion, pain displacement, alter quality of pain sensations, decreased pain, distraction, can use environmental cues for responding to post-hypnotic suggestions

High trait or state anxiety

Education, pre-procedure anxiolytics, change the environment to make it more calming or interesting to the patients, humor, hypnosis

Decreased fear, competence of clinicians performing the procedure(s), age regression, age progression, calming (e.g. ‘safe place’ imagery)

Sleep disturbance

Sleep hygiene training, pharmacological intervention, hypnosis

Improved ability to fall asleep, deep and restful sleep, feeling rested upon awakening, imagery (e.g. ‘safe place’) while drifting off to sleep

Perceived loss of control

Provide choices, hypnosis

Increased sense of control over pain intensity and bothersomeness

Hypervigilant/ sensitizing reaction

Fast-acting pharmacologicals, fastacting hypnotic inductions (e.g. focus on breathing, followed by suggestions for relaxation)

Relaxation, monitoring and changing sensations

although such agents almost always require supervision from an anesthesiologist (Patterson and Sharar, 2001). As discussed above, it is also often possible to reduce the unpleasantness of a medical procedure by changing the environment or the how the procedure is conducted. For example, entering an MRI (magnetic resonance imaging) chamber can be a terrifying experience for a child, even when no pain is involved. Some creative clinicians have created jungle scenes in which the MRI chamber is presented as a cave in the middle of the jungle. Another source of potential adversity is the treatment itself. For example, health care workers may use caustic agents during wound care that sting during application. It is possible there are alternative agents available that do not cause as much pain, and that the treatment team has simply not considered this. Acute procedural pain reduction can also often be accomplished with hypnosis. A primary reason for this is that it is almost always known

when and where a medical procedure will occur; this allows the clinician working with hypnosis to provide inductions and suggestions ahead of time. A particularly useful paradigm is to use hypnosis prior to a procedure, and provide post-hypnotic suggestions geared specifically towards the procedure. For a lumbar puncture, for example, patients can be told that, ‘Whenever you feel yourself rolling on your side and you feel your back being prepared for the procedure, this will be a signal for you to experience a rush of comfort and relaxation, even more and deeper that you are feeling right now. You can feel yourself go limp…knowing that the time of the procedure will feel like no time at all, because you are paying attention to how limp and relaxed you are’. It is important that the post-hypnotic cues are geared specifically towards events that will occur during the procedure. For example, it would not be advisable that a hospital bed will become a cue for patients to become relaxed when the procedure might occur in a chair.

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It is also useful to include earlier triggers for comfort and relaxation. For example, if it is known that the procedure will occur in a clinic, the patient can be told, ‘Whenever you enter the front door of the clinic, a surprising sense of peacefulness and well-being will overcome you. You will also experience a growing sensation of comfort that will continue to grow as long as you remain in the building’. In addition, the clinician can perform hypnosis at the time of the procedure to strengthen the post-hypnotic suggestion. If it is possible for the clinician to be with the patient during the procedure, he or she could perform a brief (e.g. 5-min) induction immediately prior to the procedure, to supplement a longer induction that may have been performed at an earlier time. If the clinician cannot be present, it is sometimes possible to cue a treating professional to perform elements of the induction and to reinforce the suggestions. Such elements can also be part of the post-hypnotic suggestions given earlier. As an example, the patient may be told, ‘Whenever you hear the nurse instruct you to count from 1 to 10 to relax yourself, you will find that you are able to reach an even deeper state of relaxation more quickly than you have right now’. Post-hypnotic suggestions for relaxation and analgesia can be convenient, as they do not require the clinician to be present during the procedure. However, hypnotic suggestions will almost certainly be more effective if they are reinforced by the presence of the clinician at the time of the procedure, and this should be considered whenever feasible. There are a number of suggestions for pain reduction available to the clinician. One of the most extensive and creative sets of suggestions for pain control came from Erickson’s writings (e.g. Erickson et al., 1976; Erickson, 1980; Erickson and Rossi, 1981). Suggestions for amnesia are particularly useful for procedures. For example, patients might be told that they will ‘…be surprised at how quickly childbirth passes … 20 minutes will go by as if only one minute is passed … or you may not remember the process of labor at all’. The patient might be told that they will dissociate to a different place (‘You may find yourself floating out of your body during the procedure’) or time (‘It will be as if you were in high school again, dancing at your senior prom’). Pain can be displaced to a less

threatening area of the body, or the patient can be encouraged to alter their sensation (‘While you might feel a sense of pressure in that area of your body, it will not be a particularly uncomfortable sensation’). The best treatment for pain-related anxiety is for the patient not to experience pain in the first place. Once patients experience severe procedural pain, if they are required to undergo additional procedures, it is likely that anticipatory anxiety will intensify their suffering. Thus, aggressive pain management protocols that include both medication management and hypnosis should be instituted to minimize pain and discomfort whenever possible and practical. However, it is not always possible to ensure no pain, and some patients will show anxiety about a procedure even if they have no history of poor pain control. Education about the procedure can be useful, especially among sensitizers, for altering any unrealistic ideas or unreasonable concerns, and therefore reducing anxiety (Everett et al., 1990). Patients can also be medicated with anti-anxiety agents such as benzodiazepines (e.g. lorazepam, diazepam) either before or after their procedure (as mentioned before, these medications also appear to have an analgesic effect when administered with pain medication). Such medications can serve to disrupt the link between anxiety and pain that is experienced by many patients. Some antianxiety agents, particularly midazolam, can create amnesia for the procedure, and thus have analgesic effects that are similar to amnesia hypnotic suggestions. When thinking about the treatment of anxiety that is associated with acute pain, it can be difficult to distinguish where anxiety ends and pain begins; the two are often inextricably intertwined. Fortunately, typical suggestions for acute pain control can address both pain and anxiety. For example, telling patients they will ‘feel more comfortable’ during a procedure addresses both elements of pain and anxiety, as do suggestions for relaxation. However, a number of suggestions are particularly useful for anxiety. For example, patients can be told that they have ‘nothing to fear’ and are ‘in safe hands.’ Suggestions to frame the sights and sounds that the clinicians knows will be associated with the procedure (e.g. a sterile room, the

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beeping heart monitor) as indications of safety and of the care of knowledgeable staff can also effectively reduce anxiety. Another particularly useful hypnotic approach that addresses both pain and anxiety is to suggest to patients that they imagine a time in the future when they are healthy, comfortable and healed (age progression). Finger signaling might be used to ensure that they have a clear positive image (‘At the time you are able to have a clear image of yourself sometime soon where you are healthy, carefree and feeling very, very good, your mind will let you know by allowing this finger to pull up in the air, seemingly on its own power’). The patient can then be given the suggestion that ‘…the time between now and that very positive time in the future will seem to go by quickly and effortlessly’. The clinician can also add a dimension of age regression to a pain-free time in the past to help the patient gain a clear image of well-being, if needed. A link between the image in the past and that of the future can then be established with other suggestions. Patients may experience a loss of control during medical procedures that exacerbates both pain and anxiety. There are a variety of measures that can be taken to allow the patients to feel more in control of the procedure. In burn wound care, patients can be encouraged to take part in the procedure and to clean some of their own wounds if they find that to be of help (Kavanagh, 1983). Another strategy for increasing control over the procedures that we have used with children is the use of ‘time out’ cards. Children are able to use a limited number of these cards to ‘buy’ breaks from wound care. Some procedures such as dentistry preclude patient involvement, but even with dentistry patients can be given choices about anesthesia or the type of drill used in order to increase their perceived control. Some patients will demonstrate a hypervigilant response to a procedure because of anxiety or their general coping style. These patients want to know everything that is going on during the procedure while it is it happening. Although this is not necessarily a problem in itself, it can potentially interfere with hypnotic approaches that involve dissociation and mentally removing one’s self from a procedure. Before using hypnosis

for a burn procedure, we like to ask the patient, ‘Are you willing to shut your eyes and totally remove yourself from the situation? Are you able to trust that the nurses are not gong to do anything to harm you or make your injury worse?’ If patients are unable to say ‘yes’ in response to these questions, some education about the safety of the wound care may be helpful. However, some patients will still refuse to give up monitoring the procedure under any circumstances. With such patients it is often more useful to go with their coping style and not seek to remove their attention from the procedure. These patients can be encouraged, for example, to pay attention to the procedure in great detail and be encouraged to monitor the sensations to ‘…see how the sensations change, becoming easier … more friendly…’. Poor sleep often accompanies both acute and chronic pain. The standard interventions for sleep problems apply to patients in acute pain, and are reviewed in detail in Jaffe and Patterson (2004). Sleep hygiene measures can be highly effective, and are discussed in more detail in Section 20.4. Also, for patients in acute pain (but not for chronic pain, see below), mixed agonist– antagonist receptor benzodiazepines can be of use (zopidem, zalaplon); alternatively, antidepressants such as trazadone can be useful for patients who are depressed or for whom other sleep agents are ineffective or contraindicated. Hypnosis will not interfere with such interventions, and can be used directly as a means to suggest improved sleep, or indirectly as a means to reduce pain and anxiety that might be interfering with sleep. There are many instances in which a patient is experiencing acute pain that requires immediate intervention. One example is a trauma patient that has just been injured, or a patient that underwent surgery with inadequate post-operative analgesia. In such circumstances, the clinician does not have the luxury of a detailed evaluation or carefully thought out plan for pain control. In this situation, it is advisable for the patient to receive fast-acting analgesics such as intravenous or intramuscular morphine. However, for any number of reasons, pharmacological interventions may be delayed or unsuccessful, and it will rarely present a problem to use hypnosis in such circumstances. Patients experiencing this

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type of acute pain may be in crisis, and it might be very difficult to capture their attention. Having patients pay attention to their breathing and gradually slowing it down can be useful at this stage. Also, the clinician can often be most useful by adopting a ‘take charge’ approach, given the patient’s likely regressed emotional state, and by modeling calmness with his or her manner. If the clinician is able to capture the patient’s attention and effectively suggest slower breathing, they can often then provide suggestions for deep relaxation. The patient may fall asleep, or appear to fall asleep, and may be left with the suggestion that upon awakening, they will experience analgesia, calmness and a sense of safety. While treatment planning and provision for acute pain problems tends to be far less complex than it is for chronic pain, there are individual differences between patients, and no single blanket approach will address this problem in all patients.

20.3.3. Case report This particular case report example is provided by Shelley Wiechman, PhD, a psychologist working with the authors at the University of Washington Burn Center. The patient was a 9-year-old boy with 40 percent flame burns to his upper body. No family members were present during hospitalization, so, in addition to severe procedural pain levels, the patient was anxious and frightened. We were consulted to help the patient deal with the acute pain associated with burn wound dressing changes, decrease his anxiety and improve his overall comfort. The patient responded very well to attention from all adults, and proved to be an easy individual with whom to build rapport. He told us that he was a Harry Potter fan, and we decided to build on this theme for his hypnotic analgesia. Prior to his wound procedure, the patient was told to get on his broomstick like Harry Potter, and imagine himself flying through forest surrounding Hogwarts. He responded rapidly to this imaginative induction, and was told that the deeper he went into the forest, the more relaxed and in control he would feel. We then provided a detailed description of what he was seeing in the forest, and suggested feelings of power, control and comfort throughout his flight. Descriptions were included for visual, auditory,

olfactory and kinesthetic senses. In addition, we provided post-hypnotic suggestions that included control over his own ability to find comfort and relaxation, and his ability to take his broomstick and fly to any place he wanted, whenever he wanted, especially whenever he needed to find comfort and relaxation. This post-hypnotic suggestion was linked to a cue which would be provided by a nurse at any time that he needed to feel more comfort and control. During the hypnosis sessions (provided in the patient’s room before wound debridement procedures), the patient would spontaneously put his arms straight out and sway as if he was flying. He looked forward to these sessions, and reported that he responded best when they were led by the therapist. However, the nurses reported that throughout his hospital stay, he would occasionally close his eyes and say that he was going flying, without prompting from an adult. The patient reported lower pain and anxiety scores during subsequent wound care sessions compared with wound sessions that occurred before the hypnosis training. We were also able to expand the script by having him fly on his broom throughout other environments (not just the Hogwarts forest). This case illustrates that, with children, formal hypnotic inductions are often far less useful then using imagery that is compelling to the patient. It also illustrated how suggestions that address multiple challenges to the patient (i.e. pain, anxiety, a sense of control) can be of use.

20.4. Chronic pain 20.4.1. Evaluation of the patient with chronic pain When evaluating and treating acute pain, the key issues that need to be addressed include: (1) trait and state anxiety, (2) presence of depressive symptoms, (3) coping style (e.g. avoidance versus sensitizing), (4) sleep quality and (5) history of response to acute pain treatments. Most often, hypnotic suggestions that target perceived pain intensity and unpleasantness (and any other distressing symptoms) that match the patient’s coping style and history are the most appropriate. Similar issues, and often more, need to be assessed and considered when evaluating patients with chronic pain.

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Identifying the biological, psychological and social factors that are most likely to be contributing to the ongoing pain and suffering in the patient with chronic pain is an iterative process that begins with an initial evaluation, but also continues as treatment progresses. At the University of Washington Pain Center, the physician usually takes about 1 h to perform the initial history and physical evaluation needed to identify the most likely biological issues contributing to the patient’s pain. It similarly takes the psychologist 1 h with the patient and, if available, another 30 min separately with the patient’s spouse or significant other, to identify the most likely psychological and social factors contributing to the patient’s pain and disability. It is beyond the scope of this chapter, not to mention our training and expertise, to describe the medical evaluation of a patient with chronic pain. Such descriptions are available elsewhere (e.g. Loeser, 2001). However, we should note that a thorough medical evaluation is necessary prior to initiating pain treatment, whether or not hypnosis will be used. This evaluation is needed to rule out any problems that require immediate biomedical attention and intervention (e.g. undiagnosed cancer, significant lesions requiring surgical interventions), as well as to identify biological causes of pain that might respond to medical treatments that could be provided along with appropriate psychological or social interventions. The evaluation of the psychological and social factors that might be contributing to the patient’s pain problem involves a systematic inquiry of each potential factor that is related to pain and functioning. In addition to asking questions that provide a baseline description of the patient and basic historical information about the pain problem (e.g. history of pain onset, treatments tried and perceived efficacy of those treatments, education history, marital/ relationship history, developmental history including history of abuse, psychological treatment history and diagnosis, cognitive functioning if indicated, alcohol and drug use history), a series of questions should be asked that can provide additional specific information necessary to identify the psychological and social factors that are most likely to be contributing to the pain problem.

Many of the same questions useful for assessing patients with acute pain, listed in Table 20.1, should also be asked of patients presenting with chronic pain, including questions to assess pain intensity and unpleasantness, presence and severity of anxiety and depressive symptoms, and presence and type of sleep disturbance. Additional questions are needed when evaluating chronic pain, however. These are presented in Table 20.3, and include questions designed to elicit from the patient information about: the meaning of pain from the patient’s perspective; the patient’s own model for understanding his or her pain; how the patient copes with chronic daily pain; presence and extent of ‘catastrophizing’ and other unhelpful cognitions; availability and extent of social support; and how others respond to the patient when he or she displays ‘pain’ or ‘well’ behaviors. The meaning a patient attaches to pain can have a significant impact on how much attention is paid to pain sensations, as well as on the amount of suffering experienced with any pain that is experienced. Does the patient believe that the pain is a signal of ongoing physical damage or that some life-threatening condition is getting worse? Is pain a challenge to be dealt with and managed, or is it viewed as an occasional distraction that has few implications for health and quality of life? It is particularly useful to determine the patient’s model for the etiology of their pain. One useful question to ask is, ‘What do you think is causing your pain?’ (or, alternatively, ‘Patients are often told many different things about what is causing their pain; what have you been told?’ followed up with, ‘And do you agree with this, or do think something else might be happening?’). If the patient’s view of the cause of the pain is consistent with the medical evaluation (‘Well, I think it is the direct result of my osteoarthritis’ or ‘I have complex regional pain syndrome’), then it is unlikely that an illness conviction (belief that something serious is causing the pain and requires a biomedical fix) is contributing to the patients pain and disability. On the other hand, expressed vague or specific concerns about the presence of ongoing physical damage or lack of healing (‘Something is wrong with my back’, or ‘I have a shattered vertebra’) in the absence of medical evidence for such beliefs

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Table 20.3 Questions to ask during a chronic pain evaluation, and the problems/issues associated with each Question

Responses can be used to evaluate…

What do you think is causing your pain?, or Patients are often told many different things about what is causing their pain, what have you been told? Do you agree with this, or do think something else might be happening?

Illness conviction and biomedical focus. Look for answers that reflect the extent to which patient views pain from a biomedical versus biopsychosocial perspective.

What treatments have you tried and what treatments, if any, are you interested in exploring further?

Illness conviction and biomedical focus. How committed is the patient to limiting treatment options to biomedical interventions? Is this a history of or willingness to try psychosocial approaches, or to take primary responsibility for pain management, or is the patient only interested in medications, a surgical intervention or other invasive procedure?

What do you do to cope with pain?, and How does your [wife/husband/partner/roommate] know when you are hurting? What does she/ he see you do or hear you say?

Use of adaptive (e.g. regular exercise, coping selfstatements, seeking social support, activity pacing, ignoring pain, task persistence) and maladaptive (e.g. guarding, pain-contingent resting, asking for assistance, pain-contingent medication use) coping strategies for pain management. Look for general patterns and whether any one coping response really stands out as central to this patient’s approach to pain management.

What goes through your mind when you have a pain flare-up?

Extent of catastrophizing or other maladaptive cognitions versus coping self-statement cognitions. Look for rigid and unrealistically negative thinking (‘It is horrible’, ‘It will never get better’), including use of extreme words such as ‘always’ and ‘never’, versus more flexible and reassuring responses (e.g. ‘I know I can handle this’).

What impact, if any, has your pain had on your relationship with your [spouse, partner, roommate]?, and How would you say that you and your [spouse, partner, roommate] are getting along?

Availability of global social and emotional support versus a stressful primary relationship (or lack of social support).

How does your [spouse, partner, roommate] know when you are hurting? What does she/ he see you do or hear you say? What does he/ she do when he/she knows you are hurting? What does he/she do when he/she sees you try and do something like exercise or a household chore even when you are hurting? What do you no longer do because of your pain? What do you do less of (but still do some) and more of because of pain?

These questions can be asked of both the patient and his/her significant other to assess (1) the specific pain behaviors shown by the patient; (2) coping responses (both adaptive and maladaptive); (3) possible reinforcers for pain and illness behaviors; and (4) possible reinforcers (or punishers) for well behaviors.

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suggests the presence of unhelpful beliefs that would need to be addressed in treatment. Another question that can get at the patient’s views about the pain is, ‘What treatments have you tried and what treatments, if any, are you interested in exploring further?’ A long history of repeated biomedically focused treatments, and continued interest in only such treatments, despite a lack of success, suggests the strong possibility of a biomedical focus, and perhaps some initial resistance to psychosocial interventions and training in pain self-management. In this case, interventions designed to increase readiness to self-manage pain (e.g. Motivational Interviewing; Jensen, 2002) or the simple passage of time may be needed before treatment that focuses on patient control over pain and its impact can begin. Another key domain that needs to be understood is how the patient is currently coping with pain. There are a large number of coping strategies that can be used to manage chronic pain. These are generally classified into ‘adaptive’ and ‘maladaptive’ strategies (Boothby et al., 1999). Adaptive pain coping strategies are those that have been hypothesized or shown to be associated with better long-term adjustment. They include such strategies as seeking social support, task persistence (not letting pain interfere with function), activity pacing (avoiding both overand under-doing activities, and rewarding oneself with brief periods of rest on a time- rather than pain-contingent basis), regular moderate exercise, ignoring pain, distracting oneself from pain, practicing self-hypnosis, meditation and/or relaxation as appropriate, and making positive self-statements (e.g. ‘I can handle this’, ‘I’ll get through this’). Maladaptive coping responses are those coping strategies thought or shown to contribute to greater pain and dysfunction in the long run, although a number of these are sometimes associated with pain relief in the short run. They include such strategies as extended rest (worst of all—bed rest) and deactivation, resting on a pain-contingent basis, guarding (not moving a body part that hurts or moving in a stiff and guarded fashion) and medication use (especially chronic benzodiazepine use, but also use of high dose opioid medications in the face of little benefit). This domain can be assessed by simply asking the patient,

‘What do you do to cope with pain?’ Another question, discussed below as a preliminary question for assessing social factors [‘How does your (wife/husband/partner/roommate) know when you are hurting? What does she/he see you do or hear you say?’], can also be used to obtain information about coping, as responses to this question often reflect attempts to cope with excessive pain (‘I lie down’, ‘I take a pain pill’, ‘I try and distract myself by going for a walk’). Frequent use of maladaptive coping and/or lack of use of adaptive coping strategies suggests that some intervention(s) designed to alter coping strategy use is indicated. Strategies for discouraging maladaptive coping include education (about the negative effects of maladaptive coping) and Motivational Interviewing strategies focused on eliciting from the patient reasons for making changes in coping (see Jensen, 2002). The primary strategy for encouraging adaptive coping, once the patient expresses an interest in learning or developing specific adaptive strategies, is to set aside time during treatment sessions to teach these strategies (e.g. teach self-hypnosis, identify specific exercises to engage in, teach the patient a strategy for gradually increasing activity tolerance; see Fordyce, 1976) and provide ample praise and reinforcement for any adaptive changes observed. Another key psychological factor that can contribute to long-term dysfunction in persons with chronic pain is the presence of catastrophizing cognitions. ‘Catastrophizing’ refers to having excessively negative thoughts and those that suggest a particularly dire outcome. Such thoughts include, for example, ‘It is horrible and I know it is never going to get any better!’, ‘My life is a mess!’ and ‘I’ll never be able to work again!’ There is some disagreement in the field of pain about whether catastrophizing responses best represent a type of coping strategy (e.g. as a way to elicit support from others; see Sullivan et al., 2001) or a type of maladaptive cognition (see Jensen et al., 1994). However, whether or not catastrophizing is viewed as a coping strategy, attribution or both, there is consensus that catastrophizing cognitions are more maladaptive than adaptive, and evidence shows consistently strong associations between catastrophizing cognitions and measures of patient dysfunction (cf. Boothby et al., 1999).

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One can obtain a clear sense of a patient’s tendency to catastrophize during the entire evaluation by listening carefully to the patient’s language. Frequent use of words that reflect either/or thinking (‘never’, ‘always’), or excessive negative views of the future that emerge when discussing treatment options provide important evidence of the presence and severity of catastrophizing responses. Also, the patient’s response to a simple direct question (‘What goes through your mind when your pain gets worse or you have a pain flare-up?’) can provide information about the patient’s ability to problemsolve flexibility around the issue of pain, versus a tendency to respond rigidly and automatically with negative thoughts that then lead to maladaptive coping. If significant catastrophizing is present, then the chances are good that the patient is depressed or has significant depressive symptoms. In this case, treating the depression should be given high priority, because pain self-management requires significant effort, and can be particularly difficult when the patient has to deal with the motivation-killing effects of this affective disorder. Given the importance of treating significant depression quickly and effectively, it is worth offering patients multiple treatments as soon as possible after depression has been diagnosed, including: (1) appropriate medication management by the patient’s treating physician; (2) reactivation and exercise (e.g. Dunn et al., 2005); (3) cognitive-restructuring (e.g. Ehde and Jensen, 2004); and (4) hypnotic approaches (Yapko, 2001; see also Yapko, Chapter 22, this volume). Sleep disturbance is another significant problem reported by many persons with chronic pain. It is also a problem that can respond well to hypnotic interventions (e.g. Elkins et al., 2004), as well as to more classic sleep hygiene training (Montgomery and Dennis, 2003). Knowledge about problems with sleep onset (‘Once you are in bed and ready to go to sleep, how long does it usually take you to get to sleep?’), nocturnal awakenings (‘About how many times a night do you wake up, on average, and how long does it usually take you to get back to sleep when you do wake up?’), early morning awakening (‘What time do you usually wake up in the morning?’), and extent of restful sleep (‘Do you usually feel rested when you wake up in the morning?’)

are all important to assess, and will impact the specific hypnotic suggestions you might consider if this is a problem for the patient. The two social factors most frequently assessed during a comprehensive evaluation of chronic pain are (1) general social support and (2) spouse or significant other responses to patient pain and well behaviors. Social support has long been studied as an important variable that can buffer the negative effects of chronic illness. Research in persons with chronic pain indicates that general social support is linked to positive mood (and lack of depression) and to lack of pain interference with activities (e.g. Jensen et al., 2002). However, given the very high risk that people with chronic pain have for developing depression, and the cascading negative impact of depression on adaptive coping, the availability of positive social support (and the modification of stressful relationships) is likely to be important for many patients. Questions that assess the nature of the quality of the relationship between the patient and the key person(s) in his or her life include, ‘What impact, if any, has your pain had on your relationship with ______?’, and ‘How would you say that you and _____ are getting along?’ Ideally, you will have an opportunity to speak with the person that is most important to the patient (and who that person is when they come to the interview can be telling; I am aware of one patient who had brought his bartender with him as his ‘significant other’ during an evaluation at our center, and one patient I interviewed brought in her pet dog) to get their responses to these two questions. More importantly, the presence of the patient’s significant other during the initial evaluation provides an opportunity for you to observe them both together for at least some period of time. For patients who live with someone, and to the extent that problems in that relationship contribute to overall stress or do not allow for the benefits of positive support, then couples’ therapy might be offered as a means of increasing mutual global social support in the relationship. For those patients who have very limited support available, for example patients who live alone and have very little regular contact with supportive others, but who might be interested in developing supportive relationships,

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communication (e.g. assertiveness) training or counseling around methods for meeting and developing close relationships may be of help. If the lack of a close supportive relationship is a significant issue that has an impact on the patient’s adjustment to pain, and this is related to developmental issues (e.g. history of abandonment or abuse), they might respond well to analytic counseling (see Baker and Nash, Chapter 16, this volume), and offering this or a referral for this treatment should be considered. Although global positive social support, or ‘unconditioned positive regard’, from at least one person can help to buffer the stress of chronic pain problems, pain-contingent positive responses (i.e. showing intermittent ‘support’, and then only or primarily when the patient displays pain behavior) seems to provide little emotional benefit, and may, in fact, undermine functioning through a learning process of reinforcement of illness behavior (Fordyce, 1976). Similarly, criticism or expressions of worry and concern when the patient begins to participate in exercise (i.e. discouragement of ‘well behavior’), while often well intentioned, can backfire and interfere with progress and adaptive functioning (cf. Schwartz et al., 2005). The series of questions used to assess significant other responses to well and illness behavior can include the following: (1) ‘How does your ____ know when you are hurting? What does she/he see you do or hear you say?’ (to assess pain behaviors typically displayed); (2) ‘What does he/she do when he/she knows or thinks that you are hurting?’ (to assess presence of positive reinforcement for pain and illness behaviors); and (3) ‘What does he/she do when he/she sees you try and do something like exercise or a household chore even when you are hurting?’ (to assess possible discouraging responses to well behaviors). Other questions that can access possible reinforcers include: (1) ‘What do you no longer do because of your pain?’ and (2) ‘What do you do less of (but still do some) and more of because of pain?’ The answers to these questions can identify possible activities that may be providing ongoing reinforcement. For example, if the patient is now doing more activities because of pain that he/she finds pleasurable, such as watching television, or avoiding activities that might be aversive, such as

household chores or paid work, these might be providing ongoing positive and negative reinforcement, respectively. The key with these, and similar, questions, is to determine if reinforcement of pain behaviors might be playing a role in the patient’s ongoing disability. Finally, in each evaluation of a person with chronic pain, as with a person with acute pain problems, it is wise to identify the presence of any specific psychological diagnoses. Approximately one-third of patients with chronic pain meet criteria for a major depressive disorder. Many other patients with chronic pain experience significant depressive symptoms, even if they do not quite meet criteria for a major depressive disorder. For many, these symptoms developed after the onset of chronic pain, and, as mentioned above, can have a significant negative impact on patient motivation for adaptive pain self-management. Significant motivation is necessary for positive outcomes of treatment, including hypnotic analgesia treatment. Therefore, it is necessary to assess the presence and severity of depression, and then provide appropriate treatment when depression is present. Although depression is the most frequent psychological diagnosis observed in patients with chronic pain, other DSM-IV-R diagnoses are also common. These include post-traumatic stress disorder, and a variety of anxiety and axis II (personality) disorders. Each of these will need to be addressed in the treatment plan, if present. Obviously, appropriate referrals should be made if the clinician does not have expertise in treating such co-morbid conditions.

20.4.2. Chronic pain treatment plan development and implementation Based on the initial evaluation, a number of factors that are probably contributing to the patient’s chronic pain and disability will be identified. The most common factors are listed in Table 20.4, and include: (1) high pain intensity; (2) significant pain bothersomeness; (3) illness conviction/biomedical focus; (4) use of maladaptive coping strategies (e.g. pain-contingent rest, inactivity, guarding or withdrawal); (5) lack of use of adaptive coping strategies (e.g. regular appropriate exercise given the condition, use of self-hypnosis if appropriate); (6) presence of

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Table 20.4. Specific problems and factors that can contribute to poor adjustment to chronic pain, associated treatment options and hypnotic suggestions that can be of benefit Problem/issue

Treatment options

High pain intensity

Appropriate medication management, See Table 20.2 appropriate exercise, hypnosis

Significant pain bothersomeness

Cognitive-restructuring, acceptance therapy, hypnosis

Decreased bothersomeness of pain, ability to ignore pain

Illness conviction/ biomedical focus

Education, hypnosis, appropriate exercise, cognitive-restructuring

Increased understanding of the complex nature of pain, and of the psychological factors that can impact pain

Use of maladaptive coping strategies/lack of use of adaptive coping strategies

Education, Motivational Interviewing modeling, operant therapy, hypnosis

Age progression imagining effective use of adaptive coping strategies

Catastrophizing

Cognitive restructuring, hypnosis

Age regression imagining adaptive cognitions in response to pain flare-ups

Sleep disturbance

Elimination of inappropriate long-term See Table 20.2 sleep agents (e.g. benzodiazepines), consider medications that might help with sleep (e.g. some antidepressants), sleep hygiene education, exercise, hypnosis

Significant anxiety, depression or personality disorder

Exercise, appropriate medications (e.g. anti-depressants), cognitiverestructuring, in-depth counseling or analysis

See Chapters 21, 22 and 23, this volume, for ideas regarding use of hypnosis for the treatment of anxiety, depression and personality disorders, respectively

Lack of social support

Couple’s therapy, communication training, in-counseling/analysis if related to personality disorder

Hypnosis generally not used directly to address issues related to a lack of social support

Presence of reinforcement of pain behavior, or discouragement of well behavior

Education, couple’s therapy or education, operant therapy

Hypnosis generally not used directly to address issues related to presence of reinforcement of pain behavior, or to the presence of discouragement of well behavior

catastrophizing cognitions; (7) sleep disturbance; (8) significant depression, anxiety or personality disorder; (7) lack of social support; and (8) presence of social reinforcement of pain behavior or social discouragement of well behavior. To the extent that each of these issues is present, it should be dealt with in order to improve the patient’s overall quality of life. For example, for patients with a maladaptive illness conviction and/or a biomedical focus for their pain problem, a reasonable treatment goal would be

Hypnotic suggestions for…

for the patient to develop a more complex biopsychosocial understanding of their pain problem; an understanding which would increase their willingness to consider and engage in psychosocial interventions such as appropriate exercise, cognitive-restructuring and self-hypnosis. For patients who are using maladaptive coping strategies or who catastrophize, the goal would be to teach them to recognize the pernicious effects of their coping efforts and cognitions, and replace them with more adaptive ones.

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After the initial evaluation of case formulation, the next step is to come up with a list of reasonable treatment options to address the problems identified. In the next section, we discuss how hypnosis, specifically, might be utilized for addressing each of the problems or issues listed in Table 20.4. Examples of specific hypnotic suggestions that we have found helpful for persons with chronic pain are presented in the Appendix (see also Barber, 1996, for additional examples of suggestions helpful for patients with chronic pain conditions).

20.4.2.1. High pain intensity and pain bothersomeness The most obvious application of hypnosis to pain management that comes to the minds of patients and clinicians is to reduce pain and associated suffering. The basic strategies for achieving this goal for acute pain (e.g. inductions followed by suggestions for relaxation, comfort, amnesia, dissociation, time distortion, pain displacement, sensation alteration, decreased pain and distraction) were described above (see also Table 20.2; and see the Appendix for specific examples of text for these suggestions). Many patients, even those with only moderate and some with minimal general hypnotic skills, are able to respond to one or more of these suggestions. When using hypnosis to improve selfmanagement of pain, we usually begin with an induction, and then provide a series of different pain management suggestions, assessing the efficacy of each with this particular patient during the sessions. The induction we most often use with patients with chronic pain begins with relaxation (see Appendix for text for relaxation suggestions, which can be used as an induction). Almost everyone is able to respond well to suggestions for relaxation, so using these as an induction can teach patients an important skill right away that is generally useful for coping with chronic pain. However, if the patient has experience with hypnosis and has a favorite induction, we would normally then start with that induction. As treatment progresses, we experiment with different inductions (including the use of imagery and ideomotor inductions) to keep the patient interested, and determine which combinations of suggestions seem

to invoke the deepest experiences of hypnosis. When an induction strategy is identified after several sessions that seems to work well with the patient, we then tend to stick with that induction for that particular patient for the remaining sessions (although always altering it a little to maximize patient interest and absorption in the induction). In short, as treatment progress, it is the patient’s response to the inductions (and subsequent suggestions, see below) that drives the content of these. Following the induction, in the first session, we usually systematically present a series of suggestions for increased comfort, decreased pain, increased control over pain and decreased bothersomeness for pain (see Appendix for examples of text that can be used for these suggestions). In our experience, suggestions for deep relaxation and reduced bothersomeness of pain are the easiest for most people to respond to, including those with relatively low baseline general hypnotic talent. However, in the first few treatment sessions, we usually offer a number of different suggestions, and assess the immediate impact of these on pain perception (by asking patients to report on their pain intensity during the hypnosis session; in order to help ensure that this does not interrupt their hypnotic experience, the clinician can say, ‘And now, while allowing the muscles of your voice to become activated while still remaining relaxed, and deeply focused, please tell me, on a 0 to 10 scale, with 0 being ‘no pain sensation’ and 10 being ‘pain sensation as intense as I could imagine’, how would you rate the current intensity of any uncomfortable sensations you are feeling now?’). Metaphors for pain management can also be provided following an induction (or as part of an induction) to patients who might be responsive to these (Eimer, 2000). Erickson, of course, was a master at using metaphors in hypnosis treatments, including treatments of chronic pain. When using this approach, the clinician tells a story that contains indirect suggestions for how the patient might more effectively manage pain or its effects. The assumption is that such stories are more easily absorbed by some patients than more direct suggestions. Indeed, in our practice, some patients seem to respond well to this approach. One example of such a ‘story’ is presented in the Appendix.

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Following the analgesia suggestions, we almost always provide post-hypnotic suggestions. However, the post-hypnotic suggestions used for patients with chronic pain usually differ from those that are used for acute procedural pain. Because the treatment goal for chronic pain is usually to minimize the experience of pain throughout the entire day (and night), not just during specific times, post-hypnotic suggestions are made that: (1) ‘…all feelings of comfort and relaxation, and any benefits of the session, will stay with you and linger beyond the session, for minutes, hours, days and, with practice, months and years’; (2) the patient may choose to practice on his or her own without a tape, at any time, and as often as needed, by ‘taking a deep breath, holding it, and letting it go…. And all of the feelings of comfort, relaxation, and…. [insert suggestions for any other perceptions or feelings tailored to the patient] will come washing back, and will then stay with you and linger … even after you are done practicing …’ (Barber, 1996); (3) the more the patient practices, with or without a practice tape, the easier it will be for the patient to enter a state of comfortable relaxation, and the more quickly he or she will respond to suggestions ‘…that are appropriate for your comfort and well-being’. The primary goal with the post-hypnotic suggestions, indeed, with the entire procedure, is to teach the patient a skill that he or she can use at any time to reduce his or her experience of pain that will, over time, become automatic. A few patients need only a few treatment and practice sessions in order to achieve substantial pain reductions that appear to be mostly permanent. Most will require a number of treatment sessions and frequent practice to be able to achieve pain relief, on (self-) command, that will last a few hours or most of the day. After each treatment session, we then discuss with the patient his or her thoughts, feelings and responses to the induction and each of the suggestions offered. Information from this discussion is used to modify future inductions and suggestions as appropriate. In addition, we frequently identify, with the patient, a nonpain goal such as improved sleep, improved confidence or increased overall well-being that the patient is particularly interested in, and incorporate suggestions that pertain to this goal.

This is done in part to ensure that the patient is able to use hypnosis treatment to address all of his or her needs, but also to increase the patient’s investment and engagement in treatment and to emphasize (patient) self-control. Based on the patient’s response to the painrelated suggestions in the first two sessions, we then select one to three of them for use in the remaining sessions. During the third session, these suggestions are provided after an induction that is tailored to the patient’s interest, skills and needs, based on his or her responses during the first two sessions. This third session and the next session (and sometimes more, if we believe that more tapes or tapes with different content would be helpful) are also taped, and the audiotape is given to the patient with the instructions that ‘…you should listen to this tape at least once a day during a time when you are awake and can focus on the tape without interruption; more often than once a day will be fine and, in fact, the more often you listen to the tape, the faster your progress will be’. We make more than one tape to allow the patient more than one option, and given him or her a chance for variety if this would be helpful.3 The remaining sessions most often continue using the primary suggestions, modified when appropriate, selected during the first two. Although response to treatment is variable, many patients report that they are able to achieve some level of pain relief following treatment and after listening to the practice tapes, and that this relief continues after the treatment sessions and practice tapes (Jensen et al., 2005). Some patients report that they are unable to achieve lasting reductions in pain intensity, but even these patients often report that the pain they do experience seems to bother them less.

3 Once, during the induction of one of the taped sessions, one of the authors (M. J.) coughed. But he continued with the session and the recording anyway. Although both the author and the patient expected the audiotape to be useless because of the loud cough, the patient reported that, in fact, the anticipation he experienced before the cough on the tape contributed to a more effective response to the induction after the cough; ‘I just wait for that cough, and then sink right down into a deep state’. This tape became the patient’s favorite.

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Most report that they feel more in control over pain, and its effects on their lives. It is important to remember, however, that hypnotic analgesia treatment should be provided in the context of understanding all of the factors that might be contributing to the patient’s pain and disability levels. For example, if the patient is complaining bitterly of severe pain, but is coping with this pain by spending the bulk of his or her time reclining in bed or on a couch, then suggestions that focus exclusively on pain reduction are unlikely to be of benefit. If significant social reinforcers for pain and illness behavior are identified, significant illness conviction is present or the patient engages in frequent catastrophizing, and these issues are not addressed in treatment, simple suggestions for pain reduction in and of themselves are not likely to produce significant or long-lasting improvements. In fact, patients with significant illness conviction and biomedical focus may be interested in hypnotic analgesia as another treatment that is ‘done to’ them (like surgery or medications), and could potentially undermine a self-management approach to pain management. Moreover, hypnosis focused merely on pain reduction out of the context of a comprehensive treatment plan that addresses the multiple biological, psychological and social issues involved could potentially be yet one more in a long line of ‘magical’ cures that the patient has tried for their pain, with its failure being viewed as yet another in a long line of discouragement. Thus, when presenting and using hypnosis for chronic pain, we label this treatment as ‘selfhypnosis’ and present it as a specific skill that patients can learn and then use themselves. We explain that the goal is to help them learn strategies to increase their confidence, strength and control over pain so that they can ‘do more, and hurt less’. We also emphasize the importance of addressing all of the potential pain-related problems identified in the initial evaluation (see Table 20.4), and of participating in treatments that will address these.

20.4.2.2. Illness conviction and biomedical focus The traditional interventions designed to reduce illness conviction and a biomedical focus in patients with chronic pain are education

(to help patients understand the complex biopsychosocial factors that influence pain and its effects on their lives), graded increases in exercise and activity (to teach patients that any pain or discomfort that often accompanies exercise tends to dissipate over time as they become stronger and develop more activity tolerance) and cognitive-restructuring (to help patient learn to alter automatic thoughts from ones that are illness focused to ones that reflect more calming and reassuring beliefs). However, hypnosis can be used to help enhance the efficacy of each of these other therapies. For example, during hypnosis, patients can be given suggestions that they ponder the fact that chronic pain is rarely the result of a single biological cause, that many factors can increase a person’s focus on and experience of pain, and that this means that they can gain more control over their experience of pain. (‘You may have found in your life that it seemed that there was only one alternative. Wouldn’t it be interesting to realize that you have so many more ways to look at your pain then you might have realized were there…’). You can then go on to describe factors and events that can contribute to pain that match the key factors in the patient’s life; factors which he or she has control over (the meaning given to pain, how others respond to the patient, etc.). Careful evaluation of the patient’s responses to these suggestions will determine if the patient finds them comforting and empowering. If so, then of course they and similar suggestions would bear repeating in future sessions and on practice tapes. Similarly, to the extent that the patient is frightened of pain associated with reactivation or exercise, hypnosis can be used to address this fear much like one would use hypnosis for managing anxiety associated with painful medical procedures. Added additional suggestions might include the obvious, (‘And you may find that it becomes so easy to do that exercise that you know that is good for you…. Even though you will know deep inside what is safe and when you should stop, you will be amazed at how strong and confident you will feel as you exercise…’). Other suggestions can focus on the benefits that naturally occur with exercise, and the view that the old feelings of muscle discomfort can be taken as signs that the muscles and tendons that

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require exercise are responding to exercise (‘.…with time, as your body becomes stronger and more flexible, you will find that the discomfort becomes less and the exercise becomes even easier …. Knowing that one sign of muscles getting stronger is that they let you know you have been using them…’). It is important, of course, that any exercise program be supervised and approved by an experienced medical professional, to ensure that continuing with exercise despite the discomfort that often accompanies exercise in persons with chronic pain is medically indicated.

20.4.2.3. Use of maladaptive coping and/or lack of adaptive coping Patients who are using pain coping strategies that are thought to contribute to increased pain and disability over time (in particular, paincontingent rest and guarding), or who are not using coping strategies thought to contribute to long-term positive outcomes (regular moderate exercise, positive coping self-statements) can be provided with individual or group didactic education to teach the consequences of different coping responses, Motivational Interviewing for making adaptive changes (Jensen, 2002), or even operant therapy during which adaptive responses to pain are selectively reinforced (Fordyce, 1976). However, we also believe that hypnosis is underutilized by pain clinicians seeking to assist patients in altering their coping responses. One particularly effective hypnotic strategy is age regression or age progression. In age regression, and following the hypnotic induction, the patient can be asked to imagine a time when he or she was moving normally (as an indirect suggestion to decrease guarding responses), exercising regularly or engaging in some specific response that would be considered adaptive for pain management. In the same, or different, session, the patient could then imagine himself or herself in the future, effectively using adaptive coping strategies to manage pain in a realistic way (e.g. ‘You can see yourself feeling confident and strong. Confident because you exercise almost every day, and you know that you are becoming stronger and stronger. Soon, you will be strong enough to do whatever it is that you need to do. You can see yourself, walking normally and briskly, feeling so good and so proud,

because you have done the work to reach this point … and you can feel proud of yourself as you are doing this work … proud and confident … building your strength, so that you feel confident in your ability to [insert some valued activity]’). In age progression, in particular, the clinician can offer effective imaginative reinforcers (feeling proud, working again and making money, completing a valued project, being active with family or friends in a valued activity) for adaptive coping; in essence, performing hypnotic/imagined operant conditioning.

20.4.2.4. Catastrophizing The first-line treatment for pain-related catastrophizing is cognitive-restructuring (Ehde and Jensen, 2003). This treatment involves teaching patients to identify, stop and then alter (to reassuring adaptive cognitions) automatic catastrophizing cognitions when they occur. While it is certainly possible, and appropriate, to engage in cognitive restructuring outside of the hypnotic context, once adaptive cognitions are identified and agreed upon by the patient as reasonable, these can be offered during hypnosis. For example, it could be suggested to patients that whenever they experience any uncomfortable feeling, not only can this be a cue to ‘…take a nice deep breath, hold it … hold it for a moment … and let it go … and experience a feeling of relaxation’, but it can also be a cue to ‘ be aware of just how surprisingly calm you can feel … calm, and confident … that you can handle discomfort … as you have before, and will again …. So easy to ignore … not bothersome at all … and it does not really need to mean anything …’. In essence, the goal is to help the patient replace any old, maladaptive, catastrophizing, cognitions with new, reassuring, thoughts in response to pain. As another example, patients can be trained in hypnosis to distance themselves from catastrophizing cognitions ‘You may notice that whenever you have those old, inaccurate automatic thoughts, that these are immediately replaced by accurate and reassuring thoughts, for example, how strong and regular you heartbeat is and how slow and regular your breathing is …. You may find that you are able to observe yourself having those silly thoughts. In fact, you might even be entertained at how exaggerated, inaccurate, and silly they really are, and how they seem

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to then just disappear, on their own … and occur less and less frequently, in fact, at some point in the future, and really only you can know this, wouldn’t it be interesting when you notice that these old, unhelpful thoughts have disappeared altogether?’

20.4.2.5. Sleep disturbance The use of hypnosis to help patients improve and maximize restful sleep in the face of pain was discussed above as it related to acute pain, and all of the interventions described there (except, perhaps, the use of sedative sleeping medications which are contraindicated for longterm use) apply here as well, including the use of medications that can help with sleep and are appropriate for long-term use (e.g. some antidepressants), sleep hygiene education and hypnotic suggestions to address any specific sleep problems. Basic sleep hygiene (having the bed become a stimulus for sleep, avoiding caffeine in the late afternoons and evenings, and getting out of bed and engaging in activity) should be encouraged in any patient who complains of sleep difficulties. In addition, regular aerobic exercise can also help with sleep, and hypnotic suggestions to encourage this and make it more pleasurable (or, at least, less uncomfortable) would be appropriate. Using hypnotic suggestions directly to improve sleep (‘you will fall into a profound sleep and will awake feeling rested in the morning’) can also be used to reinforce sleep hygiene (‘You will find yourself going to bed only when you are tired and sleepy … you will also find that you wake up when it is appropriate’). 20.4.2.6. Depression, anxiety and/or personality or character disorder Patients with significant depression, anxiety, or who have a character disorder, will ideally have had these problems addressed before pain treatment begins. As indicated above, significant depression is particularly common among persons with chronic pain, and its presence can undermine efforts to encourage pain selfmanagement. All treatment options should be considered. Medication management, cognitiverestructuring, exercise and behavioral (increase pleasurable activities) interventions have all been shown to be effective, and it is likely that more patients would benefit faster if all of these

are tried simultaneously (needless to say, such treatment should be referred out if not within the expertise of the pain clinician). In addition, however, interventions for depression, anxiety and character disorders that incorporate hypnosis also exist (see the chapters that address these issues in the present volume), and should be considered.

20.4.2.7. Lack of social support and/or reinforcement of pain and illness behavior/lack of reinforcement of well behavior Finally, the pain clinician needs to consider the extent to which lack of social support, or the presence of maladaptive social interactions, might be contributing to the patient’s pain and illness behaviors and suffering. The most common interventions to address these issues include education (to teach operant principals to the patient and his or her significant other), couple’s therapy (to increase the frequency of mutually supportive behaviors as well as to encourage patients to negotiate with their significant other alternative responses to the patient’s pain and well behaviors), communication training (to help improve the patient’s skills at building and maintaining supportive relationships) and in-depth analysis or counseling (to address characteralogical problems if these are contributing to the lack of quality relationships). While we do not typically use hypnosis to address these issues in our practice, the pain clinician needs to be aware of their role in any particular patient, and ensure that if they are playing a role, they are addressed in treatment. If they are not addressed, then efforts to improve the patient on other fronts might fail. For example, to the extent that developing and maintaining a regular exercise program is central to a patient’s improvement, then efforts to encourage exercise might be undermined if the patient’s significant other panics at the sight of watching the patient exercise (‘Stop that! You’ll hurt your back!’). Similarly, hypnotic analgesia to decrease the experience of pain might prove futile if communication about this pain is one of the few options available to the patient to help him or her manage the aversive behavior of his or her spouse.

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In summary, appropriate integration of hypnosis in chronic pain treatment requires that the clinician understand the many biopsychosocial factors that can contribute to pain and its expression, perform a thorough evaluation to assess these factors and consider them all when developing and implementing a treatment plan. Hypnosis can be a powerful tool that teaches patients to be able to gain more control over their experience of pain and suffering, and to enhance the efficacy of other curative or helpful treatments, such as exercise and cognitiverestructuring. But hypnosis should be used in conjunction with other treatments to address all of the issues contributing to pain and disability in any one patient.

20.4.3. Case report: a man with below-

level chronic spinal cord injury pain D. J. is a 40-year-old man presenting with chronic low back and hip pain below the level of his a L1–2 incomplete spinal cord injury. He was injured 20 years prior to seeing me (M. J.) in a motor vehicle accident in which he ran off the road while under the influence of alcohol. At the initial evaluation he reported being mostly sober since the accident, and entirely sober (free from all alcohol and illegal drugs) for the past 12 years. He was running his own business (a computer networking consulting business) from home. Although he had never been married, he had been living with a partner for the past 5 years, and they reported a close, supportive relationship. He reported some mild symptoms of depression and anxiety (occasional sad mood and anxiety), but did not meet criteria for a mood disorder, nor did he meet criteria for a character disorder. Pain levels pre-treatment were moderate to severe (range, 4–9 on a 0–10 scale; average, 7). He was not using any medications to manage pain, reporting that none was adequately effective, although he had tried many. Even though his pain was severe at times, he reported minimal impact on his day-to-day life except for sleep (sleep interference was rated as 4/10). There was no evidence that psychological factors were contributing significantly to his ongoing pain experience, and his hypnotizability, as assessed by the Stanford Clinical Hypnotizability

Scale, was moderate (3/5). He also reported having positive experience with ‘touch’ therapy in which he was able to experience pain relief when a layperson ‘changed my energy flow’ by moving her hands around the patient (i.e. not actually touching the patient). However, this relief was temporary. Other treatments tried, including physical therapy, massage and a number of medications, provided, at best, only minimal pain relief. Using the chronic pain treatment protocol described above, the first two treatment sessions started with a relaxation induction followed by a series of five different suggestions: very deep relaxation; sensory substitution; decreased pain; imagined anesthesia; and decreased pain unpleasantness. Before the third treatment session, we decided to focus on two of the suggestions that he seemed to respond the best to (decreased pain intensity and unpleasantness) for the treatment sessions as well as in the practice tapes. The third and fourth sessions were audiotaped and included the suggestions that the benefits of treatment would linger beyond the sessions, and also that the patient would become more skilled with practice (see the Appendix for examples of text that can be used for such suggestions). The patient was given the tapes and encouraged to practice at least once daily. The patient reported that his pain intensity consistently decreased substantially (to 0.5/10 from a range of 2–8 before the session) across each treatment session, and that the pain reduction that occurred lasted for 1–5 h. After the first two sessions, he practiced regularly, and so was able to maintain a much lower level of pain in his day-to-day life by initiating self-hypnosis whenever his pain intensity increased to uncomfortable levels (usually, greater than 2/10). He reported improvement in depressive symptoms (from a low– moderate range to virtually none; CES-D scores from 10 to 4, pre- to post-treatment), as well as in the interference of pain with sleep (from 4/10 to 0/10). At post-treatment, his average pain intensity rating was 2/10. At 12-month follow-up the patient reported that he practiced self-hypnosis for 5 min at a time (without practice tapes, but which he still had on hand ‘just in case’), 3–4 times daily. He said he used his skills to maintain his pain

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intensity at low levels, and described an ability to decrease pain intensity ‘immediately’ when he practices self-hypnosis. However, as occurred during treatment, he was not able ever to lower his pain to 0/10 using self-hypnosis. He added that he experienced his pain as more ‘friendly’ and much less ‘harsh’, ‘sharp’ and ‘stingy’ compared with how it felt before treatment

20.5. Summary and conclusion Enough controlled trials have been performed to conclude that hypnotic analgesia can effectively reduce both acute and chronic pain (Montgomery et al., 2000; Patterson and Jensen, 2003; Jensen and Patterson, 2006). However, the application of hypnosis for acute pain and chronic pain differs in important ways. When using hypnosis for acute pain, the focus of treatment is almost always on the experience of pain and associated symptoms (e.g. anxiety, sleep disturbance), and hypnotic analgesia suggestions are most often linked to the specific procedures or injuries that are causing the pain. The use of hypnotic procedures for treating chronic pain is more complex. Even when the focus of treatment is on the experience of pain, the goal of chronic pain treatment is to teach selfhypnosis skills that the patient can use on a daily basis. In the situation where pain treatment involves more goals than just decreasing pain intensity (which should be most of the time when treating chronic pain), hypnosis can also be used to enhance the efficacy of other treatments, such as cognitive-restructuring and exercise. Hypnotic interventions can also be used to address symptoms frequently associated with chronic pain, such as sleep disturbance, depression and anxiety. Our view is that hypnosis should be offered to any patient with pain who is interested in it, and that it should be integrated much more into standard pain treatment than it currently is.

Acknowledgment This work was supported by the National Institutes of Health (grant no. R01 GM4272509A1) and by the National Institutes of Health,

National Institute of Child Health and Human Development, and National Institute of Neurological Disorders and Stroke (grant no. P01 HD/ NS33988).

References Barber, J. (1996) Hypnosis and Suggestion in the Treatment of Pain. Norton and Company, New York. Boothby, J. L., Thorn, B. E., Stroud, M. W. and Jensen, M. P. (1999) Coping with pain. In D. C. Turk and R. J. Gatchel (ed.) Psychosocial Factors in Pain, pp. 343–359. Guilford Press, New York. Cervero, F. (2005) The gate theory, then and now. In H. Merskey, J. D. Loeser and R. Dubner (ed.) The Paths of Pain 1975–2005, pp. 33–48. IASP Press, Seattle. Dunn, A. L., Trivedi, M. H., Kampert, J. B., Clark, C. G. and Chambliss, H. O. (2005) Exercise treatment for depression: efficacy and dose response. American Journal of Preventative Medicine, 28: 140–141. Dworkin, R. H., Backonja, M., Rowbotham, M. C., Allen, R. R., Argoff, C. R., Bennett, G. J. et al. (2003) Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations. Archives of Neurology, 60: 1524–1534. Ehde, D. M. and Jensen, M. P. (2004) Feasibility of a cognitive restructuring intervention for treatment of chronic pain in persons with disabilities. Rehabilitation Psychology, 49: 254–258. Eimer, B. M. (2000) Clinical applications of hypnosis for brief and efficient pain management psychotherapy. American Journal of Clinical Hypnosis, 43: 17–40. Elkins, G., Marcus, J., Palamara, L. and Stearns, V. (2004) Can hypnosis reduce hot flushes in breast cancer survivors? A literature review. American Journal of Clinical Hypnosis, 47: 29–42. Erickson, M. (1980) Innovative Hypnotherapy, Vol. 4. Irvington Publishers, Inc., New York. Erickson, M. and Rossi, E. (1981) Experiencing Hypnosis: Therapeutic Approaches to Altered States. Irvington Publishers, New York. Erickson, M., Rossi, E. and Rossi, S. (1976) Hypnotic Realities: The Induction of Clinical Hypnosis and Forms of Indirect Suggestion. Irvington Publishers, Inc., New York. Everett, J. J., Patterson, D.R. and Chen, A.C. (1990) Cognitive and behavioral treatments for burn pain. The Pain Clinic, 3: 133–145. Fordyce, W. E. (1976) Behavioral Methods for Chronic Pain and Illness. Mosby, Saint Louis. Hanley, M. A., Jensen, M. P., Ehde, D. M., Hoffman, A. J., Patterson, D. R. and Robinson, L. R. (2004) Psychosocial predictors of long-term adjustment to lower-limb amputation and phantom limb pain. Disability and Rehabilitation, 26: 882–893. Haythornthwaite, J. A. and Benrud-Larson, L. M. (2000) Psychological aspects of neuropathic pain. Clinical Journal of Pain, 16: S101–S105.

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Jacobson, L. and Mariano, A. J. (2001) General considerations of chronic pain. In J. D. Loeser, S. H. Butler, C. R. Chapman and D. C. Turk (ed.) Bonica’s Management of Pain, pp. 241–254. Lippincott Williams and Wilkins, Philadelphia. Jaffe, S. E. and Patterson, D. R. (2004) Treating sleep problems in patients with burn injuries: practical considerations. Journal of Burn Care Rehabilitation, 25: 294–305. Jensen, M. P. (2002) Enhancing motivation to change in pain treatment. In D. C. Turk and R. J. Gatchel (ed.) Psychological Treatment for Pain: A Practitioner’s Handbook, 2nd edn., pp. 71–93. Guilford Press, New York. Jensen, M. P. and Patterson, D. R. (2006) Hypnotic treatment of chronic pain. Journal of Behavioral Medicine, 29: 95–124. Jensen, M. P., Turner, J. A. and Romano, J. M. (1994) Correlates of improvement in multidisciplinary treatment of chronic pain. Journal of Consulting and Clinical Psychology, 62: 172–179. Jensen, M. P., Ehde, D. M., Hoffman, A. J., Patterson, D. R., Czerniecki, J. M. and Robinson, L. R. (2002) Cognitions, coping and social environment predict adjustment to phantom limb pain. Pain, 95: 133–142. Jensen, M. P., Hanley, M. A., Engel, J. M., Romano, J. M., Barber, J., Cardenas, D.D. et al. (2005) Hypnotic analgesia for chronic pain in persons with disabilities: a case series. International Journal of Clinical and Experimental Hypnosis, 53: 198–228. Kavanagh, C. (1983) Alternative approach to burned children. American Journal of Psychiatry, 140: 268. Loeser, J. D. (2001) Medical evaluation of the patient with pain. In J. D. Loeser, S. H. Butler, C. R. Chapman and D. C. Turk (ed.) Bonica’s Management of Pain, pp. 267–278. Lippincott Williams and Wilkins, Philadelphia. McCracken, L. M., Vowles, K. E. and Eccleston, C. (2005) Acceptance-based treatment for persons with complex, long standing chronic pain: a preliminary analysis of treatment outcome in comparison to a waiting phase. Behaviour Research and Therapy, 43: 1335–1346. McGrath, P. J., Finely, G. A. and Ritchie, J. (1994) Pain, Pain, Go Away: Helping Children with Pain. Association for the Care of Children’s Health, Bethesda, MD. Melzack, R. (1990) The tragedy of needless pain. Scientific American, 262(2): 27–33.

Appendix: useful suggestions for persons with acute and chronic pain conditions4 Suggestions for relaxation (can be used with patients who are participating or will participate in a painful medical procedure, or for patients with chronic pain, to obtain increased feelings of relaxation in the face of pain; these suggestions can also make an effective induction for individuals with limited baseline hypnotic ability).

Melzack, R. and Wall, P. D. (1965) Pain mechanisms: a new theory. Science, 150: 971–979. Montgomery, G. H., DuHamel, K. N. and Redd, W. H. (2000) A meta-analysis of hypnotically induced analgesia: how effective is hypnosis? International Journal of Clinical and Experimental Hypnosis, 48: 138–153. Montgomery, P. and Dennis, J. (2003) Cognitive behavioral interventions for sleep problems in adults aged 60+. Cochrane Database of Systematic Reviews (online), CD003161. Novy, D. M., Nelson, D. V., Francis, D.J. and Turk, D. C. (1995) Perspectives of chronic pain: an evaluative comparison of restrictive and comprehensive models. Psychological Bulletin, 118: 238–247. Patterson, D. R. (1992) Practical applications of psychological techniques in controlling burn pain. Journal of Burn Care and Rehabilitation, 13: 13–18. Patterson, D.R. and Jensen, M. P. (2003) Hypnosis and clinical pain. Psychological Bulletin, 29: 495–521. Patterson, D. R. and Sharar, S. R. (2001) Burn pain. In J. D. Loeser, S, H. Butler, C. R. Chapman and D. C. Turk (ed.) Bonica’s Management of Pain, pp. 780–787. Lippincott Williams and Wilkins, Philadelphia. Patterson, D. R., Ptacek, J. T., Carrougher, G. J. and Sharar, S. (1997) Lorazepam as an adjunct to opioid analgesics in the treatment of burn pain. Pain, 72: 367–374. Schwartz, L., Jensen, M. P. and Romano, J. M. (2005) The development and psychometric evaluation of an instrument to assess spouse responses to pain and well behavior in patients with chronic pain: the Spouse Response Inventory. Journal of Pain, 6: 243–252. Sullivan, M. J., Thorn, B., Haythornthwaite, J. A., Keefe, F., Martin, M., Bradley, L. A. et al. (2001) Theoretical perspectives on the relation between catastrophizing and pain. Clinical Journal of Pain, 17: 65–71. Turk, D. C. and Gatchel, R. J. (2002) Psychological Approaches to Pain Management: A Practitioner’s Handbook. Guilford Press, New York. Wieseler-Frank, J., Maier, S. F. and Watkins, L. R. (2005) Immune-to-brain communication dynamically modulates pain: physiological and pathological consequences. Brain, Behavior, and Immunity, 19: 104–111. Yapko, M. (2001) Hypnosis in treating symptoms and risk factors of major depression. American Journal of Clinical Hypnosis, 44: 95–96.

And now …. Allow your whole body to relax … Allow all your muscles to go limp … and now let’s focus on particular muscle groups … to relax even more …. Let’s start with your right foot … Imagine

4 Many of the suggestions listed for chronic pain listed here are adaptations of suggestions used in a case series of hypnotic analgesia for chronic pain (Jensen et al., 2005), which themselves were authored for that study primarily by Joseph Barber, PhD (see Barber, 1996 for more detailed discussion of these and other suggestions for pain management).

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that all the muscles and tendons in your right foot are relaxing, … and as your right foot relaxes, being aware of those sensations that let you know that your hand feels more relaxed … perhaps a sense of warmth, or of heaviness, perhaps an interesting tingling sensation, whatever sensation that lets you know that your foot is becoming more and more relaxed … limp, heavy, warm and comfortable. And now allow that relaxation to spread … up, up into your leg … your calf, your knee, your upper leg. Your whole right leg becoming more and more relaxed, relaxed and heavy. All the tension draining away, as your leg feels heavier, and heavier, almost as if it were made of lead. So comfortable, so relaxed. And now … allow your awareness to move now to your left foot …. Imagine how your left foot is becoming limp, heavy and relaxed … more and more relaxed, heavier and heavier …. All the tension just draining away …. Let yourself be aware of any sensation that lets you know that your left foot is relaxing … a warmth, a heaviness, any sensation that lets you know that your left foot is becoming more, and more relaxed …. And now allow the relaxation to spread. Up into your left leg … calf … through your knee, and into your upper leg. So very relaxed, heavy and comfortable … your whole left leg relaxing, heavier and heavier …. And now your right hand … Imagine that all the muscles and tendons in your right hand are relaxing, … and as your right hand relaxes, being aware of any sensations that let you know that your hand feels more relaxed … whatever sensation that lets you know that your right hand is becoming more and more relaxed … limp, heavy, warm and comfortable. And now allow that relaxation too to spread … up, up into your wrist … your forearm, your elbow, your upper arm. Your whole right arm becoming more and more relaxed, relaxed and heavy. All the tension draining away, as your arm feels heavier, and heavier, almost as if it were made of lead. And now … allow your awareness to move now to your left hand …. Imagine how your left hand is becoming limp, heavy and relaxed … more and more relaxed, heavier and heavier …. All the tension just draining away …. Let yourself be aware of any sensation that lets you know that your left hand is relaxing … a warmth, a heaviness, any sensation that lets you know that your left hand is becoming more, and more relaxed …. And now allow the relaxation to spread. Up your wrist … forearm … through your elbow, and into your upper arm. So very relaxed,

heavy and comfortable … your whole left arm relaxing, heavier and heavier …. And as you continue, as you allow both of your legs and both of your arms to feel more and more relaxed, you can be aware that the relaxation continues to spread … into your shoulders. All the muscles in your shoulders letting go, relaxing, feeling the support of the (chair/bed), sinking into the (chair/bed), letting all the tension drain out of your shoulders … Feeling so relaxed, so heavy, and …. More and more at ease …. And the relaxation continues to spread … into your neck. All the muscles and tendons of your neck letting go, one by one. Just allowing your head to rest back, the feelings letting you know that your neck is relaxing, more and more, as you feel more and more comfortable, more and more at ease. Your whole body becoming relaxed, very, very relaxed, relaxed … heavy, calm and peaceful ….

Suggestions for comfort (effective for anyone who is or might be feeling uncomfortable; suggestions for comfort need not stand alone, and can be effectively inserted into other suggestions if the clinician believes the patient would benefit). And as you … [insert whatever other suggestions you are providing] … you can feel yourself becoming more and more comfortable … at ease … with nothing to bother and nothing to disturb … comfort flowing in and around your body … sinking in … deep into every muscle, every nerve, every tendon … being more, and more, aware of your own comfort … it feels so good … to feel so comfortable … physically comfortable … mentally comfortable…

Suggestions for amnesia (tends to be particularly effective for patients who score high on measures of hypnotizability for forgetting discomfort associated with specific medical procedures). For acute pain: You may find that when you sit in the dental chair that you start thinking about a movie. This might be your favorite movie, or a movie that your own mind creates. You can become so involved in this movie that you forget everything else. All you think about it is how fascinating the movie is and how much you enjoying it. With time you will realize that you have forgotten everything else. And, at some point you will surprised when you are told that the dentist is done and it is time to go home. You will have forgotten everything else other than your comfort and the interesting, absorbing movie.

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For chronic pain: As you know, there are periods of time that you feel less pain, and times that you feel more pain. Pain can come … and pain can go. Now here is something very interesting … listen carefully … after any period of time that you might have experienced more pain, on average, you will be surprised, sometimes very surprised … to look back and notice that you do not seem to be able to remember very well, if at all, any periods of greater discomfort. You may have the sense that something has happened during that period of time, but you will not recall that you felt any pain during that period. With time you will start to realize that your memories are becoming increasingly pleasant. Wouldn’t it be interesting to find that more and more you are able to focus on, and recall, periods of increased comfort, as your memory of the most important periods of your life consist of periods of hope, comfort and pleasant confidence ….

Dissociation suggestions (can be used with patients who are participating or will participate in a painful medical procedure, or for patients with chronic pain to obtain pain relief; tends to be more effective among patients who cope with pain and anxiety by avoidance). Right now you are sitting in a chair listening to my voice, breathing in and out and most likely feeling relaxed. As you remain very comfortable listening to my voice and relaxing without a care in the world, I want to talk to you about how your brain or your mind works. Your mind is capable of doing several things at once. When you are driving, your hands are directing the steering wheel, your feet are touching the gas or brakes, one hand may be touching the radio, and you may be thinking of something else all together. At the same time, you are breathing in and out and your heart is beating. These things happen quite automatically and easily … and you are not even thinking about them. Just as you are driving the car without thinking about it (and even as you listen to me, your mind is working on several different levels) one part of your mind is listening to what I am saying and hearing every word that I say, yet another part of your mind may be focusing on how relaxed you are or perhaps drifting off in a way so that it seems that you are having no thoughts at all. It really doesn’t matter what you are thinking about now, or a few seconds from now. What is very true

is that some thoughts and experiences are central to your present experience, they are in the front of your mind and awareness … and others fall somewhere in the background. Some are so far in the background that you hardly notice them at all, and in fact it can take a lot of effort just to be aware of them. But you do not have to make that effort … these other experiences can stay right back there in the back of your mind …. And the same can be very true of pain. You may have experienced going to a hotel room with a noisy road close by, or going camping with a rushing river close by. At first you really notice these distractions, but with time, the noises seem to fall into the background of your awareness. They are there, but you just can’t help but to think of other things. We can’t really hold any thought or experience in our mind forever. Whatever we are thinking eventually gives rise to something else. But the interesting thing is that what takes the place of those things for you is going to be something far more interesting, far more pleasant and far more comfortable than you might ever have imagined ….

Suggestions for time distortion (can be useful for patients who are or who will be undergoing medical procedures, for limiting the perceived time of those procedures). For acute pain: Wouldn’t it be interesting to find that you are able to change the time that you feel you are in chemotherapy? You may find that a 10 minute procedure seems to lasts 5 minutes or a 30 minute procedure lasts only 15 minutes. Perhaps a minute will only seem to last a matter of seconds, or an hour will really feel like a matter of minutes. Perhaps you will find yourself pleasantly surprised that you find yourself reflecting after the procedure that it really seemed to take no time at all. In any case, I think you will find that the time will seem to move by so much more quickly and comfortably than you ever might have guessed. You might even be picturing yourself in the future, feeling so good about how quickly it all seemed to go by ….

For chronic pain: At some point in the future, it may be hours from now, or even days from now, I don’t really know when, but at some point in the future, you will start thinking about time. And what you will notice is that the amount of time that you have felt any

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discomfort has changed. Whereas it may have once felt as if you were uncomfortable for [an hour/several hours/most of the day], you can now look back and be pleasantly surprised that this has changed. You may look back and realize that the amount of time you were uncomfortable was really only half that time. One hour can turn into a few minutes … several hours into only one hour. Or maybe, and wouldn’t this be very interesting … and pleasant … you will look back and the amount of time that you were uncomfortable only feels like a few seconds. It doesn’t matter how long you used to think you were uncomfortable … what is important is that you will notice a change, a change that will continue to occur with time.

Suggestions for pain displacement (can be useful for patients with acute or chronic pain; tends to be more effective among patients who score higher on measures of general hypnotizability). Right now, and for some time, you have been experiencing discomfort in your right hand. We both know that this has not been something that you have been very happy with, and that you would like to change. I wonder if you have ever thought about the experience of having that discomfort in a different part of your body. You may not have, because it doesn’t make much sense, does it? Why should you feel uncomfortable in your right arm when the discomfort has been in your right hand? Or why should you feel uncomfortable in your left hand … when it was once in your right hand? If you really think about it, however, the experience of pain is never consistent or stable. It never really remains in the same place … for the same amount of time … at the same intensity. It is always changing … sometimes slowly, sometimes surprisingly fast. And perhaps what you will notice now, right now … is that any discomfort you used to experience in your right hand is starting to change … change even more than it usually does. This time it is moving up your arm, or into your shoulder. It may be that it is moving all the way into your left hand, or even somewhere else. Somewhere where it really does not bother you half as much … a quarter as much. It is important to realize that the discomfort never stays in one place, and as you find it moving easily into your arm or your leg or your stomach, you find that it bothers you less. For just as you can move your pain, you can also control how much it bothers you.

Suggestions to focus on, and then change, sensations (can be used to increase focused attention and ability to alter specific sensations; tends to be more effective among patients who cope with pain and anxiety by sensitizing). Right now, you are experiencing the discomfort in your back. Often, you might have heard people tell you to ignore it, and this can make sense for some people, sometimes. But this time, I want you to do something quite different. I want you to focus on the discomfort and think about it. I want you to tell me what color it is, how big it is and how much water it would hold. Think about this very carefully and watch this discomfort … see what happens to it … maybe you have not noticed many changes at all … but, as you focus on the discomfort, notice what color it is now. Is it the same color as before? How big is it? How much water does it hold? Notice too what the true sensation is that you are experiencing. Notice too that these sensations are not good or bad. They just are. They can change, but also, how you feel about these sensations can change. As you become more, and more, absorbed in your experience of all sensations … you can notice that these sensations can start to have a more friendly quality … an interesting quality. We talk about discomfort, but we are really talking about sensations, pressure, heat, tingling. Sometimes, at least in the past, they were unpleasant … but they do not have to be. Tell me what are you experiencing? What is this experiencing changing into?

Suggestions for sensation alteration (can be useful for patients with acute or chronic pain; tends to be more effective among patients who score higher on measures of hypnotizability; see also suggestions to focus on, and then change, sensations, above). As you may know, one way that many people manage unpleasant sensations and feel more comfortable, is to substitute a different feeling, such as numbness or warmth, or tingling or pressure, for any unpleasant sensations. As you consider this, you may already be feeling different sensations— sensations that slowly and easily take the place of any uncomfortable feelings. You may have already noticed different feelings, such as numbness, warmth, or a tingling … where there used to be uncomfortable feelings. As you continue, you can notice these new and different, feelings grow; notice how natural it is to be more aware of these feelings.

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Right now, your nerves are sending all kinds of interesting feelings to your brain all the time, and your brain can learn to filter out the uncomfortable feelings. You can become more aware of these new more comfortable feelings. You can notice how you are more aware of other feelings in the areas that used to be (or, are sometimes) uncomfortable …. As you pay attention, more and more, you can start to notice interesting feelings like numbness, warmth, tingling or even pressure in the areas that used to be uncomfortable. And now you can relax further and allow these other feelings to grow, to expand, to take up more and more of your attention, so that your mind is less and less able to notice or even be aware of any uncomfortable feelings. You might find yourself noticing other interesting feelings. For example, I wonder if you might be curious about how absorbed you can become in noticing a feeling of numbness … or tingling … pressure … or whatever feeling you may notice. What a relief to replace discomfort by being more and more aware of these other sensations and feelings.

Suggestions for decreased pain (can be used by any patient experiencing pain). You may also be surprised that it’s so much easier now to simply not notice uncomfortable feelings, to simply not pay attention to anything other than your comfort …. So much easier to enjoy the relaxing, peaceful comfort of each breath. So simple, so natural, to attend to your breathing …. And as we continue, you can enjoy discovering that those uncomfortable feelings just seem somehow to change. With every breath you take, you can notice how those feelings seem to become less and less clear, less and less strong … as if they are becoming farther and farther away … or smaller and smaller … taking up less and less space in your awareness. Of course, if there is any change in these feelings, any new feelings of discomfort that might reflect a change in your health condition, your mind can note this, and you will therefore be able to take care of your health as needed and appropriate. But any old, chronic discomforts can fade away, become less as less strong. You can picture putting these feelings in a box, and then putting this box in another box, and then putting this box in yet another box, and placing that box in a room down a long hallway. So that even if you are aware of these sensations at some level, it is almost as if they are buried … far away … so easy to ignore. It’s so easy

to feel the comfort of every breath. So easy to let yourself daydream about a pleasant place, to remember a happy time in your life or to imagine a happy time you’d like to have in your life. Letting yourself feel free, right now, to just let your mind wander … to wander over pleasant memories or to wander over a pleasing image of something you’d like in your life right now. You might remember walking along a beach, the warmth of the sun on your face, a cool breeze, feeling so happy and at ease …. Maybe, if you listen, you can even hear the sound of a bird flying past … or listen for the rhythmic, reassuring sound of the surf. Such a pleasure to be here, with nothing to bother you and nothing to disturb you. With every breath you take, breathing comfort in and discomfort out, just notice how naturally you feel more and more comfort. Let each breath you take … contribute to your comfort and well-being. As you breathe, and as you notice the sensations of each breath, notice, too, that any remaining uncomfortable feelings are less and less clear, less and less strong … as if they are becoming farther and farther away … or smaller and smaller, taking up less and less space in your awareness. As if you realize that they’re really not important. Not worth paying attention to.

Suggestions for hypnotic anesthesia (can be offered to any patient experiencing pain). As you may know … an anesthetic is a powerful medicine used by doctors to eliminate awareness of uncomfortable feelings. We are now going to use your imagination to anesthetize any areas that might be uncomfortable. Now imagine any areas of discomfort being completely filled by a feeling of anesthesia … a pleasant sensation of comfort … picture these feelings spreading through that area. Notice how naturally, how easily, the anesthesia can make those areas feel curiously different and pleasantly tingly. Notice how easily you can feel those tingly sensations just wash over everything. Notice how the tingly, numb sensations absorb and block out any discomfort. Such a pleasure to be able to imagine, to really imagine … to make real … such comfort. Any discomfort becoming less and less. The powerful, and long-lasting anesthetic is doing its job. Making you comfortable. This anesthetic has such positive effects … greater comfort … a sense of calmness and of confidence … and it can last for hours … and, won’t you be surprised? … even days. As you gain more experience, this

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anesthetic becomes more powerful and effective … and can last for as long as you need.

Suggestions for distraction using ‘safe place’ imagery (like most hypnotic suggestions, this can also be used as part of an induction). And you can imagine yourself in a place that is safe, all by yourself, or with someone else, whatever is needed for this place to be safe, comforting … and interesting. This place might be somewhere you have been before and know well … you can recognize all of the familiar sights, sounds and smells … or it might be a completely new place … a place that exists in your imagination … yet it feels so real … you can really imagine yourself there … so comfortable, no one can bother you … it is like a vacation … and in this place you are so absorbed by what you can see … the colors … the sounds…, and it is so comfortable for your body … just the right temperature … that you are actually feeling more and comfortable … and this place is so absorbing, so interesting, and so … comfortable, that you hardly notice any other sensations … except maybe the perfect temperature of this place … and how good you feel, inside and out ….

Suggestions for decreased pain unpleasantness. As you sink deeper into comfort, you can be aware of just how well you can feel, with nothing to bother you, and nothing to disturb you. You are training your nervous system so that it is possible to be aware of a painful sensation, but not be bothered by it. Maybe it helps to remember that these sensations aren’t really important. They don’t really mean you need to do anything. These sensations aren’t warnings, they’re almost like old habits of your mind. You really don’t need to pay attention to them, and you certainly don’t need to feel bothered by them …. As you focus on this, notice that the sensations that you experience really do feel less and less important. Even if you feel them, you can feel less and less concerned about them … now you know that they are nothing to worry about. It’s just so satisfying to notice that, for some reason, all the sensations you can feel, all the feelings you can notice, become more and more a part of your experience of comfort and well-being, with nothing to bother you and nothing to disturb you …. Your sense of comfort can grow, so that you can be aware of how much better you can feel now … and in the future …. There are no feelings to bother you or to disturb you.

Post-hypnotic suggestions for self-hypnosis and for maintenance of benefits (can be used at the end of a hypnotic treatment session or practice audiotape/CD to increase the length of time that treatment benefits will last). Now we can begin to extend any comfort you have gained in this session into your daily life. Begin by taking a deep, comfortable, relaxing breath and hold it … hold it for a moment … and then let it all the way out. That’s right …. Really feel the sensations of each breath. Notice that breathing in feels different than breathing out. Now, I’d like you to imagine something with me. Imagine that you are breathing comfort in each time you breathe in … breathing actual comfort, each time you breathe in … and imagine you are breathing tension or discomfort out each time you breath out. As you do so, maybe you already notice a feeling of comfort washing over you, like warm water in a bath. any time you would like to feel more comfortable, any time later today, tomorrow or any other time you want to feel more comfortable, all you have to do is take a very deep, very satisfying breath and hold it … hold it … and then, as you let it all the way out … let your eyelids close and focus on your breathing. Breathe comfort in and tension out, with each breath you take. Really focus your mind on each breath, and let each breath contribute to your comfort. With each breath you take, you can feel yourself filling your awareness with more and more comfort. Remember, any time you want to feel more comfortable, just rest back and take a very deep, very satisfying breath, and hold it … and then, as you let it all the way out … let your eyelids close and focus on your breathing. Breathe comfort in, and tension out with each breath you take. Really focus your mind on each breath. Let each breath contribute to your comfort. With each breath you take, you can feel yourself filling your awareness with more and more comfort. And this comfort is yours … to keep with you, wherever you are, whatever you are doing. when you need to end the experience, you’ll find that you’re sitting up automatically, your eyes are open, your mind is clear and alert … yet the comfort remains with you. No matter how clear and alert your mind remains, this inner comfort, this inner sense of ease, can remain with you and grow. Because this is your experience. And you can have it whenever you need. The more you practice this, the easier it will

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be to keep the comfort with you. You may choose to practice for a minute or two every hour, or for several minutes a few times a day. I don’t know how you will choose to do it, but the more you practice, the better you will feel, and the more your mind will be able to use these skills, automatically, throughout the day, so that you can feel more and more comfortable.

Suggestions for lifestyle changes (can be used for patients with chronic pain when you determine that making lifestyle changes will benefit the patient and his or her ability to manage pain). As I continue talking, I want to remind you that you have a part of you mind that is a tremendous friend to you, an incredible resource to you. You may not be aware that this part of your mind is there or available to you, but it is there, it is always there. It is your internal friend that allows you to breath without thinking about it, and allows your heart to beat without giving it a thought. It is also the part of you that knows how to react without thinking, to do what is best and right for you. Right now, I want to talk to that part of you while perhaps the rest of your mind drifts off comfortably, or even listens in the background. You have had a problem that has bothered you for some time now, a problem that at times maybe seemed impossible to manage. Yet we have all had the experience in our lives of having a problem that seemed impossible to solve, and yet, one day the solution comes to us so easily, so effortlessly, and it very well may be that deep down you know exactly what it will take for you to feel more comfortable. And to tell you the truth, I don’t know what exactly that change is for you. It may be that it comes to you that changing how you think about this problem will make a huge difference in your life. Or maybe what you do to manage it. You might find yourself doing something, anything, a lot of things, to make yourself stronger … knowing that strong muscles hurt less, or you might start stretching your muscles and tendons every day, knowing that muscles and tendons that are flexible hurt less. You may make it possible to attend sessions with a physical therapist, or a yoga instructor or at your health club in an effortless way. It may be that you find yourself walking daily. I don’t know. I do know that you will start moving in some way that will seem so natural, and almost effortless, and you can feel proud of yourself for making changes, for trying something

different, to better manage your health, so that you will feel better, and better, and better … [the focus on increasing exercise is the example used here but changing cognitions, diet, alcohol use, pain medication use or gaining an increased sense of spirituality are all possible suggestions that could be integrated into this framework].

Age regression and progression (can be used to assist patients with chronic pain imagine themselves as pain-free, giving them an experience that they can the replicate in their daily life). The following suggestion is adapted from one presented during a workshop by Steve Gilligan, PhD. And as you sit here comfortably listening to my voice, I want you to picture five crystal balls or spheres in front of you, extending from the lower left corner of your visual field, and rising up as an arc in front of you, and then curving down to the right, like a rainbow. The two crystal balls in the left side of your field of view curving up will contain images from your life that have been in the past. The middle ball, at the top of the arc, will represent the present, and the two balls to the right of your visual field curving down will represent the future. I want you to focus now on the crystal ball in the lower left quadrant of your visual field. In that sphere, you will see an image of yourself sometime in the past before you developed any pain problem. When you were healthy, strong and confident in your body. This could be days, weeks, months or even years ago. This can be a symbol that represents a younger you, an image or picture of yourself, or even a memory or a feeling. However you experience it is fine. As long as it is some time in the past and is when you did not experience the pain you have reported to me. Now, in the next sphere, I want you to put a more recent image, symbol or feeling. But one that is still in the past. In this image, memory or feeling, you are still pain free. It is an image in the past but more recent than the first sphere you just were looking at. You now look at the sphere at the top of the arc, this represents the present. In this ball you see yourself today. It is [give year, day and time]. You are [give location]. Look at yourself and what you are experiencing right now. Now, we are going to move along the arc to the fourth out of five spheres. The one is in the upper right quadrant of your visual field. In this sphere you will see an image, symbol or

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have a feeling of yourself sometime in the future. It could be minutes, hours, days, weeks or years from now. But the image will be of you being hardly aware of any discomfort … almost pain free, moving comfortably and feeling confident, happy, strong … very, very well. Finally, you will now move to the fifth sphere in the lower right section of your visual field. In this ball, you see yourself even further in the future. You are still hardly aware of any pain, moving comfortably and feeling very, very well. You have reached some important goals, and feel that your life is on track, Good, I want you to now to look at all five crystal balls and to see the images in each one. Just notice what is there. It does not matter if the images change. Now, as you look at the five crystal balls, you will find a bright light connecting the five spheres. Just notice the bright light connecting the images and you experience a deep sense of them connecting.

Metaphors for pain relief (metaphors can be helpful for patients who might experience acute or chronic pain; their content depends to a large extent on the creative ability of the therapist to match the content to the patient’s needs; we offer the following as merely an example). … and now I am going to tell you something about a close friend of mine that you might find very interesting … this friend grew up with many brothers and sisters, ten in all … this made for a very interesting childhood … for one thing, he learned that he needed to eat very quickly if he was going to get enough to eat during a meal. And he still eats quickly to this day … but what he really remembers is … the noise. You cannot believe how much noise there is in a house with 11 children. The TV was always on … and sometimes, it was LOUD … the stereo seemed to be always playing … kids were

sometime yelling and fighting, babies crying, and then his mom seemed to be yelling all of the time just to get their attention …. The noise was constant, it was always there … sometimes it was really, really bad. At times … he did not feel like he could do anything but think about the noise. Sometimes it was there but not quite as bad …. It really used to bother him … and he did not know what he could do to escape … to really experience quiet … he would try yelling at his brothers and sisters to try to keep them quiet, but this just annoyed them and contributed to the noise … he even tried earplugs … at times he felt like giving up … as if it would never get better …. And then one day, when he started to get older and more experienced … and for a reason that he could not explain … the noise stopped bothering him…. It is not that it went away…. It is not as if anything changed … it just stopped bothering him. And when that happened, he felt … better … more energetic … like he could now focus his attention on what was important … it is like when you are trying to solve a math problem and suddenly the solution just comes to you … without knowing where it came from. It reminds me of being on an airplane when I was younger and being bothered by babies crying … then, after having my own children, the babies crying just didn’t seem to bother me anymore…. And this is interesting as well … in order for my friend to focus (he is now a successful scientist) … he needs at least some noise. We works with the stereo on … he does chores with the TV or stereo on … and he tells me that he hardly notices the noise … but that when things are completely quiet, he becomes distracted….it is as if it is easier for him to concentrate … to do what he needs to do, with some noise in the background … it is almost, now, a comfort to him….

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CHAPTER 21

Hypnosis and anxiety: early interventions Richard A. Bryant

21.1. Introduction Anxiety can be defined as a fear that persists even when a salient threat is not present. The most common anxiety disorders, as defined by the ‘Diagnostic and Statistical Manual of Mental Disorder’ (American Psychiatric Association, 1994), are specific phobia, social phobia, generalized anxiety disorder, obsessivecompulsive disorder, post-traumatic stress disorder (PTSD), acute stress disorder and separation anxiety disorder. Prevailing models of anxiety draw on fear conditioning to explain the acquisition and maintenance of anxiety. Evolving from early behaviorist views of classical conditioning, these models posit that exposure to an aversive event (unconditioned stimulus) leads to a strong fear reaction (unconditioned response), which becomes conditioned to many stimuli associated with the initial aversive experience (Charney et al., 1993). Accordingly, when people are exposed to reminders of the experience (conditioned stimuli), they experience a strong fear reaction (conditioned response). For example, an individual may have an initial attack while riding on a bus. The bus may become associated with the aversive experience of having the panic attack, and subsequently all associations with the bus come to trigger the perceived danger of panic. Each time the person

enters a bus, they perceive the danger signals, which will often then elicit the panic. Subsequent avoidance of all reminders of the bus will serve to reinforce the fear because the person cannot learn that the bus itself is not dangerous. One of the major models of anxiety reduction involves extinction learning. Extinction learning involves being exposed to the reminders of the anxiety but in the presence of any aversive outcome, and in this way one engages in new learning that inhibits the initial fear response. Many theorists have noted that successful treatment of an anxiety disorder can be conceptualized as extinction learning because the individual learns to feel safe in the presence of the triggers that cause an anxious reaction (i.e. the conditioned stimuli) (Davis and Myers, 2002). For example, eliciting panic symptoms (e.g. rapid breathing, pumping heart) by requiring a person to hyperventilate can lead to the person learning that they did not die or have a heart attack. Further, by requiring the person to have arousal symptoms in the bus, they can learn that the bus is a safe place and they can engage in new learning that arousal symptoms in the bus are not harmful.

21.2. Hypnotizability and

anxiety There is convergent evidence that people with anxiety disorders are characterized by increased

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levels of hypnotizability. For example, elevated hypnotizability has been observed in PTSD (Stuntman and Bliss, 1985; Spiegel et al., 1988), acute stress disorder (Bryant et al., 2003a), phobias (Frankel and Orne, 1976; John et al., 1983), as well as disorders that involve anxiety components, such as dissociative identity disorder (Spiegel, 1984; Carlson and Putnam, 1989) and bulimia nervosa (Covino et al., 1994). Some studies have found that patients with multiple anxiety disorders are more hypnotizable than those with a single phobia (Frankel and Orne, 1976). Interestingly, one study found that hypnotizability altered following treatment of PTSD, with increased hypnotizability being associated with elevated avoidance responses after treatment (Bryant et al., 2003b). Why would more anxious individuals be more hypnotizable? Several explanations can be entertained. One argument suggests that conditioning is stronger in people with higher imagery skills (Dadds et al., 1997). There is evidence that higher levels of hypnotizability are associated with increased imagery ability (Glisky et al., 1991). Highly hypnotizable people (who have greater imagery skills) may be more likely to engage in fear conditioning when they experience an anxiety state, and consequently they develop an anxiety disorder. Some anxiety disorders involve dissociative states. For example, panic attacks involve dissociative experiences, such as derealization and depersonalization (Krystal et al., 1991). A predisposition to dissociation, which may involve higher levels of hypnotizability, may contribute to development of anxiety disorders. Relatedly, diathesis-stress models suggest that people who have a predisposition towards dissociation may respond to stressful life events in a way that encompasses dissociative responses (Kihlstrom et al., 1994; Butler et al., 1996). Although hypnotizability cannot be equated with dissociation, it may reflect cognitive processes that may be associated, albeit indirectly, with dissociative mechanisms observed in anxiety responses (Roche and McConkey, 1990). It is possible that those with dissociative tendencies respond to stress in ways that lead them to anxiety conditions that involve some dissociative components.

Another possible explanation is that a common pathway may be responsible for both anxiety and hypnotizability. Sandberg and Lynn (1992) have argued that children who suffer adverse childhood experiences tend to respond to these experiences by retreating into fantasy, and accordingly develop a greater capacity for fantasy-proneness, absorption and hypnotizability. In this way, anxious individuals may have greater hypnotizability because of their tendency to engage in fantasy to a greater degree during childhood. Finally, there is evidence that highly hypnotizable people have more unwanted intrusive thoughts than low hypnotizables (Bryant and Idey, 2001). All anxiety disorders are characterized by intrusive thoughts. It is possible that the documented capacity of highly hypnotizable individuals to engage in daydreaming and fantasy (Wilson and Barber, 1983; Lynn and Rhue, 1988), to engage in divided attention (Hilgard, 1986; Crawford et al., 1993) and to attribute involuntariness to internal experiences (Kirsch and Lynn, 1999) may cause highly hypnotizable individuals to be more prone to anxiety because of a difficulty in controlling unwanted anxiety-provoking thoughts. We should be cautious in presuming the strength of an association between hypnotizability and anxiety. Much evidence indicates that hypnotic responding is influenced by contextual factors (Council et al., 1986). Much of our evidence of an association between anxiety and hypnotizability comes from studies that have administered a standard hypnotizability test in the same context as questioning the participant about anxiety symptoms. It is possible that a proportion of patients perceived questions about the anxiety disorder in a way that cued them to respond positively to the hypnotic testing. This possibility is consistent with evidence that because highly hypnotizable individuals are particularly suggestible, they may be more prone to suggestions that they experience particular symptoms (Bowers, 1991). It should also be noted that not all studies find elevated hypnotizability in anxiety populations (Frischolz et al., 1982; Owens et al., 1989). Further, some of the studies of hypnotizability in anxiety disorders have been potentially flawed by small sample sizes and selfselective recruitment procedures that may bias the results.

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21.3. Hypnotizability and

treatment response There is also some evidence that treatment response is associated with hypnotizability levels. A number of studies have reported that anxiety symptom reduction is associated with higher levels of hypnotizability. Spiegel and colleagues (1981) reported that across a large case series of treating flying phobics, highly hypnotizable individuals were more likely to report positive response to treatment. Gerschman and colleagues (1987) reported a moderate correlation (r = 0.54) between hypnotizability and response to hypnotherapy in dental phobics. Horowitz (1970) reported a modest correlation (r = 0.39) between hypnotizability and treatment outcome in snake phobics treated with hypnosis. In contrast, Bryant and colleagues (2005) reported no correlation between treatment response and hypnotizability in patients with acute stress disorder treated with hypnosis and cognitive behavior therapy. Other studies have also reported no relationship between hypnotizability and treatment response (Wadden and Anderton, 1982). On a cautionary note, it should be recognized that some of this evidence comes from studies that did not conduct assessments of hypnotizability in a manner that was independent of the treatment provided, and it is very possible that experimenter bias influenced these results. Overall, the evidence for hypnotizability predicting treatment response is mixed across disorders, including anxiety disorders.

21.4. Evidence for

hypnotherapy There are many earlier reports in the literature of hypnotic techniques leading to reductions in anxiety (Bouton and Tosi, 1983; Stanton, 1992; for a review, see Flammer and Bongartz, 2003). There are several ways to consider the evidence for the efficacy of hypnosis in reducing anxiety disorders. One is to consider the treatment gains made by patients receiving hypnotherapy relative to those who receive no treatment. This is a flawed approach because there is overwhelming evidence that nonspecific therapy effects

typically lead to treatment gains, and so receiving any form of therapy is often helpful. Considering the overwhelming evidence that cognitive-behavioral therapy (CBT) is the treatment of choice for treating anxiety (Chambless and Hollon, 1998), the challenge for hypnosis is the extent to which it can build upon treatment provided by CBT. A meta-analysis of 18 studies that compared treatment of a range of psychological disorders (including anxiety) using CBT alone or CBT combined with hypnosis found that CBT supplemented by hypnosis led to more clinical gains than CBT alone (Kirsch et al., 1995). There are relatively few well-controlled studies on the relative efficacy of hypnotherapy for managing anxiety compared with CBT. Van Dyck and Spinhoven (1997) compared in vivo exposure versus exposure combined with hypnosis for treatment of agoraphobics with panic disorder. Patients were provided with one of the treatments and after 4 weeks provided with the other in a crossover design. Although this study found no difference between treatments, the design was flawed because all patients received both treatments. A study of public speaking anxiety provided patients with cognitive therapy and in vivo exposure, or these components with hypnosis (Schoenberger et al., 1997). Both treatments performed better than a no-treatment control, and the hypnosis condition performed better than the CBT alone condition. Two controlled studies have focused on posttraumatic stress. One earlier study compared the effectiveness of desensitization, hypnotherapy, psychodynamic therapy and a wait-list control group for post-traumatic stress (Brom et al., 1989). Hypnotherapy was intended to facilitate emotional processing of trauma memories through behaviorally oriented strategies. This study found that all three active treatments were comparably effective. This study’s conclusions were limited by (a) the lack of independent assessments; (2) inadequate specification about therapy components; and (3) the absence of independent treatment fidelity checks. A more recent study randomly allocated civilian trauma survivors (n = 89) with acute stress disorder to either CBT, CBT associated with hypnosis, or supportive counseling (Bryant et al., 2005). This study added hypnosis to CBT because some

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commentators have argued that hypnosis may breach dissociative symptoms that characterize acute stress disorder (Spiegel, 1996). To this end, the hypnosis component was provided immediately prior to imaginal exposure in an attempt to facilitate emotional processing of the trauma memories. In terms of treatment completers, more participants in the supportive counseling condition (57 percent) met PTSD criteria at 6-month follow-up than those in the CBT (21 percent) or CBT + hypnosis (22 percent) condition. Interestingly, participants in the CBT + hypnosis condition reported greater reduction of re-experiencing symptoms at post-treatment than those in the CBT condition. This finding suggests that hypnosis facilitated treatment gains associated with exposure in people with post-traumatic stress.

21.5. Hypnotic strategies for

reducing anxiety It is important to remember that hypnosis per se is not a therapy. It is a tool that can be used as an adjunct to established therapy techniques that have proven efficacy in reducing anxiety symptoms.

21.5.1. Muscle relaxation Relaxation techniques are often used in anxiety management because they have the potential to reduce muscular tension and associated feelings of anxiety (Taylor, 1982). Common relaxation techniques include breathing control, progressive muscle relaxation, isometric muscle relaxation, and imagery to facilitate relaxation. Although the potency of relaxation techniques in actually reducing clinical anxiety is arguable, many clinicians provide relaxation because it can give a sense of self-mastery and symptom reduction, and may encourage compliance with therapy (Jackson, 1995). Hypnosis can facilitate the relaxation process by deepening the relaxation exercises that are embedded in the hypnotic induction, directing the individual to focus attention on the specific muscle groups or emotional responses that are being relaxed, and providing imagery to enhance the relaxation experience.

21.5.2. Imagery Hypnosis permits subjectively compelling imagery that allows the individual to believe in the suggested experience (Sheehan and McConkey, 1982). Many clinicians use imagery to facilitate anxiety reduction in two ways. It is often used to facilitate relaxation because the hypnotist can suggest images that are inherently soothing and calm. For example, by previously identifying scenes that elicit safety and relaxation in an individual, one can increase the relaxation markedly in most people. For example, by suggesting that an individual is lying on a beach on a warm and calm day, and prompting the individual to notice easing of tension and anxiety symptoms, the hypnotist can rapidly elicit relaxation. Imagery can also be very useful in exposure therapy, especially when the therapist is using imaginal forms of exposure. This technique is commonly used in treating anxiety-producing memories, images or thoughts. These symptoms are common in all anxiety conditions, and most prominent in PTSD, generalized anxiety disorder and obsessive–compulsive disorder. Imaginal exposure involves having the individual imagine their feared memory or worst imagined outcome of their feared situation, and then encouraging them to learn that their anxiety subsides while they continue to think of this event. This process leads to learning that the feared event is no longer threatening. Importantly, this learning is strongest when the anxiety that is initially experienced is intense because the subsequent decrease in anxiety strengthens the new learning of anxiety reduction (Foa and Kozak, 1986). The capacity of hypnosis to elicit vivid imagery and compelling absorption in internal experiences can usefully heighten the emotional engagement that the individual has in the anxiety-producing imagery, which in turn can lead to stronger learning that these mental events are no longer threatening. Hypnotic suggestions to engage in the imaginal or in vivo exposure, including suggestions to imagine the sensory, cognitive and emotional aspects of the experience in an intense manner, can enhance the exposure efficacy. It is for this reason that some commentators have argued that hypnotherapy is the

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treatment of choice for some anxiety disorders because it specifically breaches obstacles to accessing anxiety-producing images or memories (Spiegel, 1996). Some studies have explicitly used hypnosis as an adjunct to exposure to facilitate the imagery and emotional engagement that anxious individuals experience during therapy (Bryant et al., 2005).

21.5.3. Thought control Intrusive thoughts are a hallmark of anxiety conditions (Clark, 2005). Much research has indicated that attempts to suppress thoughts typically result in an increase of the unwanted thought (Wenzlaff and Wegner, 2000). This pattern is also evident in anxious populations, such as acute stress disorder, PTSD and highly anxious individuals (Harvey and Bryant, 1998a,b; Tolin et al., 2002). Highly hypnotizable individuals are better able to inhibit unwanted thoughts during hypnosis than low hypnotizables (Bryant and Wimalaweera, 2006). Considering the importance of thought intrusions in anxiety, clinicians should consider utilizing the cognitive capacity of highly hypnotizable individuals to use hypnosis to manage unwanted thoughts.

21.5.4. Post-hypnotic suggestions Post-hypnotic suggestions can be used to shape an individual’s behavior and experience after the therapeutic suggestion. Although there is little empirical support for the use of posthypnotic suggestions in clinical settings, it is widely used in clinical settings (Yapko, 2003). Extrapolating from substantial experimental research allows for a degree of confidence in the capacity of post-hypnotic suggestion to influence behavior in the clinical setting (Barnier and McConkey, 1998a,b). Most posthypnotic suggestions inform the hypnotized individual that they will experience a specific state or perform a certain behavior in situations outside the hypnosis setting. Post-hypnotic suggestions for an anxious individual can include suggestions to experience less anxiety during the daily routine, complete therapy homework, engage in coping strategies when distressed or notice adaptive appraisals during times of anxiety.

21.5.5. Motivational enhancement Social psychological theories of hypnosis posit that the primary potency of the hypnotic context is the powerful motivation it elicits in the participant to comply with the hypnotist’s requests (Spanos, 1986). In the clinical context, using hypnosis may increase the expectancy of success and also the extent to which the individual complies with any suggestions given by the hypnotist. Kirsch et al.’s (1995) meta-analysis found that CBT supplemented by hypnosis led to more clinical gains than CBT alone. Interestingly, scrutiny of the specific studies indicates that the CBT and CBT plus hypnosis treatments often did not differ much in terms of substantive content. Whereas CBT alone would provide relaxation training and imagery techniques, CBT combined with hypnosis often provided the same strategies but labeled the techniques as hypnotic. Adopting a social psychological interpretation, Kirsch et al. (1995) suggested that participants in many of these studies may have responded to therapy better when it was termed hypnotic because they were more motivated and expected a better response. The role of social influences on elevating the expectancy and motivation of hypnotized individuals is irrefutable and needs to be considered in terms of a possible means of enhancing treatment response.

21.5.6. Self-hypnosis and anxiety All the aforementioned strategies can be implemented in the form of self-hypnosis. Selfhypnosis involves the administration of hypnotic suggestions through self-talk or listening to a recording of hypnotic suggestions. Orne and McConkey (1981) have argued that since it is primarily the ability of the individual, rather than the skill of the hypnotist, which determines whether a person responds to heterohypnosis, all hypnosis can be thought of as self-hypnosis. However, since the technique of self-hypnosis is typically taught initially in the context of a relationship with a hypnotist (even via audiorecording), it can be argued that self-hypnosis is simply a variant of heterohypnosis. The value of self-hypnosis is that suggestions can be transported to many suggestions where the individual is requiring assistance in managing anxiety.

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Bart presented to the clinic following a sexual assault. He appeared as a highly distressed young man, who was reluctant to discuss his problems. Bart reported that 3 years earlier, he had been raped by two men after leaving a night club. He reports that the two men grabbed him as he left the club and took him to an isolated park, where they engaged in oral and anal sex. Bart reported that he was not gay, and he had found the experience so distressing that he had never discussed it with anyone. In terms of presenting problems, Bart reported that he suffered nightmares of the assault, intrusive memories, a fear of men that he does not know, avoidance of public places and of proximity to men, insomnia, irritability, poor concentration, hypervigilence to people who approach him, depression, social withdrawal and a fear of intimacy with women. Interestingly, Bart reported that some aspects of the assault were particularly distressing, and he was unable to report an entire section of the event, despite repeated prompting. He stated that he simply did not know what occurred at this time, even though he never lost consciousness throughout the ordeal. Notably, Bart reported his account of the assault in a detached manner that apparently lacked much of the affective tone that we expected in a case that was so threatening. These problems satisfy the criteria for PTSD. He satisfied the criteria for Criterion A (Stressor) by being exposed to a threatening experience and responding with fear or helplessness. He satisfied Criterion B (Re-experiencing) by reporting nightmares and intrusive distressing memories of the assault. He met Criterion C (Avoidance) because he reported avoidance of talking or thinking about the event, avoided reminders of the assault, reported amnesia of some aspects of the experience and reported emotional numbing and social withdrawal. He met Criterion D (Hyperarousal) because he reported insomnia, irritability, poor concentration and hypervigilence.

to a strong fear response in Bart, underpinned by strong noradrenergic activation that is known to exacerbate fear conditioning. The fear conditioning that occurred at the time of the trauma led to strong fear responses being elicited each time Bart was confronted by a reminder of the trauma. These reminders included being in public, seeing men, seeing his own body and his own bodily sensations; all these stimuli could trigger memories that were distressing and served to reconsolidate the memory of the traumatic experience. This level of fear conditioning resulted in Bart persistently feeling as if he was still under threat, and accordingly he continued to have insomnia, hypervigilence and poor concentration as a result of his elevated arousal. Bart responded to this distress by actively avoiding all potential reminders of the event. He would not speak or think about it, or go places where he may be reminded of men who could hurt him. Moreover, it seems that Bart engaged in passive avoidance as well, i.e. he limited the extent to which he felt aversive emotional responses by distancing himself from memories or emotions. This form of avoidance is not well understood, although there is increasing evidence that people with PTSD may have the capacity to avoid awareness of aversive experiences (Moulds and Bryant, 2002). Associated with this fear response, Bart has presented with a common set of appraisals about the event and himself that exaggerate his sense of vulnerability and his depressive response. It is very common for people with PTSD to exaggerate the likelihood of future harm, and to make maladaptive appraisals about themselves and their inability to cope after the trauma (Ehlers et al., 1998; Warda and Bryant, 1998). For example, Bart reported that ‘I should have been more of a man and stopped the attack’, ‘if I was a real man I would have got over it by now’, ‘I can never really feel safe again’ and ‘no woman is ever going to want me after this’. These appraisals have contributed markedly to Bart’s low self-esteem, depression and perception of vulnerability.

21.6.2. Formulation

21.6.3. Treatment plan

We understood Bart’s presentation in the following way. The distress caused by the rape led

Based on our treatment formulation, treatment needs to achieve four basic goals. First, we need

21.6. Case study 1: PTSD 21.6.1. Background

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to provide Bart with techniques to provide symptom relief form his elevated anxiety. Second, we need to reduce the anxiety that is repeated caused by memories and situations that trigger distress. Third, we need to identify and modify those maladaptive appraisals that are contributing to Bart’s condition. Fourth, we need to encourage Bart to engage in positive and social experiences to reduce his depressive and socially withdrawn state. The first goal will be achieved through anxiety management techniques that aim to provide coping skills to gain a sense of mastery over fear and to reduce arousal levels. Anxiety management approaches often include stress inoculation training that follows Meichenbaum’s (1975) program of psychoeducation, relaxation skills, thought stopping and self-talk. The second goal will be achieved through imaginal and in vivo exposure. Prolonged imaginal exposure requires the individual to imagine the trauma vividly for prolonged periods. The therapist assists the patient to provide a narrative of their traumatic experience in a way that emphasizes all relevant details, including sensory cues and affective responses. In an attempt to maximize the sense of reliving the experience, the individual may be asked to provide the narrative in the present tense, speak in the first person and ensure that there is focus on the most distressing aspects. Prolonged exposure typically occurs for at least 40 min, and is usually supplemented by daily homework exercises. To maximize the benefits of imaginal exposure, and especially in the case of Bart who avoids affective states associated with his memories, it is useful to conduct imaginal exposure in the context of hypnosis. Through hypnotic suggestion, Bart would be told to engage thoroughly in all his memories and emotions for the duration of the exposure. This approach would be particularly important for those components in which Bart is amnesic of the experience because he can be asked to reconstruct the experience in a fashion similar to age regression. It is important to supplement imaginal exposure with in vivo exposure that involves live graded exposure to the feared stimuli. This is an important step because in vivo exposure intends to target phobic avoidance, and this needs to be structured in a way that all anxiety-provoking

situations (except unsafe ones) are eventually approached and mastered by the trauma survivor. In the case of Bart, there is a wide array of stimuli he is avoiding and will need to be targeted in an in vivo exposure paradigm. The goal of correcting maladaptive appraisals is undertaken by implementing cognitive therapy. Cognitive models of PTSD posit that resolution of PTSD requires the integration of corrective information (Foa and Kozak, 1986). Cognitive restructuring involves teaching patients to identify and evaluate the evidence for negative automatic thoughts, as well as helping patients to evaluate their beliefs about the trauma, the self, the world and the future (Ehlers and Clark, 2000). Targeting appraisals is particularly important following sexual assault because issues of guilt, shame and vulnerability commonly contribute to ongoing PTSD and depression (Resick and Schicke, 1993). The final goal of developing strategies for increasing Bart’s social activity and exposure to positive events is achieved through positive event scheduling, and especially targeting social activities. The 3 years that Bart has spent avoiding social events has reinforced his belief that he cannot function socially and that social settings cannot provide him with any pleasure. Through structured programs that require him to engage in positive social events, he will be increasingly integrated into social networks that will both reduce his depression and counter his beliefs that social networks are dangerous.

21.6.4. Treatment Therapy commences with education that highlights the hallmark symptoms of the posttrauma response and discusses the way in which the core symptoms will be treated during the course of therapy. The aim is to legitimize the trauma reactions, to help the patient develop a formulation of their symptoms and to establish a rationale for treatment and a clear rationale about each therapy component. Ensuring that the patient understands the rationale is imperative because it underscores commitment to therapy demands. We commence therapy with anxiety management techniques. This component neatly complements the introduction of hypnosis into

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therapy because anxiety management techniques overlap significantly with normal hypnotic inductions. Prior to conducting hypnosis, it was important to clarify with Bart any concerns he had about the hypnotic procedure. A core concern of many trauma survivors is the control that they have lost during the trauma, and it is important that they feel that they have control during therapy. As some people believe that hypnosis involves a surrendering of control to the hypnotist, we commenced with clarifying with Bart that he is always in control. This control can take many forms; because he was blindfolded during his rape, Bart wanted to keep his eyes open throughout hypnosis to ensure he was in control. We administered a standard eye-fixation induction, followed by deepening suggestions, and suggestions that he could experience deeper muscle relaxation. We had previously agreed with Bart that a safe scene for him was at his father’s beach house. Accordingly, we suggested to Bart that whenever he needed to feel more relaxed, he could think of himself at the beach house and could experience a sense of safety and relaxation. Post-hypnotic suggestions were also used to suggest that after therapy sessions, he may unexpectedly notice feeling more relaxed. Importantly, suggestions were also given to Bart that if any unwanted thoughts popped into his mind, he could simply notice these thoughts and allow them to pass. People with PTSD can be disturbed by trauma memories during relaxation exercises, and it is useful to normalize this occurrence and to encourage people to observe these thoughts and move onto other thoughts. We then commenced exposure therapy with Bart by requiring him to provide us with a narrative of his trauma experience. During hypnosis, Bart was asked to relive the assault in detail. Bart understandably found this very distressing, especially since he had never discussed the event with anyone. To track the distress Bart was feeling during the exposure, we asked him regularly to provide a rating of his distress on a scale of 1 (‘no distress’) to 100 (‘extreme distress’) at different times during the narrative. Bart narrated his trauma successfully but continued to omit a segment of the assault of which he was amnesic. It is possible, though not always the case, that not administering exposure to aspects

of the narrative that are avoided may lead to relapse because these aspects are often of utmost importance. Accordingly, we administered an age regression suggestion to Bart that suggested that he could see everything that occurred. We commenced with the last thing that he could recall, which was one of the assailants telling Bart that he had to kiss the assailant while he looked into his eyes. Bart could not recall anything after that until he realized that he was lying naked on the ground with both men sitting nearby drinking beer and laughing. In the age regression, Bart was asked to return to the narrative of the assault, and at the point when the assailant said Bart was to kiss him, we asked Bart to slow the scene down and see what was happening from the safety of the other side of the park. We adopted this strategy because Bart expressed much trepidation about understanding this aspect of the assault and we believed that perceiving that there was some distance between himself and the event might facilitate the reliving. Bart accepted this strategy and told us about the events that occurred during this period. Once he began talking about these events, we required him slowly to focus on them and to engage in all the emotional and cognitive responses that he experienced during this period. We continued this focus for 40 min to ensure that he could experience mastery of these memories. At the end of this session, we also administered post-hypnotic suggestions that he would feel better about himself and his capacity to cope because he had been able to master these memories. We required Bart to practice this hypnotic exposure exercise each day for homework between therapy sessions. We then proceeded with in vivo exposure that required Bart to develop a hierarchy of feared situations that he was avoiding. These ranged from lowest to highest: going out to a shopping mall with friends, going out to a mall with one friend, going for a walk during the day with a friend, going for a walk in the day by himself, walking with a friend at night, walking by himself at night, asking a male he did not know for directions, attending a night club with friends and, finally, attending a night club by himself. Bart was required to remain in each situation until his distress reduced by 50 percent, and we asked him to repeat each situation successfully

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three times before progressing to the next level. We also provided post-hypnotic suggestions during therapy that instructed him to notice his mastery of these situations and his capacity to cope. We also built in suggestions that he did not need supports to maintain his safety. We did this because, like many trauma survivors, Bart maintained safety behaviors to decrease the likelihood of future harm. For example, he always carried a knife and mace spray. These sorts of behaviors limit the benefit of in vivo exposure because they deprive the patient of the opportunity of learning that their sense of safety is associated with the previously feared situation rather than their safety behavior. Cognitive therapy focused on Bart’s beliefs that he was at fault for not preventing the assault and that he was inadequate for not coping more effectively. Cognitive therapy works most effectively when the individual can contrast their maladaptive appraisals with compelling experiences that are reality based and undermine their unhelpful thoughts. To this end, we identified the most unhelpful appraisals reported by Bart, and subsequently during hypnosis asked him to imagine vividly scenarios that contradicted his beliefs. For example, when Bart reported that he felt he was responsible for the assault, we asked him to visualize what would have occurred if (1) a friend of his had been the victim; (2) if he had tried different strategies to protect himself; and (3) what he would say to a friend if he was blaming himself for this assault. These are normal cognitive strategies but, by asking Bart to visualize them during hypnosis, and then reaffirming his interpretation in the light of his imagined scenarios, it strengthens the learning in these new appraisals. In this case, Bart was able to conclude that none of his friends could have prevented the assault, that by actively protesting against the assault he might have been killed, and that he would definitely try to reassure any friend of his that they were not to blame. The final focus of therapy was to try to build up social and positive experiences that Bart was exposed to. We developed a positive event schedule that was integrated into his in vivo exposure, and Bart was required regularly to engage in activities that he had been avoiding for 3 years. For example, he was required

to recommence playing football, attending clubs, seeing movies, meeting with friends and socializing with women. During hypnosis, and supplemented by post-hypnotic suggestions, Bart was directed to imagine himself in these situations and feeling safe, happy and strong while he engaged in these pleasurable activities.

21.6.5. Outcome Bart commenced therapy with much fear about his capacity to cope with his trauma memories. Despite this fear, he responded well to the initial hypnosis exercises because he found much symptom relief in imagining feeling safe and relaxed in his favorite place. Although he wished to persist with this stage of therapy, we insisted on progressing with exposure because of overwhelming evidence that this is the most efficacious component of CBT. Bart was visibly distressed throughout the initial exposure sessions, but we encouraged him to persist. He failed to show any reduction in distress until we focused his attention on the ‘forgotten’ aspects of the assaults. After his exposure session focused on those aspects, Bart experienced even higher levels of distress followed by a sharp reduction in distress. At that point he became more compliant with homework exercises, and reported a marked reduction in symptoms. Over the following weeks, Bart reported fewer nightmares, memories and depression. He also became more compliant at this point with his in vivo exposure exercises. Bart became more optimistic about his future, and this assisted his use of cognitive therapy because he recognized that some of previously held beliefs were not justified. The more he socialized and approached previously avoided situations, the more he was able to challenge erroneous appraisals. After 12 sessions of therapy, Bart was reporting few PTSD and depression symptoms.

21.7. Case study 2: fear of heights 21.7.1. Background Lisa reported to a mental health clinic that she was distressed by a fear of flying. On presentation, she stated that she had feared heights for as

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long as she could remember. She stated that she feared going up on elevators, being at cliff tops or look-outs, looking out from tall buildings and flying. Lisa reported that she wanted treatment at the current time because her fear of flying was preventing her from pursuing her career in sales. She declined several promotions because the new positions would have required flying regularly. Lisa’s symptoms suggested that she suffered specific phobia for heights. She regularly avoided height situations. When she was confronted with heights, she typically suffered panic attacks, including constriction of the chest, difficulty breathing and sweating. She had an immediate need to escape the high situation, after which time she experienced immediate relief.

21.7.2. Treatment plan Treatment needed to ensure that Lisa was able to master height situations in a graded way that allowed her to experience anxiety reduction whilst still in the situation. This treatment required two stages. First, we assisted Lisa to develop a hierarchy of feared situations that elicited anxiety. These ranged from situations that elicited minimal anxiety to those that were most fearful. As our plan was to ensure that Lisa could gradually master each step on the hierarchy, we wanted 10 steps on the hierarchy to allow her ample opportunity to make graded exposures that were achievable. The second goal was to implement the graded exposure by having Lisa enter the feared situations, and remain there until her anxiety subsided. His plan was influenced largely by Lisa’s report that she would find it very difficult to enter these situations. Further, Lisa admitted that her major fear was flying, and that it was difficult to implement this into an exposure hierarchy because she rarely has the opportunity to fly.

21.7.3. Treatment Therapy commenced with the development of the hierarchy. It comprised the following 10 steps that commenced with riding up one floor of an elevator with a friend; then progressively riding up two, three and five flights by herself; then standing next to a window of a skyscraper with a friend; then doing it by herself;

then going to the airport and watching planes taking off with a friend; then repeating it by herself; then finally taking a flight. A major issue in her treatment was her fear of approaching any flights. Lisa had demonstrated at an initial session that she was adept at hypnosis. Accordingly, prior to commencing the graded exposure, we commenced an imaginal exposure program in which Lisa imagined during hypnosis that she was entering the feared situations. A brief hypnotic induction was administered, followed by detailed suggestions that she was entering the feared situation. It was essential to obtain clear details from Lisa about each scenario, as well as her cognitive, physical and emotional reactions to being in the scene prior to the imaginal exposure. The hypnotic suggestion directed her to be aware of her panic responses and her feared outcomes (e.g. suffocating in the elevator), with the goal of increasing her anxiety and distress. She was instructed to remain with these scenes, and to notice that her anxiety was reducing as time passed. Although some hypnosis work tries to counter the anxiety by replacing the feared images with pleasant or safe images, this approach was not indicated for Lisa. It was important for he to learn through hypnosis that (1) the feared outcomes would not eventuate; (2) that she could survive the experience of being in the feared situation; (3) her anxiety would decrease without any avoidance or distraction techniques; and (4) that the imagined scenes would simulate as much as possible the actual scenes that she would soon enter. Lisa responded well to these hypnosis suggestions, and reported being able to experience marked anxiety reductions in the imagined scenes. As she developed more confidence in the hypnosis, we integrated post-hypnotic suggestions that directed her to feel mastery over her anxiety when she was in the real scenes. These posthypnotic suggestions highlighted that anxiety was not an emotion to be avoided but rather was a reaction that provided her with the opportunity to learn that she could feel safe in the situation. Lisa then commenced on the hierarchy. She was required to provide ratings of her distress on a 100-point scale (0 = ‘not at all anxious’, 100 = ‘extremely anxious’), and was required to remain in the scene until her anxiety

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had reduced by 50 percent from its peak. Lisa rapidly made gains in riding the elevator and also in looking out of windows in skyscrapers. The next obstacle in treatment was flying. The major issue here was that Lisa did not have the opportunity to fly often. Accordingly, we implemented an intense period of hypnosis and selfhypnosis that focused on suggestions that she was flying. Specifically, we suggested to Lisa that she was approaching the airport, checking in, boarding the plane and realistically perceiving that she was in the plane as the engines started, and took off. Lisa had previously demonstrated that she was capable of highly absorbing experiences, and she was able to imagine these scenes vividly. More importantly, Lisa was able to experience panic-like symptoms during these imagined scenes. This level of distress was required to ensure that she would learn mastery. Each time Lisa imagined this scene, we required her to remain in the scene for 30 min, and then we suggested that she could notice that her distress was reducing. We ensured that the suggested scene did not finish until she felt relative comfort. Lisa was given an audiorecording of the hypnosis session, and instructed to practice it daily. After 1 week, the suggested scene was amended to increase her distress. Specifically, the suggestion described the plane flying through turbulence and the plane being rocked for lengthy periods, the passengers being instructed to remain seated with seatbelts on and all the air stewards being told also to sit. This element was introduced because it is important that exposure to all feared scenes is addressed to reduce the likelihood of relapse occurring. Finally, Lisa was asked to take three short flights. Prior to taking the flights, she rehearsed the strategy of calculating her feared outcome. We did not ask her to complete her self-hypnosis during the flights because we did not want her to learn that she felt safe because of the selfhypnosis (or reliance on the hypnotist’s voice). It is possible that self-hypnosis can become a safety behavior that people rely on to reduce their distress. This reliance on some behavior (such as self-hypnosis) can impede the learning that flying itself is not immediately dangerous. We instructed Lisa to evaluate the risks of danger during the flight, and to remind herself that she was not being harmed in any way.

21.7.4. Outcome Lisa responded to the initial hypnosis sessions very positively. She was able to engage in the imaged exposure very readily. Not only did she experience initial anxiety when imaging herself in various scenes, she was also able to experience anxiety reduction while still imagining herself in those scenes. Understandably, she experienced markedly more anxiety when we commenced the exposure to actual heights, such as tall buildings. Notably, Lisa reported that during the exposure activities, she became aware of the post-hypnotic suggestions of mastery of these situations. She reports that she was able to remind herself of these suggestions, which assisted her to remain in the situation until her anxiety had sufficiently reduced. When she came to take the actual flights, Lisa reported that she coped surprisingly well. On the second flight, the plane flew through marked turbulence, which immediately increased her anxiety. At that point, Lisa was able to remind herself that the bouncing was actually fun (which was a suggestion that we had built into the end section of the imagined hypnotic scenes), and she states that she was able to manage the flights successfully. Three weeks after treatment completed, Lisa accepted a new position in her company and commenced flying regularly.

21.8. Summary There is no doubt that hypnosis can facilitate established means of treating anxiety disorders. Fear conditioning and extinction models have led to treatments that involve new learning, and there is convergent evidence that this learning can be enhanced by hypnosis in numerous ways. The greater ability of hypnotized individuals to engage in imagery, focused attention, motivation to comply with instructions and imaginal rehearsal of mastery of fear all combine to potentiate the treatment gains for anxiety patients. It is unfortunate that hypnosis is not integrated more fully into randomized controlled trials of psychological therapies of anxiety disorders. The evidence that hypnosis does increase the treatment gains made by established treatments (Kirsch et al., 1995) points to the need for more rigorous study of hypnosis.

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Acknowledgments This review was supported by a NHMRC Program Grant (300304).

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CHAPTER 22

Hypnotic approaches to treating depression Michael D. Yapko

22.1. Overview The great American humorist, Mark Twain, once observed that, ‘life is one damn thing after another.’ Indeed, life does pose many challenges to all people on a regular basis. And, paradoxically, our sources of strength for coping well also represent our vulnerabilities: if you have a job, you run the risk of losing it. If you have good health, you run the risk of contracting illnesses or suffering injuries. If you have people you are close to, you run the risk the losing them to death or geographical distance. Given the difficulties that all of us encounter from time to time, it is immediately relevant to developing a clinical focus to ask a most complex question: why do some individuals face the challenges of life and manage to transcend them and, despite them, declare themselves happy? And, as a corollary question, why do other individuals face adversities that overwhelm them and not only impair them emotionally, but lead them to suffer in every other aspect of their lives as well? Depression has gone from being one of the least well understood to one of the best understood disorders that clinicians are asked to treat. An impressive array of research has highlighted the extraordinary complexity of depression, and much of this research has resulted in a proliferation of clinical approaches to treatment that hold great promise for helping individuals and

their families recover (Clarkin et al., 1996). Some of the most important insights derived from the research will be reviewed in this chapter, especially as they relate to clinical interventions which employ hypnosis. For a variety of reasons, hypnosis has historically been overlooked as a component of effective treatment. More will be said about this later, but it is important to note at the outset that hypnosis can easily be integrated with other, more established, treatment approaches that have an empirically supported base which justifies their use. Despite the huge body of scientific literature describing the risk factors, onset and course of depression, as well as the relative merits of various forms of treatment, the insights gained thus far have not yet slowed down the rapidly rising rates of depression in the USA or the world. In a recent statement from the World Health Organization (WHO), depression was declared the leading psychological cause of human suffering, and the prediction was made that the rate of depression would continue to rise to staggering proportions in the years to come (World Health Organization, 2002). To the many researchers and clinicians striving to slow the growth of depression, the WHO prediction is a disheartening blow. However, it also presents an opportunity to re-evaluate what we have

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learned about depression, and what we can do differently in our collective attempts to establish more effective treatments that can be more readily available to larger populations of depression sufferers. Depression is a terribly costly disorder on many levels. It is costly financially when people lose their ability to be productive and function well in their jobs (Greenberg et al., 1993). It is costly physically when depressed individuals cannot, or will not, take even simple steps to guard their health, thus costing much more in health care costs compared with nondepressed patients (Gabbard, 1998; Frasure-Smith et al., 2000). Depression is costly socially when it causes marital and family distress, leading to poor parenting, family disintegration, divorce and a variety of forms of antisocial behavior (Cummings, 1994; Yapko, 1999; Goodman and Gotlib, 2002). Perhaps the most costly level, however, is the personal level of suffering caused by depression. When people live in an enduring and debilitating state of despair, distress and misery, the costs in human potentials never realized cannot be overstated. Although effective treatments have been developed that will help improve the lives of those individuals who manage to seek professional help, it is one of the unfortunate truths that the very nature of depression precludes most sufferers from seeking appropriate treatment. It is estimated that not even half of the people who suffer depression will seek help and, of those who do, it is further estimated that only about half of them will receive adequate treatment (Kessler et al., 2003). There are many reasons why depressed individuals do not seek treatment, including the stigma of having a mental disorder, the lack of adequate health insurance coverage to assist with the costs of treatment, the lack of recognition that depression is the problem and, perhaps most influential, the passive and hopeless nature of depression itself, which leads the sufferer to believe that nothing will help and therefore seeking help is pointless (Seligman, 1989, 1990; Yapko, 2001a). These issues pose a special challenge to mental health professionals in particular, requiring them to educate the public about the signs and symptoms of depression, the various treatment options available and what one

can realistically expect to gain from treatment that warrants actively pursuing it. Unfortunately, the most common means of educating depressed individuals about depression has been the use of various forms of drug advertising in the media by the pharmaceutical industry (Zimmerman et al., 2004; Moncrieff and Kirsch, 2005). The suggestion is made authoritatively and repetitively to the public that depression is a consequence of a brain anomaly that medication can correct. Thus, depression sufferers are led to believe that the problem is in their brain chemistry, not their lives. There is considerable evidence that this exclusively biological view of depression is overstated to the point of inaccuracy (Yapko, 1997; Healy, 1998; Burns, 1999). What causes depression? How one answers this question is the single greatest determinant of what one will focus on and treat in therapy, either with or without hypnosis. Is depression caused by genetics? A biochemical imbalance? Psychosocial stressors? Cognitive distortions? Social inequities? Cultural and familial influences? In fact, all of these and also many other factors are well-established contributors to the onset of depression.

22.2. The complexity of

depression Depression is a heterogeneous condition, and a variety of biological, psychological and social theories have been formulated to describe its development and nature. There is substantial evidence supporting the so-called biopsychosocial model of depression, acknowledging that depression has a biological component, a psychological component and a social component (O’Connor, 2001; Pettit and Joiner, 2006). Thus, effective treatment will necessarily have the ability to focus on and amplify the most salient components of a given individual’s depression. For some individuals, that will mean focusing on physiological factors, for some that will mean focusing on intrapersonal factors, and for others it will mean focusing on interpersonal factors. Depression is routinely talked about as if it were a singular phenomenon. However, one of the factors complicating clinical practice is that

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there is no single uniform character to depression. It has been pointed out that there are 227 possible combinations of symptom presentations for making the DSM-IV diagnosis of major depression (Buchwald and Rudick-Davis, 1993; American Psychiatric Association, 1994; Pettit and Joiner, 2006). Recently, the United States Preventive Services Task Force (USPSTF, May 21, 2002) suggested that the diagnosis of depression could reliably be made from a simple two-question screening device. The two questions ask about mood (‘Have you been feeling down, sad, blue or depressed for the last month or more?’) and anhedonia (‘Have you lost interest in or stopped deriving pleasure from the things that normally interest you or give you pleasure?’). If someone answers yes to these two questions, there is a high probability that he or she is either already depressed, or is at an elevated risk for depression. Further assessment is then clearly warranted. There is another factor compounding the difficulties in assessing depression accurately, namely the co-morbid nature of depression. Depression is most often associated with other psychological and physical conditions (Stevens et al., 1995). The most common of these co-morbid conditions is some form of anxiety disorder (Barlow, 2000; Kaufman and Charney, 2000). Depression is also co-morbid with substance-related disorders, eating disorders, personality disorders and scores of medical conditions. Anxiety is not only a co-morbid condition with depression, it is also an established risk factor for depression. There is substantial evidence that clinically significant levels of anxiety precede the onset of depression, usually by many years, and that the number of anxiety disorders present, the persistence of anxious avoidance behavior and the degree of psychosocial impairment represent the strongest factors associated with the onset of depression (Wittchen et al., 2000). One could reasonably predict, then, that as life continues to grow more complicated, and as world conditions grow more volatile, the rates of anxiety will continue to rise, as will the rates of eventual co-morbid depressions. The main point is that depression does not occur in a vacuum. Depression comes about for a variety of reasons that may involve biological vulnerabilities and

environmental, contextual, catalysts. This represents the issue alluded to earlier, namely the question regarding why some individuals cope with adversity and difficulty better than others. What have we learned about effective coping from people who have suffered and transcended adversities in life, i.e. those who did not become depressed in potentially depressing circumstances?

22.3. Skills worth

learning—and teaching There are specific skills that people who have faced and transcended difficult life challenges possess. Typically, these are skills the person may not even be conscious of possessing––they are simply part of the person. These include cognitive strategies as well as coping strategies (Holahan et al., 1999; Compas et al., 2002). Examples of cognitive strategies include seeing and framing life circumstances in positive ways, expecting positive life circumstances in the future, feeling as if one has control over situational outcomes and minimal encoding of a negative event’s details into one’s memory for later recall. Examples of coping strategies of well-being include ‘positive illusions’ (i.e. exaggerated perceptions of self, the future and situational control), finding positive meanings in negative events, enjoying humor, avoiding social comparisons and placing an emphasis on spirituality and faith (Lyubomirsky, 2001). Can people who do not innately possess such skills learn them and show a measurable benefit for doing so? In other words, can a depressed person, or a person at risk for depression, learn cognitive, behavioral and social skills, and thereby reduce the frequency and severity of depressive episodes? The answer is unambiguously, yes. In a review of the therapeutic efficacy literature, there is substantial evidence for the effectiveness of cognitive-behavioral therapy (CBT) and interpersonal therapy (Beck, 1997). In fact, these therapies are widely considered to be the treatments of choice in the psychotherapy of depression (Elkin et al., 1989; Depression Guideline Panel, 1993; DeRubeis et al., 1999). Both approaches have received impressive

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empirical support, and established treatment guidelines typically suggest their use. CBT is focused on teaching the depressed client specific skills regarding clear thinking, ways to be more objective about aspects of life experience and ways better to gather and weigh information (Beck, 1976, 1996). Interpersonal therapies focus on teaching the social skills necessary to create and maintain healthy and satisfying relationships (Klerman et al., 1984). Given the frequency with which other people can be the source of one’s distress, the skills taught in the interpersonal therapy model may be especially relevant in some cases. Those therapies with the greatest empirical support for their effectiveness each emphasize teaching specific skills as a means of empowering the client. A primary function of hypnosis is to facilitate the skill acquisition process. What are some of the specific skills known to reduce depression that are enhanced with hypnotic intervention?

22.4. Five specific targets for

intervention 22.4.1 Building positive expectancy In the cognitive models of depression, primarily set forth by Aaron Beck (1967, 1976; Beck et al., 1979), Albert Ellis (1987, 1994, 1997) and Martin Seligman (1989, 1990), significant attention is paid to the hopelessness commonly found in depressed individuals. Beck specifically addresses what he terms negative expectations, while Seligman specifically addresses what he terms a stable attributional style. In both views, depressed people’s characterization of the future as negative is highly demotivating and accounts for at least some of their apparent apathy and passivity. Thus, it becomes a primary goal of treatment to help the hopeless client develop positive and motivating expectations for the future. Specific methods for hypnotically building positive expectancy have been described in detail elsewhere (Torem, 1988, 1992, 2006; Yapko, 1988, 1992, 1993, 2001a).

22.4.2. Recognizing and tolerating

ambiguity People strive to understand and make meaning out of ongoing life experience. Much of life

experience, however, is innately ambiguous, thereby making it difficult to know either a true or an objective meaning of life events. Ambiguity raises, while certainty lowers, people’s anxiety. It may reasonably be said that the cognitive distortions described by Beck represent deliberate efforts to reduce or even eliminate ambiguity as a means of coping. Unfortunately, the errors made in attempting to cope may aggravate circumstances rather than help them; the person may make inferences or draw unwarranted conclusions that are self-damaging. Thus it becomes another primary goal of treatment to help the client learn both to recognize and tolerate ambiguity in order to minimize making and negative, self injurious projections. A detailed hypnotic strategy for helping clients recognize and tolerate ambiguity has been described elsewhere (Yapko, 2001b,c).

22.4.3. Improving coping styles Recent research addressing the question of how different people respond to their depressed moods has been especially fruitful in increasing our understanding of effective versus ineffective coping styles. One coping style which will exacerbate depression is called the avoidant coping style. Avoidance is an inherently disempowering coping style because it places one in a victim’s position. When one assumes an avoidant position, one is essentially saying the problem is greater than oneself. One literally cannot recover from depression from a victim’s standpoint. The ruminative coping style has an especially strong association with depression. Rumination means repetitively and passively thinking about one’s bad feelings and may include frequently expressing to others how badly one feels and pondering seemingly endlessly why one feels bad. Ruminative responses are highly predictive of higher levels of depressive symptoms over time, depressive disorders, including new onsets, chronicity of depressive disorders, and the greater presence of anxiety symptoms (Nolen-Hoeksema, 1991, 2000, 2003). Rumination can lead to what some have called the ‘analysis paralysis’, highlighting the importance of taking sensible and timely action in addressing one’s problems, rather than merely contemplating one’s feelings. Helping depressed clients know

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when to analyze and when to act decisively are primary goals in treatment. Hypnosis to ‘seed’ (i.e. introduce and build an affinity towards) skill-building homework assignments and motivate their completion is just one example for intervening in the domain of coping style (Geary, 1994).

22.4.4. Enhancing decision-making

strategies One of the more recent and illuminating lines of research concerns the relationship between the depressed person’s decision-making strategies and the exacerbation of his or her depression. Known as the ‘stress generation’ model of depression, the evidence suggests that depressed individuals often make bad decisions that serve to intensify their depression (Hammen, 1991, 1999). This is not an intentional process, rather the person makes a poorly thought out decision, implements it, and the result is a negative consequence that makes him or her feel worse. There is a growing body of evidence that stressful life events may precipitate the onset of depression, but the reverse is equally true: depression generates stressful life events. Simply put, depressed individuals experience a higher rate of negative events that are at least partly dependent on their own behavior (Pettit and Joiner, 2006). It is fair to say that the quality of one’s life is largely the consequence of the choices one makes. For example, when a depressed individual is urged by a loved one to seek treatment, and he or she declines, that individual is making a poor decision that will probably make matters worse. Or, as another example, using alcohol or drugs to manage one’s anxiety or agitation is a decision that holds great peril (Holahan et al., 2003). There is evidence to suggest that poor decision-making does not occur only during depressive episodes. Not surprisingly, the evidence is that these same poor decision-making strategies function even in between depressive episodes. Thus, teaching effective decision making strategies that empower the person to make better life decisions is another primary goal of treatment. A hypnotic strategy for exploring one’s options and choosing among them wisely has been described elsewhere (Yapko, 2001a).

22.4.5. Developing relationships skills Mood is contagious, as are socialized values. As a result, one’s relationships with others is a particularly sensitive domain that is, unfortunately, under-represented in the depression literature. However, there is a growing body of evidence that the quality of your relationships has a profound effect on your mood and health (Dubovsky, 1997; Gabbard, 1998; Yapko, 1999). In studying the social lives of depressed individuals, the negative effects are apparent: depressed individuals tend to have fewer social skills, fewer close relationships, less elaborate social networks, less rewarding relationships and receive less social support (Keltner and Kring, 1998; Joiner and Coyne, 1999) than nondepressed individuals. Thus, depressed individuals have difficulty creating and maintaining satisfying relationships. Interpersonal patterns, then, can cause and maintain interpersonal difficulties, including perfectionism and being judgmental towards others, excessive reassurance seeking, continually expressing negative thoughts and feelings to others, lacking empathy towards others, irritability and even angry outbursts, withdrawing from others, avoiding conflicts and other such negative social behavior (Joiner et al., 1999; Pettit and Joiner, 2006). One of the most important skills for a depressed person to develop, because an absence of the skill invites victimization, is the ability to create and maintain one’s personal boundaries. When one is unable to say no to hurtful people or to set limits on their hurtful behavior, it is easy to appreciate how one can feel invaded and victimized. Thus, helping clients develop skills in limit sitting, as well as other skills necessary to build and maintain healthy relationships, is an essential part of their treatment. The five targets for intervention described above represent some of the most common areas of concern, but there are many, many others as well. These have been well described in the literature and should become familiar to all clinicians (Yapko, 1997, 1999; Burns, 1999; O’Connor, 2001).

22.5. Hypnosis in treating

depression There are numerous overlaps between the separate yet related domains of hypnosis and

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depression: (1) both come about and increase in intensity the more narrow one’s focus; (2) both are ultimately social processes, greatly influenced by one’s relationships with others, whether the other person is a clinical authority sensitively describing the therapeutic merits of exposing you to an induction procedure, or the other is a parent or spouse insensitively describing the flaws in your character; (3) both are a product of expectancy, whether the expectation is one of getting the benevolent corrective message ‘into your unconscious’ through suggestions received in a dissociated state, or whether the expectation is that no amount of effort from you will result in a success, thereby giving rise to the apathy so typical of depression; and, (4) both involve what hypnosis pioneers Theodore Sarbin and, later, Ernest Hilgard, described when they suggested hypnosis is, in part, a ‘believed-in imagination’, an experience based on the recognition that people can and do get deeply absorbed in highly subjective beliefs and perceptions that quite literally regulate the quality of their lives (Sarbin, 1997; E. R. Hilgard, personal communication, 1988). These beliefs and perceptions can be altered and amplified during the experience of hypnosis, illustrating the point well how idiosyncratic each person’s sense of reality really is, especially in response to ‘mere’ suggestions (Yapko, 1995, 2003). The notion of an individual’s personal reality essentially being a ‘believed-in imagination’ preceded the origin and development of cognitive therapy by decades, even centuries, and firmly established the relevance of hypnosis in treatment. CBT is, at this time, probably the most well-researched method of therapeutic intervention (Sacco and Beck, 1995; Burns, 1999; DeRubeis et al., 1999). It is founded on the premise that people in general, and depressed people in particular, regularly make identifiable errors in information processing, thinking and genuinely believing in their mistaken notions of what truly––and depressingly––seems like reality to them (Beck, 1976, 1997; Beck et al., 1979). This process of becoming absorbed in one’s (depressing) imaginings is, indeed, an instructive parallel to what occurs in hypnosis, where a clinician performs an induction and attempts to absorb the individual in alternative and beneficial ways of experiencing him or herself.

Through procedures employing hypnosis, the clinician creates a context where the individual can change the direction and quality of his or her focus (Barabasz and Watkins, 2005). Perhaps the suggested focus is on engaging in some new life-enhancing behavior, or perhaps on exciting and motivating glimpses of future possibilities, or possibly on re-writing some of the negative internal dialog, or somehow altering for the better any of literally scores of depressing focal points (e.g. cognitive styles, coping styles, relational styles). What the clinician suggests during hypnosis may not be any more true in an objective sense than what the person previously believed––it may just feel much better and serve the person better (Yapko, 1992, 2001a, 2003). Depression as a ‘believed-in imagination,’ i.e. a consequence of getting deeply absorbed in ways of thinking, behaving, relating or living that make life seem joyless and burdensome? Hypnosis as a means of absorbing the person in a more skillful, adaptive, beneficial, and even positive frame of mind? This is hardly an ‘off the beaten path’ perspective. On the contrary, for the treatment efficacy literature is wonderfully unambiguous in describing how when people learn the key skills for living life well, such as the skills described earlier of thinking critically, behaving effectively and building positive relationships with others, they tend to recover from depression (Beck, 1967; Depression Guideline Panel, 1993; Yapko, 1997, 1999; Burns, 1999; O’Connor, 2001; Markowitz, 2003). Hypnosis as a means of teaching people, a vehicle for getting new possibilities for thinking, feeling, behaving and relating integrated more quickly and deeply is precisely why knowledgeable clinicians do hypnosis in the first place.

22.5.1. The process is part of the

solution The process of psychotherapy is itself illustrative of the recovery process for depression. It illustrates the gathering and weighing of relevant information, the formation of specific goals, the delineation of specific steps towards the goal, the use of feedback to adjust one’s course and the use of newly acquired information to redirect and refine the whole process. Hypnosis can play a key

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role in the treatment process. Hypnosis models flexibility; its use makes an indirect statement that suggests the clinician and client can relate to each other in a variety of ways, it provides direct experience of the subjective nature of one’s perceptions and beliefs and it highlights the malleability of one’s internal experience, including the experience of one’s symptoms. What exactly does hypnosis do? Hypnosis amplifies or de-amplifies specific elements of experience. It generates associations and dissociations that can be directed therapeutically (Zeig, 1980; Kirsch et al., 1993; Yapko, 2003). Does hypnosis cure people? In my opinion, the answer is an emphatic no. It’s not hypnosis that is curative, rather, it is what happens during hypnosis that has the potential to be therapeutic. Specifically, it is the new and beneficial subjective associations the client forms during the hypnotic experience that have the potential to help the client think, feel and behave differently. Hypnosis allows for the creation of a focused context of change while minimizing the stresses of making the change. There are different ways to use hypnosis in treatment, and how one chooses to apply hypnosis will be a direct product of how one conceptualizes the nature of depression, the dynamics of psychotherapy and the capacities of hypnosis as a treatment tool. Hypnosis may be used to: (1) teach symptom management strategies, such as reducing anxiety or enhancing sleep; (2) access personal resources for skill building, such as enhancing cognitive flexibility or building problem-solving skills; (3) de-framing and reframing personal meanings, such as helping the client understand he or she is not destined always to feel the same way; and, (4) suggesting specific associations and associations, such as shifting the focus away from feelings to taking action, or shifting the focus from the past to the future. One can describe the term ‘depression’ as a global shorthand, a convenient label for a wide range of symptoms and patterns of experience. Effective treatment must first involve identifying the salient patterns that regulate the experience of depression in a given individual. We also know that therapy, any therapy, will necessarily have to interrupt ongoing patterns of experience in some way and generate some new patterns of

experience that prove beneficial to the client’s mood, outlook and behavior. The task for the clinician is to absorb the client in new patterns, whether patterns of thought as in cognitive therapy, patterns of physiology as in somaticbased interventions, or whatever patterns are addressed in a specific style of intervention. Hypnosis is multidimensional in its ability to focus anywhere and catalyze the merits of the intervention, whatever form it might take. Hypnosis amplifies experience. The first principle one learns in studying hypnosis is that what one focuses on, one amplifies. Thus, a clinician has to be deliberate about choosing focal points for his or her interventions. Focusing on someone’s cognitions, for example, shouldn’t be a standard procedure as a self-identified cognitive therapist. It should be a choice one makes to focus on the client’s thoughts because there is a powerful depressogenic pattern operating on that dimension. But, for someone else, the focus will need to be on his or her relationships, and for someone else on his or her sleep difficulties. What a clinician will focus on and amplify with hypnosis will, hopefully, differ according to the unique profile of each individual client. This is one of the great strengths of being knowledgeable about hypnosis: the ability to make good therapeutic choices based on client need outweighs loyalty to a particular theory of intervention.

22.5.2. Is there empirical support for

applying hypnosis in treating depression? Hypnosis in the treatment of depression is a relatively new application; for most of the first hundred years of psychotherapy, the use of hypnosis in treating depressed individuals was actively, even aggressively, discouraged. When acclaimed experts in hypnosis taught for decades that hypnosis would ‘strip away defenses’ and ‘precipitate psychotic reactions’ in depressed people, or ‘energize their suicidal ideation’ and thereby transform it into suicidal behavior, there seemed to be no credible therapeutic rationale for employing hypnosis with depression sufferers (Yapko, 1992, 2001a, 2006). Times have changed, though: treating people and not their diagnostic labels, structuring hypnosis sessions to build

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positive expectations for the future instead of amplifying negative ones, and finding and hypnotically expanding people’s resources instead of merely trying to explain their pathologies, are all ways clinical practice has changed for the better and how hypnosis has come to be immediately relevant to treating depression sufferers. One of the prices for having ignored hypnosis as a treatment tool all these years, however, is that controlled research on ways hypnosis can be skillfully applied in the treatment of depression, to date, has been under-studied (Alladin, 2006). There are plenty of studies that show hypnosis enhances treatment results, helps people manage anxiety, helps them feel personally empowered, enhances their mood and outlook, and helps in so many important ways (Lynn et al., 2000; Montgomery et al., 2000; Schoenberger, 2000). But, historically, these benefits have been framed as mere side-effects of treating other client populations (such as pain patients), and so the benefits of hypnosis for relieving depression can only be inferred from such data. In the only study specifically targeting hypnosis with depression, Alladin and Alibhai (2007) found CBT with hypnosis to be superior to CBT without hypnosis in treating depression. But, clinicians aren’t usually researchers, and psychotherapy is, at best, only partially about science. Clinicians can and certainly should be informed by science, but the reality is that therapy is largely about artistry. It’s about gut feelings, clinical judgment, thinking on one’s feet and quickly changing directions when one starts to hit an impasse with a client. These are not skills that can be manualized, standardized or scripted. Thus, applying hypnosis in novel ways and observing the effects is the clinician’s domain, and research can only go so far in informing it. It really is all about clinical experience and skillful judgment in planning and executing an intervention, and using the feedback that follows to determine whether it made a positive difference. Hypnosis does many things that are immediately relevant to helping depressed individuals. Hypnosis: (1) helps people focus; (2) facilitates the acquisition of new skills; (3) encourages people to define themselves as more resourceful than previously realized (enhancing their self-image as a result); (4) makes the transfer of information from one context to another easier and more efficient; (5) establishes helpful subjective

associations more intensively; (6) helps the learning process to be more experiential and meaningful; (7) defines people as active managers of their internal world; (8) helps one sharpen key perceptual distinctions; (8) allows a safe distance from powerful feelings; (9) encourages one to proceed with new possibilities in a deliberate behavioral sequence; (10) allows one to rehearse new adaptive responses; (11) helps one develop undeveloped personal resources; and (12) helps detach from a sense of victimhood. No one gets past depression without achieving all of these things and more. In the remainder of this chapter, two case examples are provided to illustrate how hypnosis might strategically be integrated into CBT and interpersonal therapy for depression. These cases both illustrate a major point of this chapter: when people are empowered better to handle the circumstances that cause them distress, whether internal or external, they improve.

22.6. Case example 1: the

case of Mary 22.6.1. Background Mary (not her real name) sought therapy to, in her words, ‘help me to stop being too emotional a person’. Specifically, Mary reported that she ‘alternated between being sad and angry’. Most of the time she felt as though her life was just ‘too difficult to keep up with,’ and at times she would ‘explode with anger’. Mary was in her early 40s, married 8 years to a man 15 years older than she, and was a stepmother to his two children from a previous marriage. She had no children of her own. She was employed full-time as an accountant. Mary’s family history was immediately relevant to her concerns. She was born to an unmarried couple, the product of an affair her single mother had with a married man. She was treated as, and in fact was, an unwanted child. Her mother made little effort to establish a loving and close bond with her, and her father was entirely removed from her life by his choice to abandon both her and her mother. Mary reports that she also received little affection and little acknowledgment from her extended family of aunts, uncles, cousins, etc., and essentially grew up feeling isolated and entirely unimportant.

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Mary was very bright and articulate, and, despite her poor home environment, she managed to do well in school and strived to perform well for her teachers. She had few close friends, but did have a couple of good friendships she maintained through grade school and high school. She managed to stay focused on meeting her school obligations and part-time job obligations as well, and grew up without suffering any additional major traumas beyond that of her impoverished home life.

22.6.2. Formulation The net effect of Mary’s history on her was to feel socially detached, develop a deep distrust for people in general, and a suspicion of anyone who seemed to show any special interest in her (she assumed it was for some hidden, self-serving agenda). She had no substantive skills in assessing people for their true character or nature, and instead dismissed people as globally untrustworthy. Such an overgeneralization is an obvious cognitive distortion, though an understandable one given her background. It reflects the lack of an ability to discriminate people who are loving, generous in spirit and trustworthy in their intentions from those who are not. Consequently, other people remain a mystery to her, and she senses no ability to define her relationship with them proactively. She is frustrated in her desire to have warmth and closeness with others, and so is hypersensitive to anything that looks even remotely like either betrayal or disapproval. Thus, she gets very angry very quickly when someone says or does something she perceives as hurtful. Mary reported that it took a very long time with many conflicts along the way to allow the man who would become her husband into her life. She has grown to trust him and love him, yet he is often the recipient of her angry tirades when he does things even she considers, in retrospect, to be minor transgressions. She ruminates endlessly about why she is the way she is, and asks herself global questions that reinforce her ruminations, such as, ‘Will I ever be normal? Why did my mom have to get pregnant with a baby she didn’t want? What if my husband leaves me?’ Her ruminations feed her negative feelings about herself and her life, and the episodes of anger compound her frustration

with herself and reinforce her belief that she is too emotional and ‘weak’. When Mary reports that she is generally suspicious of people and expects the worst from them, she is demonstrating a self-limiting pattern that involves cognitive (the belief that people are fundamentally untrustworthy and self-serving), emotional (angry and sad feelings), behavioral (angry outbursts) and interpersonal (social avoidance, withdrawal) dimensions. All of these and more would need to be addressed in a treatment as multidimensional as her problem.

22.6.3. Treatment plan In formulating a treatment plan for Mary, it was evident that she was suffering dysthymia. Its origins and current manifestations were primarily rooted in the interpersonal dimension of her life (her rejection by her family, her discomfort around other people, her conflicts with her husband). Her conclusion that she was ‘too emotional’ was a result of her self-appraisals made from her conduct with and feelings about others. A number of specific goals for treatment were readily established: 1. Establish a positive therapeutic alliance based on Mary feeling both supported and challenged by our interaction. Mary was informed that treatment would be an educational process, and would involve discussions in our sessions, the assignment of homework and task assignments to help teach and consolidate new skills, and the use of hypnosis to make learning easier and the implementation of new skills more automatic. 2. Help Mary recognize that she is ‘more than her feelings’, i.e., that her feelings are only one part of her. An ability to compartmentalize her feelings is a necessary step in learning when to listen to and respond to her feelings and when to respond from other parts of herself (e.g. rationality). This is meant to counter emotional reasoning. 3. Help Mary recognize that she is not defective or too emotional, but is missing specific skills that lead her to mismanage some situations to her own detriment. This is an essential reframing: it’s not your genes (or biochemistry, or

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history), it’s the way you manage particular contexts that work against you—and you can learn to manage them differently. This is one aspect of building positive expectancy, informing the client that by approaching things differently, things can improve. It enhances co-operation, increases treatment compliance and de-pathologizes the person. 4. Help Mary develop an assessment strategy regarding other people so she can more objectively determine their character (values, intentions, consistency, etc.) in order to be more deliberate about deciding how best to relate to them. Much of Mary’s anger is a direct consequence of having unrealistic expectations of others that she then blames them for not fulfilling. In asking Mary, ‘How do you know whether your expectations for others are reasonable?’, her telling reply was, ‘I don’t’. Mary could feel empowered around others as well as less angry with them when she could learn to recognize people’s strengths and limitations rather than wanting things from them they can’t provide and then getting angry when they don’t fulfill her wishes. Instead of fearing other people, she could be curious about them and be more insightful about them. This helps build confidence, curtails rumination and encourages one to be less internally and more externally oriented, a key aspect of becoming better at gathering and weighing relevant information. 5. Help Mary develop more flexible and realistic expectations for herself, learning to accept her feelings as valid but still having a sense of choice as to whether to express them and, if so, what the best way might be to express them. This encourages selectivity and impulse control. 6. Help Mary become more skilled at recognizing and tolerating ambiguity. Before she jumps to erroneous or merely unsupported conclusions (another cognitive error), Mary needs to generate multiple interpretations as to why people do what they do or why events occur as they do. This counters cognitive rigidity and reinforces the need to go outside oneself for more and better information (i.e. ‘reality-testing’).

Mary agreed that each of these goals was appropriate and was visibly excited that these highly relevant goals were possible to articulate and structure. This, too, gave her lots of hope and positive motivation. She assured me she would participate fully in the therapy and do whatever assignments I thought might be beneficial to her. We agreed to meet on a weekly basis for four sessions to start, and we’d evaluate our progress and determine further needs at that time.

22.6.4. Treatment Following her description of her symptoms and relevant history, questions were asked about how she determines who is trustworthy, how she decides who’s a risk, how she evaluates people and a stream of other such ‘how’ questions attempting to uncover her cognitive and behavioral sequences and decision-making strategies. When someone doesn’t have specific skills that are hurting them, these become the targets of intervention. Specifically, what patterns do people manifest that work against them in attempting to do whatever it is they’re trying to do? When Mary’s reply, for example, to the question, ‘How do you assess someone’s character?’ is answered with a global reply, ‘If they seem nice’, it is apparent she is missing some key assessment skills that can lead to her being hurt in her relationships. In Mary’s case, she was so internally absorbed (in her feelings, suspicions, past failures, etc.) around others that she was unaware of ways to gather and use information about people that they reveal in routine interactions. Thus, in the very first session, a brief hypnosis session was conducted to reduce her anxiety, focus her on external evidence about others (i.e. suggestions to notice specific patterns in the way people approach various aspects of life), and how to interpret the possible meanings of her observations in order to start to look for further evidence to confirm or disconfirm her impressions. This session, as are all my sessions, was tape recorded and the tape was given to Mary to re-experience as often as she’d like. Suggestions for being interested in and willing to do later homework assignments (‘seeding’) were also given. Following the hypnosis, she was given homework assignments to: (1) identify the rules

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that operate in specific contexts, such as protocols she must follow with her accounting clients if the interaction is to go well in order to sensitize her to the reality that interactions have rules or specific boundaries that define them; and (2) articulate her expectations of other people in writing before she gets into an interaction with them and then look for specific evidence in their words or deeds that indicate that the expectations for them are realistic. In the second session, Mary reported that our first session had been enormously informative and helpful to her. She had never considered before that perhaps her expectations of others were unrealistic. She had been too angry that people kept disappointing her. She took to heart the message that there are good people and there are not-such-good people ‘out there’, and her job was to learn to tell who was who rapidly and effectively. Thus, in this session, the discussion focused on specific ways to assess others. We discussed learning about people’s ways of dealing with their feelings, whether they tolerate differences between themselves and others well or attempt to control others, whether they are able to accept responsibility for themselves or instead blame others for their mistakes, and other such patterns of relating to others. Mary was starting to learn specific ways people differ, and this was reinforced with another hypnosis session addressing the theme of how much can be learned about someone from the choices they make, whether superficial choices such as clothing or hairstyle, or deeper choices such as career and family. The point was emphasized that people choose according to what they value, and knowing what someone values is a key not only to understanding him or her, but also to being able to predict what he or she is likely to do in various circumstances. Following the hypnosis session, Mary was given the assignment to pick people she knows and list their values and then predict what that means they are and are not likely to do in response to things she was going to say or do around them. She left excited to think she might actually be able to predict people’s behavior and not get ‘blindsided’ by them as much. In the third session, Mary reported she felt much better and was much less anxious and suspicious around others. She was seeing things in

people she’d never noticed before and said, ‘now it all seems so obvious’. She’d had no angry outbursts in the previous 2 weeks, and was regularly listening to the tapes of both hypnosis sessions. But, she said she was still unsure what to say at times when people said or did things she was unprepared for. We went through a number of examples from her life experience, and discussed common denominators of such experiences. One in particular was when she felt she was being manipulated by others who were attempting to take advantage of her in some way. Together we generated multiple possible replies to someone’s manipulations: an assertive reply, a sarcastic reply, an evasive reply, a way to stall before either answering or deferring from answering, a humorous reply, and so on. Much of her anger with herself was from her inability to have better replies readily available. This caused her to feel too easily manipulated by others and thereby disrespected. We did another hypnosis session, this time on the theme of people wanting what they want and doing what they could to get what they want, whether through manipulative tactics of inducing guilt, intimidation, flattery and other such controlling tactics. This session served to make Mary feel other people weren’t out to get her or hurt her specifically, but were just trying to get their own wishes or needs met through others. She grasped the key point that people can ask for whatever they want in whatever way they choose, but it was ultimately up to her whether she responded and how she responded. After hypnosis, she was given the homework assignment to watch the televangelists on Sunday morning and identify as many of their manipulative tactics for getting people to send them money as she could. In the fourth session, Mary reported how so many things had ‘come together’ for her––new understandings about her mother’s limitations, and new understandings about how she had seen herself as a victim of other people when, in fact, she just ‘didn’t know the rules of the game’. We discussed her insights and their implications for future relationship possibilities, and ways she could better identify and meet her needs, accepting them as valid and worthwhile. A hypnosis session was done with the emphasis on the value of knowing oneself well enough to be able

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to say, ‘this is what matters to me and this is how I want to be’ with self-acceptance and an awareness that whatever position you take on anything, others will disagree and even disapprove, but not because you’re wrong. After the session, we discussed her progress over the four sessions and agreed to meet again a month later for further discussion, problem solving or whatever an appropriate agenda at that time might be. In the fifth session, Mary declared she ‘felt happy for the first time ever’. This was a remarkable statement, and one we then discussed at length. She had sought out several couples to socialize with, an action that shocked but delighted her husband. She had not had any inappropriate angry outbursts, but had been angry a number of times and asserted herself beautifully. She was surprisingly clear that she had a boundary, a limit she could respect and maintain. She found this wonderfully empowering and said it ‘totally changes how I see people’. A short hypnosis session was done to reinforce her continuing growth in her ability to read others well, recognize and accept her unique needs and views, and be skillful in her interactions, whether with herself or with others. We agreed to meet again 2 months later for further follow-up. In the sixth and, as it turns out, her final session, Mary came in with many stories to tell of ways she had skillfully handled the manipulations of others, especially her stepdaughter, which had previously been triggers for anger and sadness. She said she no longer endlessly analyzed (i.e. ruminated about) her feelings and was much more proactive. She had begun to develop some new friendships, and was optimistic about these. All in all, she said she felt the best she had ever felt, and hoped it would continue. We discussed signs and symptoms of backsliding to be vigilant about, and how to anticipate problems and take corrective actions before the problems grew serious. We established her ability to come back for further sessions whenever she might like to, and then we terminated amiably.

22.6.5. Outcome Three months later, I received an e-mail from Mary keeping me up to date on what had been going on in her life. Her excitement was obvious,

her good feelings were well articulated and her expression of thanks most gratifying. She had grown quickly into the kind of person that she could respect: bright, competent, socially adept and emotionally sophisticated. She appreciated the skills she learned, and the manner in which she learned them, specifically commenting on how the hypnosis had helped her focus on what really mattered.

22.7. Case example 2: the

case of John 22.7.1. Background John (not his real name) came to therapy at the insistence of his parents because of a severe depressive episode he was suffering. John was 34 years old, and was currently living at home with his parents for the past year following the break up of a long-term relationship he’d been in. At almost the same time as the break up, he’d lost his job, a short-term position he’d had that was scheduled to terminate when it did. John had not been able to find another position to begin in a timely way, and so moved back into his parents’ home out of economic necessity. He was withdrawn, irritable and did little to try to find a new job when one wasn’t immediately forthcoming. Thus, he was doing badly emotionally, financially, socially and in every other way. His parents had been very supportive and hoped he’d ‘find himself ’, but, as time went on, they realized he was getting worse, not better. An eruption at home caused his parents to push him into treatment. It involved an episode of John stalking a woman he’d become attracted to through their interactions over the Internet. He’d communicated with her in a ‘chat room’, and quickly (and inappropriately) got very attached to her. They agreed to meet, and had a nice but uneventful first meeting. But, John began to obsess about her, fantasizing about ways she’d rescue him from his dreary life. When he started to show up uninvited at inopportune times and places, and didn’t understand her irritation at seeing him at such times, she became scared and had a restraining order filed against John. This both enraged and saddened him, and fueled his desire to let her know

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he cared about her and wasn’t a threat to her. He was in danger of violating the restraining order and possibly being jailed when his parents persuaded him to go for help. Interviewing John and his parents, John was deeply embarrassed by his behavior, yet maintained that if he could just see her and explain to her that he was ‘a good guy’, she’d change her mind and they could be together. John’s parents both supported his report that he had never been like this before in his life (i.e. so emotionally needy, impulsive and irrational). John agreed he needed help, and said he was mystified by himself, and could ‘no longer tell which way is up’. His anxiety was palpable, his depression level severe and he didn’t know what to do to ‘get back to normal’.

22.7.2. Formulation Following the initial description of his symptoms and relevant history, John’s parents were dismissed and the session’s focus turned to trying to understand John’s decision-making strategies and how they led him to his current state of difficulty. Asking John such questions as, ‘How did you know whether the person typing messages on a keyboard could sustain a real relationship?’ and ‘How did you decide you could make her want you?’ and many other such ‘how’ questions, the cognitive distortions of emotional reasoning, jumping to conclusions and dichotomous thinking, among others, became evident. The deficits in his problemsolving capabilities were apparent, as was his lack of impulse control. But one pattern, more than any other, regulated (not caused) these others: John’s inability to distinguish what is controllable from what isn’t. While it can reasonably be said that a depressed person’s sense of hopelessness is the broad foundation of every aspect of treatment response, a person’s perception of controllability is also a critical factor affecting his or her quality and rate of recovery. The literature on learned helplessness (Abramson et al., 1985; Peterson et al., 1993), which emphasizes the detriments of believing the outcomes you attain are independent of your effort, confirms its relevance for understanding the apathy and ‘giving up’ behavior seen in depression sufferers.

However, learned helplessness represents only one side of the controllability coin. The other side of the coin is termed the ‘illusion of control’, the belief that one can control the outcome if one simply approaches the task in the ‘right’ way. Both beliefs, that one can or can’t control outcomes, can be damaging and depressing if misapplied in a specific context. The popular Serenity Prayer that asks for the ‘wisdom to know the difference’ between what is and isn’t controllable highlights the terrible consequences of not expending effort when effort can be rewarded, and expending too much effort when such effort will inevitably fail. John’s low frustration tolerance and dichotomous thinking led him to ‘give up’ on looking for work. His emotional reasoning led him to believe his feeling he’d ‘never get a job’ was an accurate predictor, leading to the foregone conclusion there was no reason to try. Thus, John was steeped in helplessness about getting his career and finances in order. On the other side, John believed he could control how his ‘online girlfriend’ viewed him. He believed if he approached her in the ‘right’ way he could make her care about him. Instead of giving up, he tried harder to make an impossible relationship work. Telling someone who gives up easily to ‘try harder’ or telling someone obsessed with someone or something they crave to ‘give up’ is a lot like telling a depressed person to ‘cheer up’. It may be technically correct, but it’s a pointless intervention. People often know what to do, but not how to do it. John needed to learn the specifics of when to work harder and smarter, and when to walk away. And he needed to learn to use indicators other than just his emotions. People’s feelings can too easily deceive them. The ‘stress generation’ model of depression described earlier in this chapter is immediately relevant to John’s circumstances. He was depressed, and began to make bad decisions that served to exacerbate his depression. Focusing on decision-making would need to be a part of John’s treatment as well.

22.7.3. Treatment plan John was clearly suffering major depression, anxiety and perhaps, some might even suggest, a

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personality disorder. The stresses of the losses of his long-term relationship, job, independence, self-esteem, and sense of purpose and drive had all left him overwhelmed and paralyzed. Thus, the following goals of treatment, subject to revision over time, were established: 1. Reduce John’s anxiety and sense of urgency to do something, anything, right away. 2. Help John see the ‘bigger picture’, i.e. his problems are more than his ‘online girlfriend’ needing to appreciate him more. 3. Help John compartmentalize his feelings while learning to think more rationally about and assess the feasibility of his shortand long-term goals in each area of his life. 4. Help John develop a ‘discrimination strategy’, a means of reliably determining what he can and cannot control in order to choose his courses of action more deliberately. 5. Help John develop effective personal boundaries that will allow him to set higher standards for his own behavior and better tolerate and accept, even when he disagrees with, the choices others make. John agreed with each of these goals in principle, but openly expressed his doubts he could really do any of these things, particularly when he was so preoccupied with getting his girlfriend back. His skepticism was framed as understandable given how bad he was feeling right now, but he would soon learn that by learning to do some things differently, he could expect a better result. John said, albeit not in a heartfelt way, that he’d follow the treatment plan and do whatever readings and homework assignments were given to him.

22.7.4. Treatment Once it became apparent the degree of emotional reasoning John employed in his life, the next phase of the session became a psychoeducational one. John was taught about the signs and symptoms of depression, the bidirectional relationship between thoughts and feelings, the role of cognitive distortions in generating misperceptions and inappropriate behavior, the internal orientation that distorts or even precludes more objective awareness, and so forth. John showed polite interest at this early phase, but little else.

Next, still in the first session, I introduced hypnosis to John as a means of shifting his focus to other ideas and awarenesses that could help him. He asked a couple of superficial questions about hypnosis, but agreed to participate to whatever extent he could. The hypnosis session (taped and given to him, as always) focused on ambiguity as a key issue, specifically the importance of recognizing that some situations, especially when they involve other people’s thoughts or feelings, are ambiguous and it’s difficult to know for certain what’s true without evidence. The primary suggestion was to distinguish what is known from what isn’t known, and learn to recognize when the unknowns are being filled in with projections (inferences, wishes, etc.). A series of examples were offered of people reading situations disastrously incorrectly (e.g. assuming the space shuttle was ready to fly despite the frozen O-rings because of a wish to keep to a schedule, or assuming that we could topple a brutal dictator, readily install a democracy in his country and that everyone there would welcome it, etc.). The point was reiterated that people can make bad decisions based on wishes and misinformation, highlighting the need to go beyond one’s wishes and strive to be more objective about important decisions. John relaxed visibly, and seemed to grow more attentive and more deeply absorbed in the hypnotic process as it unfolded. When he opened his eyes, he sat quietly for a few minutes before saying, ‘I never really thought about how decisions get made, especially by the government. But, I get your point. I’m trying to fly and maybe I shouldn’t really think of myself as cleared for takeoff yet. I’ll have to think about that’. We discussed his reactions, and he was given the assignment to make a list of 10 things he knew he had absolute control over and 10 things he knew he had absolutely no control over in his life and to bring his lists with him the next time we’d meet, scheduled for a week later. He seemed puzzled by this, but didn’t ask any questions, nor did I offer a rationale for the assignment. When John returned for the second session, he began with a flurry of questions about hypnosis, therapy, the mind and brain, and antidepressant medications, among other things. His polite interest the previous week had now become a

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genuine one. We discussed his afterthoughts about the session, and any new observations arising this past week. He reported that he thought a lot about what it means to be a ‘prisoner of your emotions’, and decided he was one. It was a distasteful self-definition, and he felt more motivated to find a way to ‘get back in control’. I used his mention of that phrase to ask him for his assigned lists. He had complied and done the assignment, but not very thoughtfully. So, we spent quite a bit of time going over his lists, with frequent challenges to and clarifications of the items they contained. John tolerated this exercise well, and the level of depth of his analysis increased as we proceeded. By the time I got to the step in the exercise of asking him to make a list of the principles that help one determine what is and what is not controllable and to generate examples using those principles, John was starting to become clearer about the huge costs to him of either giving up prematurely or hanging on past the sensible ‘let-go’ point. We did a hypnosis session emphasizing the artistry of knowing when to hold on and when to let go, and when to do neither until more information is available. Examples were provided during hypnosis all highlighting that sometimes holding on feels worse than letting go, and vice versa, and why, therefore, it’s less about one’s feelings and more about the eventual result one is striving for. John became tearful during this session and, when asked to describe what he was aware of, he slowly said, ‘It hurts to want things I know I can’t have’. This was accepted and agreed on, and the larger point reinforced that what defines each person’s integrity, in part, is how they deal with disappointment: ‘No one likes it, but the wisdom is in accepting it as an inevitable part of life’. When John came out of hypnosis and opened his eyes, he said, ‘I never thought of giving up as a good thing before. But, I guess sometimes it is’. I reinforced the point that sometimes it is, and other times it isn’t, and his job was to learn which time was which. Just as last time, he said, ‘I’ll have to think about that’. John was given the paradoxical assignment to attempt to control the uncontrollable: spend 15 min a day trying deliberately and with great effort to make it rain, or make the stock market rally or create world peace. He smiled, asked if I was serious,

then shrugged his shoulders with a passive gesture of acceptance. When John came in for the third session, he reported he had much less desire to straighten his ‘online girlfriend’ out, and said he had realized that what she thought about him was directly influenced by his inappropriate behavior. He said he now realized that he no longer had the power to change her mind about him, that her mind was set against him. He said he didn’t want to give up and walk away knowing she thought he was a ‘flake’, but it was a disappointment he’d have to bear. He hated that she thought so badly of him, but accepted that it was a result of his own doing. He appeared to be quite sincere in saying he’d gotten the point from the last session, and that ‘the word integrity just kept rolling around and rolling around in my thoughts’. It seemed a good time to expand his conception of making decisions with integrity, and so we began to discuss what that meant about job-seeking, living at home at his parents’ expense and the other areas of his life. He became tearful, and said he didn’t feel ready to ‘rejoin the human race’. Asked what resources he needed to do that, only better than he did it before, he had no answer. Hypnosis was initiated, and the session focused on how people ‘bounce back’ from adversity, i.e. how people develop and use resilience in coping. The phrase was used in one part of the hypnosis session that, ‘there is no one so powerful as the person on a mission, the person with a clear vision of what he wants and the means to pursue it realistically’. When John came out of hypnosis, he sat quietly for awhile and then said, ‘I had a mission. But I don’t have one now.’ He was given the task to take each area of his life (e.g. physical health, finances, social, etc.) and delineate shortand long-term goals for that domain. He simply said, ‘okay’. In the fourth session, John announced he’d applied for a job as a flight attendant several months ago and was now, quite unexpectedly, being offered a job with an airline company. He was excited, upbeat, optimistic and deliberate in pointing out to me, ‘This is more my old self, which I hope I can now improve upon!’ He had to decide relatively quickly about the job offer, and the decision was complicated by his having to make his home base in another city.

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We discussed at length the ways to approach this decision, especially in light of our previous discussions. We identified the variables to consider, the likely consequences, the inter-relationship between his nature and the duties he’d have to assume, and other such factors in decisionmaking. John came to the conclusion that his ‘gut feeling’ to take the job was, this time, the right feeling to follow. I reinforced the wisdom in his discrimination that sometimes you can listen to your feelings and other times you need to ignore them because they’ll lead you astray. Only by accurate extrapolations can you know whether your feelings are leading you in the right direction, i.e. a direction that will enhance your life rather than make it worse. John committed to taking the job. In so doing, he committed to moving away from his parents, as well as the city of his failed online ‘experiment’. He could meet new people, and use his ‘control’ to observe others carefully, self-disclose selectively and build a new network of friends that could bring life-enhancing social contact into his life. Playing out the possibilities, we discussed ways to approach this issue or that challenge, and John was surprisingly verbal in articulating which things he could do something about and which things would be left up to others to decide. He had gotten the therapeutic messages. John was given the names of several trusted colleagues he could see for additional treatment in his new home town. He promised he’d write or call with follow-up information once he settled into his new life.

22.7.5. Outcome Almost 5 months later, I got a long handwritten letter telling me all that had happened. He said, ‘I always remember that phrase, there’s no one so powerful as the person on a mission, and I keep the word integrity in the front of my mind daily, almost hourly’. He said he was casually dating, and reassured me that his dating was ‘nothing serious and, thankfully, nothing obsessive’. He never did call any of the referrals I gave him, but assured me if he felt himself ‘getting weird again’ he wouldn’t hesitate to do so. He ended the letter with his thanks and appreciation for what I’d taught him.

To my surprise, I received a brief thank you note from his parents about 3 months after he moved out (2 months before John wrote to me). They filled me in on some of the details of his move. They said it was ‘quick and painful, like pulling off a bandage, but things healed and John is doing well in his new job and seems happy with it, and also with himself ’. John had learned that you can’t control other people, at least not in healthy ways. And, he had learned that sometimes you just have to ‘take the hit’, i.e. suffer the disappointment, rather than try to avoid it. These are vital life lessons to learn.

22.8. Conclusion It is no coincidence that of the therapies with the greatest level of empirical support for their effectiveness in treating depression (cognitivebehavioral and interpersonal), none of them focuses on the past and all of them focus on helping depression sufferers build the skills that can empower them. In this chapter, I have emphasized the merits of hypnosis as a vehicle for teaching new skills, encouraging active experimentation with them in everyday contexts and using the feedback from life experience continually to adapt oneself to changing demands. Such teachings directly counter the popular psychologies that emphasize nondiscriminately ‘trusting your guts’ or ‘living in the present’, or thinking ‘you can have it all’ and countless other such global phrases that set people up to get hurt when they discover the hard way these principles don’t apply in all (or perhaps even most) life situations. Hypnosis can reasonably be considered the original ‘positive psychology’. Anyone who applies hypnosis does so with the firm belief that people have more resources than they consciously realize, and that hypnosis can help bring these resources to the fore. Empowering people in this way is a natural component of an effective treatment for depression, for no one can overcome depression while feeling or behaving in a disempowered manner. It is a terrible shame that hypnosis has been underutilized in the depression treatment process when it holds such great potential to catalyze therapy. Hopefully, as we continue to

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learn more about the many pathways into depression, we will learn more about the many pathways out as well, including those involving skillful applications of hypnosis.

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Yapko, M. (1993) Hypnosis and depression. In J. Rhue, S. Lynn and I. Kirsch (ed.) Handbook of Clinical Hypnosis, pp. 339–355. American Psychological Association. Washington, DC. Yapko, M. (1995) Essentials of Hypnosis. Brunner/Mazel, New York. Yapko, M. (1997) Breaking the Patterns of Depression. Random House/Doubleday, New York. Yapko, M. (1999) Hand-Me-Down Blues: How to Stop Depression from Spreading in Families. St. Martins Griffin, New York. Yapko, M. (2001a) Treating Depression with Hypnosis: Integrating Cognitive-behavioral and Strategic Approaches. Brunner/Routledge, New York. Yapko, M. (2001b) Hypnosis in treating symptoms and risk factors of major depression. American Journal of Clinical Hypnosis, 44: 97–108.

Yapko, M. (2001c) Hypnotic intervention for ambiguity as a depressive risk factor. American Journal of Clinical Hypnosis, 44: 109–117. Yapko, M. (2003) Trancework: An Introduction to the Practice of Clinical Hypnosis, 3rd edn. Brunner/Routledge, New York. Yapko, M. (ed.) (2006) Hypnosis and Treating Depression: Applications in Clinical Practice. Routledge, New York. Zeig, J. (ed.) (1980) A Teaching Seminar with Milton H. Erickson, M.D. Brunner/Mazel, New York. Zimmerman, M., Posternak, M., Friedman, M., Attiullah, N., Baymiller, S., Boland, R., et al. (2004) Which factors influence psychiatrists’ selection of antidepressants? American Journal of Psychiatry, 161: 1285–1289.

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CHAPTER 23

Hypnosis for healthcompromising behaviors Gary Elkins and Michelle Perfect

23.1. Introduction Health-compromising behaviors represent a major source of preventable disease, and for this reason have been the focus of increased attention among health care professionals. Reductions in health risk behaviors include achieving reductions or cessations of behaviors that are harmful to health, such as tobacco use and excessive alcohol use. Modifying healthcompromising behaviors can also include enhancement of behaviors to improve health, such as adherence to a healthy diet, increasing physical activity or weight reduction. However, changes in health behavior can be difficult to achieve, and more than a quarter of Americans are at increased risk for health consequences such as cancer, stroke and hypertension due primarily to health-compromising behaviors. Hypnosis is frequently sought, and has been applied to two significant health risk behaviors: nicotine dependence and obesity. There is a great need for interventions to modify the behaviors associated with nicotine dependency and obesity, and effective hypnosis treatments have the potential both to save lives and to improve the health care of many individuals who are at risk. Cigarette smoking and use of tobacco products has been recognized as the leading preventable cause of death and disease in the USA,

and claims the lives of more than 430 000 individuals each year (US Department of Health and Human Services, 1999). Smoking is associated with a host of deadly diseases including lung cancer, chronic obstructive pulmonary disease, oral cancer, esophageal cancer, heart disease, stroke and high blood pressure (US Department of Health and Human Services, 1999). Further, it has been estimated that the number of tobaccorelated deaths each year exceeds that of deaths due to AIDS, murders, alcohol, automobile accidents, drug abuse, fires and suicide combined (Centers for Disease Control and Prevention, 2002). Despite public information on the risks associated with tobacco products, over 65.5 million people living in the USA continue to use tobacco (either smoking or smokeless tobacco) on a regular basis (Centers for Disease Control and Prevention, 2002). Most people who smoke are aware that there are serious health risks associated with smoking, and as many as 80 percent of current smokers express a desire to stop smoking ((US Department of Health and Human Services, 1990). However, fewer than 5 percent are likely to be able to quit on their own without assistance (Fiore et al., 1990). Also, obesity has been associated with a wide variety of health problems. Obesity may be defined in terms of exceeding an established body mass index (BMI). The formula for BMI is: weight (in pounds) divided by height

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Table 23.1 Classification of overweight and obesity by BMI Obesity class

BMI

Underweight

40.0

Source: National Institutes of Health/National Heart, Lung, and Blood Institute (1998).

(in inches) × 704.5. BMI cut-offs for weight classification are presented in Table 23.1, with BMIs >30 indicating obesity. Overweight status and obesity have been linked with heart disease, cancer, stroke, type 2 diabetes, sleep apnea, chronic pain, high blood pressure, high cholesterol and gallstones (Field et al., 2002). Health-compromising behaviors are difficult to modify because the behavior may have been reinforced through repeated positive or negative reinforcement. Modifications can require lifestyle changes that are difficult to achieve, and there may be ambivalence about change. This chapter reviews the literature to identify some of the key components related to effective assessment and hypnosis in the treatment of smoking and obesity. We discuss hypnosis interventions including how hypnosis may be integrated with other interventions to maximize clinical results. Case examples are presented to illustrate the authors’ approach to treatment of these health-compromising behaviors.

23.2. Nicotine dependency Given the popularity of hypnosis for smoking cessation, it is somewhat surprising that the clinical research into hypnosis for treatment of nicotine dependency has found mixed results for ITS efficacy. The success reported for hypnosis for smoking cessation ranges from as high as more than 80 percent (Crasilneck, 1990; Elkins and Rajab, 2003) to as low as 14 percent (Vermont

Lung Association, 1981). A part of the variability in outcomes may relate to the differences in intensity of the intervention and other factors related to treatment planning. In general, minimal approaches to hypnosis involving only one or two sessions have reported cessation rates of only around 20 percent, while more intensive approaches garner higher rates of cessation. Much of the research has investigated a minimal approach to hypnotic intervention such as that developed by Spiegel (1970), in which simple direct suggestions for stopping smoking are given (i.e. ‘smoking is a poison for your body; you need your body to live; etc.’) following a brief hypnotic induction. Minimal interventions of one session or only a few sessions have been studied by several investigators (Spiegel, 1970; Pederson et al., 1975; Stanton, 1978; Berkowitz et al., 1979; Javel, 1980; Cornwell et al., 1981; Rabkin et al., 1984; Hyman et al., 1986; Neufeld and Lynn, 1988; Williams, and Hall, 1988; Spanos et al., 1992, 1995; Spiegel et al., 1993). The findings regarding this minimal approach to hypnosis for smoking cessation have indicated outcomes that may be somewhat, but not greatly, superior to counseling alone or attention or other behavioral methods. For example, Rabkin et al. (1984) conducted a randomized trial comparing the hypnosis technique adapted from Spiegel (1970) with smoking cessation programs utilizing behavior modification, health education or a control conditions. Only self-report data were collected at 6-month post-treatment. Results indicated that 23 percent in the hypnosis group reported having stopped smoking and there was no significant difference between any of the groups. This finding was further reinforced by a comprehensive review of hypnosis for smoking cessation studies in which Green and Lynn (2000) also concluded that it seems apparent that minimal hypnotic interventions, such as that developed by Spiegel (1970), and group hypnosis interventions (Lynn et al., 1993) achieve only around 20 percent or less abstinence. Therefore, effective hypnosis intervention for smoking cessation may need to be intensified in some way to achieve better results. In fact, reports of more individualized and intensive approaches to hypnosis for smoking cessation

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have indeed suggested that higher rates of smoking cessation might be achieved. Holroyd (1980) suggested that the likelihood of success for hypnosis in treatment of tobacco dependency may be significantly increased by an intense approach that includes: (1) multiple sessions; (2) individualized hypnotic suggestions; (3) individualized counseling with follow-up; and (4) an intense interpersonal relationship. This would be consistent with other interventions (Fiore et al., 2000; Niaura and Abrams, 2002). To qualify as an intensive treatment, there must be a least a minimum of four sessions lasting more than 10 min each (Fiore et al., 2000). For example, Crasilneck (1990) reported on an intensive, five-session hypnotherapy intervention that was provided on a one-to-one basis to 100 patients seen in his clinical practice. Smoking cessation rates of 81 percent were reported at a 12-month follow-up. A weakness of the study was that the data were based entirely on self-reports and did not meet the criteria needed for an empirically validated treatment (Chambless and Hollen, 1998). Also, it is likely that relying on self-reports alone leads to inflated rates of cessation (Fiore et al., 2000). However, the report strongly indicated that an intensive approach to hypnotherapy might be highly effective. Also, Johnson and Karkut (1994) provided a clinical report of a hypnotherapy intervention that included multiple sessions and in which self-hypnosis practice outside the sessions was integrated into treatment. There was a self-reported smoking cessation rate of 87 percent at 3-month follow-up. However, a limitation of this study was that the results were based entirely on self-reports, there was no biologically confirmed measure of abstinence and no randomization to a control group. Recently, many of these limitations were addressed in a controlled pilot study of intensive hypnosis for smoking cessation conducted by Elkins et al. (2007) that included careful randomization to control and treatment groups and biologically determined rates of abstinence. Smokers were randomly assigned to either an intensive hypnosis intervention or wait-list control. Abstinence was confirmed by expired carbon monoxide of 8 parts per million (p.p.m.)

or less, and any inconsistencies in self-reports and carbon monoxide readings were resolved with saliva cotinine measurement. The intensive hypnotherapy intervention was designed to provide: 1. Multiple sessions (the intervention involved eight sessions with hypnotic inductions at sessions 1, 2, 4 and 7). 2. Instruction in self-hypnosis (instructions for practice of self-hypnosis were given along with an audiocassette recording of hypnotic induction and suggestion). 3. One-to-one individualized counseling with follow-up visits (individualized counseling was provided on problem solving and emotional support). 4. Therapeutic interpersonal relationship (all sessions were conducted in individual sessions with a physician or psychologist with advanced training in clinical hypnosis). 5. Individualized hypnotic suggestions (hypnotic inductions were individualized based on patients needs and preferences but followed a general transcript. Suggestions were given for deepening relaxation, absorption in relaxing imagery, commitment to stop smoking, decreased craving for nicotine, posthypnotic suggestions, practice of self-hypnosis and visualization of the positive benefits of smoking cessation. Subjects were asked at each session for their preferences for specific imagery for relaxation and dissociation. The suggestions followed a transcript; however, the specific imagery for relaxation and the positive benefits for smoking cessation were individualized based upon questions to determine the patient’s preference regarding such imagery. As shown in Table 23.2, the rates of smoking cessation, as confirmed by carbon monoxide measurements, for the intensive hypnotherapy group was 40 percent at the end of treatment, 60 percent at 12 weeks and 40 percent at 26 weeks. Also there was a significant decrease in the number of cigarettes smoked (Fig. 23.1). Reductions in numbers of cigarettes smoked may be an important step for those smokers who fail to achieve abstinence, but later go one to stop smoking completely.

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Table 23.2 Point-prevalence smoking cessation rates confirmed by carbon monoxide measurements Time after target quitting date

Percentage of subjects not smoking Control Intensive hypnotherapy

8 weeks

10%

3 months

0%

6 months

0%

40% 60%∗ 40%∗

∗P 30), and in

treatment of obesity Obesity is a chronic condition that develops as a result of an interaction between a person’s genetic predisposition and his or her sociocultural context (Platt, 1995). Despite the challenges posed by genetic factors, weight reduction primarily consists of modifying behaviors, including reducing health-compromising behaviors. Eating behaviors can be viewed along

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a continuum, in which there are individuals who have healthy habits and there are others who engage in eating behaviors that could compromise their physical as well as their mental well-being. Prior to the start of any intervention, it is essential that clinicians assess for the existence of an eating disorder. Different types of eating disorders may warrant specialized services with trained providers. An underlying mechanism of obesity has often been attributable to food addictions, placing it in a similar category to tobacco and alcohol (Wadden and Anderton, 1982). However, in contrast to those two health-compromising behaviors, people cannot abstain from eating (Platt, 1995). When considering whether a hypnosis component might be effective in the treatment of a presenting problem, it is important to determine whether the behavior is voluntary or involuntary. For example, volitional behavior, such as smoking or eating, might vary in its response to hypnosis relative to problems that are under less conscious control, such as pain. Therefore, it is important for clinicians to understand that obesity should be viewed as a complex problem with multifarious causes that each need to be targeted. There are certainly aspects of eating behavior that can be considered less volitional, such as food cravings or hunger pangs. However, eating behavior is best characterized by selfinitiated actions influenced by external cues (Wadden and Anderton, 1982). One form of modification might be through dietary control that includes selection of healthy food choices or consumption in moderation. One study (Logue et al., 2004) found that individuals who consistently practiced food portion control over a 2-year time period lost 5 percent or more of their baseline weight. In contrast, patients who did not consistently practice portion control gained 5 percent or more of their baseline weight. In particular, the effectiveness of dietary control is tied to the feasibility of maintaining the lifestyle adjustments throughout a person’s life rather than solely for the purpose of achieving weight loss. Most professionals would agree that in order to achieve weight loss, individuals must modify their eating habits (e.g. Logue et al., 2004). Typically, interventions include some behavioral components such as dietary recommendations,

self-monitoring by keeping a journal of eating behavior, and exercise (Wadden and Foster, 2000). Such interventions can produce initial weight losses of 1–2 lbs per week (Wadden and Foster, 2000), and the addition of a very low calorie diet (800 kcal/day) or a restricted portion-control diet can increase total weight loss by 30 percent or more (National Task Force on the Prevention and Treatment of Obesity, 1993; Jeffery et al., 2000). A primary problem with most weight loss programs is not the lack of initial results, but rather the fact that approximately one-third of those who lose weight gain it back within the year and almost everyone gains the weight back within 5 years (Fawzy et al., 1983). As a result, the longer a person remains involved in an intervention and support program, the more likely it is that greater and more long-lasting weight losses will be achieved (Perri et al., 1989). Therefore, it is recommended that treatment interventions for obesity extend over 6–12 months (National Institutes of Health/National Heart, Lung, and Blood Institute, 1998). More short-term interventions (i.e. lasting one or two sessions) are less likely to be effective. Fawzy et al. (1983) highlighted the literature regarding several behavioral methods, most of which are still employed in weight reduction programs. Such methods include self-control, covert modeling or aversive techniques. Selfcontrol strategies involve self-monitoring (e.g. maintaining a diary), self-reinforcement (e.g. treating oneself to a reward for attempts and successes at curtailing poor eating habits) and stimulus control (e.g. eating in the same place each day). The addition of cognitive components has been found to be effective for identifying, discussing and modifying distorted thinking and emotional dysregulation that fosters disordered eating (Gilliland and James, 1983). Such elements might include cognitive restructuring (identifying faulty beliefs and modifying irrational beliefs) or problem-solving training (Gilliland and James, 1983; Sanders, 1986). For example, Perri et al. (2001) found that the addition of a problem-solving component to behavior therapy demonstrated significantly better long-term maintenance of lost weight than behavior therapy.

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Before deciding which components should be employed in an intervention targeting weight loss and healthy eating behaviors, it is important to conduct a thorough assessment to determine what might be most suitable for a particular individual. It is important to gather baseline data to determine appropriateness for a given intervention and readiness for change. Clearly, being overweight does not necessarily equate with disordered eating. Individual differences in weight have been attributed to genetic predisposition. Such evidence has been grounded in twin and adoption studies (Platt, 1995). Baseline measurement should include calculation of BMI, waist circumference and risk status (National Institutes of Health/National Heart, Lung, and Blood Institute, 1998). Also, it is important to understand that despite having established guidelines for determining healthy ranges for weight, BMI and waist circumference, there area several societal factors that can influence acceptable weight parameters (Platt, 1995). For instance, many communities encourage thinness for aesthetic reasons; however, in some cultures a larger body size is viewed as representing health and power (Platt, 1995). In addition, eating behavior can also be triggered by emotional experiences. Likewise, stress can be an important factor, especially in regard to binge eating (Faith et al., 1997). Therefore, hypnotic interventions that emphasize relaxation and stress management may be an important component of intervention. Another important area to evaluate is the level of the individual’s motivation for modifying eating behaviors and achieving weight loss (Logue et al., 2004). A clinical interview should determine underlying issues that might be contributing to difficulties with weight management. These domains include: psychological (e.g. low self-esteem, feelings of inadequacy or lack of control, mood disturbances), interpersonal (dysfunctional family relationships, history of peer teasing, maltreatment history) and socio-cultural (e.g. cultural pressures toward a particular body type, cultural norms for physical appearance; e.g. Cochrane, 1992; Platt, 1995) Yet another consideration for the clinician is whether to evaluate hypnotizability. There have been equivocal findings pertaining to the role of hypnotizability and weight loss success.

The mixed results can at least in part be attributable to issue of voluntary versus involuntary behaviors. However, also contributing to the variable findings has been the timing of administration and the instrument used to assess hypnotizability. For instance, one small singlegroup study (Deyoub, 1979) did not find a relationship between scores on the 12-item Harvard Group Scale of Hypnotic Susceptibility (Shor and Orne, 1962) and weight loss following participation in an 8-session hypnotherapy group intervention (Deyoub, 1979). The Barber Suggestibility Scale (BSS; Barber, 1965) was used to measure hypnotizability in three studies. Deyoub and Wilkie (1980) found that BSS scores were significantly related to the degree of weight loss experienced by those who participated in the hypnosis intervention, but not correlated with weight loss among those whose treatment did not include a hypnosis component. The researchers speculated that administering the BSS prior to conducting the intervention established an expectancy set. Accordingly, individuals who scored low on the BSS and were participating in the hypnotic intervention condition may have been discouraged about the potential for the hypnosis to benefit them, whereas individuals who scored high on the BSS may have been reliant on the suggestions to change their behavior (rather than viewing hypnosis as a facilitative tool; Deyoub and Wilkie, 1980). In contrast, another study (Cochrane and Freisen, 1986) did not find a significant relationship between the BSS (Barber, 1965), also administered prior to treatment, and weight reduction. However, there was wide within-group variability and the data on hypnotizability and weight loss were not examined specific to the hypnosis condition (Cochrane and Freisen, 1986). Nonetheless, data from a study conducted by Wadden and Flaxman (1981) also did not support a significant association between weight loss and the BSS, which had instead been administered at the final treatment session. The SHSS is widely considered the ‘gold standard’ for measurement of hypnotizability (Kallio and Revonsuo, 2003). One study (Andersen, 1985) examined the association hypnotizability (measured with the SHSS:A (Weitzenhoffer and Hilgard, 1959)) and weight loss following

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participation in eight individual hypnosis sessions and 3-month post-intervention follow-up (during which time participants had been instructed to practice self-hypnosis). The results indicated a statistically significant positive association between degree of hypnotizability and success at weight reduction (Andersen, 1985). In their study, Barabasz and Spiegel (1989) also considered the impact of hypnotizability using the SHSS:C (Weitzenhoffer and Hilgard, 1962). Weight loss for the individuals who received individualized hypnotic inductions was significantly correlated to scores on the SHSS; however, hypnotizability was not related to weight loss following participation in a behavioral treatment or a hypnosis intervention that included only general suggestions (Barabasz and Spiegel, 1989). Consideration of what elements, such as individualization, will be discussed in the following section.

23.3.2. Hypnosis interventions

for obesity Studies examining the effectiveness of hynosis in the treatment of obesity have either reported on hypnosis as a single treatment or as a part of a multimodal cognitive-behavioral intervention (Vanderlinden and Vandereycken, 1994). In general, there is little empirical support for hypnosis as the only or primary therapeutic tool (Stewart, 2005). However, hypnosis may be an effective addition to a cognitive-behavioral treatment plan (Kirsch et al., 1995; Kirsch, 1996). Given the complexity of obesity and eating behavior and the influence of environmental and genetic factors, it is not surprising that hypnosis by itself has been found to be a relatively ineffective treatment. In fact, there is little support for any single treatment (Wadden and VanItallie, 1992; Foreyt and Goodrick, 1993; Kirschenbaum, 1994; National Institutes of Health/National Heart, Lung and Blood Institute, 1998). In utilizing hypnosis, it is important for clinicians to discuss clients’ perceptions of how hypnosis can be beneficial and clarify any misconceptions that hypnosis might ‘cure’ obesity. Most studies have examined the added benefit of a hypnosis component to behavioral modification programs. In one of the most

well-controlled studies in this area, Bolocofsky et al. (1985) examined the differential benefit of a behavioral weight loss program with a hypnotic induction compared with just the behavioral treatment among 109 individuals aged 17–67. Individuals who participated in both conditions lost a significant amount of weight compared with baseline. However, adding hypnosis to the behavioral regime appeared to contribute to continued weight loss. Those who received both the behavioral and hypnosis components were found to have lost significantly more weight at the 8-month and 2-year followup visits compared with those who had participated in the behavioral treatment condition. Hypnosis has also been used in combination with the behavioral intervention referred to as ‘covert modeling’. Covert modeling involves asking clients to use their imagination, visualizing a particular behavior as the therapist describes the imaginary situation in detail. A study conducted by Bornstein and Devine (1980) provided support that the adjunct of hypnosis to a covert modeling intervention contributed to initial weight loss and weight maintenance. The average weight loss was significantly greater among individuals who participated in the multimodal approach (i.e. covert modeling plus hypnosis condition) than among individuals who participated in the no-model control condition; weight loss did not differ between participants in the other conditions (i.e. covert modeling only treatment, minimum treatment condition). In addition, the individuals who had participated in the covert modeling plus hypnosis maintained their weight loss for at least 3 months post-treatment, though there was no further weight loss. Although having significant ethical implications, some professionals have suggested that aversive techniques may facilitate weight reduction. Overt aversion involves introducing an aversive stimulus when an individual engages in an undesirable behavior. Johnson and Karkut (1996) examined weight loss differences between 86 women who participated in a hypnosis-only condition and 86 women who participated in a hypnosis plus overt aversion condition (electric shock, taste and smell aversions, and individualized aversions). The hypnosis component consisted of a 90-min audiotaped induction,

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which participants were instructed to listen to on-site and then use it to continue practicing self-hypnosis at home. The recording included general imagery, suggestions regarding negative effects of certain foods or eating excessively, suggestions for self-esteem building, and dietary control recommendations. In addition to the hypnosis component, the aversive condition involved coating desired foods with vinegar, disgusting imagery targeting food cravings, and electric shock. All participants engaged in a discussion regarding a low-calorie diet. Members in both treatment conditions weighed significantly less at post-treatment and 1-month follow-up compared with baseline, but the average weight loss was similar between conditions. Interestingly, 40.7 percent of the participants in the hypnosisonly condition received six on-site hypnosis sessions, whereas 38.4 percent of the individuals in the hypnosis plus aversion condition received four on-site sessions, and everyone who participated in the latter condition declined further aversive therapy (Johnson and Karkut, 1996). One of the key elements of hypnosis interventions is the importance of individualizing the induction with suggestions relevant to the patient. In a controlled study of hypnosis for treatment of obesity, Barabasz and Spiegel (1989) examined weight differences among 45 individuals who received (1) individualized hypnotic inductions in addition to self-management treatment; (2) self-management plus hypnosis without individualization; or (3) a self-management-only treatment condition. Individuals who received individualized hypnotic inductions lost significantly more weight compared with those who participated in the self-management treatment. In an attempt to determine if the focus of hypnosis has an impact on weight loss, Stradling et al. (1998) conducted a study in which patients from a sleep disorders clinic were assigned to one of three conditions: (1) dietary advice only; (2) dietary advice plus hypnosis focused on stress reduction; and (3) dietary advice plus hypnosis focused on suggestions specific to food. The hypnosis components consisted of one 30-min individual session, one 30-min group session and an audiocassette with a taped induction to practice self-hypnosis at home. The researchers noted that they included two hypnosis groups, one focused on food and one

targeting more general stress due to the impracticality of devising a ‘sham’ hypnosis control group. The results indicated that the adjunct of hypnosis focusing on stress reduction contributed to greater weight loss compared with those in the other two conditions. These findings surprised the researchers as they had expected the hypnotic induction specific to food to contribute to greater weight loss; however, it was explained that stress management using hypnosis may have helped relieve some of the tension underlying eating behaviors (Stradling et al., 1998). There is some persuasive theoretical and empirical evidence that individuals with stronger initial beliefs about the success of a given intervention might be more likely to experience an actual reduction in the targeted problem area (Schoenberger, 2000). The potential importance of cognitive expectancies in a hypnosis intervention was explored in a study by Wadden and Flaxman (1981) in which they examined hypnotizability in addition to cognitive expectancies for the hypnosis intervention. In their study, the hypnosis intervention included a hypnotic induction, positive expectancy for the effectiveness of hypnosis, direct suggestions for weight loss, rehearsal and requests to practice self-hypnosis twice daily for 10–20 min (without further instructions on this process). There was no difference in the amount of weight lost between individuals who received the hypnosis intervention and individuals who participated in one of two other treatment conditions (covert modeling treatment or a relaxation-attention control). The data also did not support a significant association between weight loss and hypnotizability. The strongest predictor of weight loss (regardless of the type of intervention) was the measure of expectancy for treatment success. Related to expectancies are interventions that enhance participants’ belief or confidence in the intervention. One investigator (Goldstein, 1981) postulated that the benefit of a hypnosis intervention for weight loss could be enhanced by strengthening participants’ beliefs that they were actually in a trance state. Although it could also be viewed as a limitation, with the investigator also being the clinician for all participants, the study also most probably reflects treatment employed in ‘real-world’ clinical settings.

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In order to test the author’s hypothesis, women were assigned to participate in one of three conditions: (1) behavior modification; (2) hypnosis intervention without a structured experience; or (3) hypnosis intervention with a specific experience (i.e. hand levitation) as a demonstration of trance. The suggestions made in both hypnosis intervention conditions were similar to those presented in the behavior modification program, except that the suggestions were made as part of the inductions and these participants were also given exercises (e.g. instructions to visualize herself as thin, to increase her metabolic rate, to focus on feelings of pride for adhering to her diet). For individuals in the hypnosis with the experience condition, suggestions for hand levitation were administered individually to participants during the second or third session. Women in the hypnosis with arm levitation lost significantly more weight by 6 months than women in either of the other two conditions. Moreover, although only a subset of the sample, it appears that the average weight lost at 6 months among those who experienced successful arm levitation (mean = 41.7 lbs) was significantly higher than the weight loss from those who did not experience successful arm levitation (mean = 19.7 lbs; Goldstein, 1981). The findings of the aforementioned study (Goldstein, 1981) underscore important considerations for including hypnosis components in interventions for obesity. It is important to note, however, that data were only based on participants who completed at least four sessions, although there were relatively equal numbers (four or five) who did not complete the minimum number of sessions. However, there were no data to indicate the rate of attrition according to the treatment condition beyond the initial drop-out, which has implications for interpretation of what the author referred to as ‘6-month data’ since they included the weight of participants from any point between the fourth treatment session and the sixth. Nonetheless, the author suggested that the apparent benefit observed by those who participated in the hypnosis with a structured experience condition could be attributed to the phenomenon of providing ‘proof ’ to the patient that they are in a trance. It is also possible that the arm levitation was reflective of hypnotizability, and thus those

who were more hypnotizable would receive a superior benefit of the intervention. Davis and Dawson (1980) noted that patients report greater weight loss when they anticipate visits to their therapist and that the use of an audiorecording with a hypnotic induction (for self-hypnosis) appears to have utility for continued weight loss. Cochrane and Friesen (1986) did not find self-hypnosis to have a greater impact than a hypnosis intervention without an audiorecording. In their study, 60 women were assigned to one of three conditions: (1) faceto-face sessions of hypnosis (two 3-h sessions per week for 4 weeks consisting both individual and group hypnosis) plus self-hypnosis (a 15min audiorecording with hypnotic inductions to listen to at home for 6 months following the termination of the intervention); (2) hypnosis without an audiorecording; and (3) a wait-list control. The individual meetings for the hypnosis intervention consisted of metaphors for egostrengthening, decision making and motivation, ideomotor exploration in individual hypnosis, and the group sessions focused on hypnosis with maintenance suggestions. Individuals who received a hypnosis intervention were found to have lost significantly more weight than individuals on the waiting list at both 1 and 6 months following treatment termination. Weight loss did not vary according to the inclusion or omission of self-hypnosis. In summary, although studies on hypnosis as a treatment for obesity have not yielded consistent findings, most research has suggested that a hypnosis component, when used in combination with cognitive-behavioral therapy, exercise and a low-fat diet, might facilitate weight loss (Vanderlinden and Vandereycken, 1994; Schoenberger, 2000). The primary criticism in regards to the empirical support for the use of hypnosis for weight loss has been that studies have varied in their methodology, limiting the generalizability of their findings. In addition, many of them were relatively small and had various methodological limitations (Allison et al., 2001). Hypnosis has been applied to a number of different treatment protocols, and the variation in the findings may be in part attributable to the wide variations in their treatment protocols and assessment procedures (Allison et al., 2001). For instance, some of the interventions

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used group treatment (e.g. Deyoub, 1979), some used individual treatment (e.g. Goldstein, 1981) and some incorporated both (e.g. Stradling et al., 1998). Many of the studies also provided instructions for self-hypnosis, including listening to an audiotaped hypnosis induction outside of the study session (e.g. Wadden and Flaxman, 1981; Andersen, 1985; Johnson and Karkut, 1996; Stradling et al., 1998), but only specifically examined the added benefit of this skill (Cochrane and Friesen, 1986).

8. Individualized hypnotic techniques (e.g. individualized suggestions to reduce food cravings, imagery of a comfortable place, imagining the future, feeling amplification, hypnotic dream, rehearsal in fantasy, ego enhancement, improvement of body image). 9. Stress reduction (e.g. progressive muscle relaxation, deep breathing). 10. Long-term follow-up (i.e. treatment contact extending over 6–12 months).

23.3.4. Case example 23.3.3. Planning hypnosis

treatment protocols An integrated approach that incorporates multiple components, such as cognitive-behavioral strategies (e.g. goal setting and self-monitoring), nutritional counseling/dietary control and exercise, is the most effective for the treatment of obesity. Hypnosis can be individualized both to achieve weight loss and to help maintain weight reductions over time. In fact, the benefit of a hypnosis component may be most evident when evaluating continued weight loss and weight maintenance (e.g. Bolocofsky et al., 1985; Kirsch et al., 1995; Schoenberger, 2000). While specific suggestions and mental imagery may be tailored to individual preferences and needs, it is recommended that the following treatment components are included in a planning a hypnosis treatment protocol for obesity. 1. Baseline measurement (i.e. BMI, waist circumference, motivation, history of weight reduction attempts, examination of coping methods and social support resources, evaluation of mood or eating disorders, assessment of medical risk factors). 2. Goal setting (i.e. realistic goals). 3. Self-monitoring (e.g. daily food diary or journal). 4. Cognitive components (e.g. restructuring, brainstorming). 5. Dietary control (in collaboration with a nutritionist). 6. Exercise prescription (after clearance by a physician). 7. Establishing cognitive expectancies (e.g. positive expectancies for weight reduction).

The following case illustrates the integration of hypnosis with behavioral interventions including self-monitoring, diet, exercise, altering cognitive expectations, problem solving and stress management. The patient, ‘Linda’ is a 55-yearold woman with a history of chronic obesity who was sent by her family physician for recommendations in regard to hypnotherapy for weight loss. She reported that she had never been very active in terms of exercise and that she felt that stress and her eating patterns were probably the most significant underlying issues for her. Her weight was 233 lbs and her BMI was 36, putting her in the Obesity II category. She related that her primary reasons for wanting to lose weight related to her health as she stated, ‘I do not want to die from a heart attack or develop diabetes’. She also identified physical appearance and ability as motivating factors. Linda stated that she had tried several diets in the past and that her husband was supportive, but she found it difficult to make long-term lifestyle changes. She and her husband had been married for 35 years and have three children ranging in ages from 31 to 34. She stated that her husband was mildly overweight and tended to be more physically active than herself. During the initial consultation, a mental status examination was within normal limits and there was no evidence of significant anxiety or depression. Linda stated that her goal was to reduce her weight by 40 lbs, as recommended by her physician. She had completed a visit to a dietician and had a 1200 calorie diet that she wanted to ‘try to follow’. She expressed an understanding that she would need to reduce calories and begin an exercise program to achieve her goals. She identified drinking sodas and eating at high-fat

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buffets as behaviors that she would need to modify. She gave examples of her eating habits as: Breakfast—fried eggs, bacon, biscuit and soda; Morning—two more sodas; Lunch—skip lunch; Afternoon—two more sodas; Dinner— Chinese food buffet. She identified additional obstacles to overcome including stress as she stated, ‘I eat when I am stressed. When I have a lot of work to do, or when the typical stresses of life are high I like the taste of food. It doesn’t matter what food, I just want something that is not stressful and food makes me feel good’. She also stated that she just ‘enjoyed eating’ and that she tended to eat when she felt bored, stating ‘when there is nothing to do, I tend to open up the cupboards and fridge finding something to eat’. Hypnosis was discussed as an adjunctive treatment, and her expectations for herself and hypnosis were discussed. Linda expressed a positive interest in hypnosis and at the second session she brought a written summary of her expectations: ‘I am not entirely sure how hypnosis will work with my weight loss goals. I expect it will help me associate corrective thoughts, activities, feelings and behaviors to those corresponding thoughts and behaviors that are destructive to my health. Meaning, if I am stressed, through the hypnosis process I might be given the association/suggestion of exercising or some other behavior to get rid of stress instead of eating. I think I will still be able to choose whether or not I will follow the suggested behavior but I hope that through hypnosis I will be able to think about exercise or an alternative behavior before I think about eating. I would like hypnosis to help me control my appetite, control those negative emotion/behaviors that cause my poor eating choices (such as stress), and help with my motivation to exercise. I believe that hypnosis will not solve all my health problems, but I believe it can be a tool for me to reinforce good behavior and my goals’. A behavioral treatment plan was developed with Linda that included the eventual elimination of sodas, a change in her eating habits to be consistent with a 1200 calorie diet, decreasing eating out at high-fat restaurants such as buffets, decreasing sweets and beginning an exercise program. Hypnosis was discussed as a method

to reinforce these positive behaviors, manage stress and dealing with feelings of hunger, foster positive expectancies and self-esteem, and facilitate insight. She was also asked to begin keeping a daily food diary to self-monitor her behavior and to investigate exercise alternatives. The SHSS:C (Weitzenhoffer and Hilgard, 1962) was administered and she achieved a score of 11, indicating high hypnotic ability. Linda was seen on an approximately weekly/ bi-weekly basis for 9 months. Sessions 4, 12 and 26 are summarized below.

23.3.4.1. Session 4: ‘I’m scared to death!’ By the fourth session, Linda had begun following her diet and was eating out less frequently. Eating a more healthy breakfast was discussed and scheduling only two sodas a day, one in the morning and one mid-afternoon, as she continues to withdraw from sodas. Also viable exercise plans were discussed including buying either a treadmill or a recumbent bicycle, or joining a gym for women. She was using on a daily basis a self-hypnosis taperecording that had been provided to her at the second session. However, she reported increased feelings of anxiety. She was asked about personal images associated with relaxation and she related a memory of going on vacation to a cabin in Colorado. These images were included in a hypnotic induction and she stated that she felt much calmer and more confident at the end of the session. 23.3.4.2. Session 12: ‘I’ve lost 15 pounds so far’ Linda brought her food diary to each session that was reviewed for compliance and any problem situations. She had reduced her sodas to one per day, usually in the evening. She was eating a more low-fat, high-fiber diet, and had decreased eating out at buffet restaurants. She stated that in the past she would have ordered a full meal whether she ‘wanted it or not’, but now she was able to ‘resist her impulses’ and was more likely to order a salad when eating out. She and a friend had visiting a gym several times and enrolled in an exercise program with a personal trainer. The patient did well with the hypnotic induction, reporting that she was able to become very relaxed. The session was taperecorded for her to repeat a home.

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23.3.4.3. Session 26: ‘Things seem to be falling into place’ Linda made good progress and at 9 months had achieved a 38 lb weight loss. She was still a member of a gym, but had bought a rowing machine that she used at home about three evenings per week. She expressed satisfaction in being able to wear new clothes and she stated that her anxiety levels had improved that that she felt ‘calmer overall’. She reported that she was ‘taking more time for herself ’ and that her eating patterns were going well and that she seemed to ‘choose better foods now without really even thinking about it’. She stated that she was having breakfast of fruit and cereal in the mornings; that she was eating a good lunch such as soup and salad; only one soda (diet) per day; and that she was not skipping lunch anymore. She eats a ‘light dinner’ and usually listens to a hypnosis tape before going to sleep or when feeling ‘stressed out’ at the end of a day. She was congratulated on her progress and she was encouraged to return for ‘booster sessions’ as needed. An example of the hypnotic suggestions used during hypnosis sessions with Linda is as follows.

another part of your mind finding that soon you are in Colorado, at a cabin there, near a lake where you feel happy and secure. So good to be alive. You enjoy every aspect of everything around you. To be aware of the beauty of the earth, the beauty and goodness of being alive. To be fully alive everyday, as you feel this calm relaxed mind, enjoying each day more and more … and everyday remembering and experiencing this calm, clear mind and you will flow with everything around you … able to face life with its problems in a relaxed way. Flowing with the problems …. In the same way you can flow with your hunger, feeling good about it. Flowing with your hunger as your body uses up all the stored up calories and each day you will take good care of yourself with your diet and with exercise … just the right amount of each.

23.3.4.5. Self-monitoring Each day you will be mindful of recording food that you eat … and taking good care of yourself in this way …. Even now visualize and see in you mind holding the food diary and being in a restaurant and writing down in the diary what your are about to eat, the number of calories, and having a feeling of accomplishment and control as you do this.

23.3.4.6. Diet 23.3.4.4. Relaxation induction You can begin the process of hypnosis today by focusing your attention and taking a deep breath of air … as you exhale allow your eyelids to close, normally and naturally … and allow your body to relax … every muscle and every fiber of your body becoming as limp as a rag doll ….Your forehead relaxes … your neck and shoulders relax. Letting all the tension go, so that for this time every worry and every concern can be set aside … and just drift into the deepest levels of relaxation. Your back and shoulders relax … back and stomach relax … and perhaps your breathing has already become a little slower … a little deeper as you go on further and more deeply relaxed … so that even your legs and feet become completely limp and relaxed … and as this occurs you may notice a drifting or floating sensation … as you go deeper and deeper relaxed … entering the deepest levels of hypnosis … and as this occurs your mind can be at peace. Just at peace, so relaxed, calm and comfortable. Your mind becomes calm and more at ease. So that you can hear my voice with a part of your mind and with

And finding that you are making good choices about foods. You will find excessive, heavy, greasy, fat foods to be distasteful. You will enjoy taking care of yourself with a good breakfast of a high fiber cereal, fruit ….You will take good care of yourself throughout the day and eat a healthy lunch such as a good salad or a warm soup that you enjoy very much … and in the evening you will find that an appropriate amount of food is satisfying and that you will be satisfied with one or two diet sodas a day … something to enjoy and savor.

23.3.4.7. Exercise You have already begun to exercise and it is good to be with friends and go to the gym. As you exercise you will find that you are less hungry and that low fat foods are more satisfying. You will find water to be satisfying to drink …. Proteins to be satisfying and you will look forward to exercise and the feeling of gentle soreness or fatigue in your muscles as they become stronger each time you exercise … even now visualize yourself at the gym, see if you are on the treadmill, or the bicycle, or lifting

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weights … notice the good feelings and it motivates you even more.

23.3.4.8. Stress As you practice hypnosis you will be less bothered by stress. At anytime you feel stressed you will be able to enter just as relaxed a feeling as you are now … by practicing hypnosis you can relax … and even now becoming more deeply relaxed. Let go of any tension that has remained. You can feel more and more peaceful and at ease … as if you were looking out at a calm peaceful lake, and notice how calm the water is, without a ripple … and feel that same calm, relaxed feeling inside. Calm and relaxed and at peace.’

mindful of keeping a food diary, eating well, and looking forward to exercise and the good feelings that come from these things … able to see yourself in the future at your desired weight, calm and relaxed … more assertive and taking good care of yourself everyday … soon as you return to conscious alertness you will remain calm and relaxed with a good feeling of confidence in yourself and your abilities.

23.3.4.13. Alerting Now beginning the process of returning to conscious alertness … in your own time and your own pace … in a way that feels just about right for you today ….

23.3.4.9. Expectancies Knowing that you have the ability to eat well and to exercise and that your weight will surely and steadily reduce to where you want it to be. Now see yourself in the future … you have taken good care of yourself and reduced the weight. You are standing in front of a mirror … notice how good you look … how good your clothes look and fit … this is happening and will continue to happen … and it is a good thing to look forward to with confidence.

23.3.4.10. Self-esteem And each day you will find that your confidence grows stronger. You deserve respect and kindness … and each day you will be able to stand up for yourself, to express your thoughts and feelings, to be assertive in expressing what you want and need … feeling so good about yourself and who you are as a person.

23.3.4.11. Self-hypnosis Each time you practice self-hypnosis all of these suggestions will become more a part of you … more automatic … and eating well and exercise will become more a part of who you are … just so natural and a necessary part of your day, everyday …. You will find that you are able to enter a very deeply relaxed state quickly and easily and that you are able to control your reactions to any stresses and remain calm and an in control even when people and times cause stress.

23.3.4.12. Post-hypnotic suggestion As you practice hypnosis you will find that you sleep well, any anxiety becomes less, you will be

23.4. Conclusions This chapter underscored that the quality of evidence supporting the use of hypnosis interventions for health-compromising behaviors has been varied. There needs to be rigorous clinical trials conducted examining the effects of multimodal interventions, where hypnosis is one of many components. Investigations should examine both hypnotizability using a wellconstructed measure (e.g. SHSS:C; Weitzenhoffer and Hilgard, 1962) as well as assess for expectancies. Most importantly, however, is understanding not only whether or not an intervention with a hypnosis component has a superior benefit over other interventions, but also what mechanisms of actions are underlying the effectiveness of therapeutic techniques employed. That way, findings can be used to help guide ‘real-world’ application to address the complexity of these health-compromising behaviors. Health-compromising behaviors represent a major area of focus for improving health and reducing disease. A variety of behavioral interventions exist; however, problem solving and behavioral recommendations alone do not work for the majority of patients, and long-term follow-up indicates that many persons relapse into old behavior patterns. Hypnosis can be effectively used to modify behaviors related to nicotine dependency and obesity. However, hypnosis interventions that are intensified in terms of frequency of contact, individualization and interpersonal relationships, and follow-up

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or ‘booster visits’ are recommended for greater effectiveness. Also, when hypnosis is integrated within a multimodal treatment program, the synergistic effects of hypnosis interventions with other modalities may be of benefit. Additional clinical research into hypnosis is needed that includes adequate randomization, measurement of hypnotizability and expectancies, and objective outcomes to realize fully the potential benefit of hypnosis for health-compromising behaviors.

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Perri, M. G., Nezu, A. M., McKelvey, W. F., Shermer, R. L., Renjilian, D. A., Viegener, B. J. (2001) Relapse prevention training and problem-solving therapy in the long-term management of obesity. Journal of Consulting and Clinical Psychology, 69: 722–726. Platt, R.W. (1995) A brief paper on the biopsychological aspects of overweight and obesity and the relevance of these to hypnotherapeutic techniques seeking to achieve sustainable weight reduction. Australian Journal of Clinical Hypnotherapy and Hypnosis, 16: 13–20. Prochaska, J. O. and DiClemente, C. C. (1983) Stages and processes of self-change of smoking: toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51: 390–395. Rabkin, S. W., Boyko, E., Shane, F. and Kaufert, J. (1984) A randomized trial comparing smoking cessation programs utilizing behavior modification, health education, or hypnosis. Addictive Behaviors, 9: 157–173. Sanders, S. (1986) Self-hypnosis and problem solving in the treatment of obesity. Psychotherapy in Private Practice, 4: 35–41. Schoenberger, N.E. (2000) Research on hypnosis as an adjunct to cognitive-behavioral psychotherapy. International Journal of Clinical and Experimental Hypnosis, 48: 154–169. Shiffman, S., Paty, J. A., Gnys, M., Kassel, J. D. and Elash, C. (1995) Nicotine withdrawal in chippers and regular smokers: subjective and cognitive effects. Health Psychology, 14: 301–309. Shor, R.E. and Orne, E. C. (1962) Harvard Group Scale of Hypnotic Susceptibility, Form A. Consulting Psychological Press, Palo Alto, CA. Society for Research on Nicotine and Tobacco Subcommittee on Biochemical Verification (2002) Biochemical verification of tobacco use and cessation. Nicotine and Tobacco Research, 4: 149–159. Spanos, N. P., Sims, A., deFaye, B., Mondoux, T. J. and Gaqbora, N. J. (1992) Comparison of hypnotic and nonhypnotic treatments for smoking. Imagination, Cognition, and Personality, 12: 23–45. Spanos, N. P., Mondoux, T. J. and Burgess, C. A. (1995) Comparison of multicomponent hypnotic and nonhypnotic treatments for smoking. Contemporary Hypnosis, 12: 12–19. Spiegel, H. (1970) A single treatment method to stop smoking using ancillary self-hypnosis. International Journal of Clinical and Experimental Hypnosis, 18: 235–250. Spiegel, D., Frischholz, E. J., Fleiss, J. L. and Spiegel, H. (1993) Predictors of smoking abstinence following a single-session restructuring intervention with self-hypnosis. American Journal of Psychiatry, 150: 1090–1097. Spiegel, H. and Spiegel D. (1978) Trance and Treatment: Clinical Uses of Hypnosis. Basic Books, New York. Stanton, H. E. (1978) A one-session hypnotic approach to modifying smoking behavior. International Journal of Clinical and Experimental Hypnosis, 26: 22–29.

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Stanton, H. E. (1985) The relationship between hypnotic susceptibility and smoking behavior. International Journal of Psychosomatics, 32: 33–35. Stewart, J. H. (2005) Hypnosis in contemporary medicine. Mayo Clinic Proceedings, 80: 511–524. Stradling, J., Roberts, D., Wilson, A. and Lovelock, F. (1998) Controlled trial of hypnotherapy for weight loss in patients with obstructive sleep apnoea. International Journal of Obesity Related Metabolic Disorders, 22: 278–281. Stunkard, A. J. (2002) Binge eating disorder and the night eating syndrome. In: Wadden, T. A. (ed.) Handbook of Obesity Treatment. Guilford Press, New York. US Department of Health and Human Services (1990) The Health Benefits of Smoking Cessation: A Report of the Surgeon General. DHHS Publication No. CDC 90-8416. US Government Printing Office, Washington, DC. Vanderlinden, J. and Vandereycken, W. (1994) The (limited) possibilities of hypnotherapy in the treatment of obesity. American Journal of Clinical Hypnosis, 36: 248–257. Vermont Lung Association (1981) Newsletter, 11: Issue 4. Wadden, T. A. and Anderton, C. H. (1982) The clinical uses of hypnosis. Psychological Bulletin, 91: 215–243.

Wadden, T. A. and Flaxman, J. (1981) Hypnosis and weight loss: a preliminary study. International Journal of Clinical and Experimental Hypnosis, 29: 162–73. Wadden, T. A. and Foster, G. D. (2000) Behavioral treatment of obesity. Medical Clinics of North America, 84: 441–461. Wadden, T. A. and VanItallie, T. B. (ed.) (1992) Treatment of the Seriously Obese Patient. Guilford Press, New York. Wadden, T. A., Womble, L. G., Stunkard, A. J. and Anderson, D. A. (2002) Psychosocial consequences of obesity and weight loss. In T. A. Wadden and A. J. Stunkard (ed.) Handbook of Obesity Treatment, pp. 144–169. Guilford Press, New York. Weitzenhoffer, A.M. and Hilgard, E.R. (1959) Stanford Hypnotic Susceptibility Scale: Forms A and B. Consulting Psychology Press, Palo Alto, CA. Weitzenhoffer, A. M. and Hilgard, E. R. (1962) Stanford Hypnotic Susceptibility Scale, Form C. Consulting Psychology Press, Palo Alto, CA. Williams, J. M. and Hall, D. W. (1988) Use of single session hypnosis for smoking cessation. Addictive Behaviors, 13: 205–208.

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CHAPTER 24

Treating children using hypnosis Eric L. Scott, Ann Lagges and Linn LaClave

24.1. Introduction The great storyteller entices listeners to focus their imagination; and to anticipate the story’s trajectory. In doing so, the storyteller lures listeners into overhearing themselves. Hypnosis, like other therapeutic strategies, is always about momentum and change of perspective. It is through suggestion, not coercion, that we ask patients to think about, see, feel and experience their world in a different way. When it works well, it can be one of the summit experiences in a patient’s (and therapist’s) life—similar to the first glimpse over the edge of the Grand Canyon, looking out over the expanse of the ocean for the first time or witnessing the birth of a child. Hypnosis captivates the imagination, is welcoming and comforting, and leaves one with a sense of excitement and exhilaration. One need not go beyond the dramatic accounts of patients using hypnosis as the sole analgesic or anesthetic to appreciate how thrilling and life-affirming such interventions can be. The use of hypnosis with children has a long and storied past. Documented work with hypnosis started with the very early clinicians, including Anton Mesmer in the 1700s. Since then, children have been included in the work of all the well known hypnotherapists including Charcot, Freud (Sigmund) and current therapists such as Olness and Kohen (1996), Thomson (2005) and

many others. In the following review, we want to highlight how hypnosis has been used to treat a variety of medical and psychological ailments in children, to alleviate symptoms and to aid in coping with pain and distress. While the child hypnosis literature is not as extensive as the adult literature (Chaves and Dworkin, 1997; Lynn et al., 2000; Milling and Constantino, 2000), there is a rich history of creative applications of hypnosis embedded within sound therapeutic practices. The brief literature review (below) serves two purposes: (1) to illustrate the ways hypnosis has been applied with children; and (2) to create an applied framework for the clinical cases presented later in this chapter. For more complete reviews of the wider child hypnosis literature, please see Olness and Kohen (1996) and Milling and Costantino (2000).

24.2. Anxiety and pain

associated with medical procedures Because relaxation is a usual component of hypnosis, it is not surprising that many clinicians find hypnosis to be a useful tool in managing pediatric anxiety. Suggestions for mastery of feared situations can easily be incorporated into a hypnosis script. Unfortunately, the literature on the effectiveness of hypnosis as a component

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of treatment for pediatric anxiety is quite limited. The literature consists largely of case studies that describe management of anxiety associated with either a medical condition or a medical/dental procedure. Anbar (2003) describes a 12-year-old girl co-morbid for asthma and anxiety, who was taught self-hypnosis to help manage anxietyinduced upper airway symptoms that seemed largely unrelated to other signs of asthma exacerbation. In particular she complained of ‘an upper airway wheeze’ when she became emotional. Treatment took place over two sessions and involved creation of a motor cue (i.e. a suggestion that she could relax whenever she touched her finger to her thumb) and use of a patient-generated image of a tight airway opening up. Once her anxiety was managed with the use of hypnosis, her asthma became more manageable. In particular, she was able to stop regular use of systemic steroids. Other case reports describe using hypnosis to treat anxiety along with pain or serious illness (Hilgard and LeBaron, 1982; LeBaron, 2003). Hilgard and LeBaron (1982, 1984) developed an imagination-focused hypnosis for problems associated with pediatric cancer. Their primary focus throughout a series of experiments is to relieve pain, emesis and anxiety in child oncology patients. In one particular study, Hilgard and LeBaron (1982) examined the effectiveness of hypnosis in the treatment of pain and anxiety in pediatric cancer patients ages 6–19. They found that while only the highly hypnotizable children reported pain relief with hypnosis, both the highly hypnotizable and less hypnotizable children reported a decrease in anxiety. Zeltzer et al. (1984) compared the effectiveness of an imagination-focused hypnosis and a nonhypnotic distraction in relieving chemotherapy-related distress in 19 patients aged 6–17. The children were randomly assigned to either the hypnosis condition or the distraction condition. Children in the hypnosis condition were trained to use imagination-focused techniques during their chemotherapy treatment, while children in the distraction condition were taught to use jokes, humor or other distracters to reduce their distress. The results indicated that both hypnosis and distraction were equally effective in reducing

levels of distress for these children. In a follow-up study using imagination-focused hypnosis (Zeltzer et al., 1991), 54 children between the ages of 5 and 17 were taught either hypnosis or distraction techniques for reducing nausea and vomiting. These children were compared with a control group that received standard of care treatment. The results indicated that hypnosis and distraction were equally effective for controlling both nausea and vomiting over the course of their treatment compared with the standard of care group. Jacknow et al. (1994) compared hypnosis with standard medical treatment in children undergoing chemotherapy for cancer. Children newly diagnosed with cancer were assigned to either the hypnosis group or standard medical treatment, and were monitored for use of anti-nausea medications as well as anticipatory anxiety about treatment. The results indicated that children assigned to the hypnosis group used significantly less anti-emesis medications and had lower anticipatory anxiety compared with the standard medical treatment group. Kuttner (1989) describes the use of hypnosis for management of pain and anxiety related to medical procedures. Reid (1988) discusses three cases in which hypnosis is used to manage dental anxiety, and Rustvold (1994) presents a case of dental phobia treated with hypnosis. Finally, Young et al. (1991) describe the case of a boy with anxiety related to a learning disability that resulted in increased difficulty in written expression. Instruction in self-hypnosis along with behavioral techniques, such as selfmonitoring, decreased anxiety and improved writing performance. Friedrich (1991) provides a series of four case reports in which he describes using hypnotherapy to alleviate anxiety after traumatic experiences. In this review, he suggests that hypnosis can be used to address the cognitive, affective and behavioral manifestations of trauma. He suggests that it can be used to stabilize and remove symptoms of anxiety and lead to further uncovering of memories and emotions associated with the trauma. Finally, he suggests that hypnosis can be instrumental in helping the child integrate the memory and the experience into a higher level of ego development.

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24.3. Somatoform disorders Children with somatoform disorders, such as conversion disorder, pain disorder or somatization disorder, present a challenge to clinicians for two reasons: (1) insight into the psychological nature of these conditions is typically poor for both the child and family; and (2) the impairment can be severe enough to prevent a child from attending school or engaging in any other age-appropriate activities. Logically, hypnosis would seem to be a useful tool in treating these disorders. The therapist can help the child learn to alter the perception of the troubling physical symptoms, and can make suggestions for improved function. These techniques have been shown to be effective with adults (Moene and Roelfs, Chapter 26, this volume). Unfortunately, research in child area is limited to a few case reports (Caldwell and Stewart, 1981; Elkins and Carter, 1986; Shapiro and Rosenfeld, 1988; Bloom, 2001). Campo and Fritz (2001) list hypnosis as a useful component of an overall intervention approach for pediatric somatoform disorders, but do not include any discussion of types of suggestions or techniques that might prove useful.

24.4. General medical

problems Medical problems have long been the target of hypnotic interventions with children, enuresis being one of the most widely studied (e.g. Olness, 1975; Olness and Kohen, 1996). Edwards and van der Spuy (1985) provide the best empirical support to date for the use of hypnosis for the treatment of enuresis in children. They examined 24 primary and 24 secondary enuretic boys between the ages of 8 and13. Children were assigned to one of four treatment conditions which included suggestions for dry nights with and without hypnotic induction or an induction-only group compared with a no-treatment group. Results indicated that the group receiving induction plus suggestion and suggestion-only experienced significantly fewer wet nights than the other two groups. One study by Banerjee et al. (1993) compared the response of patients receiving hypnosis only

with that of patients receiving imipramine only. At 3 months into treatment there were no significant differences between the percentage of positive responders in each group. However, when the parents were surveyed 6 months after the end of treatment, more of the children in the hypnosis group remained dry compared with children receiving medication only. This was probably due to the large relapse rate of children in the medication-only group who resumed night-time urination after medication was stopped. Olness et al. (1987) tested whether hypnosis was superior to propranolol or a placebo for the relief of pediactric headaches. Twentyeight children were included in this randomized, double-blind placebo-controlled crossover comparison study. Results showed that self-hypnosis was superior to placebo and propranolol in reducing the number of headaches, but not in reducing the intensity of the headache pain. Zeltzer et al. (2002) examined the feasibility of a combined intervention using both acupuncture and hypnosis for 33 sequentially referred girls with chronic pain. The 21 who agreed to participate ranged in age from 6 to 18 and were offered six weekly individualized acupuncture and hypnosis protocols. At post-treatment, 14 of the children experienced at least a 50 percent reduction in their pain ratings. There was a trend toward lower depression and anxiety scores over the 6-week treatment, but neither of these reached statistical significance.

24.5. Characterization

of our approach Our work with hypnosis is almost exclusively done within a medical setting in a universitybased tertiary care children’s hospital in the midwest. We work as part of a multidisciplinary pediatric psychiatry consultation-liaison team. We are called by primary medical services to each of the medical inpatient units of the hospital, the emergency room and all the outpatient clinics. We see nearly 500 new children each year with a staff consisting of two halftime psychologists, one full-time psychiatric nurse and a full-time child and adolescent psychiatrist.

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At times we encounter a good deal of resistance from families when we are called. This is probably due to several reasons. First, the children and their families we treat come to the hospital for physical ailments often without expecting that there is an unmet emotional need requiring psychiatric intervention. For one reason or another, often as a complication of the medical course of their illness, or simply because of the difficulties of having a medical illness, they are demoralized and feel a sense of hopelessness. It is then, more than ever that we rely on a philosophical approach to treatment that can be well characterized by a quote taken from Olness and Kohen in their book on hypnotherapy with children: In our therapeutic work, we recognize that we are not treating problems; we are treating and helping children who happen to have problems. No matter how severe the problems of our child patients, we address ourselves to their striving for experience, for mastery, for social interaction, for the inner world of imagination, and for wellness. Thus, we gain an ally in that part of the child that wants to experience life to the fullest, and this alliance forms the foundation of treatment (Olness and Kohen, 1996, p. 6).

Others in the field also conceptualize their work with children as helping the child help themselves. Thomson (2005) in her book of therapeutic stories for helping children heal demonstrates this well when she says, ‘During therapeutic alliance, hypnotherapy can be a very powerful tool for a clinician who is invested in helping the child experience success, comfort and health. The hypnotherapeutic work enhances and strengthens the child’s natural strivings toward exploration, social relationships, fantasy and creativity’ (Thomson, 2005, p. 3). Hypnosis then, like other psychological interventions, is meant to be a tool used successfully by the patient, not a technique or procedure done to them. We are always collaborators, teachers, coaches and guides when helping a child or adult through the use of hypnosis. It is the striving toward wholeness in the face of bleak medical situations that guides our work with patients. We teach individuals that there is an intricate connection between their mind and body. We often assume the general population has

a realistic understanding of the relationship between our mind and body, but unfortunately this is not always the case. In our work, we are faced with teaching children and their families the importance of this connection. We do it through stories, metaphors and illustrations. For example, we help families understand that stress can be ‘like a pressure cooker on the body’. As a pressure cooker is placed on the stove, the heat is turned on and a valve is placed on the top of the lid, sealing the pot allowing pressure to build. However, when the pot encounters too much pressure, without proper release it can explode. One of three things needs to happen, either the pot is removed from the stove and therefore the pressure is gone, but the food is left uncooked. Not a great outcome, but better than exploding. Another option is to turn down the heat, which is analogous to changing external forces such as illness or school and work obligations. However, sometimes this is completely out of the families’ control. Finally, one could adjust the valve on the top of the pot. By teaching children and their families coping strategies, such as hypnosis, we see ourselves as preventing more emotional explosions. In situations where the family is reluctant to engage with us, this gives us some opportunity to help the family relieve some of their stress. We strive to deliver hypnosis services that are tailored to the individual and their family, recognizing that an important prerequisite to this is building and maintaining rapport with the child and his/her family. Suggesting an alternative set of coping strategies and perhaps seeing or interpreting their world in a different way could be the key to allowing a child to develop a sense of mastery and competence in the face of rather dire medical situations. The following case illustrations are meant to demonstrate our particular approach and not only engage the reader in techniques but also provide some understanding of how we make clinical decisions while doing hypnosis with patients.

24.6. Case 1 24.6.1. Background Nicholas was an 11-year-old white male hospitalized for abdominal pain, nausea and vomiting.

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Two weeks prior to this current admission he was diagnosed with gastroenteritis, usually a viral infection of the digestive system causing inflammation of the intestinal tissue resulting in abdominal cramps, diarrhea and sometimes vomiting. Upon discharge from that hospitalization he continued to have significant levels of abdominal pain, nausea, vomiting, loose stools, poor appetite and sleep disturbance secondary to his pain, nausea and vomiting. An EGD (esophagogastroduodenoscopy) and colonoscopy during his admission were consistent with a diagnosis of Crohn’s disease. The GI service, who asked us to see Nick on hospital day 6, thought his pain was ‘out of proportion’ to his current medical condition and suspected his report of pain had a psychiatric component to it. When we saw him he continued to complain of stomach pain despite using Tylenol with codeine, vicodin and morphine. His pain and discomfort were significantly interfering with his ability to carry out a normal daily routine. Indeed, when we saw him in his hospital room he was sitting in a wheelchair and refused to walk because he was feeling dizzy. He initially denied any symptoms of anxiety, depression or bipolar disorder, but as the interview and our interaction with him unfolded it was increasingly clear he had significant anxiety. His worry centered mostly on his father’s drinking behavior and the fear that his father would be hurt again after drinking. His fear was not unfounded; Nick witnessed a fall his father had while drunk one evening resulting in a hospitalization after stumbling down a flight of stairs and breaking his arm. Nick also worried about his peer’s perception of his illness and hospital stay, especially after experiencing a great deal of teasing and pressure at school by one particular peer who routinely made fun of him. Nick was very selfconscious and often brooded about interactions such as these at school. When he ruminated, he would become withdrawn and quiet, frequently complaining of headaches and stomach aches which led to some school refusals. Nick was quite healthy up to this time with only a few medical problems prior to his current episodes. These included a past history of RSV (respiratory syncytial virus), which is a common cause of pneumonia and bronchiolitis in infants and children. He also experienced one febrile

seizure as a young child. He and his parents reported no surgeries, loss of consciousness secondary to head injuries nor need for advanced testing such as EEGs, MRIs or PET scans. His only medication allergy was to Sulfa drugs. His immunizations were up to date and at the time of our first evaluation he was taking polyethylene glycol (Miralax), budesonide, lansoprazole (Prevacid), vicodin, mesalamine (Asacol) and methylphenidate (Concerta). Nick was first diagnosed with attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) when he was 3 years old, and started taking dextroamphetamine (Dexedrine) and clonidine without relief from the symptoms. Later his psychiatrist changed his medication to Concerta 54 mg in the morning and 18 mg after school. The medication relieved most of his hyperactivity, but he was also enrolled in outpatient behavior therapy to address his defiance and bouts of physical aggression at home and school. Several years prior to his current medical hospitalization, Nick was psychiatrically hospitalized for hostility, physical aggression and dangerous behavior toward himself and others. He was stabilized there and discharged back to his psychiatrist for medication management, but no outpatient psychotherapy was part of his follow-up plan however. When we first met with him, he was still having some difficulties co-operating with his mother regarding his homework, chores around the house and other responsibilities. He had also missed a great deal of school secondary to school refusal behavior and the recent bout of stomach discomfort. Nick’s social life was in turmoil after his parents divorced 5 years prior to his current hospitalization. Despite the fact that his father lived close by, Nick saw him only on an irregular basis. When Nick saw his father it was often on weekends when he was drinking heavily with one of his new girlfriends. It bothered Nick that his father had a series of girlfriends who came in and out of Nick’s life since the divorce. He quickly learned after the divorce that going to his father’s house was highly anxiety-provoking for him and something that he frequently avoided. Further complicating matters was a poor relationship that his father and mother had after their divorce. When they did interact it

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frequently ended in arguments in the driveway or in the front yard. Finances for Nick’s family had also been the source of stress for Nick as his mother worked as a waitress at a local restaurant. Overall, Nick was in a safe environment that met his basic needs, but there were many instances of social instability and interpersonal conflict that appeared to our team to be impacting his ability to manage and cope with his newly diagnosed Crohn’s disease.

24.6.2. Formulation This is a child whose lack of intra- and interpersonal strength coupled with a newly diagnosed medical illness has left him physically weak. Neither his early nor his current relationships have prepared him for the level of stressors he experienced at home, school or the hospital. He longed for satisfying social relationships with peers, but had difficulty attaining them. He frequently fought with his family and peers, and was psychiatrically hospitalized for aggression in the past. Based on our review of his medical records and conversations with him and his family, we determined that he had several acute needs. The first was corrective mastery experiences in the context of a relationship with trusting adults. This was important in part to undo problematic relationships he had in the past. His lack of trust stood in the way of making progress in psychotherapy. The second was relief from his pain. Our interpretation was that there was pain from the Crohn’s and the pain caused by his stressors in his life. As recent reviews of the treatment of other abdominal pain and disorders show, examining both sources of pain is highly relevant (Pallson, 2006). Third, he needed exercise and a daily routine to get him back to a normal schedule for an 11-year-old boy. Fourth, if he was to return to school, he had to overcome some of his fears regarding relationships there. Long-term needs that we encountered for him included repairs in his relationship with his parents. In addition, he needed relief from his stressors at school and he needed skills to relieve some of his fears about his father.

24.6.3. Treatment plan We made a decision very early on to use hypnosis with Nick for several reasons. First, it is our

experience that hypnosis can accelerate the rapport building that happens in the context of therapy, and we needed this because we were fairly certain that the medical team was going to be pushing to release him, especially if there were not medical reasons for keeping him in the hospital. Additionally, we knew that relationships in Nick’s life up to this time had been problematic, inconsistent and sometimes destructive, and we openly wondered how he would do forming a relationship with us. Because of this history and his initial reluctance to engage with us, we wanted him to have a pleasant and rewarding experience. Third, we knew that the power of therapy, and hypnosis specifically, allows people to perceive their situation and world in a very different manner. This shift in perspective can be life altering and ultimately healing. Hypnosis is often about discovering aspects of one’s life that were forgotten, ignored, overlooked or never considered. It is often these interpretations or perspectives that can bring about the healing process. It is truly the process of considering reality in a very different way.

24.6.4. Treatment Our first hypnotic session with Nick was at the end of the initial evaluation. Since I knew that time was of the essence, I set to work on building rapport, some ego-strengthening and relaxation techniques. We took this approach with him because giving him the tool of self-hypnosis could offer him two very important things. First, hypnosis could give him the opportunity to master a new skill which might help neutralize his self-doubts. Second, learning self-hypnosis under the guidance of a calm, benevolent adult might itself be emotionally restorative. Taking his developmental level into account, we knew that at age 11 he was ending the Concrete Operational stage of development and was beginning the Formal Operational stage. Attainment of concrete operations is characterized by many cognitive changes, but two here that we want to focus our attention on include increased ability with perspective taking while using multiple cues or aspects of a situation to make a judgment. The second is a dramatic decrease in egocentrism. The two faculties are related in that each is a necessary element for the emergence of abstract

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thought about problem solving. They both aid an individual’s ability to reframe a problem from a different point of view. The drop in egocentrism allows an individual to suspend or at least temporarily suspend their focus on their immediate state to consider other possibilities. During the first several sessions of hypnosis, I spent a significant amount of time building rapport since Nick was initially defensive, softspoken and hesitant to engage in conversations. It was during this rapport-building time that I learned he liked auto racing. Since we were in Indianapolis, I wanted to know if he was an Indy Racing League fan or a NASCAR fan. He revealed that he liked Jeff Gordon and had been rooting for him during the current racing season. Once I knew of his interest, I immediately began thinking of metaphors to incorporate into the hypnosis session. Since I was not knowledgeable regarding racing, we spent more time discussing elements of racing and what he might encounter if he went to the track. This not only helped me with my knowledge deficit, but also gave him the opportunity to experience someone showing interest in his interests. It was time well spent. In the second hypnotic session, we embellished the metaphor of racing and the possibilities by using some visualization and imagery of a race track. This time when I began the conversation, I wanted to help him visualize concrete objects, sights and sounds that would be found at the race track. I tried to put myself in the scene and visualize for myself what I would see, hear, smell and touch if I were walking up to a racing car. This spurred several images for me including the buildings, people, cars and objects that were leading up to the track. While he was sitting in his hospital bed with his father chiming into the conversation, I inquired about the drivers and the pit crew. Therapist: You have to talk with your pit crew. So what else? Your helmet and harness?

Therapist: Anything else that they wear other than the fire-resistant suit, gloves, boots. So they have a fire-resistant suit, helmet, harness, walkie-talkie, so they can talk with their pit crew … Nick: and the water thing (again motions from the back of his head to the front of his mouth).

I am repeating the things the Nick said so that I can get consensus and buy-in from him which is one of the things we look for in order to proceed into hypnosis. This indication tells me that he is fully engaged and more likely to enter hypnosis. Some of the words begin to form a rhythm, for example helmet and harness. I am intrigued about the relationship that happens between the driver and the pit crew as a potential for an analogous relationship with Nick and me. It could also provide a metaphor for the relationship between him and an observing ego. Therapist: Can the pit crew ever tell the driver how to make adjustments in the car? For example could they call Jeff Gordon and tell him that his tire is a little low? Or could Jeff call them and inform them of something happening with the car? Can they give him some advice about how to drive the car if his tires were pulling to the left? Nick: Yes (nodding his head) Therapist: Some adjustments that he could make like slow down or don’t take the turn so hard. Nick: … and they have spotters too. Way up in the air so that they can see. Therapist: Does each driver have their own spotter?

These exchanges about spotters are a good metaphor for the observing ego. They are not necessarily made explicit to Nick, but simply a way for the therapist to conceptualize Nick’s intrapsychic process. Nick: Yes

Therapist: They probably have to wear a special jacket …

Therapist: We might be able to think about that when you are driving your own car (referring to the use of the racing car as the object of the hypnotic episode). And they can figure out a way to help you when you are driving your own car. Maybe help you out when you aren’t feeling so comfortable.

Nick: Yeah, a fire suit (smiles and nods)

Nick: (nodding in agreement)

Nick: Yes, they have this thing that they can talk with me, like a microphone. They also have a tube for a water thing that comes around (Nick motions from the back of his head to his mouth).

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Therapist: Like if Jeff Gordon’s harness were tugging at his side, he could tell his pit-crew about it and make an adjustment. (I want him to see the discomfort he has in his side as a tolerable sensation, rather than something that needs to be eliminated immediately. Therefore, I want to create an analogous situation that Jeff Gordon may have to face and how he would deal with the sensation.) There might be something with racing that we could play around with that might help the way that the body feels. Nick: Yeah (nodding in agreement). Therapist: When we did the hypnosis yesterday we tried a couple of different techniques. The first was when I put my finger on the top of your head and you had to roll your eyes back into your head (referring to eye-roll induction). The second one was you staring up at a spot on the ceiling. Which one would you like to do today? (Notice that in this situation I ask him which form of compliance he would like to engage in during the session today, not whether he would like to do hypnosis again. Again, the hypnosis has to be set up effectively and placed within a therapeutic context. He is a good candidate for hypnosis because rapport has been established and there is a good working metaphor and word picture—racing cars). Nick: The one where you put your hand on my head (raising his hand and placing it on his head) because my eyes were watering when I stared up at the ceiling yesterday. Therapist: Let’s go ahead and do the eye-roll again. Remember yesterday, I had you roll your eyes up, up and up and then close your eyes and feel relaxed. I’ll go ahead and walk you through it until you get relaxed. (Even the use of the words, ‘walk you through it’ connects with his kinetic orientation.) Ok (placing my first two fingers on his forehead) just look up, up and way up. You may notice it hurts just a little bit, but that’s ok. Take a deep breath and let it out. Take another deep breath and as you let it out let the eyes close gently. Relaxed and comfortable, relaxed. You may notice the relaxation going into the eyelids and the face, down into the cheeks, the chin. You focus your attention to the air going in and out of the nose. You can focus your attention on the sound of my voice and breathing. You can take nice easy breaths, listening to the sound of my voice. There may be some sounds in the hallway but

you can let the mind ignore them. Now as you feel more and more relaxed, you may notice you feel more and more comfortable. As you feel more comfortable, your mind begins to think of other things and perhaps begins to drift a bit and focuses on other things. You may begin to want to think about a place you feel very comfortable. This place may be a race track.

I intentionally leave this open ended as a true suggestion, not a stipulation for continuing. It is entirely possible that he begins to think of somewhere other than a race track and I want to hold this possibility open for him. Reflecting for a moment on the induction procedure for Nick, a few things are important to ponder as a clinician. First, why choose one induction technique over another? It was not entirely clear why Nick enjoyed the eye-roll induction more than the eye fixation, but some research indicates that younger children do not do well on the eye-closure items on the Stanford Hypnotic Clinical Scale for Children (Morgan and Hilgard, 1979). Nick has demonstrated some shyness and behavioral inhibition, and so the more active work of the hypnotherapist in the eye-roll technique may suit him better than a more passive trance induction technique. This simple clinical decision highlights the need to have the ability to offer Nick a variety of hypnotic inductions in order to succeed. It also highlights that the nature of the therapeutic relationship is more important than the words used to induce the trance. This is illustrated nicely in the following quote about induction technique ‘… it is the meaning of the interpersonal interaction implied in an induction and not the simple stimulus value of certain words that is of most significance in determining the kind and extent of the hypnotic response (Barabasz and Barabasz, 2006, p. 108). It was believed by members of our team that Nick did have a good relationship that helped with his induction into hypnosis. Several elements that pointed to that included his rather agreeable disposition, his frequent nods in agreement with what was asked of him during the preparation interview and the pleasant smile on his face. These all could have been feigned, but it did not appear that way during the interaction with Nick.

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Now that he is induced into trance, the task of deepening is begun. The task of deepening in this situation begins the phase of hypnosis where a good deal of creativity and tailoring of the hypnotic experience begins. This is also where the hypnotherapist can begin entering their own trance-like state and begin to work in synchrony with the patient. Therapist: Perhaps you begin to walk on the tarmac in pit row toward the car. Each step you take you begin feeling more and more relaxed. One step, more and more relaxed. Two steps. Three steps, more and more relaxed now. Four steps, five steps, six steps, seven steps, eight, nine and ten steps. You are able to see the pit crew, the car and all the colors that are there. Feeling deeply relaxed you can be there and simply enjoy the scene for a few moments. Perhaps there are many people that are there or very few people. The car is there and so is Jeff Gordon. Nick: (His respiration rate has slowed and he is taking shallow breaths and has begun to have some rapid eye movements like those that occur when someone is dreaming. His mouth is slightly open in order to exhale. He appears very comfortable as he lies in his hospital bed.) Therapist: Perhaps you can see the car, the tires and other equipment that is there. You can hear people talking and moving about getting things ready for the race. Perhaps there are other cars racing around the track for some pre-race warm-up laps or practice laps. There is an excitement in the air. You begin to feel deeply relaxed when you consider the race that you will be in later. As you prepare for the race you begin to put the fire suit on. (Nick develops a smile on his face in response to this suggestion.) You can feel the pants, shirt, coat, boots and gloves as you put them on. They fit rather snuggly, but the pressure is comfortable and leaves you with a sense of strength, power and safety. You also put on the helmet with the walkie-talkie inside. You also notice how snuggly the helmet fits which tells you how well it will protect you when you are racing in the car. As you strap it on with a big black strap, you feel the pressure of the strap on your chin. You then take the water hose that is around your neck and you can feel it in the mouth and know that it will bring refreshing water to you when you need it. Perhaps you take a quick drink of

water to see what it feels like. When you notice the sensation it will be another signal to you to feel even more relaxed. You may want to also try out the walkie-talkie in your helmet to be sure that it is working properly. Now you may want to climb into the car. Once you’ve climbed in and you feel comfortable, just give me a signal that you have reached that point by lifting your finger. Nick: (within several seconds Nick lifts his finger.) Therapist: That’s right, now we know that you are relaxed and ready to climb into the car.

More time is spent here embellishing the metaphor and picture of the scene. As the therapist I want to give him enough of a concrete, anchoring picture of what he might encounter, using as many kinesthetic verbs and adjectives as I can, but leave him to fill in many of the other details. Now he enters the working through phase. This is where the real transformation and an alternative explanation for reality can take place. Therapist: Now as you climb into the car, you immediately notice where the harness is and begin to strap on the harness. Jeff Gordon is next to you in the driver’s seat. You climb into the passenger seat. Nick: (Smiles as he hears about climbing into the car with Jeff Gordon there.) Therapist: As he’s buckling up his harness you begin to buckle up your harness. You can feel it going around your shoulders and over your waist. You feel the pressure of the seat and hear the sound of the car as the engine is running. You look out the door and see all of the people in the stands. You look down at the harness and see it coming over the shoulder and over the lap. You feel comfortable and relaxed knowing that Jeff is going to be driving the car. People will be watching you in the stands. You know that if anything happens during the race people like the spotters and the pit crew will be there to work on the issues. As you move out onto the racetrack you can hear the engine roar and the acceleration of the car around the track. You pick up speed and hear the engine making more sound, but you know that it is simply the engine accelerating. You begin to feel

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a bit of pressure pushing you back into the seat, but you know this is only the result of you going faster and faster around the track. As Jeff takes the first turn you can feel the car banking on the turn and you can feel a bit of the harness pulling. You feel safe while you are in the car with Jeff driving. As he enters the second turn you once again have a sensation of pressure on the right side where the harness is keeping you safely fixed in the car while it careens around the track.

This is the crucial portion of the session where I am making a new suggestion—namely that his previous sensation of pain in his right side is no longer pain, but a pleasant sensation that he would gladly experience if he could have it because of a safety belt harness in Jeff Gordon’s car. The sensation is still there and I haven’t yet made any suggestions to diminish the feeling, just to change its interpretation. Nick remains calm and lying in bed with his eyes closed. He appears to have a pleasant look on his face, as if he is enjoying the scene being played out in his mind. Therapist: The more you move around the track the more excited you may become. When you become more excited you may notice that the mind begins to relax and not pay as much attention to sensations from the body. Almost as if the faster the car goes, the less the mind pays attention to the sensations. The more the mind forgets, the more the body relaxes and has a thrill of going around the track in the car with Jeff Gordon. As he makes the car move into the third turn you hear the car shift gears and slow down slightly. But then once out of the turn, Jeff shifts back down and he accelerates again. You may find yourself shouting and yelling with excitement and a feeling of exhilaration at the fast movement of the car. As he pulls into the straight away out of the fourth turn you feel the final tug at the right side, but it is smaller than ever now. As Jeff drives away from the turn it is almost as if the body begins to pull away from the sensations, and the feelings can’t keep up with the car. You and Jeff are pulling away and the feelings simply are no match for the driving car. As you move into the first turn again, you notice the slight tug at the right hip from the racing harness. It is barely even noticeable this time. This is happening because you are feeling so excited while you and

Jeff rapidly race around the track that the discomfort now is almost just a distant memory. Now as you move to the straight away between the second and third turn Jeff turns to you and asks what you think he should do with the car. Should I shift gears? Should I let up on the gas? He really wants to know how you would handle the turn. Perhaps you look at him and quickly think of just the right thing to do in that moment. Jeff then guides the car around the corner safely and quickly. He remarks how you just taught him a new maneuver and that he will definitely use it in his next race. Perhaps there is a sense of joy and excitement as Jeff just took your advice in steering the car. He then asks your advice while checking the gauges on the dash. He looks at the tire pressure, oil pressure, gas gauge and asks you if you think there is enough gas to move another lap around the track. Confidently you turn to him and say that he can make it. You may notice a smile moving across your face as he takes your advice and you take another lap. Once again racing around the track you come into the fourth turn with Jeff moving up to the wall, feeling a sense of exhilaration and speed as you race past the pit crew. They are all on their feet shouting and celebrating the great run you are having with Jeff. Perhaps you could even imagine a large crowd gathered in the stands on race day cheering and shouting. You and Jeff look in the rearview mirror and notice that there are some small cars in the distance trying to catch up to your position. Jeff begins to accelerate faster and faster to keep ahead of the approaching cars. When you take a look in the mirror you notice a very distant last car with the same image of the discomfort that you had left behind. It reminds you of all the work you have done to move away from it. It has not bothered you throughout the practice and it certainly does not look as though it will make a run at you now. With Jeff ’s maneuvering and your guidance it is clear you will finish ahead of all the other cars on the track. Neither you nor Jeff was anticipating a race today, and none was originally scheduled on the track, but racers are competitive and a race just began to happen. Jeff turns to you and says, ‘That’s why we practice, so that whenever a race does happen we’ll be ready for action’. Just then, you hear over the headset that the pit crew wants you to come in to change the cars tires.

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When the car is in the pits, the crew jacks it up, changes the tires and gets it ready for the rest of the race. Jeff turns to you and asks if you would like to finish the race. Taking this opportunity is both a great risk and a great thrill. As you pull out of the pits, you look back and notice you are slightly behind the lead car. You accelerate and take off to catch up with him. You find yourself using the skills Jeff has taught you and trying new maneuvers while on the track. Full of concentration, yet composed and relaxed, you begin passing one car after another and regaining the lead. On the final lap of the race, Jeff turns to you and says, ‘I think you’re going to do it. I think the victory is within your grasp’. The feeling of the tires on the pavement, the smell of the gasoline burning, the larger crowd cheering as you cross over the finish line to receive the checkered flag is like no other feeling you’ve had before. Victory lane is sweet and the applause you hear is exciting. When the buckle from the harness is unsnapped by the pit crew, you notice that it has been there all along, but without any discomfort. You feel excited that you have been able to race all day long with the sensation there.

Elements of the metaphor that provided the engine for change in this session include distancing from the pain by racing around the track. By actively driving the car, Nick took control over the distance and competently defeated the pain in a head-to-head competition. Facing his pain is highly consistent with a classic cognitive-behavioral strategy of exposure therapy used in many treatments for children (Kendall, 1990; March and Mulle, 1998). Reinterpretation of his symptoms by helping him to think of the pain in his right side as tugging of the seatbelt harness in the car is another tool utilized here. This was achieved in part by having him experience sensations that were antithetical to pain—exhilaration of the race, being with Jeff Gordon and relaxation. Additionally, the sensation is not removed completely by another person, which could render him powerless. Instead he took control of his pain. There could be a temptation to interpret the metaphor completely for Nick. By doing so, however, we could risk an escalation of resistance (Barabasz and Barabasz, 2006; Palsson, 2006) By abstaining from interpretation we

maximized the chance that he would sustain his attention both during the hypnotic session and for practice afterwards. Based on the smile on his face, it was clear he liked the metaphor. We wanted to ensure that Nick continued to practice these techniques and so we gave him several post-hypnotic suggestions. Generally, we give reminders to practice and help individuals experience themselves as competent and powerful to affect change. Therapist: As you stand now with Jeff in the victor’s circle the attendant gives Jeff the trophy, who gives it to you and says, ‘Great race’. You feel excited and you begin to bask in the excitement of the moment while you think of all the things you did to make it to victory lane. The interviewers and individuals from the newspapers start to ask Jeff what he did to win the race. He turns to you and says, ‘Why don’t you answer their questions because it was your expertise that got us to victory lane’. As you hold up the trophy you hear a congratulatory message over the walkie-talkie telling you how great of a job you did on the race. You tell them that you could not have done the race without their help and assistance. As the celebration comes to a close, you begin to settle down a bit and begin to think about all that you have done during the race and the lessons learned during the experience. Perhaps you would like to take a moment now to reflect and think about what happened. Take some time to notice how excited you may feel and what it is like to have victory on the track.

It is during this time that I want him actively to reflect on the experience and make note of what it feels like to experience physical relaxation. I want him to remember it so that the next time he feels uncomfortable, anxious or tense, he can recall this corrective experience and begin to take action to bring it about. Therefore, I give him the following posthypnotic suggestion. Therapist: Now that you know what it is like to feel relaxed and calm, take a moment to remember what the body feels like right now. Take some time to notice what the trophy in your hand feels like and what it means to have won it. You know now that if you would like to feel this way again, you can let the

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mind begin to think about the trophy, picture it in your mind and, by taking a slow deep breath, be able to bring both the picture and the feeling right back. You can use this whenever and wherever you wish. Go ahead and take a nice easy breath, picture the trophy and have that relaxed feeling. When you have been able to visualize the trophy and the scene, just let me know by raising your finger again. Nick: (He raised his right index finger signaling completion of the visualization.) Therapist: That’s right, now I know that you are feeling comfortable and are able to remember what brings back a sense of relaxation. Just take a moment to feel what this is like. (I give Nick about 20–30 s of quiet time to notice the sensation.)

Through the use of post-hypnotic suggestions to imagine relief when he thought of the trophy, we give him the power once again to ‘be the victor’ over his pain and anxiety. Finally, this new behavior was reinforced by our team after we learned from his nurses he took the initiative to practice on his own. Therapist: In a moment, but not before the mind is ready, you will begin to come out of trance. As I count backwards from 5 to 1 you will begin to become more alert and aware of your surroundings. 5–4–3, feeling a bit more alert and able to hear the sounds around you. 2, 1 and, whenever the mind is ready, you can open your eyes recognizing that you are back here in your hospital room. Nick: (Slowly opens his eyes and a smile breaks on his face.) Therapist: So how do you feel? Nick: Good. Therapist: Tell me what you experienced. What do you remember? Nick: I remember going around the track and the crowd cheering for me. I also liked being with Jeff Gordon. Therapist: Did you feel or experience the harness on you? Nick: Yes I could feel it tugging at my side. Therapist: Did if feel uncomfortable? Nick: Not really, it was there, but didn’t hurt. I really liked helping Jeff go around the race track though.

Therapist: I wonder if there are ways that you could use this picture and practice going to the race track using your tape. Perhaps you could use it before going to bed each night to help you fall asleep. Nick: I think I could do that. Therapist: Has the physical therapist come today to help you get up and walk? Nick: They haven’t come so far. But I think they are coming later. Therapist: I’ll bet that you can find a way to get up and move around so that the wheelchair isn’t necessary anymore. Physical therapists are good at helping people get up and move around after they haven’t been feeling so good.

Even after the trance is completed, there is a continuation of the suggestions to the patient. The comment by the therapist to suggest that the patient can find a way to walk is intentional and not a mistake. Language during and after hypnosis is important, and so these words are carefully crafted to offer an opportunity for success and mastery. That way, if he does walk, he was the one that found the way to do it. Physical therapists are good at encouragement and have many techniques of their own to motivate patients during times of difficulty. Embedding his total recovery within the context of a multidisciplinary team is almost of utmost importance for success. Subsequent meetings with Nick on an inpatient basis prior to his discharge were meant to reinforce practicing his hypnosis and reinforcement of attempts at successes. He continued with a fairly significant physical therapy regimen of 2–3 h per day in order to reinforce his attempts at mobility and resumption of a normal schedule prior to discharge. He began walking the day we saw him, though not in our presence. We elected not to place him on any psychotropic medication as we saw his problems as largely a manifestation of a somatoform disorder. Medically, he was going to be followed by the Gastroenterologists at the children’s hospital for his Crohn’s disease. He continued with significant stressors of his parent’s contention and worry about anticipated teasing at school. His global assessment of functioning at discharge was estimated to be 45–50. He remained on

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his Asacol, Budesonide, Miralax, Imipramine, Oxycodone, Naproxen and Tylenol at discharge.

24.6.5. Outcome After Nick was discharged from the hospital he was seen for approximately five more sessions of individual and family therapy in our outpatient clinic. Our first several sessions focused on getting him back into a regular routine including resumption of school attendance. To do this, we made several phone calls to his teacher and principal to ensure that his academic work would not be adversely affected by his absence from school. In particular, Nick was very concerned about standardized tests that he had missed while he was in the hospital. He received assurances from his teacher and principal about ways to make up the exams he missed. This brought significant relief to Nick. It was also during these subsequent sessions that we discovered that Nick had a significant amount of anxiety which he had not readily admitted to in the hospital. The second and third sessions included cognitive-behavioral work to provide Nick with coping strategies to deal with his anxiety. The treatment included education about anxiety, how to recognize it and a beginning problemsolving strategy in order to resolve it. This included new cognitive techniques to challenge his distorted thinking regarding his father and peers, as well as reviewing the hypnosis tape from the hospital. The final several sessions with Nick included some behavioral modification work to address an increase in rude and unco-operative behavior at home. This was a long-standing problem as Nick and his mother had been arguing and fighting for many years prior to our treatment. The majority of the work in this phase of therapy included basic parent training skills for his mother, teaching her limit-setting skills and ways to maintain her authority. We established a regular schedule, a responsibility chart and some communication practices to ensure his mother was kept abreast of his academic responsibilities. When therapy ended, Nick was pain free, was attending full days of school and felt more confident and self-assured in his relationship with

his family and friends. Additionally, he had been weaned off from his pain medications. Like Palsson (2006), the entire sequence in the work with Nick started with an induction technique, moved to a trance-deepening counting progression to induce relaxation, then a ‘therapeutic scene’ experienced by the subject’s five senses. Suggestions for Nick were highly specialized to maximize the possibility that he would be engulfed in it. Our hope was that this absorption would help him be more open to the therapeutic suggestions made for pain relief. The final stage of the hypnotic experience was the trance termination.

24.7. Case 2 Brian was a 16-year-old boy with a long history of severe aplastic anemia. Over the years, he had received frequent transfusions related to this condition, and was now hospitalized for a matched, unrelated donor stem cell transplant which, if successful, would provide long-term correction of the condition. Unfortunately, success of a matched, but unrelated stem cell transplant is only approximately 50 percent. Brian, his family and doctors had been discussing the possibility of this procedure for about 5 months, and Brian was quite aware of the risks and discomfort involved. He was referred to our pediatric psychiatry consultation service to evaluate his adjustment to his upcoming stem cell transplant. During our initial interview, Brian did report being ‘a little worried’ and scared about his upcoming transplant. Brian said that his worries increased markedly during the weeks prior to admission, but that he was trying to hide this from his family. He reported worrying that the transplant would fail, resulting in prolonged disability or death. He also worried about the toll that the procedure would take on his body. He also worried about how he would cope with being separated from much of his family, friends and regular activities for the coming months. The worries had been keeping him awake at night, and he had been self-medicating with an over-the-counter sleep aid. His appetite had also decreased markedly during the previous few weeks. Brian’s parents described him as a ‘good kid’ with no history of behavior problems. Brian was

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a junior in high school and had always been a solid A/B student. He had played baseball for many years, and was currently a star pitcher on his school’s team.

24.7.1. Formulation Brian presented with a number of issues that our team believed could be addressed through use of hypnosis. These included: Brian’s anxiety related to his medical condition and treatment, including the stress of being restricted to one room in the hospital for approximately 1 month with very significant restrictions regarding visitors, and physical discomfort associated with treatment including headaches, nausea and vomiting.

24.7.2. Treatment plan Imagery of a special place was chosen as an induction technique for Brian. This technique was chosen in part because other inductions might produce an obviously unwanted aversive experience. For example, eye fixation might have drawn focus to his headaches, which involved some visual disturbance. Arm raising or lowering, or any other technique involving movement of hands or arms, might have drawn unwanted attention to various wires and lines attached to his limbs, as well as to the increasing fatigue and weakness associated with his treatment. Another part of the rationale for choosing special place imagery as an induction was that given Brian’s restriction to his room, it was quite appealing to him to imagine being outside of the room; it allowed him the opportunity to take a break temporarily from the hospital.

24.7.3. Treatment Brian chose to imagine himself on the ball field. Details of the appearance of the field were described, along with sounds, physical sensations and some carefully selected smells to avoid triggering increased nausea. An example of the type of induction used with Brian follows: Therapist: To start off, make sure you’re as comfortable as possible. Get your pillows arranged just how you want them, and tilt the bed up or down as much as you’d like. (Brian was encouraged to do anything needed to maximize his physical comfort,

including adding or taking away blankets to keep from feeling too hot or cold. When he stated that he felt comfortable, we continued.) As you close your eyes and begin to relax, you might find it pleasant to imagine yourself on your school’s ball field. It’s a beautiful day, the sun is shining, the sky is bright blue and the air is comfortably warm with just the hint of a breeze. You pause for a moment just to let yourself take in the field and enjoy the feeling of the sun and breeze. It’s a quiet day; the stands are empty except for a few friends who are looking forward to practicing with you today. The scoreboard in the outfield still proudly displays the score from your team’s last victory. The grass is a rich green, standing out sharply against the tan sand covering the infield. Footprints from runners rounding the bases in yesterday’s game are still visible. Just let yourself take a moment to enjoy being here. (Pause) What would you like to do next? Brian: I usually warm up first … I think I’d like to do that for a while Therapist: Your friends yell to you saying that they’re ready to get started, you jog out to the pitcher’s mound, pull on your well-broken in glove, and enjoy the familiar feel of the glove and smell of leather. You start warming up; throwing to your friend at home plate, and catching the ball as he throws it back to you. Imagine how good it feels as you start to loosen up, and each throw becomes a bit stronger than the last. Imagine how the ball feels in your hand as you prepare to throw, and how the ball feels as it hits your glove when you catch it. With each pitch, imagine yourself feeling more and more at home on that ball field, and more and more focused on your game. (This is the deepening technique used in this induction.) Just let yourself continue to enjoy warming up for a while, enjoying the beautiful day, and how good it feels to just throw the ball back and forth to your friend … let me know when you feel warmed up and would like to continue. (A minute or so passes, Brian’s breathing is clearly more regular and his body appears more relaxed) Brian: OK, I feel pretty warm now, I’m going to start throwing some real pitches now and let these guys get some batting practice in. (Note how Brian’s response indicated that he was immersing himself in the image.) Therapist: Go ahead and let your friends know that you’re ready for them to start batting. Throw whatever

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type of pitch you like … it’s up to you if you’d like to give them some easy ones, or really test them with some of your best pitching. (Pause) When one of your friends does hit a pitch, imagine the crack of the bat hitting the ball, and how good it feels to jog out to retrieve that ball … let yourself pitch to them as long as you’d like … feel free to take a turn batting yourself as well if you’d like. (Pause) Let me know when you’re ready to start wrapping up practice for now. (A minute or so passes) Brian: OK, I think we’re ready to take a break. Therapist: That sounds fine. How are you feeling? Brian: I feel good … my arm is getting stronger … we’re going to do really well this season. Therapist: Now that you know how strong you are, and are feeling relaxed and confident, you can use this strength whenever you need it. You know that you can return to the ball field whenever you need a reminder of how strong and confident you are. (Pause) When you’re ready, say goodbye to your friends for now, gather your things and start walking off the field. With each step, you start to let yourself leave the ball field and start to return to your room. Gradually you begin to hear the familiar sounds of people talking in the hallway, and the overhead announcements (note care is taken not to draw attention to potentially aversive sounds such as the beeping of infusion pumps), remind yourself of the posters and pictures you’ve used to decorate the walls … the blanket on your bed that you brought from home that’s so nice and soft … slowly, when you’re ready, it might feel nice to move your hands and feet a bit, just to help yourself start to return fully from your trip to the ball field. (Pause) When you’re ready, go ahead and open your eyes … finding yourself fully alert, but still feeling as relaxed, confident and strong as you did on the ball field. (A minute or more passes allowing Brian to work at his own pace. Brian appears fully alert and relaxed.) How do you feel? Brian: I feel good … That was weird … I really felt like I was playing ball with my friends, and my arm actually feels kind of that ‘good tired’ from practicing.

Brian was encouraged to try practicing his hypnosis on his own that night. The next afternoon, when our team returned to visit Brian, he reported that he was able to use his hypnosis to help himself draw his attention away from his

worries to allow himself to relax enough to fall asleep without sleep medication. Brian and his family were extremely pleased with the results of this very brief intervention, and expressed interest in learning additional ways to use hypnosis to help with specific problems, such as the nausea and headaches. To address these issues, Brian was instructed to begin by taking himself back to the school’s ball field to help him arrive in a comfortable hypnotic state. Given Brian’s ease at learning this technique, direct instruction was much less than during the initial session. Therapist: OK Brian, go ahead and get nice and comfortable just like you did yesterday. When you’re ready, close your eyes and let yourself go back to your ball field. (Pause). Just let yourself enjoy being on the ball field, doing whatever you feel like doing today. (Pause until Brian’s breathing becomes regular, and his body appears more relaxed). Today, while you are out at the field, some of your classmates are working on the sound system for the field. The volume is way too loud, and you know it would distract you during a game. You jog over to them and ask if you can help adjust the volume. They agree, and you begin to turn the knob on the sound board. As you turn the knob down, you notice that in addition to the sound becoming quieter, any discomfort you were feeling in your body becomes less. As you turn down the volume, your head feels more comfortable, and your stomach more at ease. (Pause). Just to check, you try turning the volume up again slightly, and note that the discomfort increases slightly as well. You turn the knob back down, marveling at how you are able to control how your body feels with just a turn of the knob. With the volume down to a reasonable level, your head and stomach feel better. Whenever you need to, you know you’ll be able to help yourself feel more comfortable by just turning that knob.

A very important point to note here is that the suggestion for absence of pain or discomfort was NOT made. The emphasis was on regulating or modulating pain or other unpleasant sensations. The idea of briefly turning up the level of discomfort may seem counter-productive at first, but for many patients doing this can help increase their sense of control over the sensations.

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24.7.4. Outcome Brian continued to use hypnosis, with and without assistance from our team, and was able to manage his anxiety as well as the physical effects of his treatment. His requests for medication to manage these symptoms decreased. Given that many of these medications had a sedating effect, by minimizing their use, Brian was able to remain alert enough to engage in activities such as instant messaging his friends, playing video games, watching movies and playing his guitar. This helped him maintain connection with friends and other aspects of his life other than his illness. Being able to do this can help reduce feelings of hopelessness that can be associated with prolonged illness. When medically cleared to do so, he was also able to stay alert enough to engage in physical therapy activities which helped strengthen his body and hasten his recovery. Brian was discharged from the hospital approximately 3 weeks after his transplant. He and his family reported a high degree of satisfaction with treatment, and Brian stated that he planned to continue to use his self-hypnosis as needed as he continued his recovery at home.

24.8. Conclusion Our intent in this chapter was to provide a glimpse into the way that we use hypnosis on a day to day basis with patients we encounter in the medical setting. Both Nick and Brian presented with difficulties in managing their illness that seemed rather insurmountable to them at the time we first became involved in their care. Hypnosis was chosen for both of these individuals because it not only provided relief from immediate symptoms but more importantly provided a sense of competency, mastery and self-agency. By providing hypnosis to these patients, we opened up possibilities for them to exercise their own striving toward healing. Both of them needed rather immediate attention because time was at a premium, and in our experience hypnosis can be used rapidly as long as proper rapport has been established. Nick’s case illustrates the importance of embedding hypnosis within a wider context of other

therapeutic techniques. For example, if only hypnosis were provided to Nick in the hospital without any follow-up care for his re-entry into school, the gains he had made in the hospital may have been very short-lived. The benefit of using hypnosis early on in his care provided the opportunity to build rapport rapidly within a short amount of time. This was instrumental in facilitating continued cognitive-behavioral work later to address his anxiety. Brian’s case illustrates the need to provide complementary care within the full range of care he received while in the hospital. It worked to enhance his stay and made his discomfort more manageable. Complete symptom removal for Brian was not the initial treatment plan. A great deal of his pain and discomfort was alleviated, but avoiding the goal of complete remission prevented a set up for failure. This is why there should be a high premium placed on gathering information about patient’s expectations regarding hypnosis prior to beginning treatment. Hypnotic interventions for both Brian and Nick were highly specialized and could only have been done after a fairly thorough initial evaluation. When it was learned that Nick was a racing car fan, the treatment team began to think of metaphors that would incorporate opportunities to instill a sense of mastery, competency and relief from both anxiety and pain. The same was true for the work done with Brian in that the image of a baseball field was highly rewarding and interesting for him. In both of these cases, listening carefully to the patient for important aspects of their personal lives was the key to engaging the subject hypnotically. As a result, carefully choosing an induction or deepening technique was not of the utmost importance for either patient. Rather it was the relationship and the attention to detail of both of the therapists to notice what was of particular interest to each patient. This is an intentional part of the work that we do in hypnosis with our patients. In that sense we are not highlighting hypnosis, but rather sound therapeutic techniques. Solutions are discovered when we stop to listen to our patients, and it is noticing their striving to be competent and noticing their uniqueness that we find a therapeutic key to unlock solutions to their problems.

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References Anbar, R. D. (2003) Self-hypnosis for anxiety associated with severe asthma: a case report. BMC Pediatrics, 3: 7 Banerjee, S., Srivastav, A. and Palan, B. M. (1993) Hypnosis and self hypnosis in the management of nocturnal enuresis: a comparative study with imipramine therapy. American Journal of Clinical Hypnosis, 36: 113–119. Barabasz, A. and Barabasz, M. (2006) Effect of tailored and manualized hypnotic inductions for complicated irritable bowel syndrome patients. International Journal of Clinical and Experimental Hypnosis, 54: 110–112. Bloom, P. B. (2001) Treating adolescent conversion disorders: are hypnotic techniques reusable? International Journal of Clinical and Experimental Hypnosis, 49: 243–256. Caldwell, T. A. and Stewart, R. S. (1981) Hysterical seizures and hypnotherapy. American Journal of Clinical Hypnosis, 23: 294–298. Campo, J. V. and Fritz, G. (2001) A management model for pediatric somatization. Psychosomatics, 42: 467–476. Chaves, J. F. and Dworkin, S. F. (1997) Hypnotic control of pain: historical perspectives and future prospects. International Journal of Clinical and Experimental Hypnosis, 45: 356–376. Elkins, G. R. and Carter, B. D. (1986) Hypnotherapy in the treatment of childhood psychogenic coughing: a case report. American Journal of Clinical Hypnosis, 29: 59–63. Friedrich, W. N. (1991) Hypnotherapy with traumatized children. International Journal of Clinical and Experimental Hypnosis, 39: 67–81. Hilgard, J. R. and LeBaron, S. (1982) Relief of anxiety and pain in children and adolescents with cancer: quantitative measures and clinical observations. International Journal of Clinical and Experimental Hypnosis, 30: 417–442. Hilgard, J. R. and LeBaron, S. (1984) Hypnotherapy of Pain in Children and Adolescents with Cancer. William Kaufmann, Los Altos, CA. Jacknow, D. S., Tschann, J. M., Link, M. P. and Boyce, W. T. (1994) Hypnosis in the prevention of chemotherapy related nausea and vomiting in children: a prospective study. Developmental and Behavioral Pediatrics, 15: 258–264. Kendall, P. C. (1990) Coping Cat Workbook. Workbook Publishing, Ardmore, PA. Kuttner, L. (1989) Management of young children’s acute pain and anxiety during invasive medical procedures. Pediatrician, 16: 39–44. LeBaron, S. (2003) The use of imagination in the treatment of pain and anxiety. Australian Journal of Clinical Hypnotherapy and Hypnosis, 24: 1–13. - E. and Lynn, S.J., Kirsch, I., Barabasz, A., Cardeña, Patterson, D. (2000). Hypnosis as an empirically supported clinical intervention: The state of the

evidence and a look to the future. International Journal of Clinical and Experimental Hypnosis, 48: 239–259. March, J. S. and Mulle, K. (1998) OCD in Children and Adolescents: A Cognitive-behavioral Treatment Manual. Guilford Press, New York. Milling, L. S. and Constantino, C. A. (2000) Clinical hypnosis with children: first steps toward empirical support. International Journal of Clinical and Experimental Hypnosis, 48: 113–137. Morgan, A. H. and Hilgard, E. R. (1973) Age differences in susceptibility to hypnosis. International Journal of Clinical and Experimental Hypnosis, 21: 78–85. Morgan, A. H. and Hilgard, E. R. (1979) The Stanford Hypnotic Clinical Scale for Children. American Journal of Clinical Hypnosis, 21: 148–169. Olness, K. (1975) The use of self-hypnosis in the treatment of childhood nocturnal enuresis. Clinical Pediatrics, 14: 273–279. Olness, K. and Kohen, D. (1996) Hypnosis and Hypnotherapy with Children. Guilford Press, New York. Olness, K., MacDonald, J. T. and Uden, D. L. (1987) Comparison of self-hypnosis and porpranolol in the treatment of juvenile classic migraine. Pediatrics, 79: 593–597. Palsson, O. S. (2006) Standardized hypnosis treatment for irritable bowel syndrome. International Journal of Clinical and Experimental Hypnosis, 54: 51–64. Reid, A. R. (1988) Some suggestion techniques for dental anxiety in children. Australian Journal of Clinical Hypnotherapy and Hypnosis, 9: 85–88. Rustvold, S. R. (1994) Hypnotherapy for treatment of dental phobia in children. General Dentistry, 42: 346–348. Shapiro, E. G. and Rosenfeld, A. A. (1988) Children with somatoform disorders: diagnostic classification and treatment. Psychotherapy Patient, 4: 169–188. Thomson, L. (2005) Harry the Hypno-potamus: Metaphorical Tales for the Treatment of Children. Crown House Publishing, Ltd., Carmarthen, UK. Young, M. H., Montano, R. J., Goldberg, R. L. (1991) Self-hypnosis, sensory cuing, and response prevention: Decreasing anxiety and improving written output of a preadolescent with learning disabilities. American Journal of Clinical Hypnosis, 34: 129–136. Zeltzer, L., LeBaron, S. and Zeltzer, P. M. (1984). The effectiveness of behavioral intervention for reduction of nausea and vomiting in children and adolescents receiving chemotherapy, Journal of Clinical Oncology, 2: 683–690. Zeltzer, L. K., Dolgin, M. J., LeBaron, S. and LeBaron, C. (1991) A randomized, controlled study of behavioral intervention for chemotherapy distress in children with cancer. Pediatrics, 88: 34–42. Zeltzer, L. K., Tsao, J. C. I., Stelling, C., Powers, M., Levy, S. and Waterhouse. M. (2002) A phase I study on the feasibility and acceptability of an acupuncture/hypnosis intervention for chronic pediatric pain. Journal of Pain and Symptom Management, 24: 437–446.

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CHAPTER 25

Medical illnesses, conditions and procedures Nicholas A. Covino

25.1. Introduction Medical patients present an important clinical opportunity for mental health practitioners. No longer do persons in need of psychological care walk primarily through the hospital door marked: ‘Psychiatry’. Pediatricians and primary care doctors are, increasingly, the front line interventionists treating depression and anxiety in children, adolescents and adults (Pincus et al., 1998; Rushton et al., 2000). More recently, oncologists, cardiologists and those who care for patients with chronic diseases such as asthma, irritable bowel syndrome (IBS) and diabetes see the benefits of psychological care for their patients. The major risk factors for illness and mortality (e.g. anger, nutrition, smoking and medical adherence) have psychological roots; most illnesses have psychological consequences, and vexing medical complaints (e.g. insomnia, IBS) are heavily influenced by cognitive, affective and behavioral factors. Psychoanalysts use the term ‘surface’ as a metaphor to describe a focus of patient care. Psychotherapeutic interventions with medical patients can occur on several such surfaces. They can assist with symptom relief, increased

compliance with medical procedures and improved adherence to medical care. Some patients and medical problems involve simple disorders of arousal inviting the well-known changes in respiration, heart rate, muscle tension, blood flow and pressure, motility and glucose production that accompany changes in autonomic nervous system activity. For these, relaxation and distraction interventions can be sufficient to produce symptomatic relief. However, as conditioning principles, co-morbid affective disorders and/or psychodynamic conflicts enter the picture, the success of any intervention (medical or psychological) can become quite compromised. Figure 25.1 depicts four variables of influence upon medical patients that, also, offer avenues of access to ameliorate and improve mental and medical health. As the model indicates, some medical problems will be heavily influenced by one dimension or another, or several. However, even the patient with a disorder of arousal can bring behavioral, affective and psychodynamic problems to the illness. Psychological interventions that include hypnosis can be useful to patients and providers at each of these points. This chapter will review the figured dimensions of health and illness, present several hypnosis techniques to assist with the

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stressors believed to have a causative role in illness onset. As the field progressed, medical illnesses are taken more as physiological ‘givens’ with greater interest in identifying psychological factors that influence and are influenced by medical illness and procedures.

Psychodynamics

Affects

Behavior

25.2.1. Medical procedures

Arousal

Fig. 25.1 Variables of influence upon medical patients.

care of the medically ill and offer a few illustrative case reports. An important prelude comment: mental health practitioners, who work among these patients, must pay special attention to the alterations in mental status that are common consequences of medications and/or certain medical illnesses (Preston et al., 2004). It is not sufficient for the nonphysician to cede this responsibility to medically trained providers. It is everyone’s responsibility who works in medicine to monitor and evaluate the potential consequences of medicines and illnesses on patients’ thoughts, affects and behaviors, and to make appropriate referrals.

25.2. Problems of arousal The early work of Holmes and Rahe (1967) and Benson (1975) extended the theories of Cannon (1932) and Selye (1956) to present a link between stressful events, arousal and physiological response. Lazarus and his colleagues (Lazarus and Folkman 1984) aided our understanding that cognitive factors were the critical agents in moderating a stress or eliciting the ‘relaxation response’ in patients. It is not only beauty that is in the mind of the beholder, they propose, but danger, apprehension and the meaning made of life events will vary for individuals and can be modified by psychological means (Folkman et al., 1979). Early psychosomatic research was preoccupied with identifying personality factors and

Medical procedures as simple as inoculation, phlebotomy, dental work and diabetes care or as complex as surgery can be stressful occasions for patients and alter their autonomic nervous systems. When hypnosis was offered to patients undergoing invasive diagnostic or surgical interventions in radiology, the procedures were more rapidly completed and the patients experienced greater comfort (Lang et al., 1996, 2000). In these similar studies, patients were allowed to control their medications and they reported significantly less anxiety, required less pain medication, completed the procedures more frequently than the nonhypnosis group, and maintained greater hemodynamic stability during the procedure. Also, the medical team required less time to complete the procedure when patients were aided by hypnosis versus attention alone or standard care. Children with cancer have been more effectively aided by hypnosis than standard care and distraction when they undertook lumbar puncture and bone marrow aspiration procedures (Zeltzer and LeBaron, 1982; Liossi and Hatira 1999, 2003). A group of children found that the trauma and pain associated with voiding cystourethrography (VCUG) procedures were reduced with hypnosis, as was the time required for the procedure (Butler et al., 2005). In an age of managed care, an intervention that allows for speedier work, quicker recovery and greater patient comfort is highly valuable in the medical setting.

25.2.2. Psychophysiological insomnia

and functional gastrointestinal disorders (FGID) Psychophysiological insomnia and FGID are mind–body problems of arousal that are highly influenced by cognitive processes. Insomniacs use increased oxygen during the day and at night (Bonnet and Arand, 2003); demonstrate

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persistent elevations in temperature, heart rate, basal skin response and vasoconstriction prior to and during sleep (Bonnet and Arand, 1995, 1998); and report more frequent pre-sleep negative cognitive activity (Nelson and Harvey, 2003a,b). A repetitive cycle of arousal, that includes catastrophic thinking, increased cardiopulmonary activity, the release of hormones and neurotransmitters, and maladaptive behaviors, maintains the disorder. Sedative medications are sometimes prescribed, but psychological therapies that emphasize relaxation, cognitive restructuring and ‘sleep hygiene’ (e.g. scheduled bedtime, avoiding naps, leaving the bed when sleep is delayed, etc.) are medically recommended treatments (National Institutes of Health, 2005). Likewise, patients with FGID commonly show increased gastrointestinal motility in the face of psychophysiological arousal (Drossman et al., 1997; Casati, 2000) and the absence of symptoms and dysmotility during sleep (Kellow et al., 1990; Fukudo, 1993). As the model in Figure 25.1 indicates, patients with these problems might present with behavioral, affective or psychodynamic issues that will complicate the treatment of insomnia and FGID. Cognitive-behavioral therapys (CBT) has been effective in providing significant relief and symptom reduction for these patients, within a short period of time (Blanchard 2001; National Institutes of Health, 2005). In randomized, controlled studies, patients treated with CBT showed significant improvement in sleep latency and efficiency over relaxation training and a commonly prescribed sleep medicine, and reported greater satisfaction with their treatment at 6 months (Jacobs, 1993; Edinger et al., 2001). Bastien et al. (2004) found that this intervention could be delivered as effectively through a 20-min telephone call as in a 90-min group or 60-min individual session. Likewise, CBT interventions have provided relief, within several weeks, to FGID patients in clinical studies versus symptom monitoring or standard care (Blanchard et al., 1992) and when tested in waitlist and crossover designs (Tkachuk et al., 2003). Unfortunately, the effectiveness of hypnosis interventions for insomnia patients has not been rigorously studied. Case reports and clinical experience indicate that the results achieved by CBT interventions could be achieved with

hypnosis, but empirical evidence in this area is lacking. On the other hand, sufficient research exists to support the efficacy of hypnosis interventions for FGID patients. Early work by Whorwell and his colleagues (Whorwell et al., 1984, 1987; Prior et al., 1990) found symptom reduction and, even, symptom elimination within weeks of care. Recent investigations with similar protocols found that these gains are maintained at 4 months (Palsson et al., 2002; Gonsalkorale et al., 2003). The weight of these studies suggests that patients with problems of psychophysiological arousal can be simply treated by an intervention that alters perception (e.g. cognition and sensation) and encourages deep relaxation.

25.2.3. Case report: FGID and IBS 25.2.3.1. Background Adam, a businessman in his mid-thirties, was referred by his gastroenterologist for help with IBS. Since college, he has experienced regular periods of bloating, dysmotility during times of stress, loose stool, fears of urgent bowel movements, frequent bathroom visits and abdominal pain relieved by bowel movement that fulfilled the Rome I criteria for IBS. Of late, these episodes could be as frequent as several times per month. Nonprescription medicines (charcoal) and dietary management offer him some, but incomplete, relief. Often, Adam finds himself anticipating social situations with a need to plan bathroom stops. It is common for him to purchase aisle seats at concerts and plays so that he will not have to ‘walk over people and call attention to myself ’ when he needs to use the toilet. He recalls a family trip in his teens, during which his father failed to respond to his request to stop the car at a bathroom, resulting in an embarrassing, urgent, bowel moment in his pants, which he concealed. Happily married for 6 years with a 5-year-old son, Adam is considering a move to another job for professional reasons. While he reports that change has always been challenging for him and that he is apprehensive about making the move, he is able to pursue his career with some energy. The eldest of five children, he is a frequent visitor to his nuclear family for Sunday dinners. He describes his father as critical and disconnected

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and his mother as a generous, nurturing person, but one who ‘keeps score’ on who is present for extended family events and shows a cold shoulder to anyone who pursues other plans. For some time in his early marriage, he visited his mother weekly, in addition to family dinners, and she maintained responsibility for some of his personal business affairs.

25.2.3.2. Formulation Issues of autonomy, self-assertion and shame are evident in his history,and it is easy to see his worry concerning this new phase of his career and the general assumption of the role of emancipated adult. With a mother who actively rewards the ‘child’ dimension of her ‘adult-children’ by cooking weekly Sunday meals and playing a role in their business affairs, one might expect to see Adam’s worry mount as he is required to pursue a new career frontier. It is unclear why psychophysiological arousal is located in his gut, as it almost always is, but his worry mounts with significant moves from the safe haven of his nuclear family to explore new vistas on his own. Father’s criticism invites self-doubt, and his mother’s obvious disapproval for those who dare to depart from the family, as she defines it, make emancipation a risky and worrisome business. Comfort with attention to his own personal needs is difficult for Adam, and he projects that others will notice and be annoyed by his requests for space, be these requests for a job interview or room to pass in order to get to the bathroom. It becomes important to plan his trips and social events excessively so as to manage his expected crises. Such images, also, produce their own disruption of arousal and gut functioning. It is important to see the considerable mental health that this man possesses. In spite of his family style, he has married well and is the father of a happy child. His work challenges are age-appropriate, albeit with some physiological symptoms, and he has a good deal of success to show for himself at an early age. Although therapy is new to him, Adam is very bright, articulate and has the capacity for self-reflection. His wife is supportive and patient. 25.2.3.3. Treatment Most interventions begin with patient education regarding gastrointestinal functioning and

the mind–body connection in IBS. In plain language, the link between cognition, psychophysiological arousal and gastric motility is explained. In addition, developmental and family styles that contribute to increased arousal at predictable stages are described. In a brief treatment, less time is spent with uncovering other material, abreaction or family interventions. Likewise, the repetition and working through of autonomy and issues of criticism and disapproval within the doctor–patient relationship are left for more extended psychotherapy. Through hypnosis, Adam was taught to relax by imagining and experiencing limp and heavy muscles from head to foot, and to experience the mind–body relationship by hand levitation. Training in hand warming and cooling developed the suggested idea that: ‘The body follows the lead of the mind and what the mind thinks, the body does’. By attending to his cognitive process, Adam was taught to identify several dysfunctional thinking styles (e.g. catastrophizing, overgeneralization). He used hypnosis to concentrate on restructured thoughts as well as to imaginatively expose himself to experiences of gastrointestinal (GI) ‘accidents’ with the accompanying feelings of fear, shame and subsequent acceptance.

25.2.3.4. Treatment outcome Adam’s considerable strengths, along with the specific nature of his problem of arousal, contributed to a successful and brief treatment course. Most IBS patients who are treated with this protocol show significant improvement within a short period of time. After 2 months of weekly sessions, Adam reported considerable relief from his GI symptoms along with independence from illness preoccupation and diminished anxiety. With the help of his wife, he reworked his overinvolvement with his family of origin and began to attend family gatherings intermittently and when they suited the needs of his new family. Within 6 months, he was gainfully employed in a much more satisfying position.

25.3. Problems of behavior Certain stimulus conditions shape behaviors that have considerable relevance in medicine. Whether through direct, indirect or fantasized associations

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(i.e. classical conditioning) or various schedules of rewards and punishments (operant conditioning), humans learn to anticipate certain outcomes, avoid problematic experiences and develop curious responses to otherwise neutral or unrelated stimuli. In the medical setting, problems of behavior such as hyperemesis (i.e. persistent nausea and vomiting) and cigarette smoking present significant health consequences. In addition, avoidance behaviors, phobias and other conditioned phenomena can interfere significantly with proper medical management. Cancer patients undertake intensive pharmacological treatments with lengthy and almost unpronounceable names (e.g. cyclopho phamide/methotrexate/5-fluorouracil, 5-fluorouracil/doxorubicin/cyclophosphamide) that produce severe nausea and vomiting. Even with the application of new anti-emetic medications, patients experience extreme physical and emotional discomfort. Classical conditioning processes link the smells, sights and thoughts of treatment with the medications’ unpleasant physical side effects to create anticipatory nausea and vomiting (ANV). On a subsequent visit to the hospital, following an aversive experience with chemotherapy, some associated stimulus, such as the smell of the hospital or the image of the nurse, evokes an episode of nausea and vomiting prior to undertaking treatment. ANV is among the most aversive and feared of the side-effects from cancer care, and is a major cause of noncompliance and premature termination of treatment, especially among younger people (Zelter et al., 1991). Behavioral techniques such as distraction and systematic desensitization have been effective at reducing ANV in this population (Redd et al., 2001). Exposure techniques that utilize imagination and in vivo techniques to present fearful images and experiences gradually to patients are able to reduce the power of these stimuli to produce ANV (Redd et al., 2001). The antiemetic effect of systematic desensitization has been found to be superior to counseling and standard care (Morrow and Morrell, 1982). Distraction and relaxation techniques also have shown significant reductions in patient distress and ANV symptoms (Vasterling et al., 1993). When hypnosis was tested against these relaxation and distraction techniques in a randomized experiment with children, it produced the greatest reduction

in anticipatory and post-chemotherapy symptoms (Zeltzer et al., 1991). Reliance on antiemetic drugs and the incidence of nausea and vomiting were both diminished when children were trained to use hypnosis to manage these (Jacknow et al., 1994).

25.3.1. Cigarette smoking Cigarette advertisers capitalize on conditioning principles by repeatedly pairing a harsh, odorous, carcinogenic product with beautiful people and situations. In addition to the positive messages, cigarettes relieve burdensome affects (negative reinforcement) and stimulate (reward) the mesolimbic system in pleasurable ways. However, a combined program of psychological and pharmacological interventions enables a substantial number of smokers to free themselves from this health-compromising habit (Hughes et al., 1999). Analyses of the literature regarding the efficacy of hypnotic interventions with smoking cessation find that despite methodologically limited investigations, hypnosis can make a specific contribution to the treatment of this problem (Lynn et al., 1993; Greene and Lynn, 2000). A meta-analysis of more than 600 studies, involving more than 6000 patients, found a quit rate of 36 percent for those patients who were offered hypnosis interventions (Viwesvaran and Schmidt, 1992). This result compares quite favorably with the small numbers (e.g. 3–10 percent) who quit on their own or with doctor’s advice each year (Hughes et al., 1999). Behavioral techniques play a significant role in smoking cessation, with aversive interventions such as rapid smoking and stimulus control techniques such as restricting smoking behaviors to certain times and places contributing to a positive outcome (US Department of Health and Human Services, 1996). Nicotine replacement, through the use of chewing gum or transdermal patches, minimally contributes a 2-fold increase in success rates for smoking intervention programs (Gourlay and Benowitz, 1996). By helping patients to manage nicotine withdrawal and, probably, by reducing the satisfaction derived by tobacco-delivered nicotine, these pharmacological contributors permit the psychological work to take effect without physiological challenge. Spiegel (1970) presented a motivational technique that assumed the pleasures of smoking, but

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invited patients to see its deleterious impact upon their health. The mantra: ‘Smoking is a poison to my body. I need my body to live. I owe my body trust and protection’, has been recited by thousands of former smokers. In fact, the majority of hypnosis research studies have employed this method. Unfortunately, clinical research in this area suffers from the absence of multimodal designs that integrate behavioral techniques, nicotine replacement and psychological strategies into treatment plans that are beyond the motivational (Covino and Bottari, 2001). As the clinical example below indicates, smoking cessation treatment should include demonstrated cognitive-behavioral techniques, pharmacology and a variety of hypnosis interventions to assist patients optimally.

25.3.2. Case report: nicotine

dependence 25.3.2.1. Background Joan is a single woman in her early 40s who had been a pack-a-day smoker since the middle years of college. She made three efforts to stop smoking in recent years and was successful for as long as 6 months. During both of her pregnancies she did stop smoking, but returned to it shortly after the birth of the children, because she enjoyed the habit. At times of boredom and increased arousal, Joan believes that cigarettes ‘comfort’ her. She is critical of her ‘past failures’ to stop and expressed a strong wish to do so now. ‘I have to quit for the health of my children, and I am now afraid of developing emphysema. I hate what this nasty habit is doing to my skin and the constant odor it gives to my clothes and car’. Joan’s primary care doctor recently cautioned her about a developing problem of shortness of breath due to cigarettes, and she has become increasingly concerned that her smoking status interferes with her social life. Past efforts at smoking cessation have not included nicotine replacement or the assistance of any program. Successfully employed in the computer industry, Joan is a bright woman with a supportive network of family and friends. She has been amicably divorced for the past 6 years and is in regular contact with her children. Although she describes periods of dysphoria, Joan does not

have a personal or family history of affective disorder or substance abuse. Family history is unremarkable, with Joan being the second child of an intact, working class family. Exercise and fitness are important to her, as is the development of a more active social life with a goal of marriage.

25.3.2.2. Formulation Joan has a lengthy history of nicotine dependence and an average habit of use. She attributes smoking with self-care and comfort, and her habit is negatively reinforced by the way that smoking diminishes her unpleasant feelings of boredom and anger. Joan’s words indicate that she is ready to undertake a treatment program and that she has a number of personal motivations to quit. For several brief periods, she has been successful in the past, but the motivation for stopping diminished with the birth of her children. A brief review of her personal and family history is unremarkable for affective disorder, substance abuse or significant mental illness. Unless psychological issues interfere significantly with her treatment, the history will remain incomplete, which is a not uncommon scenario for people who seek treatment for this problem. 25.3.2.3. Treatment A ‘quit-date’ is established for 3 weeks time and Joan is educated in the psychological and physiological dimensions of cigarette dependence. A transdermal patch is purchased to allow her to control nicotine withdrawal for a period of 3 months, while she manages the psychological dimension of her habit. Behavioral techniques such as stimulus control, aversion and extinction are reviewed, and an action plan is developed. Joan will increase her attention to the aversive aspects of her habit by rapidly smoking two cigarettes in succession for each of the next 5 days. With this rapid smoking technique she will blow the smoke into a folded sheet of paper and re-breathe it to increase her awareness of the noxious aspects of smoking. Smoking will be allowed only in a designated place and not in the car or immediately after meals, in order to diminish the power of discriminative stimuli such as meals, coffee, television and the automobile. During the second week, she will smoke

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only during two designated 5-min smoking times in an effort to disconnect emotions and smoking behaviors. She began to make a list of those whom she would tell of her decision to stop, as well as some items to purchase with her unspent cigarette money. Hypnosis training began in the first week with suggestions for relaxation and distraction. Joan was taught self-hypnosis and instructed to use this several times each day. Spiegel’s technique was taught, along with imagery involving her healthy presence at the marriages of her children and the birth of grandchildren. In the third week, Joan took a ‘practice quit day’ prior to the scheduled event, by abstaining from cigarettes for the day. The hypnosis exercise for that day involved inviting her to: hold the pack in her hand; cut the cellophane wrapper with the red ribbon; open the foil and smell the sharp fragrance of the 20 friends that she knew so well; take one of the cigarettes from the pack and feel the bite of the dry cotton filter as it touches the tongue and, perhaps, becoming aware of the mouth salivating in anticipation of the taste of smoke; striking a match, listening to the burning sulfur and being aware of its distinctive smell; take a deep anticipatory breath . . . blow out the match and let the cigarette fall to the floor; relax the body from head to foot. Having learned a method of managing a craving for cigarettes, Joan decided to begin with the transdermal patch and continue with not smoking, even though she was several days ahead of schedule. A meeting was scheduled for 3 days hence, during which Joan, who was still not smoking, used hypnosis to practice coping with several situations in which she feared that she would be likely to smoke.

25.3.2.4. Treatment outcome A telephone call to Joan in 2 weeks found her abstinent from smoking, and a report from her physician at 6 months confirmed the same.

25.4. Problems of affect 25.4.1. Anger, anxiety and

depression Anger, anxiety and depression are common comorbid conditions in medicine. In cardiovascular

disease, for example, anger is a well-established, but undertreated, precursor of myocardial infarction. A long line of longitudinal research establishes overcontrolled hostility at the same level of risk for heart attack and cardiac death as smoking and obesity (Rosenman et al., 1975; Williams et al., 2000), yet little preventative work is done in this area. Panic disorder is a prime mimic for coronary artery disease (CAD). More than 30 percent of those who are admitted to the emergency wards with chest pain are found to have panic disorder and not cardiovascular disease (Borzecki et al., 2000). Often these patients are sent home with the ‘good news’ that they do not have CAD, but with considerable uncertainty and worry, often leading them to repeat emergency room visits and excessive use of medical services (Huffman et al., 2002). Persons who experienced an episode of major depression prior to their middle years die of cardiovascular and unexplained causes more frequently than their nondepressed counterparts, even when poor health habits such as smoking and alcohol abuse are controlled (Wulsin et al., 1999, 2005).

25.4.2. Pain Pain is the most prominent medical complaint where patients often suffer from anxiety, depression or a mixture of both (Banks and Kerns, 1996). Co-morbid affective disorders increase the difficulty of successful medical treatment for pain patients, often requiring the addition of psychotropic medications and adjunctive psychological treatments. The efficacy of hypnotic interventions in this area has been well reviewed and is encouraging (Patterson and Jensen, 2003). Since this text includes an entire chapter devoted to the subject by two experts in the area (Chapter 20), pain management will be omitted from this review.

25.4.3. Asthma Asthma is a chronic disease of the pulmonary system with which patients experience wheezing, shortness of breath and increased production of mucus in response to infection, allergy or exercise. These symptoms can be reversed by medications, but they are often made worse by anxiety. Approximately 25 percent of those with asthma and chronic obstructive pulmonary

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disease (COPD) suffer from panic disorder (Karajgi et al., 1990). A recent, longitudinal, study found that asthmatics had a 4.5-fold lifetime likelihood of developing panic disorder and, interestingly, those with panic disorder were six times more likely to develop asthma in their lifetime (Hasler et al., 2005). Hypersensitivity to interoceptive cues leads to a cyclic response of catastrophic thinking, increased psychophysiological arousal, hyperventilation, increased dyspnea, panic and then increased hyperventilation and dyspnea. Since benzodiazepines reduce the drive to breathe, complex cognitive-behavioral and serotonin-based medicines are often required as interventions for this population (Smoller et al., 1998). For decades, pulmonologists have known that psychological factors can make asthma worse. More than 23 studies have demonstrated that suggestion for airways obstruction (commonly when saline mist is presented as a bronchodilator) leads to clinically significant change in pulmonary function for more than one-third of asthma sufferers (Isenberg et al., 1992). On the other hand, some clinical research finds that asthma patients who are trained to manage their fear with hypnosis are able to reduce symptoms and medication dependence (Maher-Loughnan et al., 1962) as well as increase their pulmonary functioning (Ben-Zvi et al., 1982; Ewer and Stewart, 1986). Patients with problems of affect need to manage both their significant emotional distress and their medical symptoms. Untreated affective disorders, be it depression or anxiety, will defeat an otherwise appropriate medical plan. Hypnosis can be quite beneficial as part of a comprehensive biopsychosocial intervention for patients with chronic pain, cardiovascular disease and asthma.

25.4.4. Case report: bronchial

asthma 25.4.4.1. Background Kate is a 43-year-old woman who was referred by the pulmonary department following a severe asthma attack that she experienced while traveling with her partner in Spain. A patient with asthma from childhood, she has been quite well maintained for years by inhaled medicines that she took when needed. Both the patient and

the medical team believe that this severe asthma attack was triggered by an allergic response to something that she ate while traveling. Kate was alone at a restaurant and became quite frightened about her condition, the availability of medical care and if her partner could find her, should she require hospitalization. Although the episode subsided and they returned to the country immediately, it has been very difficult for Kate and her doctors to manage her asthma without steroid medications. Since her return, Kate has continued to experience daily episodes of shortness of breath and considerable anxiety. She is currently on a leave of absence from work, due to this illness. Anxiety and panic have been problems for Kate since she was a child. Although she is a successful salesperson, she acknowledges regular episodes of sweating, palpitations, tingling, nausea, lightheadedness and shortness of breath. She was treated by a cognitive-behavioral psychologist several years ago, who instructed her in relaxation and distraction techniques which gave her some relief. Only on occasion have the anxiety symptoms interfered with her work. and she and her doctors developed a ritual for coping with her anxiety and shortness of breath that includes the use of inhaled medications and relaxation. Despite the recent crisis, Kate does not recall any specific food allergies, but she does become symptomatic in the presence of smoke and some animals. For the past 10 years, Kate has been in a committed relationship. Frances is a computer technologist whom Kate describes as loving, supportive, strong and intellectually curious. The two enjoy traveling and they have been to many parts of the world, as a side benefit of Kate’s sales position. Kate is an only child whose father had a heart attack at work and died, when she was 12 years old. He was a high school teacher to whom she felt a very close attachment. Subsequent to his death, Kate’s mother became depressed and difficult to relate to. Kate remembers feeling apprehensive about leaving home for college, and experienced some significant anxiety and occasional panic attacks during her freshman year. It was then that she contacted the college Counseling Center and was referred to the psychologist whom she found to be quite helpful. Kate dated some in college and found a network of supportive friends with

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whom she remains in contact. Apart from her asthma, she is in very good health and usually takes only the inhaled medicines when she feels considerably short of breath.

25.4.4.2 Formulation Separation and loss have long been held as psychological issues that complicate asthma. Although research finds that these dynamics can be common to any patient with a chronic illness and that many asthmatics do not present with such issues, Kate’s experience of shortness of breath is likely to be exacerbated by her tendency to panic. At the least, Kate’s father’s death at an early age and her mother’s withdrawal left her at the mercy of considerable anxiety. Most children find it difficult to feel safe in the aftermath of the death of a parent, and this is complicated by Kate’s mother’s disciplinary style. The inability of children to provide for themselves is heightened when parents choose withdrawal of affection and unavailability to show their displeasure with a child’s behavior. Such a style might have been preferred by Kate’s mother, even prior to her very early teen years, but the threat of parent loss, even for a short period of time, would be quite frightening for a youngster who had already experienced parent loss by death. Kate’s relationship with her mother seems to be quite conflicted, and it seems that she has not had an opportunity toy grieve her father’s death adequatel. 25.4.4.3. Treatment After the initial interview, the pulmonary nurse practitioner prescribed Sertraline to manage some of Kate’s anxiety. Initial work in hypnosis reviewed some of the historically successful uses of imagination to relax, distract and reassure her in the face of an experience of shortness of breath. Diaphragmatic breathing was rehearsed in hypnosis along with scenes in which she pictured herself coping effectively with an asthma attack by relaxing, taking a few puffs of her medications and picturing herself seated in a comfortable, safe spot. With that comfortable spot established, Kate was instructed, in hypnosis, to say a number that described the state of her breathing difficulty; to picture a situation and experience thoughts and ideas that would make it

slightly worse and rate that; then to return to her baseline. This lesson was rehearsed a number of times with Kate allowing her distress to increase by several numbers. Because of her considerable anxiety and the fact that she was out of work, treatment was accelerated to alternate days. Kate was able to ambulate and to leave home for brief periods on her own, but was still apprehensive about returning to work. She was encouraged to make a plan with her employer to take several sick days in the subsequent week and to return for half days at the end of that week. On the third session, an affect bridge technique was employed to facilitate her associations with the panic. With little challenge, Kate recalled a number of childhood experiences during which her mother, displeased by Kate’s behavior, refused to speak to her. She flushed, perspired and became visibly shaken as she recalled her fears that mother would become lost to her, as was her father. In subsequent sessions, Kate developed a hierarchy of difficult situations in which she imagined becoming short of breath, feeling the tightness in her body, light headedness and shallow breathing. Each image was gradually presented in hypnosis to experience imaginatively, until Kate could maintain total comfort with the most difficult scene. Since she, surprisingly, did not include a restaurant scene in her hierarchy, several were presented, leading her to the same level of comfort.

25.4.4.4. Treatment outcome By Wednesday of the second week, Kate returned to work for half a day. She felt well enough to return for the full day by Thursday, leaving on Friday only to attend our session. She was able to resume her daily activities with relative calm and comfort by the end of that second week (six sessions). However, weekly psychotherapy was scheduled for the next 8 months to discuss her relationship with her mother and the unresolved grief at the loss of her father. Near the end of her psychotherapy, she wanted to discontinue the Sertraline and worked with her nurse practitioner to do so. Kate was able to return to the use of p.r.n. medications for her breathing and maintained a regular habit of meditation to manage her emotional distress.

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25.5. Problems involving

psychodynamics Recent debates regarding suggestion and memory have revivified the Freudian indictment of hypnosis as a lesser, and sometimes dangerous, vehicle for psychotherapy. The field’s recovered preoccupation with the validity of psychotherapeutic material brought forward with the aid of hypnosis has, unfortunately, dampened the enthusiasm of researchers and clinicians for its use as a psychotherapeutic tool. Yet, it is precisely because hypnosis offers patients and providers the opportunity to employ fantasy, interpersonal relationship and suggestion to alter cognition, affect and behavior that clinicians must rediscover this useful technique for medical care. Many patients have difficulty finding words to describe their affective distress, which then becomes expressed somatically. Like hyperemotional children, such patients ‘show’ physical symptoms, because they have difficulty ‘telling’ of their distress. Hypnosis can be a vehicle for some to identify and find words and symbols to express their emotional distress in a ‘tranceitional’ space that leads to increased control and decreased arousal. Chapter 16 of this volume is a fine place for the interested reader to become acquainted with the use of hypnosis as a developmental, psychotherapeutic technique. Individuals make meaning of their illness and their experience with caregivers that can be uncovered, articulated and reworked with the aid of well known projective techniques in hypnosis. The opportunity that hypnosis brings for patients to distance themselves from emotions, attitudes and fears ‘discovered’ in hypnosis is a well known advantage to clinicians. The potential for hypnosis to alter or assist with the management of traumatic memories can be quite helpful to medical patients who anticipate experiencing pain, for example, in much the same way as they have in the past. Much can be gained, and little lost, if the imaginative material is taken symbolically rather than literally. In many medical situations, the personality characteristics and intrapsychic conflicts (or cognitive schemata) of the patient must be managed, since time does not permit much psychotherapeutic intervention. Whether to

motivate, to accommodate or to negotiate, the patient’s characteristic style of thinking, feeling and behaving can be addressed through hypnosis and managed to benefit the patient. For the purpose of this discussion, this construct will be labeled ‘personality style’. One of my teachers said that a great advantage of using hypnosis in psychotherapy was that the patient had to be quiet and listen to the therapist for as long as the therapist wished as he exhorted him to change! In longer term psychotherapy, characteristic patterns can be ameliorated or transformed. In brief treatments without sufficient time for personality change, they must be negotiated with lest the most empirically supported treatment becomes defeated by the patient’s resistance to or conflict about becoming well. Often, important relationships can be imaginatively recruited to provide comfort for the suffering or anxious person. Sometimes, a mantra can be created to motivate someone to complete a procedure or get through a treatment. In brief treatments (which are commonly those of behavioral medicine), it is the therapist who changes the most! Our patients require us to adapt to their personality style and needs in order to help them to accommodate to medical treatments and symptom management, more than to offer insight into their core beliefs and conflicts in order to achieve structural or personality change. Well-trained mental health providers are able to offer considerable assistance through hypnosis to medical patients, as the following case report indicates.

25.5.1. Case report: pre-surgical

anxiety 25.5.1.1. Background Jack is a 77-year-old man who will undergo knee replacement surgery in 3 weeks. This is his first surgical experience and he is apprehensive about the pain associated with the recovery and, vaguely, but significantly, fearful about the procedure. An older friend had a similar surgery and recovered well, but he described a long and difficult rehabilitation. Despite the fact that his doctor has assured him that this surgery will be uncomplicated, Jack is quite apprehensive about it.

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‘I don’t feel that I deserve a successful outcome’, he reports. Jack’s marriage of 40 years has been a distant and less than satisfying one. The early and middle years were characterized by a good deal of argument and bickering that gave way to the couple having largely independent, loveless, lives. He describes his wife as overbearing and self-centered, and himself as someone who has forfeited control over his life. The couple have three children who live a considerable distance away, and they have no grandchildren. Recently, Jack had a falling out with the only child with whom he has a relationship. Angry about his son’s offer to have him as a guest during his recovery from surgery, Jack yelled that he did not want nor need his help and wished that he would leave him alone. His two daughters are married, but he hasn’t had much of a relationship with them for more than 20 years. Raised as an only child by his mother and grandmother, Jack’s parents divorced when he was quite young. He never saw his father and recalled very few males in his life. He was a studious boy and succeeded in school, but his family lacked the funds to support college. Jack went to work in his teen years and found himself a successful career in sales. After many years of Catholic education, Jack feels that he never measures up. Criticism has been a way of life for him, both as donor and as recipient. A recent involvement with a group of Pentecostal Christians has been eye opening and affirming. The passion, liveliness and the acceptance that he finds in this group has been healing. Jack does not drink and does not report a family or personal history of affective disorder nor major mental illness.

25.5.1.2. Formulation Jack’s history of anger and difficulty with closeness is in contrast to a rather charming interpersonal presentation. In spite of his charm, closeness with others is difficult for him to acquire and to maintain. There is a sad and rather masochistic quality to the relationship with his wife and family. Jack is neither able to leave his marriage nor improve it. Likewise, he is frightened by his son’s overtures of care and concern, and pushes him away. His family history is without much joy and he has recreated a detached, joyless life for himself as an adult. Anger, guilt, self-criticism, distance

and suffering cycle within his life and leave Jack a disconnected man. His wish for closeness is somewhat satisfied by an assumed charm that is engaging but difficult to maintain or to develop with authenticity. Despite his pessimism and disconnection, he does reach out for help with this surgery and has the capacity to speak with some degree of openness about his fears.

25.5.1.3. Treatment Given the need to work quickly, five sessions were scheduled, following the initial evaluation. In the first two hypnosis sessions, Jack was quite able to use hypnosis to find a place of comfort and succeeded in producing a number of ideomotor alterations of perception. Ego strengthening suggestions were offered and received. Jack used the trance to recall several experiences in his life where he was able to accomplish something that he feared that he was unable to. The images, feelings and physical sensations (e.g. how he held his head, the strength of his shoulders) that accompanied these gains were experienced, again, with hypnosis. Despite his charm and friendliness, it seemed wise, given his anxiety about closeness, to adopt the stance of a coach or teacher, rather than that of a comforting friend. In the third hypnosis session, an affect bridge technique was employed to explore more about Jack’s sense of unworthiness. In hypnosis, he followed this idea and the attendant feelings to recall the argument with his son and several incidents in his life that involved expressions of significant anger. Regret and tears accompanied memories of arguments with his wife and daughters, and the loss of a very good friend in his thirties. In the fourth session, additional work with the affect bridge led Jack to recall an argument with his mother when he was about 8. A conflict around chores escalated to shouting and threats of physical punishment. Jack’s mother withdrew in tears and his grandmother scolded him for upsetting her. He recalled his grandmother saying that Jack’s father left the family because he couldn’t handle parenting and that Jack should behave better for his mother. Tears and a profound sense of sadness disrupted the trance, but Jack was able to talk openly about his previously unarticulated sense that he was responsible for his parents’ divorce. His sense of being unloved by his father

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who never made an effort to have a relationship with him was quite profound and very sad. In the fifth session, Jack was invited in hypnosis to picture a committee meeting, similar to a Board of Directors. As he looked about the room, he imagined people with strong opinions about a proposal that he had made to them. Several were very worried about the impact of his plan on the company; some were angry about the proposal’s scope and at Jack for daring to present it; others were in agreement with his plan; and others even admired his wisdom, patience and courage. As Jack reviewed the faces around the table and listened to their points of view, he was instructed to understand that there were many points of view and emotions around the table and that this diversity of strong opinion is almost always present around important decisions in life. His job, as chairperson, is to balance these and not just listen to the loudest or the most intense voices. Having received their input and with the understanding that there are many ideas and feelings, a number of them in agreement with him, Jack is free to proceed with his plan. In the final session, Jack uses hypnosis to visualize his trip to the hospital. Emphasis is paid to the sights, sounds and smells of the various scenes which serve as cues for him to remember that he is in the hands of experts who do this work day in and day out. Whenever he finds himself becoming upset, Jack is instructed to take a deep breath and recall the place of comfort that he imagined in the first session. Encouraged to see himself turning over the work of the surgery to the experts, Jack is told that he will find it easy to void and to follow the suggestions of the nurses as they help him with ambulation and recovery. Finally, Jack practices several analgesic techniques for his use with pain control after the surgery.

25.5.1.4. Treatment outcome A note from Jack indicated that he experienced the surgery quite well. Just prior to the operation, he wrote a note of apology to his son. In addition to addressing the specific event, Jack was very open about his awareness of the distance that he has kept from people and his wish to make a change in that. He thanked his son for his offer of support and said that his doctor and he agreed that a rehabilitation facility would provide the

best post-surgical care. Jack’s son called prior to the surgery and thanked his father for the note. He also visited him during his hospital stay.

Acknowledgments I would like to express my thanks and appreciation to Ms Katie Phalan for her usual excellent assistance in the preparation of this manuscript.

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Prior, A., Colgan, S. M. and Whorwell, P. J. (1990) Changes in rectal sensitivity after hypnotherapy in patients with irritable-bowel syndrome. Gut, 31: 896–898. Preston, J., O’Neal, J. and Talaga, M. (2004) Handbook of Clinical Psychopharmacology for Therapists. New Harbinger Publications, Oakland, CA. Redd, W. H., Montgomery, G. H. and DuHamel, K. N. (2001) Behavioral intervention for cancer treatment side effects. Journal of the National Cancer Institute, 93: 810–823. Rosenman, R. H., Brand, R. J., Jenkins, D., Friedman, M., Straus, R. and Wurm, M. (1975) Coronary heart disease in Western Collaborative Group Study: final follow-up experience of 8 1/2 years. Journal of the American Medical Association, 233: 872–877. Rushton, J. L., Clark, S. J. and Freed, G. L. (2000) Pediatrician and family physician prescription of selective serotonin reuptake inhibitors. Pediatrics, 105: 82–88. Selye, H. (1956) The Stress of Life. McGraw-Hill, New York. Smoller, J. W., Pollack, M. H., Systrom, D. and Kradin, R. L. (1998) Sertraline effects on dyspnea in patients with obstructive airways disease. Psychosomatics, 39: 24–29. Spiegel, H. (1970) A single treatment method to stop smoking using ancillary self-hypnosis. International Journal of Clinical and Experimental Hypnosis, 18: 235–250. Tkachuk, G. (2003) Randomized controlled trial of cognitive-behavioral group therapy for irritable bowel syndrome in a medical setting. Journal of Clinical Psychology in a Medical Setting, 10: 57–69. US Department of Health and Human Services (1996) Clinical Practice Guideline #18 Smoking Cessation. US Government Printing Office, Washington, DC.

Vasterling, J., Jenkins, R. A., Tope, D. M. and Burish, T. G. (1993) Cognitive distraction and relaxation training for the control of side effects due to caner chemotherapy. Journal of Behavioral Medicine, 16: 65–80. Viswesvaran, C. and Schmidt, F. (1992) A meta-analytic comparison of the effectiveness of smoking cessation methods. Journal of Applied Psychology, 77: 554–561. Whorwell, P. J., Prior, A. and Faragher, E. B. (1984) Controlled trial of hypnotherapy in the treatment of severe refractory irritable-bowel syndrome. Lancet, 2: 1232–1234. Whorwell, P. J., Prior, A. and Colgan, S. M. (1987) Hypnotherapy in severe irritable-bowel syndrome. Gut, 28: 423–425. Williams, J. E., Paton, C. C., Siegler, I. C., Eigenbrodt, M. L., Nieto, F. J. and Tyroler, H. A. (2000) Anger proneness predicts coronary heart disease risk: prospective analysis from the atherosclerosis risk in communities (ARIC) study. Circulation, 101: 2034–2039. Wulsin, L. R., Vaillant, G. E., Wells and V. E. (1999) A systematic review of the mortality of depression. Psychosomatic Medicine, 61: 18–20.Wulsin, L. R., Evans, J. C., Vasan, R. S., Murabito, J. M., Kelly-Hayes, M. and Benjamin, E. J. (2005) Depressive symptoms, coronary heart disease, and overall mortality in the Framingham heart study. Psychosomatic Medicine, 67: 697–702. Zeltzer, L. and LeBaron, S. (1982) Hypnosis and nonhypnotic techniques for reduction of pain and anxiety during painful procedures in children and adolescents with cancer. Journal of Pediatiatrics, 101: 1032–1035. Zeltzer, L. K., Dolgin, M. J., LeBaron, S. and LeBaron, C. (1991) A randomized, controlled study of behavioral intervention for chemotherapy distress in children with cancer. Pediatrics, 88: 34–42.

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CHAPTER 26

Hypnosis in the treatment of conversion and somatization disorders Franny C. Moene and Karin Roelofs

26.1. Domain of the problem Conversion disorder (CD) refers to the presence of deficits affecting the voluntary motor or sensory functions. These symptoms suggest neurological or other organic causes, but are believed to be associated with psychological stressors (American Psychiatric Association, 1994). Conversion and somatization symptoms were initially described in the context of hysteria, and have always been subject to debate and conceptual confusion. That this debate is still alive is reflected in the manner in which the disorder is currently classified within the two major current nosologies: in the DSM-IV (American Psychiatric Association, 1994) CD is a type of somatoform disorder; In the ICD-10 (World Health Oraganization, 1992) it is a dissociative disorder. For convenience, we follow the DSM-IV criteria, although in our theoretical review we present arguments for a dissociative classification. Neurological symptoms for which no adequate physiological explanation can be found can be subsumed not only under the diagnosis of CD, but also under the diagnosis of somatization disorder (SD). Aside from differences in symptom numbers and illness chronicity, the available data indicate that there is little that distinguishes

CD from SD (Ron, 2001; Wade, 2001; Brown, 2004). We focus on CD, with the notion that most of the described features and treatment models apply to both CD and SD. The presentation of conversion symptoms mimics a broad spectrum of neurological diseases. The most common conversion symptoms are motor symptoms, such as paralysis, incoordination, ataxia and tremor. The second most common symptom cluster consists of somatosensory symptoms that may involve anesthesia, blindness and sometimes deafness. Another cluster of symptoms may involve seizure-like activity. There can also be a mixed presentation in which there are motor symptoms, sensory and seizure-like symptoms. According to the DSM-IV criteria of CD, the onset or exacerbation of these symptoms has to be associated with psychological stress or trauma. Childhood sexual, physical and emotional abuse have indeed been linked to conversion and somatization symptoms (e.g. Morrison, 1989; Betts and Boden, 1992; Alper et al., 1993; Binzer and Eisemann, 1998; Kuyk et al., 1999; Litwin and Cardeña, 2000; Roelofs et al., 2002a; Salmon et al., 2003; Brown et al., 2005) Further, it is not uncommon for conversion symptoms to develop following exposure to acute stressors

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(Binzer et al., 1997; Roelofs et al., 2005). Nevertheless, several authors have questioned the necessity of identifying psychosocial precipitants in order to make a firm diagnosis of CD or SD (e.g. Merskey, 1979; Ron, 1994). Although clear environmental precursors are often found, they can be absent in some cases (Ron, 1994; Roelofs et al., 2002a). Psychiatric co-morbidity is common in CD. Axis-1 (DSM-IV) co-morbidity, mainly of depression and anxiety disorders, is observed in 22–75 per cent of the patients (Mace and Trimble, 1996; Binzer et al., 1997; Crimlisk et al., 1998). Personality disorders are observed in 37–59 percent of the patients (Binzer et al., 1997; Crimlisk et al., 1998; Moene et al., 2001; Roelofs et al., 2002b). In some of these studies, histrionic personality disorders have been observed, but other types of disorders such as dependent personality disorder are far more common. The co-morbidity rates of neurological disorders largely depend on the treatment setting. Whereas approximately 50 percent of the patients in neurological settings show neurological co-morbidity (Marsden, 1986; Factor et al., 1995), only 3 percent of the patients in psychiatric settings were identified to have additional neurological disorders (Roy, 1979). Despite the difficulties of excluding neurological disease and malingering, CD can be diagnosed with a fair amount of reliability provided standard diagnostic protocols are carefully followed (e.g. Crimlisk et al., 1998; Halligan et al., 2001). This view was recently supported by two neurophysiological studies showing differential neurophysiological correlates for CD and malingering in cases of sensory (Lorenz et al., 1998) and motor loss (Spence et al., 2000), respectively.

patients with conversion blindness could modify their behavior in response to visual information they deny seeing. Yet they remain oblivious to this strategy. Sackheim et al. (1979) proposed that hysterically blind patients performed differently on a visual task depending on whether or not the visual task was presented as a test for blindness. In a clinical setting, we observed a patient who claimed to have no visual awareness of his immediate environment, but who was reasonably able to maneuver through an examination room without bumping into the furniture. In the case of conversion paralysis, a conversion patient is unable to move one or more parts of the body intentionally. Under less controlled or intentional circumstances such as during sleep (Lauerma, 1993) or hypnosis (Moene et al., 1998) the patient may, however, show some movement with the affected area. Ziv et al. (1998) clearly demonstrated this phenomenon by testing the involuntary extension of an affected leg when voluntarily flexing the contralateral (normal functioning) leg against resistance. Compared with healthy controls and patients with neurological weakness, patients with conversion paralysis showed significantly more involuntary than voluntarily limb contractions with the affected limb. These discrepancies between explicit (voluntary) and implicit (involuntary) motor as well as sensory functions have raised a lot of confusion in clinical practice. The question of what accounts for these contradictory phenomena has intrigued and preoccupied philosophers, psychiatrists and neurologists throughout history.

26.2. Theoretical models

To describe the cognitive and emotional shifts observed with CD patients, we focus here on dissociative explanations. The basic assumption of dissociation theory is that under the influence of psychological stress, dissociation can occur between higher level explicit information processing and lower level implicit information processing, in which the explicit information processes fail (Janet, 1907). According to this theory, the apparent contradictions in symptom presentation in the previously mentioned example of conversion blindness where the patient

Despite the variety of manifestations of conversion symptoms, the symptoms share one important feature, i.e. the CD patient’s symptom presentation is observably altered by environmental and social influences, yet the patient remains unaware of it. There appears to be a disconnection between conscious experience or knowledge and implicit automatic or procedural knowledge (Kihlstrom, 1992). For example, Bryant and McConkey (1989) showed that

26.3. Explanatory constructs

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was able to move around the furniture adequately may be explained by the assumption that, whereas explicit conscious visual information processing fails, the visual stimuli are still being processed on a lower, implicit level (Kihlstrom, 1992). Dissociation theory of CD dates back to Janet (1859–1947), who attributed this functional dissociation of higher and lower level information processing to an attentional narrowing in response to stress, and regarded it as a form of hypnosis. Janet (1925) argued that there is a relationship between childhood traumatization and dissociative symptoms that is mediated by a process in which the traumatized individual uses his or her innate hypnotic capacities to induce self-hypnosis as a defensive response to overwhelming traumatic events (Bliss, 1984; Putnam, 1989). In line with Janet, contemporary researchers such as Hilgard (1977), Bliss (1984), Nehmia (1991), Kihlstrom (1992) and Oakley (1999a,b) have also argued that conversion symptoms may result from spontaneous self-hypnosis involving a dissociation of sensory or motor functions. Kihlstrom (1992) made an explicit modification of Janet’s dissociation model. Although both theories share many features, in contrast to Janet, Kihlstrom regards dissociation as a nonpathological ‘normal’ psychological process. In his model, the term dissociation is used descriptively rather than mechanistically, and traumatic experiences are no longer incorporated as a causal factor in the development of dissociative symptoms. The most important assumptions and empirical evidence of modern dissociation models, such as Kihlstrom’s model, are outlined below. Several neurophysiological and neuropsychological studies support the view that higher level motor and sensory control functions are disturbed in CD while lower level control functions remain intact. For example, two event-related potential (ERP) single case studies showed intact early sensory processing accompanied by an altered P300 (potential associated with awareness) in conversion patients with motor (Lorenz et al., 1998) and sensory (Fukuda et al., 1996) symptoms, respectively. Also, a single case positron emission tomography (PET) study by Marshall et al. (1997) showed that when a patient with unilateral conversion paralysis of the left

leg attempted to move her affected leg, there was no activation of the right primary motor cortex (M1), but there was increased activation in two prefrontal inhibitory structures, the right anterior cingulate (ACC) and orbitofrontal cortex (OFC). The authors concluded that the ACC and the OFC inhibited the prefrontal (willed) effects on the right M1 when the patient deliberately attempted to move her affected left leg. Similar brain structures were involved in a case of sensory conversion symptoms (Tiihonen et al., 1995). Also recent motor imagery and motor priming studies (Roelofs et al., 2001, 2002c, 2003,2006; De Lange et al., 2007) showed conversion paralysis to be associated with impaired higher level motor control and relatively intact lower level motor control. In short, there is good evidence from recent neurophysiological and neuropsychological studies that CD is concomitant with dissociated higher level and lower level control processes. Like Janet, contemporary authors such as Kihlstrom (1992) and Oakley (1999a,b) note the similarity of CD symptoms and the dissociative aspects of hypnosis. Recent neuroimaging studies provide some support for the suggested overlap between hypnotically suggested phenomena and conversion symptoms. A single case PET study showed hypnotically suggested paralysis (Halligan et al., 2000) to involve the same frontal inhibitory structures (OFC and ACC) as those identified in the above-mentioned case of conversion paralysis (Marshall et al., 1997). Also, using mental hand rotation tasks, Roelofs et al. (2002d) found hypnotic paralysis to result in impairments similar to those previously observed in patients with conversion paralysis (Roelofs et al., 2001). Moreover, the parallel between conversion symptoms and hypnotic phenomena is supported by the fact that many conversion symptoms have a hypnotic counterpart, and CD is often accompanied by elevated levels of hypnotic suggestibility (Janet, 1907; Ludwig, 1972; Bendefeldt et al., 1976; Bliss, 1984; Roelofs et al., 2002b). The fact that there are many similarities between the symptoms of CD and hypnotic phenomena has long been recognized in clinical practice. The shared characteristics are a lack of concern regarding the symptoms, a feeling of involuntariness, the influence of motivation and social factors, as well as the display of implicit processing.

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Oakley (1999a) states that several characteristics underlying conversion symptoms and hypnotic phenomena are similar and clearly related to the difference between implicit versus explicit perception (i.e. awareness) or knowledge (i.e. consciousness). In his model of self-awareness and consciousness, Oakley distinguishes a higher level self-awareness system and a lower level semi-autonomic executive control system (see also Norman and Shallice, 1986). Oakley contends that most of our actions and thoughts are processed within the lower level executive control system, without subjective awareness. This executive system can be directly influenced by both internal factors (i.e. self-suggestion, conflict, motivation) and external factors (i.e. heterosuggestion, social or psychological pressure, expectations) and can in turn produce both hypnotic and conversion symptoms. This explains the CD patient’s la belle indifference and dearth of explicit knowledge: patients have implicit knowledge of how to move their legs but have no explicit knowledge of this skill, which also explains why they are so unusually indifferent to their plight. In his model, Oakley regards motor conversion symptoms as the result of the inhibition of wilful movement by the central executive structure. More recently, Brown (2004) has developed a more integrated cognitive model putting more emphasis on the development and content of symptom-related mental representations that are selected by the central executive control mechanisms. Following the cognitive-behavioral tradition, Brown describes putative precipitative (antecedents), moderating (maintaining) and consequential (reinforcing) factors in CD and SD. In the model, autosuggestions or heterosuggestions form only one of the possible precipitating factors that may form the basis for symptom-related cognitive representations. Other factors are sensorimotor experiences associated with physical illness and traumatic events, indirect exposure to physical states in others and socio-cultural transmission of information about health and illness. As far as moderating factors in Brown’s model, attentional processes such as the recurrent reallocation of attention onto symptoms by the central executive control system is the primary pathogenic factor in the development of symptom chronicity.

An important example is self-focused attention that may lead to increased awareness of bodily sensations and enhanced reports of bodily symptoms. Other examples of moderating factors are illness worry or behavioral responses such as seeking reassurance. To summarize, dissociation theory has recently been placed in a broader cognitive-behavioral perspective within current hierarchical cognitive theories (Oakley, 1999a,b; Brown, 2004). Although Oakley regards CD primarily as an autosuggestive disorder, Brown recognizes more factors that may affect conversion and somatization symptoms. It should also be noted that patients with CD do not show the expected elevated scores on measures of dissociation such as the Dissociative Experiences Scale (DES; Bernstein and Putnam, 1986; Roelofs et al., 2001). Authors such as Oakley (1999a,b) and Brown (2004) propose that the construct dissociation is not necessary require a meaningful link between conversion symptoms and hypnotic phenomena. Despite these drawbacks of dissociation theory, the view that CD is characterized by dissociation between lower level and higher level control processes is widely accepted and supported by extensive empirical evidence.

26.4. Clinical applications Given the many parallels between hypnotic and conversion phenomena, hypnosis may provide a fruitful context for the treatment of CD.

26.4.1. A review of the research

literature The use of hypnosis as a form of treatment for CD has been extensively described in numerous single case studies and some case series (Janet, 1907; Wilkins and Field, 1968; Kroger and Fezler, 1976; Spiegel and Spiegel, 1978; Sackheim et al., 1979; Patterson, 1980; Conrad, 1985). Oakley (2001) reviewed 12 single case studies, mostly speech disturbances and motor symptoms, in which hypnotic procedures were successfully used in the treatment of CD. Interestingly, as well as employing hypnotic procedures, most studies used a number of adjunctive techniques and strategies such as cognitive-behavioral techniques, speech therapy

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and face-saving strategies. Indeed, most professional hypnosis societies consider hypnosis as an adjunctive technique to be used in support of a broad-based treatment approaches, such as cognitive-behavioral, psychodynamic and rehabilitation therapies. Many authors recommend a comprehensive, eclectic or multimodal treatment approach. In line with this idea, Wade (2001) used qualitative criteria to evaluate the therapy effectiveness of a selection of multiple case studies of CD patients as well as a broader field of patients with Somatization Disorder (SD), and concluded that a multidisciplinary rehabilitation approach with several simultaneous interventions may be most successful. This conclusion is in agreement with current forms of cognitive theories like the earlier mentioned hierarchical cognitive theory of Oakley (1999b) and the integrative conceptual model of unexplained illness based on cognitive psychological principles by Brown (2004). Brown argues that the treatment of choice depends on a detailed assessment of the patient’s symptoms, the factors associated with their onset and maintenance. He goes on to say that it can involve cognitive-behavioral therapy, suggestive therapy with or without hypnosis, psychodynamic ally-oriented therapy, and occupational therapy or physiotherapy. Two studies by Hoogduin and Van Dyck (1992) and Moene et al. (1998) used such forms of eclectic therapy. In the study by Hoogduin and Van Dyck, eight inpatients with CD received hypnosis-based treatment and physical revalidation. At follow-up (6–72 months post-treatment), three patients had completely recovered and five had improved considerably (with one of the five showing a short relapse). In Moene et al. (1998) the authors describe a pilot study consisting of eight consecutive CD patients. All patients had been diagnosed with CD for many years. The mean duration of treatment for this clinical trial was 2 months as an inpatient and 20 sessions as an outpatient. One patient dropped out and seven completed treatment with symptom removal. Three patients relapsed during follow-up. Controlled studies on the treatment of CD are scarce and, until recently, there were none available controlling for natural changes that may

occur without intervention. Controlled single case studies have shown cognitive-behavioral, operant, cue conditioning and symptomfocused approaches to be promising (Agras et al., 1969; Hersen et al., 1972; Ohno et al., 1974; Kallman et al., 1975; Turner and Hersen, 1975). However, controlled clinical trials providing information on the successful treatment of long-standing CDs and follow-up information are very few in number (Munford and Paz, 1978; Montgomery and Espie, 1986; Kop et al., 1992). To our knowledge there are only two randomized controlled group studies on the treatment of CD and SD. They followed an eclectic approach including hypnotic techniques involving both inpatients (Moene et al., 2002) and outpatients with CD (Moene et al., 2003b). In the Moene et al. (2002) study, the investigators treated 45 adult inpatients with CD of the motor type, or SD with motor conversion symptoms, using a comprehensive 2-month treatment program. All patients participated in group therapy aimed at increasing the patients’ problemsolving capacity using behavioral and cognitive techniques. In addition to the group therapy, the patients followed an individual symptomdirected program consisting of physiotherapy, individual exercise sessions and bed rest. A total of 24 patients received additional hypnotic treatment with 8 weekly 1-h sessions using symptomoriented and exploratory techniques. The control group of 21 patients received an additional treatment without specific interventions for conversion symptoms. For patients who completed follow-up, the mean time as an inpatient was 2.9 months. For the total sample, significant treatment results were found on all outcomes measuring symptom reduction and reduction of impairments in the domains of physical activities, activities of daily life and social activities. At a 6-month follow-up, the improvement was maintained and even increased across all outcome measures. Use of hypnosis appeared to yield no additional benefit. The second randomized controlled clinical trial involved 44 outpatients. Moene et al. (2003b) found that patients with conversion symptoms who had completed a 10-week hypnosis-based therapy protocol (symptom-oriented and exploratory techniques) significantly improved relative to baseline. Their improvement exceeded

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that of a wait-list condition and was maintained at 6-month follow-up. Twelve patients were referred for further treatment sessions beyond the 10-week post-treatment assessment with a mean number of 6.3 extra sessions. The findings from these trials suggest that hypnosis-based interventions are efficacious for patients with conversion symptoms. Nevertheless, the hypnotic techniques appeared not to add significantly to the efficacy of the eclectic, inpatient treatment program. Also, in both studies hypnotizability was not found to contribute specifically to treatment outcome. However, the effect sizes of the hypnotizability/outcome correlation ranged from 0.25 to 0.35. This is a typical effect size for the association between patient variables and psychotherapy outcome (Garfield, 1994). In the case presentation section of this chapter, the eclectic approach used by Moene et al. (2002, 2003b) will be described and illustrated in more detail. The various hypnotic techniques that are used in this approach are described immediately below.

26.4.2. Hypnotic techniques in CD There are no studies specifically examining the effectiveness of various hypnotic strategies or techniques for the treatment of specific CD symptom categories such as paralysis or aphonia. Nevertheless, the literature describes two kinds of hypnotic procedures: symptom-focused and exploratory techniques. The symptom-focused strategies involve the aforementioned predominantly cognitive-behavioral, symptom-oriented approaches, as well as the direct and indirect influencing of symptoms by operant conditioning techniques and cue conditioning. In these strategies, hypnosis is used formally or in a hypnotic context. Exploratory techniques such as revivification or age regression refer to insight-oriented and expression-oriented psychotherapeutic techniques. They are used to explore emotions that are associated with the symptoms or their onset. It is suggested to the patient that giving expression to the pent-up or dissociated emotions and dealing with them both during hypnosis and in the waking state may positively influence the symptoms. In both the symptom-oriented and exploratory hypnotic approaches, direct, indirect

and post-hypnotic suggestions of symptom reduction are used. Some authors stress the importance of learning self-hypnosis. Indeed there is some evidence that home practice of hypnotic relaxation may be a therapeutically significant aspect of symptom reduction strategies (Spinhoven, 1989).

26.5. Symptom-oriented

techniques In this section several symptom-oriented techniques will be described and illustrated for the main symptom complexes: motor, sensory and pseudo-seizures or convulsions (pseudo-epilepsy; PES), followed by a general description of explorative techniques.

26.5.1. Motor symptoms such as

paralysis, contractures and uncontrollable movements 26.5.1.1. Making use of the present rest capacity with flaccid paralysis In cases of paralysis, suggestions are for the patient to pay attention to any kinetic reactions he/she may be having in the affected limb (e.g. tingling, pain, and differences in temperature or tiny muscular spasms in the affected limb. These sensations can be strengthened by suggestive reinforcement such as ‘the longer you concentrate on the tiny muscle spasms, the stronger they will become’. As sensations begin to strengthen, we move to suggestions for small muscle movements followed by larger muscle movements. Emphasizing and praising every occurrence of little (spontaneous) movements is important. 26.5.1.2. The nonaffected limb helps the affected one In this intervention (Hoogduin et al., 1993) the patient is asked to concentrate on the nonaffected limb, to become aware of the sensations that are present in the limb, to name them and to visualize them. The therapist then gives the suggestion that the affected body part has forgotten or unlearned how to feel the sensory perception and physical sensation, and that the nonaffected limb is going to re-train the affected one. Thereafter, suggestions follow that certain

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movements and motor sensations can flow from the healthy area to the affected body part so that the patient can also experience it there. (For an illustration, see Section 26.9, case 1.)

26.5.1.3. Relaxation and imagination Also for symptoms of hand contraction, hypnotic suggestion can be used to influence the symptoms and enlarge subjective feelings of control. The hypnotic suggestion involves relaxation of the arm and hand muscles together with presentation of the image of a balloon being blown up in order to get the hand with the contracted fist to open and close by itself (Hoogduin et al., 1993). 26.5.1.4. Imagination of normal functioning in the past With this technique, while under hypnosis the patient goes back to the time when voluntary movement still functioned. Moene and Rümke (2004) used this technique with a young woman who had paralysis of a hand. Illustration: After hypnotic induction, Joan went back to thoughts of a lakeshore at the campgrounds where she always felt very happy. Then the suggestion was given for her affected hand to pick up stones and let them slide away. Along with this, the suggestion that she also experience this with increasingly more sensory perception was given, and also that she should feel the precise tension in her hand muscles that was necessary to pick up the stones. After this, other different images were used, such as feeling the sand in her hand and making sand drawings with her hand in combination with suggestions of increasing muscle strength, sensory feeling and recovery of movement.

A comparable approach for patients with aphonia is from Drost (1996), who used this technique diagnostically and therapeutically in an informal hypnotic context to demonstrate the functional character of speech disturbances by letting patients go back to a pleasant experience in time when speech was still normal. During hypnosis, the therapist suggests that the patient begin talking about the pleasant situation whereby the voice can ‘relearn’ the skills to talk again.

26.5.1.5. Making use of the fact that during sleep, the symptoms are absent This technique is mostly applied for tremors or pseudo-ataxia. Here the clinician makes use of

the fact that many CD symptoms abate during sleep (Hoogduin and Van Dyck, 1990). The treatment is built up step-by-step. First, while in hypnosis, the patient is asked to lie down in a sleeping position and to try to sleep. Next the therapist gives suggestions for rest and muscle relaxation. Finally, the explanation is given to the patient, who is in a state of deep relaxation, to imagine that he has reached the mental state that is comparable with the sleep whereby the symptoms will abate. Eventually the same sequence is followed but with the patient in an upright (i.e. sitting) position. The following sessions might include suggestions that the patient falls asleep with open eyes, while remaining relaxed. The patient is taught how to do self-hypnosis and instructed to practice the exercises at home.

26.5.1.6. Catalepsy induction This technique (developed by Sacerdote, 1970, and termed reverse hand levitation), can be used when the patient has no control over his or her muscular movements or in the presence of tremors or pseudo-ataxia (Erickson, 1980; Hoogduin and Van Dyck, 1990). The method is as follows: the patient sits in a chair with elbows supported on the armrests. The therapist takes the wrist between thumb and index finger and lifts the lower arm to a vertical position. By now changing the support of the arm and letting it loose again, gradually a situation of catalepsy, or a transformable stiffness or wax-like malleability is suggested and sustained by the CD patient. The catalepsy can again be applied in different extremities or in the torso in the same manner. A complete body catalepsy is stimulated for patients who have trouble with uncontrollable movements in their whole body. The patient first practices with catalepsy of a limb and, when that is successful, the suggestion is given that this experience (the feeling and the actual perception of stiffness) can generalize through the whole body. Another method is to make the opposite movement alternately with the body until it feels frozen or stiff (for an illustration, see Section 26.10, case 2). In a number of cases there is a so-called rebound effect, a temporary return of the tremors or uncontrollable movements after the catalepsy has subsided. It would be prudent to anticipate

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this phenomenon in the treatment so that a patient does not become anxious or disheartened when it occurs. Experience has taught that with longer duration of control over the movements, the rebound effect gradually diminishes. In order to influence this, one can use posthypnotic suggestion to support the notion that the relief from tremor will remain increasingly longer.

26.5.1.7. Letting go Another applicable method for shaking and tremors is letting go. Many patients try to resist the uncontrollable movements by tensing their muscles. The effect of this strategy is often more movement, not less. In many cases, explanation of this unwilled effect, in combination with the prescribed rest periods and letting go of the resistance, can be the solution to the problem. Progressive relaxation with or without hypnosis can enable the patient to let go of the resistance and thus gain an element of control. During hypnotic relaxation, the patient can be given the suggestion not to resist the movements, to shake them off, and to make the body heavy and languid, whereby the movements will become increasingly slower and eventually shall stop. In complicated situations, cue conditioning for distraction of the attention can be a supportive technique. It is sometimes almost impossible for patients who shake to direct attention on their exercises or to breath normally. Illustration: Mr van Zuid has a shaking leg. While administering a local stimulus on his arm for approximately 15 s, he receives the instruction to focus his attention fully on the area where the stimulus is given and to combine this with deep stomach breathing, whereby he utters the word ‘loose’ while exhaling. The letter ‘s’ from the word is pronounced until the end of the exhalation: stimulus inhaling exhaling loossse …. The next stimulus is only given when the shaking increases again.

26.5.2. Somatosensory symptoms

(e.g. anesthesia, tunnel vision or blindness and deafness) Sensory disorders often accompany CD, but seldom endure. With recovery from the disorder, recovery of sensations usually occurs.

The therapist can offer this suggestion as support or the suggestion that sensations are the beginning of recovery from the symptoms. The assertive re-appearance of total loss, or the change in function of sight or hearing during certain periods of time is less prevalent than with motor conversion symptoms.

26.5.2.1. Making use of visual and auditory imagination in conversion blindness or deafness In order to support the patient’s motivation, it is important that the therapist starts with pleasant and familiar images, sounds or objects. The patient receives the suggestion to call upon these while going into a deeply relaxing state during certain times of the day. Thereafter, the suggestion is given that ‘it is precisely from this positive and relaxed state of mind, that consciously learning to see and hear will be facilitated, and that one day it will manifest itself, initially just a bit, but after that, there will be more and more conscious awareness of images or sounds during longer periods of time’. De Haan and Bergsma (2002) describe the use of rest capacity in the treatment of a young woman with conversion blindness. She initially learns to visualize. After inducing hypnosis, she has to stare at an object in the therapy room, and then to visualize it with her eyes closed. When this is achieved, she receives the task of staring at objects for certain periods during the hours that she is not blind at home, and then to visualize them while hypnotized during the hours of the day that she is blind. Furthermore, she receives the suggestion that she must wait until her eyes are at the point when she no longer precisely knows if she is visualizing or actually seeing the object. In our experience, when a patient begins to voice this type of confusion, restoration of function is close at hand. Illustration: Paul, age 19, has a partial loss of vision. He sees differences in color, but nothing more. This improves at certain times of the day, and he is somewhat able to perceive, albeit vaguely, what his surroundings look like. The therapist uses this for treating the complaints. The patient receives visualization exercises with the task of playing with the colors, to intensify and minimize them, as well as making the color areas larger and smaller. He must

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perform this exercise daily and register the results. Even though he faithfully practices, he doesn’t really progress. There is approximately a 30 per cent improvement. Psychologically, things continue to improve for him. The conditions for recovery surely appear to be present through this. Before release, he goes to see his ophthalmologist who reports that his condition is satisfyingly improving, and prescribes vitamin B. The therapist realizes that Paul wants to relinquish his symptoms without loss of face. She gives Paul the powerful suggestion that the complaints will completely disappear because things are going so well right now. She also mentions that the ophthalmologist sees the situation positively. Three months later when sitting in the waiting room, Paul sees the therapist and says that she really looks exactly as he had imagined she would. His vision seems to have completely returned.

26.5.3. Seizures or convulsions 26.5.3.1. Hypnotic self-control procedures Kuyk et al. (1999) used hypnosis for the identification of PES and showed that hypnotic recovery of memory of the events occurring during a seizure was only possible in the case of pseudo-seizures and not in real seizures. This technique is called hypnotic recall and it can also be used therapeutically to explore the mental state of the patient during a pseudo-seizure. It may also help to enhance control over symptom-eliciting stimuli and the pseudo-epileptic attacks themselves. The patient is told that such attacks are the result of increasing tension in the body from long-lasting strain, acute stress or threat without there being an electrical release in the brain. The release of tension takes place in the muscles. Usually with this, one shifts into another state of consciousness. Then it is explained that hypnosis is a state of mind wherein one can enter into this changed state of consciousness, before as well as during the attack (Moene, 1991; Moene et al., 2003a). The patient is administered a hypnotic procedure and is asked to think back about the beginning of the last attack. Evocation of this experience is done as vividly as possible by asking about (and intensifying) the sensory as well as the emotional experiences. When it is clear which tension-eliciting situations or experiences the patient reacts to, other attacks can also be charted in this way.

Through this, the patient and the therapist get an image of situational triggers that immediately precede the attacks. The patient can decrease the burgeoning tension and can learn to resist the attacks by practicing with antagonistic reactions during hypnosis and in a waking state. An example of such a method is cue conditioning. Illustration: Mrs James and cue conditioning. A tingling sensation is the first warning that an attack is underway. In hypnosis, Mrs James learns to relax quickly. When she feels the tingling sensation, she stops doing whatever she is doing, she goes into a quick trance by thinking of her relax-chair which is a synonym for deep relaxation and rest; she then takes a deep breath, holds it for a few seconds, breathes out and lets all tension leave her body.

26.5.3.2. Provoking attacks: prescribing the symptom as a self-control procedure This approach is indicated in cases where the occurrences of attacks are strongly determined by anticipatory anxiety (Hoogduin et al., 1996). The relationship between anxiety and the attack is explained to the patient. During hypnosis, the patient is given suggestions vividly to re-live one of the more recently occurring attacks and to describe the antecedent situation. Then, still during hypnosis, an attack is induced by deliberately using these situational triggers with attendant anxiety. As the symptoms eventually recede, the therapist emphasizes that if the patient can ‘turn on’ the attacks by becoming anxious, he/she can learn to control them by becoming relaxed in the face of the situational triggers. As this process of elicitation and recovery is repeated, the patient learns how to elicit and terminate the attack. The final goal is that the patient learns to avoid attacks by becoming more conscious of the antecedent events and/or by interrupting the anxiety before it escalates. Illustration: During hypnosis, John King, a 36-yearold man, goes back in time to the moments before the last attack. The therapist asks him to concentrate on the first signals, and he intensifies them by repeating them. The attack then begins, and the therapist describes what happens: ‘I see your arms spasm, your breathing speeds up, you now begin to shake your legs too. It’s going well, and now we’re going to help you get out of the attack. You will first notice that your breathing will calm down and your

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arms will feel heavier. This is the first sign that your body will feel more relaxed, calmer and heavier’. Every change in the appearance of John’s situation is noted and is coupled to the suggestions that the relaxation will increase and that this is a sign that he is returning to normal consciousness. The exercise is discussed after hypnosis is terminated. The patient is complimented for his boldness and accomplishment. Then a brief form of exercise program is discussed and practiced with him. The core of this program is that the patient goes increasingly deeper into hypnosis and purposefully imagines the cues that precede an attack. Then, with self-suggestions of relaxation, heaviness, and calm breathing he counter-conditions the cues.

26.6. Expressive techniques Expressive techniques, focused on the emotional experiencing of trauma or conflict, may be helpful in achieving clinical improvement. However, they should be applied with great care and should never be focused on the literal recovery of lost memories given the danger for iatrogenic suggestion during therapy (Brewin, 2003; McNally, 2003). If expressive techniques are used with trauma patients, this has to be integrated in a therapeutic context in which traumarelated problems are carefully treated. This may be particularly important for patients with pseudo-epileptic attacks, because several authors emphasize the role of sexual abuse in the etiology of PES (Betts and Boden, 1992; Bowman, 1993; Bowman and Markand, 1995).

26.6.1. Revivification and/or

age regression These techniques can be used in cases where the symptom onset is associated with a specific distressing experience. The patient returns to thoughts of pertinent occurrences or to the initial period of the CD whereby the suggestion is given that the ability to express the emotional experiences of the past will positively influence the symptoms. Illustration: Mary, a 41-year-old woman, has had total paralysis and numbness in her right leg for 4 years. She is aware of her incest history, confirmed through a third party. Symptom-oriented techniques

are not successful in restoring movement to her leg, possibly because of the absence of any sensations. Use of an exploratory technique is then considered. Mary has reported a traumatic experience wherein the offender abused her such that he so forcefully pushed her right leg against the wall that, after initially feeling much pain, she then experienced her leg as completely numb and nonexistent. During a hypnosis session, she recounts this experience, which makes her anxious. The therapist reassures her and offers a plausible rationale that he therapeutically uses, namely that her leg surely was there and still belongs there, but that she didn’t feel her leg because it was repressed for a long time. Further, she is asked what she would have preferred to do with that leg. When she reveals that she would have wanted to kick the offender away, the therapist decides to use this wish in order to awaken the paralyzed leg with its first movement. Mary receives the suggestion to make a strong kick with the nonparalyzed leg and to allow the symbolic expression of resistance flow to the paralyzed leg through which it too will be able to move again. Contractions of small and large muscles in the affected leg are then observed.

Brady and Lind (1987) describe an example of a similar technique in a case of hysterical blindness. A young man is blinded after a fire in the house where he grew up, where his sister was seriously wounded. During the hypnosis, he reveals that he blames himself for first thinking of himself and escaping from the house, going back later to rescue his sister who had already been rescued by the fire department. After this is clarified, the suggestion is given that this inner conflict should be discussed in psychotherapy and his vision can recover.

26.7. Complications arising

during treatment with hypnosis It is important that therapists are aware of the fact that during all phases of the hypnotherapeutic treatment for CD, unexpected phenomena and patient responses can arise. Usually these reactions are described as idiosyncratic responses to hypnotic suggestions (e.g. the raising of both arms when suggestions for unilateral arm levitation is given). For clinical practice the

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fact that these effects sometimes occur must be accepted. It must be understood, however, that when ‘something odd’ happens, it can often be woven into the intervention so as to support the therapeutic work. Moene and Hoogduin (1999) offer detailed guidelines as to how to accommodate these phenomena and utilize them in a positive and creative way. They describe a patient who has a generalized reaction to hand levitation. Their main message to the patient is that what appears to be an initial worsening or transformation of symptoms with hypnosis is really an opportunity for the patient to enhance control over the presentation of symptoms and improve the understanding of them. Illustration: Mrs D., with a hypnotizability score of 4 out of 5 [Stanford Hypnotic Clinical Scale (SHCS) Morgan and Hilgard, 1974] is treated for a paresis of the left leg. In the course of the treatment she is given instructions for hand levitation to which she responds positively. It is then suggested to her that because her arm has successfully and adequately responded, hypnosis might be the indicated method to learn how better to control body movements. Shortly afterwards the therapist sees her raising both legs spontaneously. The therapist decides to use this unexpected response. She tells Mrs D. that she must be a very talented hypnotic subject to be able to use so quickly what she has just learned, and she indicates that this could well mean that the recovery from the paresis will take place faster than initially expected. After this, the therapist gives Mrs D. suggestions about a further increase of the upward movement. She is then urged to concentrate intensely on the sensations in her paralyzed leg and become aware of these sensations to break through the blockage of sensation in this leg. Following suggestions of heaviness, formal hypnosis is ended. Further hypnotherapeutic sessions focus attention on feeling sensations and muscle contractions in the paralyzed leg.

26.8. The structure of the case

illustrations The hypnotic techniques described in the previous sections are seldom employed on their own in the treatment of CD and SD. In our view, a hypnotic intervention acquires its therapeutic

impact to the degree that it is embedded in a comprehensive and well-articulated therapeutic frame. Before we describe in detail the hypnotic strategies used with two CD patients, we first set the stage with a brief description of the therapeutic context in which these strategies were used at the psychiatric Hospital De Grote Rivieren in Dordrecht (The Netherlands) (for a fuller description, see Moene et al., 1998); Moene and Rümke, 2004).

26.8.1. The treatment model:

a brief outline Given the psychosomatic nature of CD and SD, both the assessment and treatment phases are carried out with the close co-operation of psychotherapists and physiologists. This enables a combination of psychological interventions and physical rehabilitation, which is of particular importance in the case of chronic motor symptoms.

26.8.1.1. Assessment phase 1. Somatic/neurological screening to rule out organic disorder. 2. Behavioral analysis by a psychotherapist: identification of predisposing, precipitating and perpetuating factors that triggered the onset of the symptoms (e.g. history of physical illness, life events); assessing psychiatric co-morbidity and investigation of relevant topics such as the patient’s own theories regarding the cause of the symptoms and involvement in insurance or juridical procedures. 3. Examination by a physiotherapist (including EMG assessments) wherein the symptoms and the consequential physical limitations are inventoried. The motor skills and limitations, the physical burden and the necessary help with activities of daily life are charted. 26.8.1.2. Consultation The patient and his family are offered a plausible rationale to explain the symptoms and the treatment model presented. It is important that the rationale squares with the patient’s subjective experiences and his belief system, and that the treatment is received by the patient as logical.

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26.8.1.3. Treatment phases 1. Psychotherapy (individual and/or systemic) focused on the precipitation, the maintenance and the consequential factors of the disorder. Cognitive-behavioral interventions are also directly focused on the symptoms. 2. Hypnosis that is symptom oriented or/and expressive. In order to make successful use of hypnosis, the patient must be hypnotizable, and have the ability to concentrate on sensory as well as the motor experience. Motivation is also required. It is important to explain the use of hypnosis and to discuss any lingering concerns. For this, the earlier mentioned facts about the relationship between hypnosis and CD are used. 3. Individual physiotherapy for training of the lost, reduced or altered physical functions and counteracting the possible secondary physiological consequences of long-standing CD, such as muscular atrophy, pain or poor blood circulation. 4. Group therapy aimed at improving the patient’s problem-solving techniques and social skills training to prepare patients for returning to normal social interactions without the symptoms.

26.9. Case 1. A symptomatic

approach using hypnotic imagery and behavioral methods Mrs Jones, a 46-year-old married woman with three children ages 21, 19 and 15 has conversion paralysis in both legs and the left arm, diagnosed as conversion symptoms in the context of a somatization disorder. She uses an electric wheelchair in order to move around. From her youth on, Mrs Jones experienced multiple physical complaints such as chronic fatigue, loss of muscle strength, difficulty standing and walking, paresis of the left arm, aphonia and double vision, all of which cannot be properly explained by medical examinations. She reports that she had been exposed to physical threats and explosive outbursts of anger from her father for years

and that he had sexually abused her once. Third parties confirm this. Mrs Jones had her first two children soon after getting married She was unhappy because it was necessary for her to work in the family business. Over the years, Mrs Jones consulted many physicians and specialists for her physical complaints. She received many explanations. She says that this made her feel very insecure. When she was 33 years old, her motor problems started. First, there was loss of strength in the left arm, and later paralysis of the same arm and of both legs. She was shocked and relieved to hear a diagnosis of multiple sclerosis during an eye examination. On the other hand, she also had her doubts about the diagnosis because her symptoms did not conform to those of multiple sclerosis patients. Her children and husband prepared themselves for having an invalid mother and wife. They shared the household tasks and received assistance from home help services. Several antecedent and consequent factors are identified as being relevant for the treatment. As assessed by the SHCS (Morgan and Hilgard, 1974; Oyen and Spinhoven, 1983) Mrs Jones was highly hypnotizable (score of 5 on the SHCS). Further, she appeared physiologically reactive to suggestions regarding her having multiple sclerosis and past abuse by her father (see also Brown, 2004). Other noteworthy factors were her belief that the symptoms were attributable to multiple sclerosis; her fear of being stigmatized if her neighbors knew of her psychiatric treatment; and her family’s reinforcing illness behavior. The assessment team (psychotherapist, physical therapist and, in this case, the neurologist) advised the couple that: (1) the patient does not have multiple sclerosis; and (2) the hospital specializes in the type of disorder that she does have. The patient was then told she has a diagnosis of CD, a disorder that is treatable. The patient was told that if she felt she must tell neighbors something about her treatment she can say ‘a dysfunctional muscle disorder was discovered that luckily can be helped with intensive training’. If the patient is convinced that muscles and nerve paths are irrecoverably defective, then mobilizing hope is quite difficult. Hence, the

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physiotherapist and the psychotherapist thoroughly explain the difference between the destruction of muscles and nerves resulting from organic injury and pathology associated with CD. Furthermore, Mrs Jones is told: People with conversion motor symptoms have forgotten or unlearned the conscious control of body movement, but this procedural knowledge is present at an unconscious level. The fact that patients can no longer consciously execute their movements has to do with a mechanism that is called dissociation. This occurs when people are under a lot of stress for a long period of time, are exhausted or have had drastic or traumatic experiences. Because of this, the conscious and unconscious (automatic) functioning of our movement has split apart. The nervous system is disrupted and the patient loses the conscious control of his voluntary movements. In a way it is a little like a computer. All the hardware can be present and installed in the correct manner, but if there is no well-functioning software, it is useless. The reason we use hypnosis is that for some patients it can help re-connect them with knowledge about movement—knowledge which they have unlearned because of stress. Once this connection is made, a patient can refine their movement pattern with the help of physiotherapy.

The explanation is supported with drawings and schematic representations of the body and of the psychological processes that the patient has experienced. The therapist elaborates with examples from the patient’s own history and symptom status. Finally, the therapist mentions that in case stressful or traumatic events are factors that have caused the disruption, they will be examined and dealt with in the treatment.

26.9.1. The phases of the hypnotic

strategy The first focus of the treatment with Mrs Jones is the paralysis of the left arm and the utilization of the fact that her right arm is still functioning normally. The hypnotic strategy consists of different phases: 1. Introduction of hypnosis and preliminary exercises. 2. Using the technique where the nonaffected limb teaches the affected limb.

3. Shaping of other movements of the paralyzed hand and arm. 4. Generalization of movements in normal daily life. 5. Imagination of normal functioning in the past with the paralyzed legs.

26.9.1.1. Introduction of hypnosis and preliminary exercises Mrs Jones learns how to relax her body with a combination of suggestive and relaxing visualizations. To create a positive and hopeful therapeutic climate, during hypnosis Mrs Jones is given the suggestion that she will now learn a new form of control over her body movements, but not by the exertion of her will, because patients with CD know that as they try to move, they cannot exercise this kind of willed and conscious control over their body movements. She is told that there is another kind of control, a more unconscious, automatic control that she will learn to apply skilfully in hypnosis. And when she will be able to move her affected limb in hypnosis, she can generalize this ability to the normal waking state. Then the physiotherapist will give her a training program to help her strengthen her muscles, and learn to co-ordinate her movements so that she will be able to walk and move again. This hypnotic exercise is audiotaped and like all of the following exercises, Mrs Jones is told to practice it herself twice a day, listening to the instructions recorded on the cassette, and register how deeply involved and relaxed she feels when doing the exercise (low, medium or high). 26.9.1.2. The nonaffected to affected limb technique The therapist uses the normal movement possibilities of the right arm and hand. The hypnotic technique called the nonaffected limb helps the affected one is then used in different variations. At first, arm levitation is induced with the right arm (unaffected arm). Mrs Jones is asked to open her eyes during hypnosis, to look at her arm and amaze herself that she is able to do this. Thereafter, she concentrates on the sensory and motor perceptions that are present in the nonaffected arm. She verbalizes and visualizes them. Then she receives a forceful suggestion that the

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right arm’s movement perceptions and the muscle tension will flow through from the healthy arm to the affected left arm, causing it to rise as well. The suggestion is given that she will experience this as she concentrates on the image of the affected arm making the same movement. Furthermore, all the possible physical perceptions in the paralyzed arm are suggested, stimulated and embedded in the framework of revitalizing the nerve and muscle activity. It is important that all of the perceptions that Mrs Jones reports, such as differences in temperature, stinging, tingling and muscle movements, including minuscule ones, are used by the therapist and expanded upon in order to achieve a first movement. Mrs Jones is successful in lifting her left arm a few centimeters. Now that Mrs. Jones has witnessed the movement, the therapist gives the post-hypnotic suggestion that she can relearn all the other movements that are needed to return the control of the arm to her. After hypnosis is terminated Mrs Jones watches the videorecording of the session and sees for herself what she has achieved. Just as with all of the following steps, she is vigorously praised. Mrs Jones then shares the video with her family. In the next sessions the therapist suggests both raising the arm (suggestions that it is becoming lighter) and lowering the arm (suggestions that it is getting heavier.

26.9.1.3. Shaping of other movements of the hand and arm Now Mrs Jones learns to make a fist and then to relax it. For this she must place her two hands next to each other on her wheelchair tray. During hypnosis, the therapist asks her to make a fist with her healthy hand, to concentrate on the perceptions of her hand and the muscle tension that is needed to make the fist. Then she is given suggestions comparable with the first exercise about the flowing through of movement-related perception to the paralyzed arm. She succeeds in making a fist with her paralyzed hand after practicing a few times and with encouragement from the therapist. Over a number of sessions other movements are similarly supported in the following order: moving the arms sideways, like directing an orchestra; folding her hands like as in prayer; moving her fingers by imagining that she is playing a piano;

and finally more routine daily movements. The movements are in the order of difficulty.

26.9.1.4. Further movements throughout the week When Mrs Jones masters the movements in hypnosis, she is given the post-hypnotic suggestion that: ‘You come out of trance after practicing, but the arm will stay in trance for a longer time so that the movements can be retained during ‘normal’ consciousness … every time more and more easily and longer … and that gradually only looking at the arm and imagining that it is functioning normally is sufficient to allow it to occur … and finally the movements will feel just as normal as those of the healthy arm … 26.9.1.5. Imagination of normal functioning in the past with the paralyzed legs The second phase of the treatment focused on the paralysis of both legs. In this case it is difficult to use the same method as with the paralysis of the left arm, because both legs are paralyzed. First the patient must literally witness her muscles generating movement. Therefore, the physiotherapist uses a form of electro-technical application, an EMG (electromyogram) by which Mrs Jones’ muscle contractions are awakened. The physiotherapist applies a local, mild and harmless electrical stimulus whereby muscle contractions are induced in one of the paralyzed legs. When the patient experiences the muscle contractions and sees them translated in an intensity graph on the display of the EMG apparatus, she is convinced that her muscles and nerve paths function well enough for her to regain control of them. It is also possible to evoke muscle contractions manually. When the physiotherapist varies the speed by which he moves the paralyzed leg of the patient, reflexive movements can be realized. When she succeeds in independently waking the contractions, the exercises are geared towards strengthening them. Thereafter, she practices daily with tensioning, and the amount of times that she succeeds in tensing the muscle group is recorded in a graph. Hypnosis is now used as an adjunct to the physiotherapeutic treatment. Mrs Jones is told that she can use her knowledge of her previous

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experiences with hypnosis to ‘get into contact with her legs’ and try to let all the physical sensations she knows from her arms now flow to her legs. Furthermore, it is suggested that she can help the therapeutic process when she imagines her legs moving. The therapist uses the age regression technique to go back to a time when normal movement in her legs was still possible. Then she has to choose a pleasant experience from the past in which she was standing and walking. The suggestion is given that: when you see yourself doing so, you can come closer and closer to yourself like a camera zooming in … and become more and more aware … of the feelings and sensations the movements give you … and then, at a certain moment … you yourself will be the one who is experiencing the standing and walking.

These exercises go well, but then a complication arises. There is stagnation in the physical rehabilitation program. It appears that Mrs Jones trains too intensively because she is afraid her family might think that she is not working hard enough in her therapy and that she will not be allowed to return home, but instead has to go to a rehabilitation clinic. This causes a great deal of anxiety which in turn compromises therapeutic progress. This is discussed with her to highlight the relation that exists between tension-provoking events and the worsening of her symptoms. After a family session with psychotherapist and physiotherapist in which this is discussed, Mrs Jones is reassured and she continues her training. Gradually the rehabilitation programme is expanded from single contractions in her legs and feet to complete movement patterns that are then generalized and aligned step-by-step with normal daily functioning. This last phase only begins when she has complete control over all the muscle groups in her legs.

26.9.2. Psychotherapy: discussing

somatization and trauma By way of recording complaints and keeping track of her exercise therapy results, Mrs Jones learns to see the relationship among tensionprovoking experiences better in the home situation or during the treatment, and her physical reaction to tension, which includes a worsening

of her existing complaints or the introduction of new symptoms. This reaction pattern is discussed in light of the somatization in her history. Sensitivity, physical vulnerability and past traumatic experiences are the keys that frame the explanation of her somatization. During the course of this expressive work, Mrs Jones, in the presence of her husband, releases her anger about her past by burning a mock childhood house that she had constructed in creative therapy.

26.9.3. Returning to normal activities

without the symptoms A few family sessions are devoted to helping Mrs Jones re-assume her proper place in the home. Family members speak openly about their often-ambivalent feelings regarding their mother’s sickness, and about the consequences it has had for them. The mere fact that Mrs. Jones is better forces family members to change routines.

26.9.4. Outcome After 4 months of treatment, Mrs Jones is released from inpatient care. She is assigned to outpatient aftercare for 2 years. During outpatient care she develops a psychogenic aphonia in reaction to tensions with her youngest daughter. She decides to use her self-hypnosis techniques to re-establish her ability to speak clearly. She is successful. At 2-year followup Mrs Jones is walking regularly, sometimes with, and sometimes without, a cane.

26.10. Case 2. A combination

of a symptomatic approach using catalepsy and exposure and an insight-oriented approach using revivification 26.10.1. Assessment phase Mrs Allen is a divorced 48-year-old nurse who presents with a 3-year history of shaking and rotating movements of her head and right arm that occur in sudden episodes. She reports that these movements are out of her control.

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In addition, she walks bent-over, which she associates with back and neck pain. Mrs Allen easily loses her balance and she falls on a daily basis. Furthermore, she has a noticeable speech disorder, slurring her words somewhat. Mrs Allen is either in a wheelchair or walks with the aid of a walker (zimmer frame). She can no longer perform her work and is on disability. Two years before the appearance of the complaints, Mrs Allen discovered that her husband had been having a long-term extramarital affair, and had fathered a 15-year-old child. With this discovery, Mrs Allen’s relationship with her husband worsened. For a long time during her marriage she was violently abused. Her husband would beat her around the head and shoulders. Mrs Allen was ashamed of her symptoms and gradually withdrew socially, having contact only with her brother who supported her as best he could. Assessment revealed Mrs Allen to be a good hypnotic subject (SHCS = 4). She was hypothesized to be sensitive to the automatic activation of the cognitive and somatosensory representations associated with the traumatic events, e.g. the physical abuse by her ex-husband and his verbal threats. Other maintaining factors were her social phobic complaints and social isolation.

26.10.2. Consultation During the consultation, Mrs Allen receives the following hypothetical but plausible rationale for her complaints: Happily, the examination shows that your muscles and nerve paths are in good order, but your locomotion has been disrupted. Your physical movements seem to have a life of their own. You do not have full conscious control over movement any more and you are not able to calm your body down when you want to. We know that your complaints were caused during a long period in which you were under a lot of pressure because there were a lot of traumatic experiences in your relationship with your ex-husband. It was then necessary for you to protect yourself physically from him. You consciously reacted to your abuse with this protection pattern. You bowed down and protected your head with your right arm. Because this pattern of movement was repeated over and over again in a context of fear, this movement was of vital importance for you.

It is possible that it has become an automatic ingrained response and reveals itself as a kind of reflex whenever the tension increases. This occurs regardless of the fact that there is currently no direct physical danger in your life. We understand that you are not consciously aware why you are having symptoms. We have seen these reactions in the animal kingdom. A famous example of this is the phenomenon of head-withdrawal. When an animal has been regularly hit in the past, it always ducks away even in safe situations when someone with a raised hand approaches them quickly. Everything that has happened to you had not only physical consequences for you, but also psychological consequences. That is why you feel more anxiety and are less sure of yourself, and you don’t dare leave the house as much. You have been avoiding social situations and find yourself in a vicious circle through which your world is getting smaller and smaller. Attention will be given to these facets in your treatment. Do you recognize these things in yourself?

The treatment plan contains the following: gaining insight into how the movements began and discussing the important experiences from her history (hypnosis/psychotherapy); an exercise program to learn how to re-gain control of the movements (hypnosis/psychotherapy); and participation in a group therapy program to improve her assertiveness and developing social contacts and activities.

26.10.3. Hypnosis and psychotherapy First, Mrs Allen becomes familiar with hypnosis and autohypnosis (induction; deduction; deepening). She also practices with audiotaped ego-strengthening exercises, and in hypnosis she creates a symbolic ‘safe place’ for herself where she can go when she needs it. Then, age regression is used in order explore the emotions associated with the symptoms. To help Mrs Allen become accustomed to reflecting on the past in hypnosis, the therapist suggests she return to pleasant and positive events in her life. During hypnosis she reflects on incidents of being physically abused by her ex-husband. She remembers an argument about the extramarital affair. Her ex-husband hits her on the head several times. While in hypnosis Mrs Allen describes being very anxious; she tries to protect

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herself by holding her arms to her head and turning her head away. She starts reacting with the same movements that burden her. The therapist decides to utilize the situation therapeutically and describes what he sees happening, and he re-labels her behavior in a positive sense: You duck and try to protect yourself against the strikes that you receive. This was the only way you were able to protect yourself from your ex-husband’s physical overpowering, but at the same time you resist with all of your strength. The severity of your movements shows how great your strength and resistance were against the negative approach of your ex-husband.

The therapist encourages Mrs Allen to express her emotions and to say to her ex-husband what she thinks of him. Then the suggestion is given that her muscles can relax afterwards and that calmness can come to her body. Eventually the movements calm down and finally cease. The therapist then gives a three-part post-hypnotic suggestion: (1) she now knows what the movements represent; (2) she has now experienced how decisive and strong she actually is; and (3) the exercise program can teach her how to regain the control over her muscle movements. The exercise program consists of learning catalepsy (see p. 631). First the therapist teaches Mrs Allan catalepsy of the arm. Achieving this is complimented and she is asked to direct her attention to how the sensation of catalepsy feels and to store this information in her memory so that she can invoke these experiences in hypnosis (i.e. cue conditioning for rapid procedure). Afterwards, the catalepsy is discontinued by shaking the arm. This exercise is practiced a number of times until Mrs Allen succeeds in inducing the catalepsy in a very short time. Then she practices with the left arm and with both arms. Next Mrs Allen practices with this method when her complaints are actually present, first together with the therapist and then independently. When she is able to sit sufficiently calmly for a long enough time, a self-control procedure is practiced, the so-called 1–2–3 technique. This technique reverts back to what she had practiced earlier, namely the cue conditioning for rapid procedure. The therapist practices with Mrs Allen while both are standing. He supports

her shaking arm and wrist, and extends the arm until it is in a horizontal position. Then he asks Mrs Allen to go into hypnosis and to concentrate on the sensations of catalepsy with the following suggestions: (1) concentrate on your shoulder and on the sensation of catalepsy: calm, rest, control; (2) let that feeling flow through to your elbow: calm, rest, control; and (3) let that feeling flow through to your hand: calm, rest, control. Then the therapist guides the arm down until it hangs limply, and the procedure is practiced again. The procedure is repeated every time the arm or hand shakes or trembles until she restores calm. Through this, Mrs Allen also gains more control when performing normal daily movements. Gradually an attitude of self-efficacy develops where Mrs Allen has a quiet confidence that she can master the symptoms. Eventually, Mrs Allen practices with small role-plays to retain the catalepsy in more difficult situations such as with open eyes, while talking with the therapist, in the home situation and in public places. The 1–2–3 technique is repeated each time she begins to shake. In this way she learns to be in control of her complaints anywhere she is, and to intervene early, when there is only a glimmer of a problem. During the therapy sessions, the therapist found it important to be aware of Ms Allen’s breathing. There is often hyperventilation or shallow breathing associated with the motor symptoms. Suggestions to breathe deeply and to allow for breathing from the stomach are effective when Mrs Allen masters the method she practices at home. With assistance, and with gradual exposure to social situations, Mrs Allen succeeds in going outside again and visiting people.

26.10.4. Outcome Near the end of the 3-month inpatient treatment, and merging into the outpatient therapy, Mrs Allen’s gradually returns to daily life, spending more and more time at home. She continues to practice hypnosis intensively at home. She is prudently vigilant for difficult or burdening situations which might trigger symptoms. She does not return to work, but she does do volunteer work for a few half-days

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during the week. This gives her the freedom that she needs. Her slurred speech has improved 75 percent without having paid any specific attention to it in treatment. The intervals between her aftercare appointments are continually extended and are finalized after 6 months. At one year follow-up, her treatment gains were maintained.

26.11. Discussion and

conclusions The main purpose of this chapter was to discuss a comprehensive protocol for the treatment of CD and SD, including the use of hypnotic techniques Several theoretical models and neurophysiological studies emphasizing the parallel between hypnotic and conversion phenomena support the use of hypnosis in the treatment of CD. Group studies as well as clinical case studies support that notion that hypnosis can be helpful for some patients suffering from CD. For these patients, customized hypnotic techniques appear to help restore motor control via indirect and direct suggestions Although hypnosis was not identified as a necessary factor in the treatment model described in this chapter, the comprehensive treatment program as a whole appeared to be highly effective. These findings are in line with the findings from a review by Wade (2001) indicating that a multidisciplinary rehabilitation approach with several simultaneous interventions may be most successful. Such an eclectic approach is consistent with the fact that CD and SD constitute a heterogeneous group with differing etiological backgrounds. The argument that CD should be treated as a symptom rather than a primary diagnosis appears to be quite valid. Although primary attention should be paid to symptom reduction within all treatment strategies, comorbidity should also determine the specific choice of treatment or combination of treatment strategies. For example, patients having SD with a long-standing history of conversion symptoms combined with pain require different treatment than SD patients having a history where sexual and/or physical abuse predominated.

Another complicating factor in the treatment of CD is that the connection between conversion symptoms and psychological triggers is often clear. When this is the case, our default option is to focus on the physiological, social and psychological consequences of the symptoms. The physiotherapeutic treatment takes the lead role, and the psychotherapeutic interventions are mainly geared towards breaking through the social and psychological barriers which maintain the symptoms.

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Hoogduin, C. A. L., Akkermans, M., Oudshoorn, D. N. and Reinders, M. (1993) Hypnotherapy and contractures of the hand. American Journal of Clinical Hypnosis, 36: 106–112. Hoogduin. C. A. L., Moene, F. C., Näring, G., Sonneveld, J. and Brans, H. (1996) Insultprovocatie bij de diagnostiek van conversiestoornis met toevallen. Tijdschrift voor Directieve Therapie, 4: 371–385. Janet, P. (1907) The Major Symptoms of Hysteria. MacMillan, New York. Janet, P. (1925, 1976) Psychological Healing, Vol. 1 (2 vols). Macmillan Reprint, Arno Press, New York. Kallman, W. M., Hersen, M. and O’Toole, D. H. (1975) The use of social reinforcement in a case of conversion reaction. Behavior Therapy, 6: 411–413. Kihlstrom, J. F. (1992) Dissociative and conversion disorders. In D. J. Stein and J. E. Young (ed.) Cognitive Science and Clinical Disorders, pp. 247–270. Academic Press, San Diego. Kop, P. F. M., Van der Heijden, H. P., Hoogduin, C. A. L. and Schaap, C. P. D. R. (1995) Operant procedures applied to a conversion disorder. Clinical Psychology and Psychotherapy, 1: 59–66. Kroger, W. S. and Fezler, W. D. (1976) Hypnosis and Behavior Modification: Imagery Conditioning, pp. 289–295. Lippincott Company, Philadelphia. Kuyk, J., Spinhoven, P., Van Emde Boas, W. and Van Dyck, R. (1999) Dissociation in temporal lobe epilepsy and pseudo-epileptic seizure patients. Journal of Nervous and Mental Disease, 187: 713–720. Lauerma, H. (1993) Nocturnal limb movements in conversion paralysis. Journal of Nervous and Mental Disease, 181: 707–708. Litwin, R. and Cardeña, E. (2000) Demographic and seizure variables, but not hypnotizability or dissociation, differentiated psychogenic from organic seizures. Journal of Trauma and Dissociation, 1: 99–122. Lorenz, J., Kunze, K. and Bromm, B. (1998) Differentiation of conversive sensory loss and malingering by P300 in a modified oddball task. NeuroReport, 9: 187–191. Ludwig, A. M. (1972) Hysteria: a neurobiological theory. Archives of General Psychiatry, 27: 771–777. Mace, C. J. and Trimble, M. R. (1996) Ten-year prognosis of conversion disorder. British Journal of Psychiatry, 169: 282–288. Marsden, C. D. (1986) Hysteria—a neurologist view. Psychological Medicine, 16: 277–288. Marshall, J. C., Halligan, P. W., Fink, G. R., Wade, D. T. and Frackowiak, R. S. (1997) The functional anatomy of a hysterical paralysis. Cognition, 64: B1–B8. McNally, R. J. (2003) Remembering Trauma. The Belknap Press of Harvard University Press, Cambridge, MA. Merskey, H. (1979) The Analysis of Hysteria. Balliere, Tindall and Cassell, London. Moene, F. C. (2003c) Aanvalsgewijs optredende dissociatieve klachten. In O. van der Hart (ed.) Trauma, Dissociatie en Hypnose, handboek, Deel 2, Hoofdstuk 11. Swets and Zeitlinger, Amsterdam pp.335–356. Moene, F. C. and Hoogduin, C. A.L. (1999) The creative use of unexpected responses in de hypnotherapy of patients with conversion disorders. International Journal of Clinical and Experimental Hypnosis, 47: 209–227.

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Moene, F. C. and Rümke, M. (2004) Behandeling van de Conversiestoornis. Praktijkreeks Gedragstherapie, deel 20. Bohn Stafleu Van Loghum, Houten. Moene, F. C., Hoogduin, C. A.L. and Van Dyck, R. (1998) The inpatient treatment of patients suffering from (motor) conversion symptoms: a description of eight cases. International Journal of Clinical and Experimental Hypnosis, 46: 171–190. Moene, F. C., Spinhoven, Ph., Hoogduin, C. A. L. and Van Dyck, R. (2001) Prediction of outcome in patients with motor conversion disorder, treated with hypnosis and a multimethod treatment program. In F. C. Moene (ed.) Hypnosis and Conversion Disorder: Assessment and Treatment Issues, pp. 157–168. Cure and Care Publishers, Zeist. Moene, F. C., Spinhoven, Ph., Hoogduin, C. A. L. and Van Dyck, R. (2002) A randomized controlled clinical trial on the additional effect of hypnosis in a comprehensive treatment programme in patients with conversion disorder of the motor type. Psychotherapy and Psychosomatics, 71: 66–76. Moene, F. C., Rümke, M. and Jongerius, A. M. M. (2003a) Behandeling van de conversiestoornis. In C. van der Feltz-Cornelis and H. van der Horst (ed.) Handboek Somatisatie: Lichamelijk Onverklaarde Klachten in de Eerste en Tweede Lijn, pp. 221–232. De Tijdstroom, Utrecht. Moene, F. C., Spinhoven, Ph., Hoogduin, C. A.L. and Van Dyck, R. (2003b) A randomized controlled clinical trial of a hypnosis-based treatment for patients with conversion. International Journal of Clinical and Experimental Hypnosis, 51: 29–51. Montgomery, J. M. and Espie, C. A. (1986) Behavioral management of hysterical pseudoseizures. Journal of Behavior Psychotherapy, 14: 334–340. Morgan, A. H. and Hilgard, E. R. (1974) The Stanford Clinical Scale for Adults. American Journal of Clinical Hypnosis, 21: 134–147. Morrison, J. (1989) Childhood sexual histories of women with somatization disorder. American Journal of Psychiatry, 146: 239–241. Munford, P. R. and Paz, G. (1978) Differential attention in the treatment of astasia-abasia. Journal of Behavior Therapy and Experimental Psychiatry, 9: 369–371. Nehmia, J. C. (1991) Dissociation, conversion and somatization. In A. Tasman and S. M. Goldfinger (ed.) American Psychiatric Press Review, 10, pp. 248–260. American Psychiatric Association, Washington, DC. Norman, D. A. and Shallice, T. (1986) Attention to action: willed and automatic control of behavior. In R. J. Davidson, G. E. Schwartz and D. Shapiro (ed.) Consciousness and Self-regulation, 4. Advances in Research and Theory, pp. 1–18. Plenum Press, New York. Oakley, D. A. (1999a) Hypnosis and conversion hysteria: a unifying model. Cognitive Neuropsychiatry, 4: 243–265. Oakley, D. A. (1999b) Hypnosis and consciousness: a structural model. Contemporary Hypnosis, 16: 215–223. Oakley, D. A. (2001) Hypnosis and suggestion in the treatment of hysteria. In P. W. Halligan, C. Bass and J. C. Marshall (ed.) Contemporary Approaches to the Study of Hysteria: Clinical and Theoretical Perspectives, pp. 312–330. Oxford University Press, New York.

Ohno, Y., Mineyasu, S., Takeya, T., Akagi, M., Tanaka, Y. and Ikemi, Y. (1974) The treatment of hysterical blindness by behavior therapy. Psychosomatics, 15: 79–82. Oyen, F. and Spinhoven, Ph. (1983) Nederlandse bewerking van de SHCS. Tijdschrift voor Directieve Therapie, 2: 155–172. Patterson, R. B. (1980) Hypnotherapy of hysterical monocular blindness: a case report. American Journal of Clinical Hypnosis, 23: 119–121. Putnam, F. W. (1989) Pierre Janet and modern views of dissociation. Journal of Traumatic Stress, 2: 413–429. Roelofs, K., Näring, G. W. B., Keijsers, G. P. J., Hoogduin, C. A. L., Van Galen, G. P. and Maris, E. (2001) Motor imagery in conversion paralysis. Cognitive Neuropsychiatry, 6: 21–40. Roelofs, K., Keijsers, G. P. J., Hoogduin, C. A. L., Näring, G.W. B. and Moene, F. C. (2002a) Childhood abuse in patients with conversion disorder. American Journal of Psychiatry, 159: 1908–1913. Roelofs, K., Hoogduin, C. A. L., Keijsers, G. P. J., Näring, G. W. B., Moene, F. C. and Sandijck, P. (2002b) Hypnotic susceptibility in patients with conversion disorder. Journal of Abnormal Psychology, 3: 390–395. Roelofs, K., Van Galen, G. P., Keijsers, G. P. J. and Hoogduin, C. A. L. (2002c) Motor initiation and motor execution in patients with conversion paralysis. Acta Psychologica, 110: 21–34. Roelofs, K., Hoogduin, C. A. L. and Keijsers, G. P. J. (2002d) Motor imagery in hypnotic paralysis. International Journal of Clinical and Experimental Hypnosis, 50: 51–66. Roelofs, K., Van Galen, G. P., Eling, P., Keijsers, G. P. J. and Hoogduin, C. A. L. (2003) Endogenous and exogenous spatial attention in patients with conversion paresis. Cognitive Neuropsychology, 20: 733–745. Roelofs, K., Spinhoven, Ph., Sandijck, P., Moene, F. C. and Hoogduin, C. A. L. (2005) The impact of early trauma and later life-events on symptom severity in conversion disorder. Journal of Nervous and Mental Disease, 193: 508–514. Roelofs, K., de Bruijn, E. R. A. and Van Galen, G. P. (2007) Hypersensitivity to conflict in conversion paralysis. An event-related potential study. Biological Psychology, 71: 316–325. Ron, M. A. (1994) Somatisation in neurological practice. Journal of Neurology, Neurosurgery, and Psychiatry, 57: 1161–1164. Ron, M. A. (2001) The prognosis of hysteria/somatization disorder. In P. W. Halligan, C. Bass and J. Marshall (ed.) Contemporary Approaches to the Study of Hysteria: Clinical and Theoretical Perspectives, pp. 271–282. Oxford University Press, Oxford. Roy, A. (1979) Hysteria: a case note study. Canadian Journal of Psychiatry, 24: 157. Sacerdote, P. (1970) Theory and practice of pain control in malignancy and other protracted or recurring painful illnesses. International Journal of Clinical and Experimental Hypnosis, 18: 160–180.

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CHAPTER 27

Trauma-related disorders and dissociation Mary Jo Peebles

27.1. The domain of the

problem The term trauma-related disorders, instead of simply trauma, is used in the title of this chapter because people who need a trauma-focused psychotherapy can present in hidden ways. Posttraumatic stress disorder (PTSD) is the clearest and most familiar presentation; however, people who have been traumatized alternatively can suffer no lasting symptomatology, can present with symptoms of dysregulation (of emotions, of self, of impulse control or of physiology) or can even develop severe psychiatric disturbances such as borderline personality disorder, schizoaffective illness with psychosis or dissociative identity disorder. What this chapter addresses is the application of hypnosis when a careful evaluation of the patient’s symptoms, history and functioning determines that a trauma model of psychotherapy is called for. Dissociation is also addressed in this chapter because dissociation is a coping mechanism commonly called into play when there has been trauma. In fact, if a person’s struggle to restabilize after trauma has reached the point that psychotherapy is necessary, dissociation has usually become problematic in some way. Being able to recognize both blatant and subtle forms of dissociation helps us locate traumatic triggers for the patient and fend off unhelpful

abreactive flooking. Helping the patient learn to use dissociation adaptively, and repairing the splits in self-integration caused by chronic overuse of dissociation, are also part of any traumafocused work. These skills become particularly salient when hypnosis is included in trauma treatment because hypnosis is an altered state which is itself to some degree dissociative.

27.2. The clinical application 27.2.1. What do we mean by a

trauma model? It can be argued that there are four core frameworks for organizing the direction and focus of a psychotherapy process, whatever one’s theoretical language and emphasis (Peebles-Kleiger, 2002a). The trauma model is one of these core frameworks. This model is used when we need to (1) re-regulate biological and neurological processes and processing that have become chronically unstable and dysregulated due to trauma; and (2) re-integrate fractures in the experience of self, significant others, memory, processing of emotion and orientation to the world left by the efforts to cope with trauma. Across multiple theoretical perspectives (e.g. behavioral, cognitive, psychodynamic, relational/ humanistic), the consensus has emerged clinically and empirically that trauma-focused work contains three necessary aspects: stabilization;

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controlled reprocessing; and integration. These aspects are frequently referred to as phases; however, the term, ‘phase’ is misleading because it implies a linear progression from one step to the next. Trauma work is never that linear. It is more overlapping and recursive. We stabilize; bits of memory pop out and we focus on regulating the remembering; simultaneously we reinforce the stabilization; some integration takes place; but then new unexpected but related slices of memory pop out to shake up the stabilization and integration once again. And so it continues. It is helpful, though, when describing the specific tasks and methods within the three phases, to discuss them independently. Peebles-Kleiger (2002a, pp. 148–165) devotes a chapter to outlining these tasks and methods, and she provides examples of implementation from several theoretical viewpoints. The reader is referred to that text for a summary of the basic methodology and the rationales (and research supporting those rationales) behind the particular tasks and methods within each phase. A number of other texts describe therapeutic work with these patients in even more detail. They examine the special technical aspects of psychotherapy with these patients and describe how cultural, developmental and forensic matters influence the course of treatment (e.g. Courtois, 1988, 1999; Herman, 1992; van der Kolk et al., 1996; Bromberg, 1998a; Brown et al., 1998; Chu, 1998; Solomon and Siegel, 2003; Koenig et al., 2004).

27.2.2. Hypnosis and trauma There is a wealth of clinical material on the use of hypnosis in the treatment of trauma. Brown and Fromm (1986, p. 273) summarize the early literature detailing with how hypnosis has been used to treat traumatic reactions going back to the treatment of hysteria during the late nineteenth century and the treatment of ‘shellshocked’ solders in both world wars. Brown and Fromm also summarize a key paradigmatic shift in the application of hypnosis to trauma treatment that mirrored a shift in psychotherapy in general. Originally, theorists posited that trauma-related pathology was caused by terrifyingly intense affect that nonetheless remained

unexpressed (Breuer and Freud, 1893–1895; Janet, 1909, 1919/1925). It was believed a cure could be realized by using hypnosis to enable the patient to abreact the painful memories, as if the patient were purging herself of psychic toxins. In fact, Breuer and Freud call this approach the ‘cathartic method’. Within that original paradigm, hypnosis was used to access memory in order to re-live its full emotional impact. It is universally understood now that, by itself, abreaction is not sufficient for recovery, and can in fact risk psychological damage when used as a stand-alone approach. Therefore, the current paradigm of trauma treatment keeps mastery, stabilization and integration at the core of healing, with exposure to memories being secondary and cautiously dosed. The utilization of hypnosis in trauma treatment has correspondingly become measured, carefully focused and expanded with the aim of including fostering of self-regulation, internal/external boundaries, amplification of the healing aspects of the therapeutic relationship, boundaries between past and present, and choice. There has been a special interest in finding creative ways to deepen integration via imagery, metaphor and amplification of corresponding sensorimotor cues. In short, while hypnosis is rightly still used to enable the patient to encounter troubling memories and feelings, it is even more critically useful in establishing the sturdy therapeutic frame required of this work: a context of alliance, support and hope, all in service of stabilization, controlled reprocessing and integration (e.g. Brown and Fromm, 1986; Peebles and Fisher, 1987; Peebles, 1989; Spiegel, 1993; Fromm and Nash, 1997; Brown et al., 1998). The consensus about the interface of hypnosis and trauma treatment is that, again, hypnosis is merely a particular state or experience, which is being used in the context of therapy to further a range of therapeutic (not forensic) goals. Using hypnosis as a forensic tool is an entirely different enterprise that is fraught with controversy and ethical challenge. Therefore, when using hypnosis in the context of treatment (particularly trauma treatment), one needs to (1) ensure that the rationale for the hypnotic intervention is securely embedded in the therapeutic frame; (2) stay centered on the fact that nothing about

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hypnosis trumps the lawfulness of human memory with all its profound plasticity; and (3) be knowledgeable about the legal/ethical obligations to inform patients about the purpose of using hypnosis therapeutically and to disabuse them of the notion that hypnosis will reveal ‘what really happened.’ A number of instructive texts address forensic concerns: Kluft (1994), Brown et al. (1998) and Lynn and McConkey (1998). This chapter will confine itself to therapeutic issues only. Dissociation is a broad-ranging term with many aspects. It refers to the general process of severing associations or connections, be they connections between ideas, between thinking and feeling, between different emotional or personality aspects of oneself or between events in time. Subjectively, dissociation can be felt by a person as a foggy, spacy, ‘zoned-out’ mental state or as a numbed physical state that is akin to feeling wrapped in cotton. Sometimes, the world can feel unreal, like a dream. Dissociation can occur outside one’s awareness and be apparent only to others, such as when a person blanks-out something they said or did or loses time. In and of itself, dissociation is not pathological. It is a universal phenomenon that has a biological base and carries adaptational value for survival. It is ubiquitous in children as a coping strategy. Its temporary, mild use in adults can be protective and helpful. However, when dissociation takes over one’s perceptual and cognitive style; when it becomes one’s primary coping strategy; or when it becomes so severe that a person ceases to track entering and exiting dissociation, and no longer maintains awareness of experiences held within different subjective realms, then dissociation becomes problematic. Prolonged use of dissociation (frequently seen with severe, chronic trauma) creates serious disruptions in continuity of experience that can create splintering in one’s sense of self and eventually in identity and reality. What once might have been a pliable protective device supporting resilience, becomes instead a brittle, desperate attempt to disengage radically from painful material. It compromises or even fragments identity, and it saps vitality. A comprehensive literature exists on the use of hypnosis in treating and repairing serious

disorders of dissociation such as dissociative identity disorder (Putnam, 1989; Kluft and Fine, 1993) and on the use of hypnosis in working therapeutically with less serious and more common dissociative conditions (Watkins and Watkins, 1997; Frederick and McNeal, 1999; Frederick, 2005). These texts provide comprehensive, detailed and research-informed protocols for utilizing hypnosis in the work with disorders of dissociation. This chapter is informed by these invaluable sources as well. It would be natural to assume that when reference is made to utilizing hypnosis within trauma treatment, one is referring to standard, formal trance procedures, comprised of aspects of induction, deepening, suggestion and debriefing. Certainly, this sequence occurs. However, in actual practice, it is the management of spontaneous trance that is called even more frequently into play—how to recognize spontaneous trance, work within it and reverse it if necessary (and know which is needed when). Familiarity and comfort with working within informal trance induction can be indispensable to the work, and is a more common use of hypnosis in trauma treatment than is typically written about. It is important to understand that hypnosis is only one of many tools that can help in the treatment of trauma. A traumatized mind is a mind that has been fractured. As clinicians, we have at our disposal multiple methods to repair fractures in the mind (e.g. cognitive interventions to re-set disfigured beliefs and expectations; relational appreciation of how to use the therapeutic relationship to mend fractured templates of self and others; behavioral interventions to rewire conditioned responses; psychodynamic interventions to strengthen and repair damaged capacities to regulate emotion and check reality). That said, a clinician who is familiar with hypnotic phenomena has an inside track into the ways in which the dissociated mind experiences and communicates. In this regard, experience with hypnosis is second only to experience working with children when it comes to developing a clinician’s capacity for the type of listening and communicating required in trauma-related therapeutic work. To study hypnosis (and to work with children) is to become intimately familiar with the mind’s

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nonlinear and creative capacities: (1) to compartmentalize, being simultaneously aware and yet unaware of sensations, perceptions and thoughts (Hilgard, 1977); (2) to shift the focus of attention, allowing more, or less, into awareness; (3) to allow seemingly divergent realities to co-exist unquestioningly; (4) to process through imagery not words; (5) to experience another’s unspoken thoughts or emotions with the same sensory vividness as if they’d been explicitly spoken; and (6) to encounter sensory sensations of thought or image so vivid that it is as if action has occurred. In short, experience with hypnosis allows the clinician fluency in the syntax of the dissociated mind so he can better hear and bring forth the details and nuances of the world inside the patient’s outer presentation.

27.2.3. The technique: illustrated by

clinical examples What does the work actually look like? The response will vary because each clinician is different and encounters different kinds of patients with different kinds of trauma depending on the nature of her particular practice. The examples I will present come from my practice as a solo clinician seeing higher functioning, self-pay clients. I will describe two trauma-focused cases in which I wove hypnosis into the psychotherapy experience. The first case is an example of utilizing hypnosis without formal induction, and the second is an example of utilizing hypnosis with formal induction with someone who requested hypnosis. Neither patient presented requesting help with trauma. (This is characteristic of most of the people in my practice with whom I do trauma-focused work.) To try to draw out principles that are likely to be common among the work of different clinicians, I will intersperse, among the descriptive details of the work, referenced commentary on the ideas driving my inferences and choices of intervention. I will put this commentary in italics to distinguish it from the case description.

27.3. Case 1: Dr E. 27.3.1. Background Dr E. was a physician, with his own small, but successful, self-run clinic. He employed a handful

of personnel—a receptionist, nurses and a bookkeeper. Since his leaving a group practice about 10 years before, he had preferred operating solo. The downside was his having to manage all aspects of the practice, medical and nonmedical. The upside was he could craft a practice which best suited his interests and temperament. Dr E. was nearly 46 years old and had been divorced for 2 years when he came to me. He had been treated first by a psychiatrist because he had been having trouble sleeping and had flirted with the idea that he might be depressed. Hence he sought medication which might help him with both problems. He was not particularly interested in therapy. First, he had watched his ex-wife be in therapy throughout her life, and he was unimpressed with the results. Second, there was a quick-stepping, skittish quality about him, and taking a pill appealed to the part of him who wanted a rapid diagnosis and quick results. Uncharacteristically, after seeing him in intake, the psychiatrist asked for psychological testing. The psychiatrist detected something about Dr E. that did not quite fit together. Dr E. was too enthusiastic and energetic to be classically depressed and, although he complained of intermittent bouts of suicidal thoughts, he did so without much angst—in fact, his spontaneous, ruddy-faced smile and quick, good-natured way of using his wit to laugh at himself rendered him charmingly engaging. The psychiatrist found himself pulled to join the patient in laughing off darker material. Hence the referral for testing. Dr E. could be both skeptical and earnest. Both were equally true. Thus, although skeptical of testing, he agreed to it. The results were sobering. The psychologist who did the testing was pessimistic about Dr E.’s capacity to change with any kind of psychotherapy and even about his ability to comply reliably with a medication process. He (the psychologist) believed the patient to have a significant, previously undiagnosed problem with alcohol abuse that appeared, from the psychologist’s view, to underlie the majority of the patient’s troubles. Further, he saw him as having significant difficulty trusting others, a limited capacity for introspection and troublesome problems regulating his emotions, with the potential for lapses in emotional control. The psychologist was concerned that any therapy

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process could quickly spiral into a competitive dance driven by suspicion, a sense of vulnerability and a resulting need to dominate the process. His summary diagnosis was that the patient suffered from an antisocial personality disorder, with depressive, self-defeating and schizoid traits. Suffice it to say, the psychiatrist was discouraged by the test results, and therefore unsure what to offer Dr E. that could be of much help. Medication for depression seemed only weakly indicated; the psychiatrist offered medication targeting the sleep difficulty instead. In addition, Dr E. had also mentioned, somewhat in passing, that he was frustrated with difficulties in sexual performance that had been cropping up in his dating since his divorce. The psychiatrist knew I did some biofeedback, and he referred Dr E. to me with the rationale that a medicalized, computerized, quantitative approach to an isolated symptom (e.g. sexual difficulties) might be the only place to begin.

27.3.2. The range of clinical

presentation—commentary The fact that someone has experienced a traumatic stressor does not guarantee that they need treatment. Conversely, people who come to us with neither initial report of traumatic stressors nor overt, classic PTSD symptoms may turn out not only to need treatment, but to require a treatment focused on trauma. Confidence in one’s capacity to recognize when treatment is required, and when that treatment requires a traumarelated focus, is strengthened by knowing some of the statistics about traumatic stressors and people’s reactions to them. Interestingly, most people have experienced a traumatic event. According to surveys of tens of thousands of people in the USA, approximately two-thirds of adults in the USA report having experienced a traumatic stressor during their lifetime (Breslau et al., 1991, 1998; Davidson et al., 1991; Norris, 1992; Pope and FeldmanSummers, 1992; Resnick et al., 1993; Fairbank et al., 1995; Kessler et al., 1995). In countries or cultures subjected to chronic war, famine, terrorism or political torture, the percentage is even higher (Monagle, 1999). However, the response to a traumatic stressor varies immensely depending on the characteristics of the stressor, the qualities

of the person and the nature of the recovery environment (Green et al., 1985). Simply having experienced a traumatic stressor does not mean the person will need therapy. Statistics regarding the impact of the nature of the stressor on response suggest that single-event natural disasters, that affect single (rather than multiple) dimensions of a person’s life, are the least toxic to one’s psychological health in the long term. In one study, the majority (85 percent) of people exposed to natural disasters (meeting DSM criteria for a traumatic stressor) did not develop symptoms reaching threshold for a PTSD diagnosis (van der Kolk et al., 2005). In contrast, stressors of an interpersonal nature (particularly when chronic, particularly when they include violence and most particularly the earlier they occur in one’s childhood) render the individual at special risk for complicated, lasting effects of psychobiological dysregulation typically not captured in the DSM diagnosis of PTSD. A sampling of such symptoms of dysregulation includes suicidal feelings, difficulty regulating affect, self-injury behaviors, substance abuse, promiscuity and dissociative symptoms, among others. Van der Kolk and colleagues (2005) found that interpersonal abuse typically led to dysregulatory symptoms, and that the younger one was when the interpersonal abuse began, the more likely it was that dysregulatory symptoms emerged. In their study, the majority of children (61 percent) who suffered interpersonal victimization before age 14 developed some combination of dysregulatory symptoms, while only 8 percent of people who had suffered natural disasters developed such symptoms (van der Kolk et al., 2005). Sometimes severe, chronic interpersonal trauma is a factor contributing to even more severe psychiatric disorders such as borderline personality disorder or schizoaffective disorder. For example, Michael Stone’s (1990) classic study of the treatment and outcome of 500 hospitalized patients discovered that a history of parental incest, parental brutality or both figured in the histories of 24.8 percent of patients diagnosed with borderline personality disorder; this percentage was even higher when patients were included whose abuse had been at the hands of nonfamily members. In the same study, a trauma history was more prevalent (27 percent) than genetic

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predisposition (12.5 percent) in Stone’s cohort of schizoaffective patients. Further, the group of schizoaffective patients with genetic contribution did not overlap the group with incest history, suggesting the hypothesis that severe interpersonal traumatization could fracture one’s mind to the same psychotic extent that genetic predisposition could. As Stone put it, ‘… these patients may have come into the world not especially vulnerable genetically, only to succumb to a condition in every way mimicking a mixed psychosis— a condition set in motion purely by the same extremes of sexual/physical abuse that, under other circumstances, give rise to the syndrome of multiple personality. Here we may legitimately speak of a “posttraumatic psychosis”… certainly, realitytesting may give way under the impact of severe trauma … (1990, p. 238, emphasis Stone’s). Finally, it is helpful for clinicians to be aware that PTSD rarely occurs alone without other symptoms and disorders also being present. Eighty-eight percent of people diagnosed with PTSD have at least one other psychiatric diagnosis and 59 percent have three or more disorders (van der Kolk et al., 2005; Spinazzola et al., 2005). The most common of these co-existing diagnoses are depression (48 percent) and alcohol abuse (52 percent); additional, frequently co-occurring diagnoses are substance abuse and phobias. People with PTSD are 15 times more likely to have made a suicide attempt than those without the diagnosis. Stating it differently, 1 percent of people with no psychiatric diagnoses attempt suicide; 4 percent of people with a psychiatric diagnosis attempt suicide; but 20 percent of people with PTSD attempt suicide (Spinazzola et al., 2005). Notably, it is often these other diagnoses that create the attention necessary to bring the person to therapy, rather than any mention of trauma. It takes awareness, careful listening and a good history to reveal the possibility that a focus on trauma may help organize the treatment work effectively. It is clear from these data why using hypnosis in the treatment of trauma-related disorders goes beyond familiarity with the PTSD diagnosis alone. Clinicians who will be using hypnosis in the treatment of trauma will need to be experienced in treating a variety of psychiatric conditions and a range of severity of disorganization and destabilization.

27.3.3. The therapeutic relationship I should explain that, although I do some biofeedback work in my practice, it is confined to basic measures of autonomic arousal such as shallow breathing, skin temperature, galvanic skin response and muscle tension. I had never used biofeedback to treat disorders of sexual performance, nor did I have special training in sex therapy per se. However, the psychiatrist was a long-standing colleague of mine. We had worked together closely over the years; we had a sense of each other’s work. I did not question his referral for those reasons. I understood that sometimes, in the density of a clinical moment, we may have a sense of what the patient might need or where to begin without having all the words immediately to back up our impressions. Because I trusted my colleague based on multiple previous clinical experiences with him, I did not focus on the overt disconnection between what he said the patient needed and what my skill-box could provide. Instead, I began with the premise that what I could provide and what the psychiatrist sensed the patient needed overlapped somewhere. We just did not know where quite yet. I liked Dr E. immediately. Rather than being withdrawn or aloof (as the test report term, ‘schizoid traits’, might suggest), he appeared full of life—he was both engaging and mentally quick. He jousted pugnaciously and gamboled delightedly with word usage. He loved exercising his mind, and seemed to want someone to play with. Simultaneously, he restlessly tossed off insights with scrappy vigilance, but with an impish edge. It was as though he were testing if I were alert; if he could defeat me; if he could speed past me; if I would keep up with him; if there was the chance he might trust me; if disappointment was inevitable; if all this would become the same old game it always turned out to be. One could see by the color in his cheeks and the sparkle in his eye that this complex mixture of ingredients created the kind of encounter that made him come alive. I remembered the psychologist’s words, ‘competitive dance’. But I also remembered the adjoining qualifying phrase, ‘driven by suspicion and vulnerability’. Where was the suspicion and vulnerability, and what were they about?

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When I asked him to tell me a little bit about himself, he spoke spontaneously about his early life. He was the oldest and only son of four children, born to a wealthy, powerful attorney and a beautiful socialite. He felt that to his mother he could do no wrong, and yet, as he described vignettes of his mother, she seemed to be constantly shaping him, pulling him in quite close emotionally, and instructing him in how to satisfy women better than his father did. He described how, when he was latency aged, she schooled him in the importance of attending to a woman’s feelings, and when he was an adolescent, she alluded to bedroom details to illustrate the boorishness in his father that he should decidedly not emulate. He described his father as someone volatile and immense, who used his razor-sharp intellect and penetrating gaze to bore into a person with withering exactitude, shredding them into pieces and throwing them away. He painted scenes of father’s ruling the house with his rages, and he wondered aloud, as he spoke, if father might have been bipolar. Dr E.’s demeanor, as he was describing his father, was one of rueful, flushed, good humor, as if you just had to laugh at what a character that guy, his father, was. Yet, when I asked him if he had ever been scared, he remembered something his mother once told him after his father died: that as early as age 2, whenever father entered the room, Dr E. used to shake uncontrollably. The test results had puzzled and floored him, but again he spontaneously laughed as if to say, ‘What else can you do but laugh at stuff like that?!’ He remembered the psychologist telling him that not only was alcohol a major problem, but that he was the kind of person who was probably physically abusive in the house. Dr E. said he drank, but not more than two to three times weekly and never to the point where he blacked out or felt ‘drunk’. He reported never having laid a hand on anyone physically in his house. (The psychiatrist reported to me that Dr E.’s ex-wife had concurred with Dr E.’s report about this.) When I asked Dr E. what he most wanted to get out of treatment, he seemed to forget for a moment that he had been referred to me because of his sexual difficulties. Instead, in a moment of sudden, unexpected clarity and

openness he stated, ‘I talk a lot, but nothing changes, nothing connects’. He went on, ‘I want somehow to reconnect, my mind with my body, and vice versa’. The plaintive lucidity of this simple wish spoke of a man who was open to his feelings and his experience … and potentially to relationship—how else could he know something was missing, and how else could he share and admit that to me? This was puzzlingly discrepant with the test report findings of ‘difficulty trusting’ and ‘limited capacity for introspection’. On the other hand, the quality of Dr E.’s speech did echo something the testing psychologist must have been registering. I noticed that although his face was flushed and his body was taut with radiating energy, the pupils of his eyes were tightly controlled lenses. They were pinprick holes, tiny apertures, within a sea of unmoving, gray glass. Was that his suspiciousness peering out? I also noticed that Dr E. talked very quickly. His mind was like the spinning of a hummingbird’s wings. Sometimes ideas were glanced at, and flitted between, in such rapid succession that a paragraph of words could become blurred in meaning to me. I began to realize I was getting overwhelmed. It was not the quantity of ideas, or an inability to track segues between them intellectually. What I could not hold onto were the multiple emotional resonances building inside me—the inner reverberations to each of Dr E.’s ideas, with every reverberation opening multiple doors within me, stimulating even more reverberations, that began accruing with overwhelming speed and intensity until there was nothing but an internal spinning of emotional information, none of which was being spoken to or acknowledged by Dr E. Was that what the psychologist had called a limited capacity for introspection? I began to feel like a passenger in a car with no brakes. I was hurtling at breakneck speed, one minute dazzled at the mesmerizing landscape and another minute, dizzy with a tinge of motion sickness. Soon, nothing was any longer dazzling; instead, I began to feel slightly numb. I found myself watching, rather than interacting. I needed to push myself and exert energy to try to open up space into the conversation. When I finally did speak, to try to comment on something he had just said, I fumbled and felt lost, oddly and uncomfortably mentally frozen.

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27.3.4. The classic three of trauma

reaction—commentary Given the multiple ways trauma effects can present, what helps the clinician consider the possibility of trauma when its presence is not immediately apparent? In this regard, Horowitz’s (1986) rigorous fieldwork identifying the biphasic qualities of intrusion and avoidance has withstood the test of time, and does cut across the range of symptom presentation, if one tracks both their blatant and sophisticated manifestations. Horowitz’s findings form the basis for two of the three symptom clusters of the PTSD diagnosis. In its blatant manifestations, intrusion refers to the repetitive, involuntary re-experiencing of feeling, image, thought or behavior fragments of the original traumatizing events, and avoidance refers to ways of getting away from awareness, memory or sensory registration of stimuli that trigger re-experiencing aspects of the traumatizing events.

Sophisticated dissociation There are two types of sophisticated intrusion/ avoidance: sophisticated dissociation and sophisticated abreaction. Here I comment on the former. In Case 2, I comment on the latter. What is important to keep sight of clinically is that intrusive and avoidant phenomena can be less dramatic than described in DSM. They can be embedded, in sophisticated ways, within the person’s manner of speaking, relating and behaving. In my practice, the blatant forms of intrusion such as dramatic flashbacks or blatant avoidant (dissociative) behavior such as a stunned, blanched face with sightless stare occur more with: (1) people with recent, acute, adult-onset trauma (more classic PTSD); (2) patients who have been in therapy for a while and whose work has purposely focused on loosening automatic coping styles to access underlying intensity; (3) people who are constitutionally fragile and who thus perhaps never reliably stabilized with consistently dependable coping mechanisms in the wake of early, chronic trauma histories; or (4) patients who may have been fairly stabilized, but who suffered a recent traumatic stressor that unexpectedly triggered emotional access to an early trauma history. For different reasons, these four groups of people are less well protected from the raw immediacy of the original memories, and thus show

less disguised, more dramatic manifestations of intrusive and avoidant phenomena. However, for a large group of patients seen in an outpatient clinical practice, intrusive and avoidant phenomena take on subtler forms. This frequently occurs for people with a history of chronic interpersonal trauma, but who (perhaps because of internal/external resources such as intelligence, imagination, special skills, ways they had to escape, a person in their early environment who served as a stabilizing touchstone) have found sophisticated ways to use their intellectual and interpersonal skills to cope, fit in and be productive. These people may not complain of trauma memories, but instead are troubled by depression, chronic dissatisfaction in relationships, problems with temper, etc. Upon questioning, they may reveal significant symptoms of dysregulation (e.g. trouble sleeping, irritability, difficulty regulating spending, intermittent struggles with substances, history of mild or significant eating disorders, history of verbal outbursts or history of feeling run-over by others because of not speaking, history of sexual disorders) that the patient hadn’t thought of as primary issues. It is helpful to listen carefully as the patient speaks—to open oneself to the experience of the patient’s speaking, momentarily toning down the precise tracking of each word. When rapid (even lively seeming) verbal agility does not stir engagement in the therapist but instead incurs a sort of numbing and dissociation, or an experience of feeling overwhelmed, then the therapist may be experiencing a sophisticated manifestation of the patient’s dissociation. The patient’s voice inflections may seem expressive, but in fact are too many or too ‘bright’, or just enough off the message to create mental confusion within the therapist rather than clarity and emotional engagement. Or, the patient’s nonverbal mannerisms—arrhythmic agitations of the hands or shifts in the body—form complicated, nonrepeating patterns that can’t be accommodated to and thus begin to distract and confuse. Rather than the hands extending the message of the words, they obfuscate and thus create gaps in the therapist’s registration of the words. The line of conversation becomes pockmarked into discontinuous bits, which then can’t be encoded by the therapist as an organized whole, and thus can’t be tracked or remembered easily. Like all forms of avoidance, sophisticated

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dissociation protects the patient by distancing him from his own emotions and memories, and by distancing his therapist from feeling an immediate emotional connection with him (that could risk stirring flooding relational memories).

2.7.3.5. The counter-transference I have not always known what to do with feeling numb in a therapy session. In fact, it has only been after figuring this out that I have realized, in retrospect, I had previously been ashamed of and anxious about my reaction. I had thought something was wrong with me (wrong with my psyche, wrong with my empathy)—why else was I beginning to get fuzzybrained and having difficulty feeling in the session? So I had tried to hide the reaction from myself, not letting the awareness of it last long. When it popped up, I would try various ways to alert myself mentally (occasionally even surreptitiously trying to pinch myself!), almost as if I were trying to force myself into a beta wave state. However, once it became clearer to me that this was a feeling, like any other, and as such could be tolerated and explored and considered as a potential expression of the affect reverberating back and forth within the space between me and the patient, then the recognition of it as dissociation was immediate—because it was now mentally allowable to me for consideration. By the time I was treating Dr E., I had gained some familiarity with recognizing and working with my reaction of numbing so that it took only a couple of sessions with Dr E. for it to reach my awareness with him. The awareness was still not immediate, however, because Dr E. was so expressive and lively that my brain was confused by the contradiction between his liveliness and my numbness. In addition, I think something in me was activated by Dr E.’s unspoken competitiveness and challenge to keep up with him; as a result, I became reluctant to admit that I was not up to the task. But once I was able to accept being aware of being numb, I then had a helpful piece of information about something that was happening in the room between us. Being able to name the numbness (i.e. call it dissociation) made it possible for me to work mentally with it; e.g. ‘If I am dissociating, I must be getting emotionally overwhelmed

because dissociation is a signal of overload’. And further, ‘Maybe Dr E.’s rapidly skating across ideas, without sinking into the emotion of them, is his own sophisticated form of dissociation that is protecting him from feelings or awarenesses that otherwise might overwhelm him’.

27.3.6. Trauma and counter-

transference—commentary An intriguing, and potentially highly rewarding aspect, of doing depth, relational work in psychotherapy (which is the base from which I listen) is that we as therapists are one instrument or medium through which the patient expresses herself. The patient moves through us. Thus, listening carefully means more than just tracking words attentively. It also involves attunement to one’s self and the resonances that begin bubbling up from within, be they physical sensations, images, meandering thoughts, emotions or attitude. Attunement is not hypervigilance. It is openness to what is there, without judgment or premature conclusions. From this space, counter-transference becomes so much more than the historical definition of projecting our conflicted feelings or relational expectations onto the patient, distorting an accurate registration of what is there. Certainly this happens, and is part of what a therapist learns to recognize and learn from. But we have learned to language a few additional aspects of counter-transference over the one hundred years the concept has been written about. There is the aspect of counter-transference in which the patient projects into us unspoken ways she feels or undescribed ways people in her life have felt towards her. This aspect provides a rich window into a patient’s internal world and thus becomes an invaluable tool in any treatment, but particularly in the treatment of trauma in which so much is initially unworded (PeeblesKleiger, 1989). There is also the aspect of counter-transference in which parts (aspects or selves) of the patient interact with parts of us at an underlying, unspoken level. There is always a subtext of interaction at a nonverbal level within the therapy room—various simultaneous realities if you will—in which different aspects of the patient are engaging with different aspects of

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oneself in interchanges or choreography that create simultaneous, multilayered dimensionalities to what is being spoken aloud. Allowing awareness of these dimensionalities opens a richness to the listening in which so much more can be heard and eventually worded between patient and therapist. This expands the space of awareness within the patient, opening up the potential for letting hidden, split-off parts emerge and eventually become available to her in her own ongoing, internal conversations. Languaging intersubjectivity (and accepting it) in the field of dynamic psychotherapy has allowed clinicians to speak more frequently about this reality of the work rather than its being relegated only to the domain of work with psychotic patients (such as described by Searles (1979) or Grotstein (1994)). Some have spoken of this process as unconscious communication (Mayer, 1996); others, as listening with the third ear (Reik, 1948), or intuition (Gladwell, 2005; Piha, 2005). Freud wrote about it as telepathy (Freud, 1921; Devereux, 1953; Ehrenwald, 1955; Meerloo, 1964; Eisenbud, 1970). Certain research provides a physiological understanding of it as entrainment of brain waves and rhythms of activation (Linton et al., 1977; Banyai et al., 1982; Russek and Schwartz, 1994; McCraty et al., 1998, 2004–2005). Hypnosis heightens it (Baker, 2000; Peebles-Kleiger, 2001). In addition, awareness of the interplay of the patient’s multiplicities with one’s own multiplicities is essential to reparative trauma treatment because splintering of the self is inevitable in trauma, and mending such splinters requires being able to hear that which is being hidden or is unworded, as well as that which is being spoken. However, that which is being hidden in the patient often communicates only through what is hidden or unworded in the therapist. Some call this process enactment; others call it conversations among and between self-states of ‘not-me’ or ‘unsymbolized relational experience’ (Bromberg, 1998b, 2003; Chevetz and Bromberg, 2004). Thus, listening to what is not being spoken, with multiplicity in mind, and to oneself as well as to the patient, makes possible the enlivenment of and access to multiple self-states in an aggregate way, which is at the heart of reparative work with trauma patients.

Multiplicity—the continuum Being comfortable conversing within the metaphor or literalness of ‘parts’, without worry about pathology or disintegration, can add an invaluable medium (i.e. an imagistic, transitional play space that can communicate more than words) to the verbal psychotherapy work with trauma. It can be helpful to consider the possibility that multiplicity and nonlinearity are more the pervasive norm of human experience than the exception. Psychoanalysis may have been misleading in this regard when it originally conceptualized imagistic, sensory-based thinking as expressions of the ‘immature’ mind (Brenner, 1973, p. 49). This particular aspect of mind was the place in which negatives or conditionals held no meaning, in which mutually contradictory ideas could co-exist peacefully, in which several different thoughts could be represented by a single image or allusion, and in which a sense of time did not exist or limit the boundaries of thought. Later analysts (Kris, 1936) explained how creativity required access to that place of mind, but, still, the expression for this access, ‘regression in the service of the ego’, continued to convey the idea that nonlinear, imagistic, multiplistic thinking was inferior to languagebased, sequential thought (and thus was ‘regressed’ to) rather than a vital, necessary and co-equal expression of adaptive mental functioning.1 However, when developmental studies of children gained ascendancy over reconstructive theories of childhood, the notion of co-existence of multiple states of mind, and co-equal importance of nonlanguaged sensing and sense of self, became normalized. Stern (1985) described how different evolutions of mentalization and sense of self ‘remain(ed) fully functioning and active throughout life. All continue to grow and coexist’ (p. 11), rather than later ones replacing earlier ones. Dahl (2005) spoke to the psycho-neurological logicality of multiplicity when she described how the very structure of the child’s mind changes so much with each year of growth that a subjective experience of literally ‘different minds’

1 Gill and Brenman (1959) pointed out how hypnosis could provide access to this sensory, imagistic, timeless style of thinking.

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is an inevitable part of normal development. As Bromberg (1993) wrote, ‘the experience of being a unitary self is an acquired, developmentally adaptive illusion’ (p. 182), and ‘the self (is) a multiplicity of “self-states” that during the course of normal development attain an aggregate experience of coherence that overrides the awareness of their discontinuity’ (Bromberg in Chefetz and Bromberg, 2004, p. 419). To keep oneself oriented within this metaphor of parts and concept of multiplicity, one can consider a continuum of creative, to average, to problematic. The more access to and comfortable flexibility among parts, the more creative one can be. Conversely, the more rigidly segregated the parts of self are in terms of inaccessibility, amnesia and isolated impenetrability, the more brittle the personality and the more likely the person is to be symptomatic and in need of therapeutic help. Within this particular theoretical perspective, the goal of treatment becomes aggregation of parts (however flexibly or rigidly subdivided), not integration (Chefetz in Chefetz and Bromberg, 2004, p. 432).

27.3.7. Formulating hypotheses It is important, as a check when formulating hypotheses, to generate more than the one that first occurs to us. So, to myself, I wondered whether (instead of a reflection of traumabased, sophisticated dissociation) Dr E.’s rapid thinking and speaking could perhaps reflect a mild form of bipolar disorder, given his expansiveness of thinking, his energetic congeniality, his father’s possible mood disorder, and the volume and pressure of his thinking. Or, perhaps I was simply having trouble keeping up with an intelligent, narcissistic man? In search of more hypotheses, I noticed aloud with Dr E. how quickly he jumped among things and asked him if he had noticed or thought about that. He tossed off my observation with a laugh saying that he’d thought for years he probably had attention deficit diorder (ADD). He noted his difficulty attending to detail, being on time and keeping his records organized; he credited his receptionist for keeping his professional life straight. So now I was juggling several possibilities, each of which took us in a slightly different treatment direction: Dr E. might need help with the expansive thinking of a

bipolar disorder; he might protect himself in narcissistic ways; he might have ADD; and/or he could be showing indications of a possible complex trauma etiology. Further, what were we to make of the fact that his psychological test report concluded that Dr E. was unreflective, resistant to change and possibly antisocial? Clearly Dr E. had revealed flickers of a capacity for openness to himself and hints of a reaching out to me. Although intellectually agile, Dr E. certainly was neither emotionally slick nor unconcerned in the way one sometimes thinks about someone with an antisocial personality disorder. The shifting variegations of color hues across his face as we interacted revealed the impact the encounter was having on him. Thus, maybe there was more potential here for a relational connection … but under what conditions could this potential be tapped? It occurred to me that whether Dr E. and I only kept a symptomatic focus on the mechanics of sexual performance, or whether (and how) we pursued a more broad-based expressive therapy, pivoted on clarifying the diagnostic issues outlined above. As a way of reaching for that clarity, I decided to examine the raw test data (i.e. his actual test responses and scores) upon which his recent psychological test report had been based. To do this, I asked him for, and received, his written permission to request his original test data from the examining psychologist.

27.3.8. Hyperarousal—commentary As a result of the body’s emergency response during the fear and anxiety aroused during perceived danger, the autonomic nervous system goes on high alert, churning out excessive amounts of cortisol, glutamate, norepinephrine and dopamine, and frequently lowering serotonin. This state of high alert can disrupt sleep and concentration, and can create chronic irritability, an emotional ‘short fuse’, and/or hypervigilance with an exaggerated startle response. Some research has suggested that when it persists over time (particularly during early development of the brain), chronic hyperarousal, with the cascade of chemicals associated with it, can result in learning disabilities, ADD and a range of neurobiological disorders of regulation (Everly, 1995; Friedman et al., 1995; van der Kolk 1996; De Bellis et al., 1999;

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Gurvits, et al., 2000). Reversing hyperarousal and helping the patient learn to self-regulate is key in reversing the negative effects of trauma; in fact, the persistence of chronic hyperarousal (in particular, the symptom of prolonged sleep deprivation) is one of two elements associated with failure to resolve acute trauma (Mellman et al., 1998; Maercker et al., 2000). Hypnosis, with its capacity for down-regulating and its quality of being able to be taught to the patient as a tool she can take with her, is particularly well suited for this work. When patients enter therapy with multiple symptoms of chronic hyperarousal, traumatization is one of several etiological possibilities.

27.3.9. Dr E.: Case formulation The formulation of there being a trauma base to Dr E.’s difficulties did not occur to me in exactly the sequence, linear fashion and intellectual precision that I am laying out here. Up to this point in this narrative, this written explanation of my thinking has contained much more verbal exactitude and articulation than existed at the time. This narrative is an accurate description of what was occurring, but at the time, so much of my mentalization was occurring simultaneously and experientially. It was only upon examination of the test data, that the analytic part of my thinking became fully engaged and the pieces began to fit together. The first thing that struck me in the test data was that the diagnosis of ADD was in fact not supported by the test results. His measure of working memory (the ability to retain multiple pieces of information and accurately manipulate them) was at the 99th percentile. No other measures to assess ADD had been given. What was I to make then of his rapid, scattered thinking? To discern whether a diagnosis of ADD was justified clearly required further testing. And what we had so far suggested it might not be the source of his agitation. The projective tests revealed Dr E. to be an open man, but one for whom life was an ongoing struggle to fend off severe dysregulation.2 He was 2 I interpret projective tests from a model of integrating quantitative, norm-referenced data with repeating dynamic themes, not from a model of generating subjective, symbolic conclusions about the images given (Peebles-Kleiger, 2002b).

highly reactive to feeling triggers, particularly anger and violence. He struggled to keep his balance by tracking all that he was seeing and trying to account for everything. Often, he was remarkably creative when doing so. But, when affect was too intense, his reasoning and clear perception became strained and sometimes unraveled. He tried to master his anxiety with his humor. Sometimes this worked and sometimes it was not enough, and at those latter times, his burden and sense of desperation became manifest. Relationships and connection were a second source of potential dysregulation. Dr E. had a capacity for solid, co-operative and even intimate relationships. However, too often these kinds of connections opened him up to a sense of loss or uncontrolled helpless, whirling or falling. When that happened, Dr E. could get alarmingly expansive and intensely in charge—but that was his effort to regulate the out-of-control, dangerous falling. Or, he could look ‘narcissistic’—but it was the kind of narcissism that was a retreat into the solitude of nature or literature as a regulatory self-protection; it was not a summary of his relational capacity. When there was a gentleness and sensitivity between two people, Dr E. could allow the closeness of touch and appreciation that brought him a sense of peace. However, sensitivity was a two-edge sword for him—it brought with it a shadow of femininity for him that opened him up to a flooding of dysregulated violence and confused perceptions all over again. In technical terms, Dr E.’s testing responses did show characteristics indicative of bipolar depression. Simultaneously, however, the solidity of his psychological strengths, punctuated by the suddenness and severity of his sudden drops into dysregulation, also spoke to trauma. Further supporting this latter hypothesis were his responses to a self-report questionnaire asking about early memories. On that page, Dr E. listed arrestingly succinct descriptions of a boy in danger and knocked about, for instance: I remember being repeatedly slapped across the face by my father for lying about having thrown a stone near my younger brother … (I was) held and spit upon in seventh grade by a group of class bullies … (when I was) five years old, my father discovered me sleeping on razor blades I had pulled out of the top of the linen closet to play with in my room before falling asleep.

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On the next page, he wrote that writing down those memories was ‘uncomfortable’, and that from filling out the questionnaire, he had learned, ‘The human capacity for suppression is nearly endless.’ After considering the test report, Dr E.’s actual test response data, his interpersonal presentation (his rapidity of speech and thinking with the complementary dissociation induced in the relationship), his historical information (father’s violence, mother’s sexual intrusiveness, significant peer bullying) and his presenting symptoms (sleep problems, sexual dysfunction, self-reported difficulty sustaining organization and attention, Internet addiction, occasional tightness of breath, drivenness to adrenalin rushes via constant crises—all indicators of hyperarousal, possibly chronic), I formulated a working hypothesis. Dr E. struggled with underlying depression (as he had suspected), and very probably a bipolar depression. However, there was substantial support for considering the core of his difficulties to be significant emotional, relational and biological dysregulation that was an expression of a complex trauma response. The degree to which his depression could be understood as a byproduct of the complex trauma response would need to be determined after an adequate trial of treatment. The testing psychologist’s summary diagnosis of antisocial personality disorder needed to be integrated into the working formulation; clinical mistakes are made whenever we try to resolve complexity by eliminating conflicting data rather than puzzling over how to synthesize it (PeeblesKleiger, 2002b). My thought was that perhaps the DSM criteria that originally galvanized the psychologist’s diagnosis of ‘antisocial’ were irritability and aggression, impulsivity, failure to maintain consistency, failure to conform— all of which could be equally thought of as expressions of dysregulation, particularly dysregulation triggered by aggression—the very emotion shown in the test data to be particularly dysregulating to Dr E. and the emotion associated with his early ‘uncomfortable’ memories. The testing psychologist’s summary diagnosis of ‘schizoid traits’ could be alternatively understood as Dr E.’s seeking refuge in solitary, self-engaged, self-protective absorption in literature and nature (as illuminated by the test data).

Finally, the testing psychologist’s summary diagnosis of ‘self-defeating behaviors’ was a helpful heads-up as to the direction Dr E.’s aggressive dysregulation and depressive trends might take him should those affects get the upper hand.

27.3.10. Dr E.: treatment plan Dr E. had been referred to me for biofeedback in association with his difficulties initiating and sustaining sexual performance in dating relationships. However, in speaking with him, it became clear he needed more, and my read of the situation was that he could make use of more. The problem was that the very thing he needed—a relationally based psychotherapy focused on complex trauma—risked triggering his self-protective efforts to control, compete, entertain, isolate and/or combat, because it was closeness with another that threatened him with ghosts of traumatic memories. Still, I knew from the test data, and from his engagement with me, that he was hungry for connection, and capable of it if one could work with him to maintain the delicate balance of safe conditions. So, I spoke forthrightly with him. I drew him back to his early words, ‘I talk a lot, but nothing changes, nothing connects … I want somehow to reconnect, my mind with my body, and vice versa’, and explained my theories about why things remained disconnected in him. I speculated that this core disconnection, based on complex trauma, was probably at the root of his sexual difficulties … and his other difficulties as well. I described to him how he needed a psychotherapy that was more than the hand-holding he had cynically thought was all his wife had received; how he needed repeated experiences of safety, stabilization and intellectual mastery in the face of tolerably re-experienced encounters with closeness, anger and loss in order to ‘rewire’ the associational pathways and conditioned reactivity and dysregulation. I said a twice-weekly frequency would be ideal.

27.3.11. What is trauma; what is traumatic?—commentary The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (American

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Psychiatric Association, 1994) defines a traumatic stressor thus: The person has been exposed to a traumatic event in which both of the following were present: 1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others; 2) the person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior (p. 209).

As carefully refined as this DSM-IV definition is, clinical realities are still more complex. What is traumatic is that which delivers a blow to the continuity of experience so powerful that it fragments the experience of continuity itself. The brain cannot hold the experience in mind because the intensity of emotions neurochemically inhibits the capacity to track it intellectually, or the unimaginability of the event(s) shatters pre-existing constructs for how people and the world work, or the pieces of the experience are so incompatible with each other that the very effort to hold all the pieces together splinters the mind that is trying to do so. Thus, it is not only, as DSM defines it, threats to one’s physical integrity that can be traumatic; it is also threats to one’s mental integrity— threats to one’s confidence in tracking reality, to one’s sense that core people are predictable and safe, to one’s sense that the world is stable, and to one’s confidence that one can be effective when it’s not—that can be traumatic as well. And chronically fragmenting interpersonal experiences, witnessed or lived, experienced at an early enough age, can threaten mental integrity and exterminate the child’s ability to take the safety and inevitability of his thinking, his world and his future for granted. Thus, a hand need never have been laid on the child to create symptoms of traumatization. Chronic fear and confusion are destabilizing, at a neurological level, in and of themselves (e.g. witness the fracturing effects of long-term exposure to a double-bind communicative style (Bateson et al., 1956)). And it is the chronicity of such destabilization—chronic dysregulation—that lies at the point of convergence of the damaging neuro/bio/psycho/social effects of trauma (Ford et al., 2005).

We speak of the effects of chronic, early trauma as having a neurologically ‘wired in’ quality because the early interpersonal environment literally shapes and builds (in terms of volume, synaptic pathways, neurochemical and neurohormonal release, and dendritic growth) the way the developing brain processes events, reaches conclusions and regulates mind and body. Relatedly, the attunement and containment, or lack thereof, provided by early caregivers across both normative and unexpected emotional overstimulation literally create, or fail to create, the connections in the child’s brain (between frontal lobes and limbic system) for regulation, thus rendering his brain capable of steadying itself or vulnerable to short-circuiting (Schore, 1994, 2003a,b). This is essential information for clinicians who are treating trauma. Its understanding helps us have acceptance and respect for the invincibility of certain triggered reactions; because we are fighting the reality of years of conditioned neurological responses, we are best off directing our clinical energies toward helping the patient learn to catch and over-ride these responses rather than aiming to extinguish them. Its understanding gives clarity as to why stabilization and self-regulation are so essential to trauma treatment: A continuously agitated mind is mimicking the original trauma neurology— hurtling the brain into a continuous abreactive experience—and a continuously agitated mind cannot register and absorb new experiences (Lupien and Lepage, 2001; Buchanan et al., 2006). Its understanding also offers a neural explanation for the necessity for corrective relational experiences and the necessity for there being repeated multiple times as a way of effecting ‘new’ ‘re-wiring’. The characteristics of the child’s early attachments subsequently influence the qualities of the relationships he is familiar with and thus gravitates toward as an adult. He seeks out more of the same because that is all he has known; anything different is experienced as foreign psychologically and thus feels like a disjunctive or odd, noncompelling experience. For those with histories of childhood traumatization, this gravitating toward more of the same results in continually re-exposing oneself to repeated traumatization. The continued re-traumatization cements in one’s expectations of self as

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fragmented, disconnected, depressed, overwhelmed, ineffective, etc. The continued re-traumatization also conditions automatic expectations of others as inevitably disappointing or damaging. Further, the continued retraumatization continually re-bathes the brain in stress neurochemicals and neurohormones contributing, some research suggests, to neurologically based problems with chronic emotional reactivity, difficulty maintaining calm focus (ADHD), substance-use difficulties, etc. These processes are believed ultimately to shape the brain itself (see Hyperarousal, pp. 657–658). Thus, research is ample to support that what constitutes a traumatic stressor extends beyond what DSM has thus far identified and includes chronic interpersonal experiences of dysregulation as well. Bromberg (2003) states, ‘Trauma (is accurately defined) not according to its specific content, form, or objective magnitude, but by the degree to which it cannot be held or contained by a person without a flooding of unintegratable affect’ (p. 690). I recommend Bromberg’s definition of trauma because it offers a comprehensive umbrella for a variety of traumatic events (shortlived and chronic, long ago and recent, physically threatening and psychologically threatening) that alert us to the need for applying the trauma model to psychotherapy. In addition, Bromberg’s definition communicates implicitly the reasoning behind the trauma model of treatment: if the flooding of unintegratable affect is the source of the brain’s and mind’s fragmentation, then the treatment becomes slowing the flood down enough so that individual threads of the experience can be picked out, named, made discussable, eventually reliably recognized, all within the context of a continuously regulating other. In these ways, the previously unintegratable affect becomes integratable. When this happens, the person has a chance to know her experience rather than only being blown away by it; she has a chance to get some distance and begin to connect the dots intellectually; she begins to feel known; feeling known helps her begin to feel more in one piece, maybe with some hope and some beginnings of trust; and at that point she stands a chance of rebuilding a new map of in what ways the world, people and good things may be counted upon. This model of trauma treatment strives for a sort of ‘re-wiring’ of the brain

through deconditioning responses, creating alternative associational pathways and developing more reliable neuropsychobiological regulatory systems.

Simple versus complicated (complex) trauma Being described in several ways throughout this chapter is the concept that the treatment of trauma, and the use of hypnosis in its treatment, can be simpler or more complex depending on the kind of traumatic event, when it occurred in the person’s life and how long it went on. The more an event is a single event, of brief duration, with no man-made violence, occurring in adulthood, the more it will evoke a ‘simple’ or less complicated trauma response. In contrast, the more the trauma consists of multiple events, over extended time, with man-made violence, and occurring in childhood, the more the trauma will create a complex trauma response. A ‘simple’ trauma response is severely destabilizing, but its resolution can be more straightforward because: it tends to create fewer fractures within the person’s continuity of self and experience of others; the disruptions in one’s experience of safety in the world tend to be more easily repaired because there is a fabric of stable, predictable experiences to fall back on; and the treatment work is not saddled with reworking gnarly, relationship-hampering characterological traits that arose as protective responses to trauma or having to rewire conditioned neurochemical responses that, if left untreated, continue to destabilize continually. This is due to the neurocognitive impact prolonged hyperarousal can have on the developing brain and, consequently, the child’s developing emotional, interpersonal and coping style capacities. For example, prolonged stress creates excessive excitatory stimulation of the central nervous system. This prolonged excessive stimulation can be toxic by releasing a cascade of excitatory neurotransmitters (glutamate, norepinephrine, dopamine) which in high concentrations are capable of damaging or destroying the neural substrates they serve, as well as lowering the stimulation threshold for subsequent hyperarousal effects (Everly, 1995; Friedman et al., 1995; De Bellis et al., 1999a). This neural excitatory toxicity damage translates into effects

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such as memory and concentration impairment, aggressive behavior or hyperirritability, attention deficit and diminished affiliative behavior (see Gurvits et al., 2000). Additional neurobiological effects include diminished serotonin levels (van der Kolk, 1996), complex shifts in cortisol levels (Everly 1995; van der Kolk, 1996) and impairment in limbic system function as well as possibly structure (van der Kolk, 1996; De Bellis et al., 1999b; Metcalfe and Jacobs, 1999). These effects are associated, respectively, with hypersensitive, irritable, and impulsive behavior, impairments in memory and concentration, and disruptions in assessments of danger and explicit memory formation. Thus, the child exposed to the chronic overstimulation of fear, anxiety or a sense of danger is at risk for temporary or permanent impairment to neurocognitive systems that regulate arousal and the encoding of information about the world. The psychological implications for a child of such neurocognitive events are substantive and complex (Perry et al., 1995; Thomas, 1995). Dysregulation of arousal systems, hypersensitivity, disruptions in the assessment of danger and proneness toward aggression and impulsivity naturally are going to have a profound negative impact on the maturation of emotional regulation capacity. Difficulties attending, concentrating, remembering and assessing danger will negatively affect developing interpersonal capacities including self-esteem and attachment structures (e.g. Nathan, 1998). In addition, experiences of prolonged helplessness in the face of perceived danger shapes the templates the child fashions about the reliability and trustworthiness of others, the effectiveness of one’s self-agency and the possibility of safety in the world, frequently stunting the child’s developing sense of hope in the future (Terr, 1983, 1991) and his ability to believe in and accept help from others. Interestingly, it was a book about hypnosis (Brown and Fromm, 1986) that contained one of the first references to this notion of trauma as simple versus ‘complicated’ (their term) and the different treatment requirements for each. Judith Herman’s (1992) book on ‘complex’ trauma (her term), with its in-depth synthesis of existing knowledge about the effects of prolonged trauma in the context of violence and control, became a reference point for research

on the diagnosis called DESNOS (Disorders of Extreme Stress Not Otherwise Specified). The October, 2005 issue of Journal of Traumatic Stress (vol. 18, no. 5, pp. 379–460) carries a special section of articles about complex trauma, its characteristic symptoms of dysregulation and the resulting special treatment needs that those require.

27.3.12. Dr E.: treatment Dr E. was understandably (and one could say wisely, given his history and resulting vulnerabilities) skittish about a psychotherapy process. He began to focus, with an intensity not previously present, on his sexual performance symptoms and on his having expected that I would have provided him biofeedback for this.3 In fact, he put forth his theory that all of his relational and emotional difficulties had at their heart his inability to rely on himself in bed. He felt that if he could feel confident in his ability to master the physiology of the bedroom, he would be able to sustain relationships, he would be organized and focused in his self-care, and he would not be anxious and depressed. I listened. I pondered aloud that we both were saying important things. Could I refer him to a colleague (a sex therapist) with whom I could collaborate? Together, we could all work towards the same aims. He agreed. And he agreed to see me once weekly (not twice per week). I have seen Dr E. for a little over a year. From a trauma-focused perspective, the psychotherapy has worked from many angles to create a stabilizing place inside Dr E. I begin from the center of our relationship, appreciating that the experience he has with me, in the emotional back and forth between us, carries the potential for creating a new relational template within him.

3 I had let Dr E. know in our first meeting about my not being experienced in treating sexual dysfunctions with biofeedback except from the vantage point of giving him tools for overall autonomic regulation and relaxation. He had been interested in our still meeting anyway despite my disclaimer. In our initial sessions, he never returned to the concerns about his sexual symptoms. He did not return to them until I recommended twice weekly relationally based therapy. His return to them then was with an intensity and proposed centrality that had not been there previously.

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Because this template is experienced implicitly, at a nonverbal, neurophysiological level, it is a particularly powerful tool in therapy. I can amplify the therapeutic aspects of this effect, and assist Dr E.’s ability to sustain and replicate the therapeutic aspects of it, by speaking explicitly … about what is taking place when we emotionally connect, what internal structures are being built within him, and how what is taking place will help him with his goals of feeling more connected to himself. When I name something that happens between us, or what I notice within him, the invisibility and implicitness of the process is then verbalized, defined and its value made tangible. Once the emotional process between us becomes tangible to Dr E., he can begin to notice and track responses within himself—ironically, like biofeedback, but with me as the registering and reflecting ‘machine’. For example, when Dr E. rapidly (with intensity but no definable emotion) spins out the details of his girlfriend’s telling him over dinner how inadequate he is as a father and how she can understand why his wife left him because clearly he can’t manage his life and is way too needy, I become momentarily flooded with all that has just happened to him emotionally … and he has left me behind and is speeding into the next vignette. I stop him, probably clearly showing feelings of being stunned and incredulous, and say, ‘Wait a minute. Could we just slow down for a second? I’m just catching up with what you just told me. Boy. That leaves me reeling. What did that feel like for you?’ He answers, with a startled, tight laugh, ‘I’m not thinking much about it. You mean why did she say that? She was referring to (speeding up again) what I had told her about forgetting to pick up my kid for his soccer practice and she has a problem with that; listen, it’s true, I am forgetful, but she’s afraid— I know this about her—she tries to figure everything out—it goes back to her parents’ marriage and how surprised and everything she told me she was when it didn’t work out, and she just thinks if she can nail me somehow, the same thing won’t happen to her; she likes to analyze everything …’ I interrupt again. ‘I’m getting lost again—I’m still stuck on what she said to you at dinner. It sounded really critical; what I meant was, what did that feel like to you?’ His face winces, as if uncomfortable. He tries to laugh.

‘Well, it didn’t feel so great’. He shifts, as if trying to get away from something. ‘I mean I guess it was critical’. I repeat the girlfriend’s words: ‘Inadequate?’ ‘Needy?’ He is slowed down now. ‘Well, you’re right. I get your point. She’s got this judgmental side to her’. He tries to joke. ‘Why do I keep ending up with women like this?’ I say, with gentle seriousness, ‘Maybe it’s so familiar to you that you just don’t notice it’. He is reflective. ‘Yeah, I like the edge—the banter back and forth—I like that she’s quick, but … there’s this harshness …’. He shakes his head. The working model in my head is that Dr E. is reliving the relational templates from his family home, in which one dodged bullets of sarcasm and put-downs, delivered in rapid succession meant to bring the other down. Intensity ran high, but it wasn’t identified as emotion; it was merely rapid mental running and dodging and, later, trying to give it back. The pace was frenetic. To slow down wasn’t safe. The object was to not feel, to not take the other in, because the connections were toxic. Dr E.’s reliving of these templates is a form of behavioral remembering or intrusive recall. This is one reason I draw his attention to the frenetic pace. Another reason is that his style of running and dodging achieves what it was originally meant to do—it prevents him from taking me, or himself, in. However, because of that, he can’t feel what he is feeling; he is in a chronic state of agitation; and he has lost the means to self-soothe. As part of the stabilization aspect of trauma-focused work, my job is to help him learn ways to self-regulate and gradually desist repeatedly exposing himself to the mini-traumatizations he constantly (unwittingly) opens himself up to.

27.3.13. Becoming, through

conversation—commentary One learns, and becomes more fully, who one is within conversation with another. In the process of speaking,4 one hears aloud one’s thoughts outside oneself, and thus one can hear in a different way, walk around the thoughts, view them from different angles, and absorb, comprehend and amend them. When speaking occurs with/to 4 Or signing, or picturing—whatever form the process of symbolic communication takes

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another, who is truly listening and absorbing and reflecting back what she is hearing, then what is inside us achieves even fuller dimensionality through crystallizing, in concrete, visible form, the actuality of thought itself—what was once unheard, unfelt thought now reaches visible, sensorially experienced impact on and response from the other. The resonance and depth of this process are universally longed for but become even more urgent where there has been trauma. Where trauma occurs, bits of experience get broken off, disconnected from and hidden—as an outcome of the fragmentation caused by a brain overwhelmed, and as a way of self-protecting against ongoing assault. Too much of this and the person loses track of himself. He complains of feeling disconnected. In this case, the conversation with the therapist—the authentic interchange, the back and forth of expressing, hearing and absorbing one’s expression, watching the impact of one’s expression, taking that impact back in to fill out the fullness of one’s expression—is crucial in mending the patient’s experience of disconnection and fragmentation. When the therapist can pay close attention to regulating the fullness of the conversation, so that the patient can absorb what is happening rather than being flooded by it, then the patient finds himself not simply telling, reporting or rattling off a story; he suddenly experiences what it is like to be connected with himself in the telling. Sustaining this connection, through the other, with oneself, creates an experience of living through the story, of staying (becoming) intact while living through something real, rather than either simply recounting a distanced tale or becoming lost and swallowed up in a nightmare. We teach the patient, through modeling, how to track his internal signals of imminent flooding. We teach him, through modeling, how to slow down and ground himself in the face of those signals. The patient then develops confidence in being able to create the safety and pacing necessary to stay whole (and/or restabilize) through the experience of perceiving and remembering. That confidence allows the patient to risk exploring more, and revealing to self (through revealing to therapist) more of the hidden parts with their details, until a fuller and fuller sense of self becomes experienced and known. All of this creates new structures within

the patient so he is better equipped to stay fully present in moments of present-day reality and relationships without the constant scanning and hypervigilance that are part of disconnection. Being fully present within himself then allows him to become more open to life—thus allowing energy, vitality, and a sense of connection to flow. These thoughts, about how relationship, conversation and connection form the crucial medium through which internal structures are built, particularly for patients with trauma histories, are why I, though an analyst, would hesitate long and hard, and search for a reason to put a person with a trauma focus on the couch. Schore (1996) speaks of the import of visual gaze as the key portal through which the infant takes in the pleasure and interest of the caretaker—the core ingredients necessary for emotional attachment—which is the core condition necessary for forming (via ongoing mutual attunements) the frontocortico-limbic connections in the brain necessary for being regulated and stabilized emotionally and biologically.5 How, then, can we not use gaze as a vital medium through which we do the stabilization and structuralization work of trauma? Maintaining the intensity of face-to-face work is more emotionally demanding because the reverberations within the mutual visual input amplify intimacy. However, when face-to-face, the therapist can track more of the micromovements across the patient’s face for attunement, and the patient can absorb the therapist’s nonverbal cues to track honesty and authenticity and to grip concrete, sensory markers of presence when needing grounding.

27.3.14. Specifics of hypnotic technique Dr E. and I don’t seek out traumatizing memories to go over in the sessions. I have not used hypnosis to allow access to rooms and hallways of the past. I have not used hypnosis to slow intrusive flashbacks down, creating techniques of mastery over memories that are flooding him too quickly (e.g. Peebles, 1989). This is not where 5 ‘The

mother’s emotionally expressive face is, by far, the most potent visual stimulus in the infant’s environment’ (Schore, 1996, p. 61).

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Dr E.’s treatment has been taking place for now. Instead, Dr E. lives out after-images of his traumatic memories in his current relationships outside the sessions, and within the sessions he lives out the ways he learned to self-protect (the sophisticated dissociation). Neither is done within his awareness. So I try to help him become aware of what is taking place—not judgmentally, but with understanding. I understand aloud with him that this is the way he has lived, and that there has been good reason for it. However, simultaneously, it has been this way of living that has left him feeling disconnected. I believe it is the understanding, and the stayingwith him relationally, that have been opening the door for him to risk episodes of slowing down with me—to the point that he has had moments of experiencing the connection, and it has soothed him. He has been delighted, surprised and made anxious by this unfamiliar feeling of feeling soothed in a relationship with another. It is here that I have been using hypnosis. More specifically, when I find a way, usually after repeated attempts, to break into his racing delivery of life’s details from the week, I selfconsciously seek and hold eye contact with him. The eye-gaze is a natural form of induction. It is natural because it is biological—the infant’s most potent way of taking the world in, the basis of attachment, that in turn is the medium in which regulation is transmitted and learned (Schore, 1996). Once Dr E. slows down enough to stay in the eye-gaze, I slow him down further by pacing (matching first the rhythms of his breathing, moving, speaking), then gradually slowing down the pace—of my rhythms of speaking, moving, phrasing—all the while intentionally holding firm with the connection of eye-gaze, until he begins to slow more, physiologically and mentally. I can actually see his face relax, and the coloring shift to a more even, fresh pinkening (rather than an unnatural, rough, angulated redness or a flat, blanched quality). His eyes seem to relax into an open taking me in. I attend to my language, seeding what I am saying with metaphors and sensory detail about concepts I believe would be helpful to him. For example, in a basic way, I might say, ‘And just notice how it feels … to slow down … in this way … everything calmer … than it was before … and how that feels … and that feels

good, … doesn’t it’. The message is one of noticing what he is feeling physically, noticing the pleasurable sensations of soothing within the slowing down and how that contrasts with the speeding up, attending to this as an alternative to his other templates for connecting, and realizing the safety of its being within his control, its being within him to replicate and its being a source of hope for his longed-for connection with himself. All of this is done without designating the experience, with Dr E., as a formal induction of trance. Hypnosis has never been mentioned between us. But I am aware (usually a second or two after I have naturally begun to use it) that what I am doing is inducing and deepening a trance experience to amplify, model and thus teach an experience of self-regulation within Dr E. The moment I become aware that I have moved into a hypnotic space with him, I can then move intentionally, and allow (even foster) a trance experience to develop. My awareness that trance is taking place allows acknowledgment of Dr E.’s heightened receptivity. In response, I can provide experience-near focusing that may help solidify the neurophysiological shift contained in Dr E.’s experiencing, and learning to effect independently, safe self-regulation. For example, I may say (carefully maintaining eyegaze, a slowed-down tempo and a pacing of rhythm and inflection), ‘And you see, this is what it can feel like, being slowed down, taking someone in … see, how you can feel exactly what you are feeling right now … how you can be connected … with yourself … with what is happening … with your breathing … in … and out … just notice … that’s right … and … it’s … ok’. It is too early in Dr E.’s experience with these kinds of moments for me to add metaphors that extend his awareness beyond focus on the concrete sensations in the moment. However, as his familiarity and comfort with this kind of connection expands, comments such as, ‘Like the healing warmth of sunlight on your face, the gentle listening of a trusted other can allow you to slow down, breathe in, and feel the fullness of a deep experience of safety and comfort’, would be possible. I appreciate that the use of informal induction and natural trance is controversial. My own hypnosis training was initially from an ego

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psychology, not Ericksonian, point of view, and for most of my career I was adamant in my conviction that trance induction should be named and agreed upon explicitly between client and clinician before proceeding, primarily believing that not to do so bypassed the patient’s autonomy and choice, was thus disrespectful and potentially manipulative, and risked crippling the patient by fostering dependency on an amplification of the positive transference. In my practice, however, I have come to see that trance-like elements are always there (particularly when there has been trauma). To disrupt them abruptly is artificial and sometimes merely an expression of my own anxiety about so much receptivity in my patient. Gradually, I have come to utilize those moments therapeutically, as an opportunity sometimes to reach a patient who may be racing beyond verbal reach and can only be touched experientially through the implicit experience offered in trance. Or, an opportunity to solidify and/or mimic what developmentally is normally provided at a largely nonverbal level. Or, an opportunity to amplify and expand the patient’s capacity to track internal cues and details and resonances from external communications. And always the thrust in my use of informal trance induction is in expanding the patient’s own capacities and in emphasizing the locus of control within him, so that he can eventually initiate and replicate on his own the safe experiences he has in the office with me.

relational safety. However, anticipations of the future are faulty truths because in actuality they can only be reflections of the past. Further, anticipations of the future ironically tend to create the very condition that is being feared since anticipating something will happen leads a person to act in ways that actually shape the relational unfolding towards the anticipation itself. Thus, anticipations lock one into repetition. Real control lies in the confidence in one’s capacity to live through, without destabilizing or fragmenting, whatever a relational moment will bring. However, that kind of confidence can only be built, over time, through repeated experiences of mastery. It can feel nearly impossible, but suspending anticipations and living in the moment is the natural antidote and a core component of forging new relational templates. In psychotherapy, living through the moments of relationship with the therapist and the moments of remembering the past constitutes the application of and testing ground for this concept. Self-regulation, even as basic and concrete as breathing in and breathing out and, through this, feeling one’s body as steadily there, thus solidifying the knowledge that one’s self remains intact and steadily there as well, is an essential tool for grounding oneself through disruptions. This type of self-regulation is so compatible with self-hypnosis that the two are easily thought of as overlapping domains in a Venn diagram.6

27.3.16. Toward stabilization 27.3.15. Creating new templates—

commentary When a person has lived through prolonged traumatic experiences of a relational nature, relationship itself becomes a trigger, or conditioned stimulus, for expectations of disruption and destabilization. The person naturally braces herself in the face of closeness. Different people brace or self-protect in individual ways, utilizing the personality strengths that are theirs. Accompanying this bracing, is its natural and necessary partner, hypervigilance. With hypervigilance, the person scans the experience of closeness for the least sign of imminent or faroff disruption. The person crunches the interpersonal data to anticipate what will happen as a way of creating the illusion of control over

Dr E., like many high-functioning individuals with a trauma history, has self-regulated by not feeling what he is living. His natural, default position has been one of self-protection via sophisticated forms of dissociation. The cost has been that by doing so, he has also kept intimacy and closeness at bay, extinguishing the chance to feel alive in the moment with other people. The result for him has been a life lived predominantly in agitation punctuated by highs (that are often merely outbursts of overstimulation) and lows that bring him in unexpected touch with an

6 I am indebted to Nick Covino, PhD (SCEH Annual mtgs, Charleston, SC, November, 2005) for quoting his mentor as stating that there are few complex concepts that can’t be illustrated by a Venn diagram.

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abysmal inner aloneness. Missing appointments, coming late, talking so rapidly without pause that I have difficulty being let in, not remembering links that we have previously constructed together, have all been ways of trying to selfprotect and self-regulate by severing connections (‘diss’-tancing, ‘diss’-associating—see quote below). My job has been one of listening, through the density of his speeding-up, through the fog of his induced dissociation, for where he is inside. My job has been one of finding him, and helping him feel safe enough to follow me back to the self in him that I found. And I have used hypnosis, via informal trance induction, to augment this. All of this I have considered the work of stabilization within an essentially trauma-focused treatment. I disavow and disown. I deny and dismiss. I ignore and avoid. I even pretend and distract. Sometimes I do these things without realizing I do. And when the chips are down, and these other things fail to keep my Self safe, then I diss-ociate; I depersonalize, derealize, and forget, or I confuse …. When I am Diss-ed via Dissociation, then “I” am safe in my lostness, my safe numb protectedness. And this is true until I grow much older and there is not so much need for lostness and nothingness of being. Then I may find myself in pain over my numbness, and long to be alive, fully alive, essence-ially speaking, that is (Chefetz in Chefetz and Bromberg, 2004, p. 426).

27.3.17. Dr E.: outcome Dr E. has remained in psychotherapy. He cancels about 20 percent of his sessions and is up to 15 min late for half of the remainder. When thinking about the lateness and cancellations, one must remember that Dr E. is the kind of man who would easily not come at all if he weren’t relationally connected with me in some way; it would be easy for him to terminate indefinitely, citing scheduling complications due to his busy medical practice. Thus, I view the uneven attendance as opportunities to track and listen to his communications of anxiety about trust and interpersonal danger. Dr E. can momentarily fall into a dark space in which he feels isolated and teetering on the brink of hopelessness. However, he has not gone over the edge into suicidal ideation, and his risktaking behaviors have diminished considerably.

He has been followed by the original referring psychiatrist, and went through a trial of antidepressant medication; however, he discontinued this medication on his own after 6 months because he couldn’t feel it helping in any way and he did feel it interfering with sexual functioning. He is able to sleep longer at night without awakening; however, several times weekly, he fights going to sleep for several hours past the time he first felt tired. Finally, Dr E. broke off with a woman he felt intensely drawn to but who was demeaning, belittling and unpredictable. The woman he is with now is smart and responds emotionally to him, without judgment or harshness. He is confidently sexual with her. However, he has a gnawing discomfort, as if there must be something better than this. He feels a spark is missing. He makes next to nothing of his sexual confidence with her, stating it is only because he is in control and she is in love with him. I persistently notice with him how drawn he is to women with sharp-edged intensity and putdowns; he uneasily sees this, but can’t give it up. He says the adrenalin rush of the unpredictable feeds something in him. This latter is a common feeling in people with a history of traumainduced, chronic dysregulation. I will be helping Dr E. appreciate this as a conditioned neurophysiological response to originally toxic conditions, so that he can learn to track and protect himself from continued, self-induced re-traumatizations. As the work of stabilization continues and solidifies (and if Dr E. remains in treatment), he will be readier, and in a safer, more predictably self-regulating place, to tackle remembering, with connection to feelings, some of his original, traumatic, familial situations. At that point, trance will be used in the sessions (but now internalized, from our previous work, as his own self-hypnotic techniques) to regulate and gain control over unexpected moments of flooding, disruption and destabilization caused by the remembering-with-feeling (as opposed to the remembering-with-dissociation). Multiple repetitions of such experiences of mastery, over whatever time is needed, will strengthen Dr E.’s capacities, and confidence in his capacities, to live through feelings, life and relationships more fully aware. Meanwhile, interweaving these experiences of mastery and stabilization

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with experimentations in daily life with new ways of relating with others, thinking about the world and connecting with himself will be the work of developing the new templates inherent in the integration aspect of trauma-focused work. And this is how a literal, neurophysiological, neurochemical and neuro-associational (if not neuro-structural as well) ‘rewiring’ takes place in relationally based, long-term, trauma-focused work with someone with complex trauma.

27.4. Case 2: Mrs Larchton 27.4.1. Background Mrs Larchton is a feisty, creative woman of 59 years who had been in several treatment processes at difficult junctures in her life. A few years before seeing me, she had been in a longterm process of 8 years (once to twice weekly), for help renegotiating healthier relationships with her two adult children and her husband. Mrs L. had a childhood pockmarked with significant trauma. Her father had been convicted of murder and sent to prison to await the death penalty when Mrs L. was less than 2. However, the mother had told Mrs L. that her father had joined the navy and was deployed in a series of lengthy, classified missions. Secretly, the mother divorced her husband, and moved herself and her daughter from North Dakota to California, all the while continuing the myth that the father was contributing to his country and one day would return home. For years, the girl believed this. She waited for his return. Even after her brain told her it couldn’t be true, she continued to believe, because she hadn’t learned what else to do. Mrs L.’s mother was an alcoholic, often irrational and unable to get out of bed. Mrs L. had to buy groceries and fix the meals. Her mother continually berated her, calling her selfish and only interested in her own needs. At an early age, she was sent to a convent school to board. There she was the youngest girl, and the older ones had little to do with her. However, the school provided stability, and when the nuns called her in at age 14 to let her know her mother hadn’t been paying tuition for months, Mrs L. was stunned and frozen. This could not be true. She lied to the nuns and made up a story about how the money was really there but

had been tied up in hospital bills. She then went out and literally begged, borrowed, stole and worked (surreptitiously) to pay her own way at the school. She married at 19, to a man who was (in retrospect) mentally unstable with probably an atypical psychosis and sociopathic tendencies. He physically and verbally abused her, and later sexually abused their child. She broke from him, tumultuously, when she could, and married a stable man. Her second husband was significantly slower than she intellectually—which created its own problems—but he was not abusive. Mrs L. was noticeably intelligent and quick. Her capacity to register visual details and sensory input of tones, colors, facial expressions and nonverbal rhythms was a gift and a burden. Because of how much she took in, she was easily overstimulated. For example, after weeks of unstopped immersion in her work as a writer, she would physically collapse, unable to get out of bed, spent, without energy and often in physical pain. Or, she would plan elaborate trips, only to go and become overwhelmingly flooded by all the sights, sounds and sensations after a few short days. In her previous individual and group therapy work, she had discussed and processed all the details of her life. However, interestingly, the concepts of overstimulation, difficulty selfregulating and probable traumatization were not ones with which she had emerged. Mrs L. was referred to me by her most recent, previous therapist. Mrs L. had been offered the opportunity to give a lecture at a local university on one of her books. She was enlivened by the idea, but almost to the point of paralysis. She couldn’t imagine being able to speak in front of people. She was an exquisitely alive and energized woman, alert to people around her and capable of engaging with vitality and wit. However, simultaneously, she froze with intense, physiological panic when asked to speak publicly. Her previous therapist knew I did work with hypnosis. Since Mrs L. was asking for help with a circumscribed symptom (public speaking anxiety); since she had already completed several episodes of lengthy therapy; and since she was talented in imaginative involvement and intrigued by the idea of hypnosis, her previous therapist referred her to me for a brief piece of work utilizing hypnosis to target her speaking anxiety.

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27.4.2. Mrs Larchton: formulation Mrs Larchton’s history clearly lent itself to a formulation about complex trauma. However, she had already undergone extensive treatment that in sum total addressed the details of her upbringing fairly comprehensively. Put differently, she had processed memories of her past, linking them to symptoms and behavior in her adult life, which allegedly had enabled her to move on with a fuller and more rewarding engagement with the present. Where then was one to place her symptom of public speaking anxiety? What shaped my response to this question was Mrs L.’s clinical presentation with me in the initial few sessions. Periodically, Mrs L. talked and thought in rapid arcs of associations. The emotion would intensify until the room filled. It felt like an emergency was exploding and the way out was, alarmingly, shrinking fast. Unlike with Dr E., with Mrs L. I was far from numb. While she fast-talked, I became electrified, on pins and needles, and my stomach twisted in ever-tightening knots. My muscles locked in tension, and I was intermittently forgetting to breathe. I forced my mind to listen carefully. On the surface layer of words, Mrs L.’s description of her public speaking anxiety was informative and relevant; but just behind the word layer was surging undeniably escalating noise. My body was hearing that noise, and it was the noise behind the words that was agitating me at a physical level. It was then that I began to notice Mrs L. was beginning to loop over and over again through variations on a scenario of doom. She sounded frantic. I also noticed that my clarifying and pragmatic problem-solving interventions were not bringing her relief; instead, they were having the same effect as pouring gasoline on a rapidly out of control blaze. As it turned out, Mrs L. was being sucked into a past space of trauma, without either of us initially knowing it. Overtly, she was talking about how her speaking anxiety became worse if she felt she could not leave the room. However, internally, she had inadvertently slipped into the distant past. I first heard it in the mounting panic of her voice. Then I realized it was in her eyes as well. They were slightly off focus and glazed; she wasn’t fully taking me in. She was hearing the

words I was speaking in the now. (When I asked her to, she could repeat them back to me.) But emotionally, she was responding as if it was then. My tone, presence and ideas were not having impact; they were not sinking in.

27.4.3. Sophisticated abreaction—

commentary As explained earlier, symptoms of intrusion and avoidance can be blatant or more sophisticated (see p. 64). With sophisticated intrusive phenomena (which I think of as sophisticated abreaction), the patient may begin unexpectedly escalating in intensity and pressure that don’t immediately match the content. He may jump rapidly among details, his voice tone swelling with urgency, but his words insisting that control and logic are holding sway. The therapist’s physiology, with or without the therapist’s awareness, may begin to match more the patient’s actual physiology rather than the patient’s stated control. For example, the therapist may begin to speed up autonomically, tightening and thus internally mirroring the patient’s pressure and urgency. Perhaps, in response to the autonomically signaled sense of emergency experienced at a subliminal level, the therapist may find herself jumping to offering directives, re-establishing focus or concretely problem solving. However, at such times, the patient typically shows neither relief nor calm in the face of this effort at pragmatic problem solving; instead, his agitation can escalate further. Worse yet, a certain repetitive quality can begin to take hold, as if the patient is running the same loop of tape over and over, the urgency escalating with each looping. Neither the perseveration nor the seeming help rejection may match the patient’s intelligence, his usual ability to work collaboratively or his capacity to step outside the box and reflect. If the therapist is able to pause mentally at such junctures, and carefully listen, she may hear how urgency itself is driving the communication, more so than the story’s particulars. If this is the case, it can help at such times for the therapist to suggest that both patient and therapist pause, slow down, and begin listening together to the way the patient is communicating in order to hear more clearly what is trying to be said. In slowing down the pace, sometimes it becomes possible to isolate

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when things began to change. By ‘working backward’ in this way, therapist and patient identify the trigger(s). In sum, qualities that signal the possibility of a sophisticated abreaction are (1) the patient’s inability to slow down or disengage from what he is saying even when the therapist tries to interrupt; (2) the patient’s reiterating his story, repeating phrases and questions over and over despite the therapist’s attempts to answer; (3) the patient’s steady escalation of intensity and anxiety; and (4) the lack of decompression or resolution even with multiple intervention efforts. Interestingly, these same qualities characterize children’s traumatic play (Terr, 1983, 1988).

Triggers Trigger is another word for conditioned stimulus, and the behavioral principles of classical conditioning are the same: a certain perception, sound, smell or emotional fragment is similar enough to aspects of the originally traumatizing experiences that it propels the patient into an unexpected and unwanted abreactive experience.7 Remember again that, clinically, abreaction is not simply about dramatic catharses in which one loses a sense of one’s immediate surroundings. An abreaction can be sophisticated enough to pass beneath the radar screen of identification. It can be a sudden, volatile tongue-lashing of a store clerk, or turning on a dime to cut off a relationship. It can be an engulfing mood state that descends precipitously—a neurochemical ‘signature’, if you will, from the originally traumatizing events (e.g. LeDoux, 1992). When the intensification of a sophisticated abreaction occurs, there has always been a trigger. This trigger, or conditioned stimulus, initiates its conditioned response—a rapid neurological release of neurochemicals and sequencing of neuronal firings along practiced associational pathways. These brain events are responsible for the subjective sense of re-experiencing aspects of the originally traumatizing events. Sometimes, such ‘emotional memories’ can come upon one so quickly, with so little sense of volition or conscious context, or internal experience of continuity in one’s subjective

7 The terms, abreaction, flashback, reliving and re-enactment are all essentially descriptive of intrusive phenomen

experience of Self, that a feeling of ‘not-me’ (Chefetz and Bromberg, 2004) occurs.

27.4.4. Mrs Larchton’s sophisticated

abreaction Mrs L. was caught in a sophisticated form of abreaction. She was not in touch with who I was; she was not using the present verb tense to describe distant events; she was not even explicitly speaking to her past. However, she was emotionally escalating, autonomically quickening, looping unbrokenly through identical questions and detail, having difficulty disengaging from the topic, and worsening rather than calming. Mrs L. had been triggered. When several clear, normal-toned efforts to redirect her failed, I called upon my hypnotic training in re-alerting people from trance. I selfconsciously used a firmly edged, more commanding voice, with slightly deeper tones. It was my voice for the final numbers of counting people out of trance. I called her name, twice. She shook her head slightly, as if alerting. I asked her what happened. ‘What do you mean?’ she asked, confused. I reviewed the last couple of minutes, pointing out that she seemed unable to slow down, even when I had asked her to. She laughed nervously, saying that sometimes she erupts, ‘like Mount Vesuvius’. When this happens, she doesn’t know how to stop it. It takes her over; she often doesn’t catch it coming until it is already there. We sorted the beginning of the moment out. The trigger seemed to be describing her inability to escape the room when publicly speaking. Connecting with the feeling of being unable to escape in the present was the conditioned stimulus that propelled her into the mother’s room of her childhood house in the past. I commented on her loss of distance and the power of her feeling memories as she returned to that room. Mrs L. was fed up. ‘I mean after all, with all the therapy I’ve had, for all these years, you’d think these things would be dead and buried!’ she fumed. I reassured her that her years of therapy would prove invaluable bulwarks against full-blown re-traumatization. However, I focused in on one leftover aspect that apparently had not been much dealt with: her vulnerability to sudden triggering and subsequent acute dysregulation.

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Thus, my formulation was that while Mrs L. had dealt with gutsiness and perseverance to overcome a scarring childhood via the understanding wrung from psychotherapy, her capacity to self-regulate had remained in weakened form. She had never named this vulnerability within her anything other than her Mount Vesuvius. Her mother had called her an ‘overly sensitive’ child, and certainly she had been gifted in this world with finely spun sensitivities. However, what she had not appreciated was that, whatever her innate sensitivities had been at birth, she had been later sensitized by life’s events to living within inches of neurophysiological dyscontrol. I was happy to take her on and teach her hypnotically mediated techniques to regulate her public speaking anxiety. But as I did so, I would be mindful of the larger picture of complex trauma-induced dyscontrol, and I would weave in implicit metaphors and explicit explanations designed to help with both focal symptom and big picture alike.

27.4.5. Mrs Larchton: treatment plan I suggested we meet weekly for 6 months prior to her speaking engagement, and then, if all went well, we could taper to every other week at that time. The intent was to make this a reasonably time-limited treatment and to taper off to termination as her specific goals were met. We agreed to use hypnosis, with formal induction, within most sessions, and to utilize the practicing of specific self-hypnosis assignments between sessions to augment the face-to-face work and solidify her gains.

27.4.6. Mrs Larchton: treatment Mrs L. was quite visually gifted. She was able to move quickly into trance with simple eye closure and counting. She could create and become absorbed in vividly imagistic spaces with rich, sensory detail. We used a combination of hypnosis, breathing techniques, recognition and exploration of negative therapeutic reactions, and pragmatic organizational and problem-solving help. All of this was offered within the context of a relationship that provided an experience of attunement, regulation, interest, undaunted constancy in the face of her intensity and a generous supply of intellectual explanations

of why her symptoms occurred and why what we were doing worked. It is impossible to separate the powerful regulating effects offered implicitly within the texture of the relationship itself from the explicitly given circumscribed tools and techniques. Nor does one need to; both are essential, inextricably intertwined and interdependently potentiating of each other. In the first few sessions, we used a version of systematic desensitization, within trance to master the autonomic hyperarousal associated with public speaking. We devised a hierarchy of increasingly agitating details of the public speaking, and moved slowly up this list from less to more intense items. Using a SUDS (Subjective Units of Distress) scale, we tracked Mrs L,’s sense of panic. When we moved to a more uncomfortable step on the list, we utilized calming imagery, with vivid sensory detail, until Mrs L. mastered that step as measured by lowering her SUDS to a 2 or 1. One of her favorite calming images was that of a waterfall. The way the waterfall formed a sheet of water filling her visual surface; the way the sound could fill her ears; the way the water could become allconsumingly opaque or nearly transparent as needed; and the way the rushing of the water could wash and cleanse were all aspects that were utilized at different times and for different purposes. Initially, Mrs L. was delighted with the rapid, immediate and concretely felt results achieved by the hypnosis. Her experience of coming into the session agitated and leaving calm was a powerful ratification for her of the effects of trance. By the third session, however, she began to experience glitches in the effectiveness of the hypnotically mediated suggestions for calming. The waterfall image did not immediately restore her sense of well-being and she panicked. Soon after, every imagistically mediated metaphorical suggestion started twisting into something that felt harmful to her and raised her panic. For example, the waterfall faded. The colors of the beautiful garden became muted and dull, as if things were dying. I used a split screen technique with the suggestion of her waterfall imagery on one side and an image that captured what was bothering her on the other side. I then suggested that the two images begin to merge, layering one on top of the other, and asked her

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to describe simply what then happened, in her and in the images. She described a dark, brown, craggy mountain as her threatening image. However, when the waterfall merged with the mountain, the mountain crowded out the water and stuck in the way of any sense of peace. At this point, because her panic was mounting instead of declining, I had Mrs L. immediately turn off the imagery and emerge from trance. Face to face, maintaining eye contact with her, I named and educated Mrs L. about her having shifted into a panic mode. We went over, from different angles, and with different words, the contrast between her receptive state in which imagery helped her and was benign, and the panic state, in which imagery suddenly turned sour and attacked her sense of well-being. I wanted her as an ally in noticing this shift whenever it occurred so that we could immediately avert its typical, rapidly out-of-control, downward spiral into panic.

27.4.7. Catching and reversing

sophisticated abreactions— commentary It is important to recognize and interrupt the traumatic ‘play’ aspect embedded in the verbalizations of adults for several reasons. First, like with any form of uncontrolled abreaction, the repetition of the cascading of emergency neurochemicals and the behavioral manifestations of ensuing panic maneuvers signal and intensify each other, serving further to ‘burn in’ (reinforce the conditioned response of; lower the threshold for) the neuronal firing along the neuro-associational pathways of the traumatic experiences. In short, as we all know, uncontrolled abreaction is psychologically and neurologically damaging. Second, while in that state of sophisticated abreaction, the patient’s capacity to process information is altered in counter-therapeutic ways. Because this is a sophisticated abreaction, without dramatic flashback qualities, it is easy to assume the patient is continuing to track and reason with us in his usual, cognitively mature ways. However, more often, a mini-cognitive regression is occurring. Symptoms of cognitive regression include: (1) hyperalert amplification of perceptual details of intonation, inflections, facial expressions; (2) however, simultaneous, constricted perceptual focus, resulting in selective

(and sometimes distorted) memory for what is being said or occurring; (3) diminished ability to take in complexity, meaning an increased vulnerability to black and white thinking; (4) temporary loss of access to expectations of benevolence; (5) heightened expectations of attack that can create the mental experience of attack when allowed to persist with prolonged, unmitigated intensity; (6) difficulty achieving perspective or making links between ideas; (7) cognitive rigidity (i.e. difficulty shifting sets). In short, the frontal lobes are not as effectively engaged as usual; therefore, they don’t as easily temper and contextualize the patient’s limbic firings. Within such a state, although the patient’s vocabulary, logic and eye contact may appear unimpaired, the silently occurring cognitive regression described above is inhibiting his ability to reason outside the past he is reliving. This is because the trauma memory contains not simply events, but also the quality of the neurological processing that was taking place during those events. Both are welded together, encoded as one package. The ways of reasoning and regulating and feeling that occurred at the time of trauma leave a unique neurobiological signature, that is reread by the brain and body when reliving occurs. Thus, the patient emotionally and logically reacts inside the panic of the then, rather than outside, with the logic available from the now. This is one reason why the patient can feel difficult to reach during even a subtle reliving. The therapist’s attempts to ‘talk’ about actual versus feared danger, about the difference between perceptions and conclusions, or about the possible inefficiency of the patient’s problem-solving efforts may do little more than escalate the patient into more agitation. This can be confusing, to therapist and patient, until the experience is identified as a sophisticated abreaction. Neurocognitively speaking, learning is impaired during this type of cognitive regression. Information isn’t being registered accurately; linking and organizing mechanisms unravel; and memory is severely disrupted. Clearly, the patient needs to move out of this neurological state to have a chance of doing something productive with it intellectually. Consequently, when the therapist recognizes the patient has fallen into the regression characterizing a sophisticated abreaction, the task becomes one of helping the patient shift and engage alternative modes of cortical functioning. The patient having repeated experiences of catching the regression

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in reasoning and successfully shifting out of it strengthens her confidence and psychological ‘muscle’—both necessary for intentionally accessing trauma memories. Accessing implies the ability to come and go. Accessing allows feeling the traumatic experience from the inside of it, but describing it with the mental capacities that lie outside it. Accessing is emotional remembering, rather than reliving. It is from this place of accessing, rather than reliving, that the work occurs of reorganizing traumatic memories, constructing words, creating context, integrating splits in the Self, and experiencing healthier relational connections—all of which open up new trajectories into the future.

27.4.8. Course of treatment Because Mrs L. had the advantage of some solid therapy under her belt, she could move easily with me into the mode of exploring and connecting dots—in this case, figuring out what was that mountain that was stubbornly blocking her waterfall. Images of her mother came to mind, and she found herself vividly hearing (mentally, not literally) her mother saying things like, ‘You’re sick; You can’t do it; Lie down and rest; You’ll fail’. Instantaneously, these words lit up life-long messages from mother of, ‘Stay with me … I’m crippled; you need to take care of me …. You’re selfish if you get better and leave’. We spent two sessions like this, first solidifying how to recognize and reverse the shift into the downward spiral of abreactive panic, and, second, constructing the words held within the image of the craggy mountain. Armed then with both a strengthened capacity to reverse abreaction collaboratively and some clues as to why the abreaction had occurred, we approached trance again. This time, when the waterfall weakened and the craggy mountain appeared, I had the patient picture her mother on a TV screen speaking the words she had heard her speak when out of trance. I had the patient focus on the separateness of her self watching the television, and her mother on the screen. I had her use the remote control to turn down the volume, switch channels, mute and turn off the set. Throughout this imagistic exercise, I emphasized the link to Mrs L.’s control, over letting in or keeping out, the words and power of her long

ago passed away mother. After working in this way, the mountain diminished and the waterfall flowed once again. The next glitch occurred a few sessions later. Once again, her images seemed to shift and change out of her control. The beautiful reds of flowers began to look like blood. The warm sun in her imagined garden dimmed to grayness under the press of clouds. Once again, I moved her out of trance to slow the pace down and help her regain intellectual control so that she could then regain emotional control. She talked in passive voice about the images changing. I emphasized how they were her images, and she could control what they did. I did not say the rest of what I was thinking just then; namely, that I was encountering a leftover traumainduced characterological trait of occasional passivity and paralysis in the face of seemingly overwhelming events. I chose not to say it because at that moment, to Mrs L., my insight would have been only empty words. Instead, I worked, hands-on, with this insight in images; as long as Mrs L. wasn’t caught in a rapidly spiraling downturn, intervention through images often reached the inside of her more efficiently than abstractions and words. I used a couple of quick, eyes-open exercises of picturing the red flowers, turning them to blood herself, then turning them back to a beautiful red. Similarly, with the image of the sun, I had her isolate just that picture, dim it then bring it to life again. I emphasized as she did these things that she was in control of the images she chose to let in and the ones she chose to keep out. My guiding principle was substituting the mastery of now over the passivity of the traumatizing past. The next session we moved back into trance, and Mrs L. developed a more detailed image elaborating the practice from the session before. She saw herself in an intriguing museum. In one marble-floored room, there was an arresting sculpture, taking up the entire length of the room. It was an immensely disturbing depiction of burdened people, leaning on each other, melting, with distorted features. She was standing in the archway bordering this room. From this vantage point, however, she could also look left into a second room. The wall of this room held a vast picture window that consumed the entire wall. Through this window, one peered

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into a lush garden bedecked with exotic, graceful and delicate orchids. Mrs L. could consciously choose to turn away from the melting, grotesque sculpture. She could also consciously choose to turn towards and walk into the room with the window of orchids. This scene became pivotal imagery to which we returned and referred throughout our work together. It graphically condensed the message that while she had not had control of what happened to her as a child, she did have control now over what she chose to move towards, let in and dwell with. Meanwhile, the hypnosis work targeting Mrs L.’s speaking anxiety was continuing, handin-hand with practicing deep breathing exercises and experimenting with practical suggestions for concrete behaviors outside the sessions (e.g. utilizing online search engines to research her talks; practicing the art of engaging the audience with questions that forward the thread of her discussion; developing plans for ‘escape’ should she feel queasy or physically in pain). The final glitch in the smooth running of the calming effects of hypnotically mediated imagery emerged as Mrs L. started to notice the positive effects of the hypnosis generalizing to situations outside the consulting room. She said she didn’t want to think about or tell me how much the hypnosis was working because she didn’t want to jinx it. I inquired further. She became anxious and out of her spilled her longheld conviction, cemented by early experiences, that good things never last. Over several sessions, we became more familiar with the intricacies of this conviction. Having lived through deception and abrupt and devastating discoveries of loss, Mrs L. had concluded long ago that nothing good lasts. I introduced her to the idea that her conclusion had been understandably self-protective. It had prepared her for the worst (even though it had robbed her from fully experiencing the best). I pointed out how nothing bad lasted either, and how what was truly beautiful and good was just as real as what was horrific and bad. I soberly reflected that both existed; both were real; both were true. Therefore, each could be felt in its entirety, without the conclusion that one was more certain, and thus, eclipsed the other. As was her gift, Mrs L. developed imagery that captured this concept. In trance, she recalled

a tree she had recently been privileged to see on a glorious October day. As she was walking, she had suddenly been compelled to look up, and there, above her, in full canopy, was a sea of golden yellow, spreading across and filling her eyes, melting butter, warm honey, splayed against crystalline, blue skies. The image was breathtaking to her in its beauty and perfection, and purity of form mixed with color. This forever became her visual reminder that those moments of beauty have just as much right to fill the sky as the moments of awful loss. Both are real. She had felt the sensory fullness and detail of the tree. Nothing that had happened to her before or since could take that away. So she knew, at a concrete, sensory level that beauty did exist and was not wiped out by that which was bad. Thus, she could now consider concluding that good things could be felt, and in that way lastingly exist with potency inside her.

27.4.9. The work of integration—

commentary The integration aspect of trauma-focused psychotherapy involves reconfiguring what we used to expect as inevitable, by taking into account what we now have tasted as possible. As one 10-year-old patient put it, ‘It’s like throwing a thousand jigsaw puzzle pieces into the air and watching them land in a new picture’. Psychoanalysts have called this working through. Behavioral therapists have called it desensitization. Cognitive therapists have called it building new schemata. Trauma therapists have called it the phase of rebuilding shattered assumptions about the world, the self and others. With our increased success at integrating neurobiological insights with infant, developmental and trauma research, we can also call it a literal rewiring, at a neurological level, of automatic, associational pathways of neuronal firings in the brain. Repeated experiences of safety with the therapist (and eventually with others in the day to day world as the patient risks new ways of relating) literally create new neurobiologically based templates of how relationships, self and the world can work. The old templates will always remain, ready to be activated. However, one’s confidence in recovering from such activations can grow, and the new templates are created, both from these

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experiences of recovery and from new experiences of engaging differently with life. And, as with each aspect of trauma-focused therapy, the relationship is key. It is through the experience of seeing and hearing into the patient—of creating an experience of resonance inside oneself, of listening from within where the patient is—that one can begin to realize attunement, to the nuances, rhythms, language and emotional movements of the person who sits in the room with us. And it is through this attunement that we can help create the new neurological pathways, between frontal lobes and limbic system, for emotional regulation (Schore, 2003b) and, eventually, new associational transformations as well. As clinicians familiar with hypnosis, we do this naturally, simply calling it by different names … attunement is the ‘pacing’ of which Ericksonian therapists speak; it is the entrainment of which neurophysiologists write. And once we pace, we can ‘lead’ (Zeig and Rennick, 1991). Once we entrain, we can shape the direction of the entrainment. Through the portal of eye gaze, and the vehicles of voice tone, language, inflection, cadence and self-regulation, we pace and lead the patient to calming, breathing, desensitizing fears, experiencing connection where there was previously isolation. This is the stuff of holding and containment that is essential for reworking trauma experiences, rebounding from re-livings, and rewiring the new templates that interweave new possibilities into the memories of old horrors.

Transference in trauma The classic definition of transference is that one transfers one’s experience of key people from the past onto the therapist, thus perceiving and reacting to him as if he is similar to those key people. Embedded in the definition is the assumption that the perceptions of transference are distortions of the real person of the therapist. It is within the distortions, in the space between perception and ‘reality’, that therapist and patient discover the implicit details of the people in the patient’s past. As such, transference provides an opportunity to learn what memory cannot provide and words cannot describe. Accurate perceptions In working with trauma, transference happens and is invaluable in the ways described above.

However, there is more that is also essential. The patient doesn’t simply distort who the therapist is. Sometimes the patient accurately perceives aspects of the therapist’s selves inside the therapist, some of whom the therapist may be aware of and some of whom the therapist may not. The success of the work depends on the therapist’s willingness to suspend defensiveness, judgementalism and the evaluation of transference as distortions-only, and to consider where the patient may be right, not simply where the patient is wrong. This is always true, but it is particularly true with patients who have suffered complex trauma. This is because their sense of reality testing, interpersonal judgment and perceptual accuracy about when to trust is on the line. What is perceived, and the lack of permission to speak and react to what is perceived, often is a sticking point from the past that continues to imprison them relationally in traumatic templates. Thus, it is often only through permitting the therapeutic relationship itself to be a testing ground for ‘speaking truth to power’ (American Friends Service Committee, 1955) that allows patients suffering from complex trauma to have a chance of recalibrating their ways of testing the trustworthiness of relationships—ways that may have been warped from the effects of the past. The therapist’s willingness to engage fully in the relationship, her capacity to listen to, recognize and wrestle with/welcome back inside aspects of herself that are being reflected back to her, and her capacity to work (without losing perspective and a clear sense of whose needs are being served) in manageable, boundaried pieces with the patient about his accurate perceptions all give the patient a chance to heal relationally in a deep way.

The structurally organizing power of ‘being with’ A key contribution to pathogenesis in trauma, particularly complex trauma, is the experience of isolation (not being seen, heard or known) when moving through overwhelming life event(s). For a child, isolation amplifies the sense of endlessness to the autonomic flooding. Further, when no one seems there and there is nothing one can do to stop anything, hopelessness becomes inevitable and a sense of future vaporizes (Terr, 1983, 1991). Therefore, one aspect of the repair of trauma is transforming that experience of isolation into one of connection (Peebles, 1989). The experience of

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the therapist, as real and vibrantly there, becomes crucial in building structure within the patient. There are so many aspects to how relationship builds structure in psychotherapy (e.g. Greenspan, 1997; Baker, 2000; Westen and Gabbard, 2002; Gabbard and Westen, 2003; Schore, 2003b) that it is beyond this chapter to detail them here. A few examples of the kinds of trauma-relevant internal structuralizations and organization that grow from the continuity and containment of ‘being with’ the patient are: (1) transforming the terror of endlessness into an experience of circumscribed moments; (2) transforming engulfment, flooding and shapelessness into the ability to move in and out of frightening experiences and the ability to differentiate details within those experiences; and (3) transforming fragmentation into a capacity to know and hold the pieces so that one literally holds one’s Self together. To reiterate, these kinds of structuralizations are possible only through fully experienced relationship. And these kinds of structuralization are crucial to making remembering, instead of reliving, possible.

27.4.10. Mrs Larchton: outcome Mrs L. saw me for a total of 28 sessions over 10 months. She was able to give her series of talks successfully. This accomplishment further strengthened her internally as experiences of mastery always do. It opened the door for her to take other risks relationally and vocationally. What has remained most lasting for Mrs L. have been her techniques and tools for enhanced self-regulation. She recognizes better when she is overwhelmed and does not call herself ‘highstrung’ or ‘overly sensitive’ as before. Instead, she reminds herself to take life in smaller chunks, and that slower and less may actually yield more for longer. Her efforts are not seamless. They are full of the discouragements and setbacks of normal life. But they now contain more chances for joy and risk than she was capable of before. Occasionally, Mrs L. returns to work with me for a few refresher sessions. Her history of complex trauma is always uppermost in my mind as a context for whatever symptom or emotional struggle she may bring in. It is from that backdrop that I develop formulations for her symptoms. It is from that starting point that I choose whether to emphasize stabilization, brief reprocessing or a refresher on the integration of new

templates for self, others and the world. And it is within any of these places that hypnosis has always proved a valuable and potent tool to augment the work for her.

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CHAPTER 28

Hypnosis in sport: cases, techniques and issues William P. Morgan and Aaron J. Stegner

28.1. Introduction

28.2. Earlier reviews

This chapter focuses on professional consultation with emphasis on key points derived from selected cases, along with techniques and issues involving the use of hypnosis in exercise and sport settings. Athletes, coaches and sports medicine physicians sometimes request hypnosis for performance enhancement, as well as for the restoration of previous levels of performance following compromise. A fundamental question in both cases involves the matter of actual capacity. For example, with endurance events, it is possible to assess the individual’s aerobic capacity as measured by exertion on a treadmill or bicycle ergometer. This capacity, if measured properly, is not influenced by motivation and other subjective factors, but rather represents an objective physiological limit. The metabolic cost of the task can be accurately determined, and this value can be compared with the individual’s measured capacity. The guidelines to be advanced will go beyond the speculative level to include actual empirical data gathered in case studies, as well as results from other case studies reported in the literature.

There are a number of case reports and research studies applying quasi-experimental designs to address whether or not human physical performance can be enhanced with hypnosis. The first of these was carried out by Clark L. Hull and his colleagues in a series of ingenious experiments performed over a 10-year period at the University of Wisconsin and later at Yale University. This programmatic research was summarized in a heuristic volume titled Hypnosis and Suggestibility (Hull 1933), with two chapters specifically addressing whether hypnotic suggestion enable individuals to transcend voluntary capacity. Hull concluded there is little solid evidence for hypnosis enhancing performance beyond volitional capacity. A research literature review dealing with the influence of hypnosis on muscular performance by Johnson (1961a) confirmed the general conclusion reached by Hull (1933) almost three decades earlier. Johnson (1961a) pointed out that while popular opinion often attributes superhuman powers to hypnosis, and while certain individuals do experience marked performance gains under certain hypnotic conditions, ‘… the fact

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remains that the controlled studies conducted to date do not present clear-cut or consistent evidence of heightened performance in the hypnotic or post-hypnotic states’ (p. 2). Interestingly Johnson (1961a) noted that both hypnotic and post-hypnotic suggestions designed to impair muscular performance are much more likely to be successful. Later reviews by Barber (1966), Morgan (1972, 1980a, 1993), and Morgan and Brown (1983) were similarly equivocal. Barber et al. (1966) demonstrated that suggestion in the motivated ‘waking’ state was just as effective as hypnotic suggestion in the enhancement of muscular strength and endurance. There can be little argument about the need to have experimental and control groups both exposed to everything except the independent variable (e.g. hypnosis) being manipulated (Garvin et al., 2001). It is likely that in many studies hypnotic performance exceeded that of control because subjects in the hypnosis condition were more motivated than during the nonhypnosis control condition. Arguably then, the increment of hypnotic performance over nonhypnotic performance is not an effect of hypnosis per se, but rather the result of subjects in the hypnotic condition being more motivated, and exerting more effort. Happily, in the case of maximal aerobic power discussed earlier, factors such as motivation, the inability or willingness to endure discomfort, and other subjective issues on the part of the individual being tested are ruled out because the criterion measure is defined as the point where further increases in workload (e.g. treadmill speed and/or grade) fail to result in an increase of oxygen uptake. That is, ‘maximum’ is defined as an objective physiological entity rather than the individual’s subjective decision to discontinue. Unfortunately, most of the hypnosis research dealing with physical performance has relied on the use of tasks that are governed by the individual’s subjective decision to continue or discontinue exertion. Examples would be strength of grip as measured by a dynamometer, holding of the arms in a horizontal plane with or without weights held in the extended hands, reaction time, treadmill running to selfimposed exhaustion, and so on. All of these measures are subject to numerous behavioral artifacts such as demand characteristics, experimenter expectancies, placebo effect, pact of

ignorance, pre-test sensitization and order effects (Morgan, 1997). Indeed Evans and Orne (1965) report an order effect such that the control/hypnosis order renders no effect for condition, but the hypnosis/ control does, with hypnosis performance superior to control performance. It has also been recognized for a number of years that true maximal performance on such tasks is regulated in large measure by inhibitory mechanisms. These inhibitory mechanisms are regarded as protective since Gorton (1959) has reported that complications arising from electroconvulsive therapy (ECT) during its earliest years of application sometimes led to muscle contracting at forces so great that bone fractures, joint dislocations and ligament tears often resulted. In a classic experiment reported by Ikai and Steinhaus (1961), it was demonstrated that hypnotic suggestions, as well as other treatments (e.g. alcohol, amphetamine, loud noises) led to significant increases in maximal elbow flexion strength due to disinhibition of inhibitory mechanisms. This leads to the view that most tests of maximal muscular efforts are merely pseudo-maximums. These reports provide a compelling theoretical rationale for the efficacy of hypnosis in efforts to enhance muscular performance through removal of the inhibitory mechanisms that govern maximal efforts. A third explanation for the inconsistent results in this research literature relates to the inadequate statistical power in many of the published studies that have produced equivocal or negative findings. Many of the studies in this area of inquiry have relied on small sample sizes in concert with the use of dependent variables characterized by substantial variability. A fourth explanation relates to the general failure in this research literature to consider individual differences. This is important since investigators have sometimes reported that an experimental group (nomothetic data) failed to improve, but one or more individuals (idiographic data) experienced phenomenal gains. Examples of cases illustrating this point follow.

28.3. Instructive case studies

in exercise performance Continuously tracking the symptom status of one (or a few) psychotherapy patients across

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baseline and intervention phases can potentially yield data sets well suited to revealing whether, when and sometimes even why an intervention works. Peterson (2004) predicts, ‘Databases grounded in the actual experiences practitioners encounter will provide a descriptive foundation for a science that suits the nature we are trying to comprehend’ (p. 205). Peterson is not alone in this sentiment. Barlow and Hersen (1984), Bergin and Strupp (1970) and Kazdin (1982, 1992) have long noted that the practitionergenerated case-based time-series design fully qualifies as a true experiment, and that it ought to stand alongside the more common group designs [e.g. randomized controlled trial (RCT)] as a viable approach to expanding our knowledge about whether, how and for whom psychotherapy works. Many of the early breakthrough discoveries of psychological science were products of single organism methodologies (Fechner, 1889; Ebbinghaus, 1913; Kohler, 1925; Watson, 1925; Pavlov, 1927; Skinner, 1938; for review see H. Morgan and R. K. Morgan, 2004). Skinner was a particularly strong advocate of single-organism time-series designs probably because they track what interested him most: when, how and under what conditions new behavioral repertoires unfold in real time. In his view, the dominant large-N paradigm in psychology and its focus on group means actually obscures the anatomy of change.

28.3.1. Remarkable case material

encountered in group research 28.3.1.1 Example 1 (Johnson and Kramer, 1961) Warren Johnson and his associates conducted a series of experiments at the University of Maryland during the 1960s dealing with the study of hypnosis and physical performance, and most of this research was summarized in a review paper (Johnson, 1961a). This systematic inquiry was characterized by the use of rigorous research designs, and this work avoided many of the shortcomings associated with earlier and later work in this field. In the study to be summarized, for example, Johnson and Kramer (1961) evaluated 10 young, trained athletes. The experimental design consisted of nonhypnotic, hypnotic (deep) and

post-hypnotic (deep and light trance) suggestions on four different days prior to a battery of tests. The physical tests were designed to measure muscular strength (dynamometer), muscular power (jump and reach test) and muscular endurance. The latter test consisted of supine press of a 47-lb barbell that was lifted to the beat of a metronome to exhaustion. Hypnotic suggestion did not result in improvement on the strength or power tasks, but endurance improved significantly under all hypnosis conditions compared with the nonhypnosis condition. Remarkably one subject, hereafter referred to as ‘Charles’, had such an enormous increase in performance following hypnotic suggestion that Johnson and Kramer (1961) elected to exclude his data on the endurance test (supine press) from the remainder of the group, and these data were presented as a case report in the manuscript. The nine individuals included in the nomothetic analysis had scores ranging from 35 to 55 on the four pre-study practice sessions. Charles was described as an aggressive, mesomorphic, 235-lb professional athlete. This individual scored 130 repetitions during the pre-study phase of the experiment. The order of testing for this participant was A, B, C, D, and he received stereotyped suggestion without hypnosis on the first experimental day (A). His performance matched the pre-study value of 130 repetitions on this trial. Stereotyped suggestion in deep trance was employed on the second day (B), and his performance increased to 180 repetitions when stopped by the investigator. This is an example of a case where true maximal performance was probably limited during the prestudy phase by inhibitory mechanisms, and it is possible that this inhibition or ‘governor’ played some type of protective role. The investigator’s decision to stop the test would seem prudent, but there was no muscle injury or pain following this remarkable performance. The third experimental trial (C) involved post-hypnotic suggestion in deep trance, and the investigator elected to have Charles continue to self-imposed exhaustion. His performance increased even more to 230 repetitions, and on the fourth day (D) involving post-hypnotic suggestion in light trance, he increased to 333 repetitions. Charles was tested some weeks later following the experiment without hypnosis or suggestion, and he was again stopped by the investigator when he

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reached 350 repetitions. Johnson and Kramer (1961) reported that in all five tests ‘… he had a crisis at about each 90 presses, but after a struggle and violent effort he would resume the cadence, sometimes after a burst of rapid presses’ (p. 526). Examples of this nature are commonly regarded as ‘superhuman’ in the field of exercise and sport psychology, and they are sometimes referred to as ‘psychological breakthroughs’. Of course, it is only one’s vantage point that permits such a division of mind and body. It is difficult to imagine that ‘physiological’ change and mechanisms are not involved when such phenomenal physical efforts take place. There is an extensive body of literature in the field of exercise science dealing with fatigue and the factors limiting sustained effort. Accumulation of blood and muscle lactate along with other exercise metabolites eventually leads to fatigue and impairment. What is the limiting factor? How can superhuman feats be possible? Do changes occur in the central nervous system that result in efferent messages being sent to the working musculature? Or, do changes occur in the periphery with the result that afferent flow leads to modification of effort sense at a central level? We now know that hypnotic perturbation of effort sense not only results in cardiovascular changes, but brain activation takes place as well (Williamson et al., 2001, 2002). Some might argue that we merely need to know whether or not hypnotic suggestion can influence physical performance, it is not necessary to know how this occurs. This is a mistake, however, since we need to know how and why effects take place in order to advance both our science and our practice. During the 1960s when Johnson and his colleagues were conducting their pioneering research at the University of Maryland, it was not possible to employ magnetic resonance imaging (MRI), positron emission tomography (PET) or single photon emsission computed tomography (SPECT) in studies of the type they were conducting. That is now possible, and we need multidisciplinary inquiry in order to understand better the nature of hypnosis, as well as the influence of hypnosis on human performance. Nevertheless, there are additional observations made by Johnson and Kramer (1961) that still possess currency today, and these instructive points are summarized next.

Since Johnson and Kramer (1961) employed post-hypnotic amnesia, Charles did not know his score after the second experimental trial. However, following the trance and testing, he reported that he knew ‘… he had been through something’ (p. 526). This can be explained in part by the investigators’ report that a pool of sweat had accumulated on the bench and under Charles’s head following this trial. After the third trial which involved post-hypnotic suggestion where he had conscious recall of the testing, Charles stated ‘… that repeatedly he was quite sure that he could do no more but to his surprise would see his arms rise with the weight’ (p. 527). Several months following the experiment, hypnotic age regression was employed, and Charles was regressed to the day when hypnosis was first employed in the test series. When asked to experience and verbalize the hypnosis session, ‘… he gave evidence of having taken the suggestions extremely literally and to have dealt with the situation on a life or death basis’ (p. 527). In order to get a better appreciation of the nature of this seemingly superhuman feat, Johnson and Kramer (1961) proceeded to test a 250-lb successful professional football player. This athlete was a champion in the field events as well, and he was a habitual weight lifter. He was tested without hypnosis or suggestion, and he was merely asked to perform the same supine press task and to do his best. He was tested on four separate days with scores of 90, 94, 92 and 92. This observation would seem to justify the view that Charles had experienced transcendence of normal capacity as first discussed by Hull (1933). In concluding their discussion of the endurance test data, Johnson and Kramer (1961) note that Charles’s performance was ‘… too exceptional to be included in the statistical analysis’. And, they go on to say that data of this type require an additional explanation. In an effort to offer further insights regarding this case, they cite writing on the physiology of supraspinal mechanisms. In commenting on the increase in muscular strength associated with emotional excitement, Gellhorn has pointed out that such increases are associated not only with the influence of adrenomedullary secretions on muscle, but with intensification of discharges from the motor cortex. Such a cortical effect was thought at the time to be the result of impulses from the

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hypothalamus, and more recent brain imaging reports by Williamson et al. (2001, 2002, 2005) support the contention that hypnotic suggestion can lead to changes in ‘central command’, which in turn results in cardiovascular effects, as well as changes in brain activation.

28.3.1.2. Example 2 (Mittleman et al., 1992) The influence of self-hypnosis on thermal responses during immersion in 25°C water was evaluated in this example. The efficacy of hypnosis in improving thermogenic responses during bicycle ergometer exercise performed while immersed in cold water was examined in 12 males. The independent variable in this study was change in body heat storage, and this was measured objectively with an on-line computerized system. The participants in this study were evaluated under a control condition and again within 24 h in the hypnosis condition. There were no group differences (nomothetic data) in the rate of heat production, heat loss, mean skin temperature or deep body temperature (rectal) in the control and hypnosis conditions. Furthermore, hypnotic susceptibility was not correlated with changes in thermal status. The exercise was performed at an oxygen uptake of about 1.5 l/min, and the ratings of perceived exertion did not differ in the two conditions. However, perceived sensation of cold was lower during the second rest period of the hypnotic immersion. It is possible that the lack of agreement between the objective thermal ratings and the perceived sensation of cold might have resulted from compliance arising from demand characteristics operating in the experimental milieu. Inspection of individual thermal responses (idiographic data) offers an alternative explanation. Three of the participants in this experiment reported the use of images of warm environments during the hypnosis condition, and these individuals lost heat at a faster rate during hypnosis compared with the control condition. These results can be viewed as paradoxical in the sense that these individuals responded in a manner that was opposite to the hypothesis or expectation. In other words, while most (n = 9) of the participants in this study had no thermal effect with hypnosis, three of the 12 lost heat at a faster rate. The investigators indicate that these

three individuals reported the use of relaxation and mental imagery such as ‘cycling on a warm day’. Shivering is a natural response in such an environment, and this activity has the protective advantage of producing heat. It is possible that relaxation resulted in the suppression of shivering with a resultant reduction in heat production. The investigators also speculated that ‘… image of a warm day may evoke vasodilation to enhance rate of heat loss’ (p. 695). The authors of this report conclude that use of a brief hypnotic training program did not improve thermogenic responses to cool water immersion. This conclusion seems to be appropriate on the basis of the nomothetic data analysis. Examination of the thermal responses in the three individuals who reported the use of relaxation and imagery leads to an important finding since the paradoxical effect (heat loss) was unexpected; this could lead to hypothermia with sustained exposure to cold. While hypnosis might be quite effective in improving the sensation of warmth when exposed to a cold environment, this could lead to suppression of the shivering response, vasodilation, heat loss and hypothermia. Indeed, the use of hypnosis in an effort to cope with exposure to cold might be more effective with the use of exercise imagery rather than relaxation. This report makes an important contribution to our understanding, but only when the nomothetic and idiographic data are both considered. The report also demonstrates the efficacy of multidisciplinary inquiry in efforts to understand hypnotic phenomena better. Use of hypnosis alone in such a setting, without physiological markers, might easily result in erroneous conclusions.

28.3.1.3. Example 3 (Morgan et al., 1983) The efficacy of a nonhypnotic cognitive strategy designed to enhance endurance performance was evaluated by Morgan et al. (1983) with 27 healthy males. The cognitive strategy was labeled as ‘dissociation’, and pilot research had revealed this procedure to be 19 percent superior to placebo and control treatments. Maximal aerobic power was first assessed in the 27 individuals on a treadmill, and they were randomly assigned to a control (n = 13) or dissociation (n = 14) group. On a separate day all of these volunteers were assessed on a treadmill walk to

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exhaustion at 80 percent of their individual maximum, and this performance was regarded as the baseline measure of endurance. The two groups were found to have similar endurance times of 16.7 (dissociation) and 16.6 (control) min. All participants were again evaluated on endurance time to exhaustion, and each individual had at least 48 h of rest between the baseline and experimental exercise bouts. The procedures employed in the second trial were identical, with the exception that those individuals in the dissociation group were given a set of stereotyped instructions published by Morgan et al. (1983). The dissociation narrative was crafted on the basis of (1) earlier interviews performed with marathon runners (Morgan and Pollock 1977); (2) a cognitive strategy reported to be employed by Tibetan monks (Mahetangs) trained in ‘swiftness of foot’ (Watson 1973); and (3) the relaxation response described by Benson et al. (1978). The approach described by Watson (1973) is a form of ‘cultic’ meditation, whereas the relaxation response of Benson et al. (1978) is conceptualized as ‘noncultic’ meditation. The approach taken in our experiment relied on repetition of the word ‘down’ in synchrony with leg movement rather than the word ‘one’ used by Benson et al. (1978) or a sacred/secret word or phrase used by the monks trained in the art of longdistance running. We did not define this procedure as a form of hypnosis, but rather we conceptualized the dissociative strategy as noncultic meditation. It has been suggested by some hypnosis researchers and clinicians that our use of eye fixation and repetition of a pseudo-mantra in synchrony with leg movement could represent a form of autohypnosis. While we cannot argue that our approach would not result in hypnoticlike experiences, we did not define or conceptualize the procedure as hypnosis when recruiting potential participants or providing informed consent. The results of this experiment yielded a substantial increase in endurance performance for the dissociation group, whereas the control group was unchanged. There was a mean difference in performance amounting to 7 min in favor of the dissociation group, and the effect size for this difference was 1.6. However, the two groups did not differ on other variables of interest measured at the fifth or final minutes

of exercise. Heart rate, ventilation, oxygen uptake, carbon dioxide production, epinephrine, norepinephrine, lactate, state anxiety and perceived exertion did not differ in the two groups. It appears that dissociation enabled the individuals to tolerate the accumulation of blood lactate, epinephrine, norepinephrine and respiratory distress for a longer period of time. Eleven of the 14 individuals in the experimental group experienced an increase in performance with the use of dissociation, and the results for one of these individuals were quite remarkable. The idiographic data for this outlier are sufficiently unusual to warrant further discussion. The principal reason for evaluating the maximal aerobic power and having all individuals tested at a fixed percentage of maximum in this study was to ensure that a relative demand was placed on all participants (e.g. 80 percent O2max). By using a relative metabolic demand, the high fit individual is required to do more work (e.g. steeper grade) than those judged to possess lower levels of fitness. One individual in the dissociation group, hereafter referred to as ‘Roger’, had an endurance time of 45 min compared with the group’s mean time of 21.5 min, and this value was approximately 2.5 standard deviations above that observed for the group. Roger also . happened to have the highest VO2max value (i.e. 70 ml/kg/min) of anyone in the study, and such a value is comparable with levels noted in elite distance runners (Morgan and Pollock 1977). It is even more remarkable that Roger was not an endurance athlete, nor was he engaged in aerobic training at the time of his involvement in the experiment. Roger was also unique in another regard. His blood lactate level was observed to be slightly above a resting. value when he was exercising at 80 percent of VO2max. This observation, in concert with his high aerobic power, suggests that Roger had the potential to be a successful marathon runner. With this hypothesis in mind, he was evaluated in our laboratory several weeks after the completion of the experiment (Morgan et al. 1983). Roger volunteered to take part in a simulated marathon carried out on a motor-driven treadmill, and the details of this simulation appear in Morgan (1981). It was estimated that he would be able to complete the marathon distance of 26 miles, 385 yards (42.2 km) while running at

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a speed of 7.5 mph (12.1 km/h) on level grade. It was understood that he would be able to decrease the treadmill speed by giving a thumbs down signal, and he was able to run for 140 min at the prescribed speed, at which time he signaled a desire to have the speed decreased. The principal findings for this simulation are summarized in Figure 28.1. The speed was decreased to a walking pace, followed by complete rest, a return to running at 6 mph, increasing to 6.5 mph, and finally stopping altogether following 200 min of exertion which involved a distance of 23 completed miles of the simulated marathon. It was agreed a priori that the investigators would terminate the simulation if the individual’s rectal temperature reached 40°C or if any electrocardiographic abnormalities were observed. There was a gradual increase in the individual’s heart rate and rectal temperature during the first 2 h of the simulated marathon. His heart rate reached 160 beats per min (bpm)

and his rectal temperature was 38.9°C at the 15mile point, and there was no reason to believe that he was approaching the ‘wall’ often described by marathon runners (Morgan and Pollock, 1977). While his heart rate was well below his maximal value of 195 bpm during most of the run, it will be noted that an increase from 160 to 180 bpm occurred as he reached the 23rd mile. His rectal temperature had been 38.9°C prior to the rest and walking phase, but it approached the 40°C threshold established for termina-tion of the simulation. Ratings of perceived exertion according to Borg’s category rating scale also revealed that he had reached his limit, and the simulation was terminated at this point. This nonhypnotic example has been presented in order to illustrate several points. First, efforts to enhance maximal physical performance should be carried out within a multidisciplinary context in order to understand how

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performance enhancement occurs. Second, the use of an intervention model based on input from disciplinary expertise from fields such as psychology, physiology and medicine ensures the health and safety of clients, as well as participants in experiments. Third, this work illustrates that endurance performance can be significantly enhanced above customary baseline levels in most individuals with selected psychological procedures of the type employed in this research. Fourth, it is sometimes possible in the case of some individuals not only to transcend normal physical capacity, but to evoke superhuman feats in such individuals. It is not possible, however, to understand such phenomena using disciplinary models of a unitary nature. Our discussion will now proceed to the use of hypnosis in efforts to understand and enhance physical performance in selected cases.

28.3.2. Remarkable case-based

material collected in the context of an n of 1 study What follows is a collection of case studies that might be included in a discussion of hypnosis and physical performance, and while our selection of case material may be regarded as arbitrary, we have made these selections in order to illustrate specific techniques and issues regarded as relevant in professional consultation. The first case was described by Eysenck (1941) in a classic paper involving the experimental study of the improvement of mental and physical functions with hypnosis. Two additional cases described by Morgan (1993, 2002) follow in order to emphasize the importance of multidisciplinary inquiry in such consultation efforts.

28.3.2.1. Example 1 (Eysenck, 1941) One of the first and most compelling examples involving the influence of hypnosis on the transcendence of normal physical performance was a case study published by Eysenck (1941). The subject, Mr R., was a former schoolmaster, about 50 years of age. Eysenck reports that he was chosen for study because of his ability to enter deep hypnosis easily, and his depth of hypnosis varied little across experimental trials. The hypnotic induction was based upon the method of eye fixation along with suggestions based on

those described earlier by Young (1925). Mr R. was not only able to enter deep hypnosis, but he experienced complete post-hypnotic amnesia. A total of 30 physical and mental tests were administered, and approximately 60 h of testing across days was completed. Mr R.’s performance averaged 33 percent higher in the hypnotic compared with the control condition for the 30 tests. One of the tests involved muscular endurance, and the results will be summarized next given the chapter’s focus. It should be emphasized that Eysenck (1941) did not employ suggestions designed to enhance performance. Therefore, the gains noted for the hypnosis condition were not due to the confounding of hypnosis and suggestion which has plagued much of the related research in this area. Mr R. was asked to squeeze a dynamometer 24 times as hard as possible with rest pauses of 10 s between each contraction. Testing was performed on 10 separate occasions, and the trials were alternated in the control (C) and hypnosis (H) order. The order was C–H–H–C half of the time and H–C–C–H the other half of the time. The average responses for the two conditions are summarized in Figure 28.2 where the responses for the first and second, third and fourth, and so on through contractions 23 and 24 are averaged. Twelve data points appear for the two conditions, and each point represents the average of 10 contractions performed by Mr R. A typical fatigue curve was observed for the control condition with a gradual reduction from about 1,750 g at the outset to about 1,200 g of force at the conclusion. This pattern was not observed for the hypnosis condition where the initial contraction averaged about 1,825 g, decreased to about 1,500 g at the tenth trial, and was sustained at this level throughout the remainder of the trials. This remarkable gain in performance was presumably due to hypnosis per se since no suggestion was employed in either condition. Inspection of Figure 28.2 reveals that force of contraction did not fall after the tenth contraction under hypnosis, but a steep decline took place from this point onward for the control condition. At the completion of both conditions, Mr R. was asked on one or two occasions to continue squeezing the dynamometer following completion of the trial, and the data for these epochs are illustrated by the dotted lines in the figure.

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It will be noted that performance declined dramatically at this point in the control condition, but force production was maintained with hypnosis. In his discussion of this phenomenal performance Eysenck (1941) reported that Mr R. ‘… goes on, machine-like, without tiring’ (p. 312) and ‘… fatigue is inhibited under hypnosis’ (p. 315). These results are truly remarkable, and they serve to support the hypothesis that hypnosis can result in the transcendence of normal capacity. But, how does hypnosis bring about such an effect? A dynamometer test of the type described by Eysenck (1941) would certainly result in a number of biochemical and cardiovascular effects. It would be expected, for example, that a significant accumulation of muscle and blood lactate would occur along with elevations in

plasma levels of epinephrine and norepinephrine, and it would be predicted that a fatigue curve of the type illustrated for the control condition would result. It would also be anticipated that perceived exertion would increase with the onset of fatigue in the control condition, and therefore, it would be interesting to know what happens to effort sense under hypnosis. It is known that hypnotic perturbation of effort sense can be increased and decreased in a systematic manner during cycle ergometry maintained at a constant power output of 100 W (Morgan et al., 1973, 1976; Williamson et al., 2001). Regional cerebral blood flow (rCBF) and cardiovascular changes have also been shown to change with the perturbation of effort sense during constant load exercise

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(Williamson et al., 2001), as well as during the imagery of exercise at rest (Williamson et al., 2002). The type of imagery was patterned after that described by Wang and Morgan (1992), and it consisted of ‘internal’ as opposed to ‘external’ imagery. Furthermore, the imagery of exercise was associated with changes in perception of effort, rCBF and cardiovascular responses identical with those noted for actual exercise. With the advent of brain imaging technology, it has been possible to demonstrate that hypnosis not only alters cardiovascular responses, but brain activation is influenced as well during handgrip exercise (Williamson et al., 2001). Hence, it is likely that a number of biochemical, cardiovascular and neurophysiological changes took place during the experiment described much earlier by Eysenck (1941). Appropriate physiological measures should be employed in future research and clinical applications designed to enhance physical performance with hypnosis. This recommendation calls for the use of multidisciplinary models in order to understand better the nature of performance enhancement.

28.3.2.2. Example 2 (Morgan, 1993) The case report described in the following example was published earlier in a chapter titled ‘Hypnosis and sport psychology’ (Morgan, 1993), and it is reproduced in the present work with permission of the American Psychological Association. This case describes a common problem in which an athlete is no longer able to perform at his or her customary level. The case involved a 21-year-old distance runner, hereafter referred to as ‘Steve’, who had previously established a school and conference record but was unable to replicate the performance. Indeed, Steve was not able even to complete many of his races, much less dominate a given competition. Problems of this nature are usually diagnosed as ‘staleness’ in the field of sports medicine, and the only effective treatment appears to be rest (Morgan et al., 1987a). However, this was not the problem in the present case. Steve’s ability to perform at his previous level was judged by the coach simply to reflect inadequate motivation and unwillingness to tolerate the distress and discomfort associated with high-level performance. On the other

hand, Steve reported that he was willing to do anything to perform at his previous level, and he felt that his principal problem stemmed from inadequate coaching. Although Steve and the coach were both interested in the restoration of the runner’s previous performance ability, they were clearly at odds with one another. Indeed, the conflict had reached the point where the two were unable to discuss the matter, and Steve had turned to his team physician for support. However, a thorough physical examination, including blood and urine chemistries routinely used in sports medicine, failed to reveal any medical problems. The physician proposed that hypnosis be used in an effort to resolve this problem, and the athlete was eager to try such an approach. However, it seemed appropriate first to evaluate Steve’s physical capacity in order to ensure that he was actually capable of performing at the desired level. It is well documented that aerobic power is an important factor in successful distance running. Therefore, Steve was administered a test of maximal aerobic power on a treadmill. This required that he run at a pace of 19.3 km/h on the treadmill, and the grade was increased by 2 percent every minute until he could no longer continue. The results of this treadmill test are summarized in Figure . 28.3. Steve achieved a peak or maximal VO2 of 70 ml/kg/min by the fifth minute of exercise, and his ability to uptake oxygen fell during the sixth minute. In other words, a true physiological maximum, as opposed to a volitional or symptomatic maximum, was achieved. The recorded value of 70 ml/kg/min represents the average reported for elite distance runners (Morgan and Pollock, 1977), and Steve was therefore physiologically capable of achieving the desired performance level. However, our calculations revealed that it would be necessary for him to average 96 percent of his maximum throughout the event to replicate his record performance. This could potentially be problematic because exercise metabolites such as lactic acid begin to accumulate and to limit performance during prolonged exercise at 60–80 percent of maximum in most trained individuals. In other words, it would have been possible for Steve to perform at the desired level, but such an effort would be associated with considerable discomfort (pain).

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•

VO2 ml/kg min

70 68 66 64 62 60

3

4 5 Minute of Exercise

6

(19.3 km/hr and increasing grade)

Fig. 28.3 Graph depicting the calculation of maximal oxygen uptake measured during a treadmill test performed at a speed of 19.3 km/h and increasing grade during each minute of exercise.

Steve was observed to score within the normal range on anxiety, depression and neuroticism as measured by the State-Trait Anxiety Inventory (STAI), Depression Adjective Check List (DACL) and Eysenck Personality Inventory (EPI), respectively. He scored significantly higher than the population norms on extroversion (EPI), but this has been a common finding for many athletes (Morgan, 1980b). He was found to be hypnotizable following preliminary induction and deepening sessions, and he was eager to pursue ‘insight training’ through hypnosis and deep relaxation. Steve was viewed as a good candidate for hypnosis for the following reasons: (1) there were no medical contraindications detected; (2) he possessed the necessary physiological capacity to achieve the desired goal; (3) there were no apparent psychological contraindications; and (4) he was able to enter into a deep trance. Steve was next age-regressed to the day of his championship performance, and he was instructed to describe the competition as well as any related events that he judged to be relevant. However, rather than telling him that ‘the race was about to begin’ or instructing him in the customary ‘on your marks’ command, he was asked to recall all events leading up to the race on that day. He was instructed, For example, try to remember how you felt when you awakened that morning; your breakfast or any

foods or liquids you consumed; the temperature before and during the race; the nature and condition of the course; interactions with your coach, team-mates and opponents; your general frame of mind; and then proceed to the starting line when you are ready.

Steve’s team physician and the first author had previously asked him if it would be acceptable for either or both of them to ask questions during the session, and Steve had no objections. Steve had a somewhat serious or pensive look, but within a few minutes he began to smile and chuckle, saying that he had false-started. When asked why this was so amusing, he replied that it was ‘ridiculous since there is no advantage to a fast start in a distance race’. This event can be viewed as a critical incident because runners and swimmers will intentionally false-start at times in an effort to reduce tension. Others will do this in an effort to upset or ‘unnerve’ their opponents. At any rate, his facial expression became serious once again, and his motor behavior (e.g. grimacing and limb movements) suggested the race had begun. The verbatim narrative follows: The pace is really fast. I’m at the front of the pack. I don’t think I can hold this pace much longer, but I feel pretty good. The pace is picking up … I don’t think I can hold it … my side is beginning to ache … I have had a pain in the side many times. It will

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go away if I continue to press. There … it feels good now. The pain is gone, but I’m having trouble breathing. I’m beginning to suck air … the pain is unbearable … I’m going to drop out of the race as soon as I find a soft spot. There’s a soft, grassy spot up ahead … I’m going to stop and lay in the soft grassy spot … wait, I can’t, three of my teammates are up on top of the next grade … they are yelling at me to kick … I can’t let them down. I will keep going. I’m over the hill now … on level grade … it feels ok … I’m alright. There’s another hill up ahead. I don’t like hills … It is starting to hurt again … can’t keep this up … I’m going to find a soft spot again and stop. There’s a spot ahead … I’m going to quit … I’m slowing down … this is it. Wait, there … I see a television set about ten feet off the ground at the top of the hill … hey, I’m on the TV, but this race isn’t televised … but I can see myself clearly on the TV … I’m not here anymore … I’m on the TV. Now there’s another TV, but to the right of the first one. My parents are on that TV, and they are watching me run this race on the other TV. I can’t stop now. I can’t let them down. Got to keep going. I’m not here … I’m on TV. It’s starting to feel better. I feel like I’m in a vacuum now. I can’t feel anything. My feet aren’t hitting the ground anymore … I can’t feel the wind hitting me. Hey, I’m a Yankee Clipper … I’m on the high seas … I’m flying … the sails are full … the wind is pushing me … I’m going to blow out … I’m going to kick … I don’t feel pain anymore … This is going to be a PB, maybe a record, I’m flying now, there is no one in sight, this is my race, there’s the tape, I’m almost there, the tape hit my chest, it feels weird … weird … weird … the tape feels weird … that’s the end … the end … the end … the end.

Steve appeared to be deeply relaxed at this point, and he had previously agreed to answer any questions we might have following his recall of the race. He was asked, ‘You almost dropped out of the race twice. Why didn’t you simply slow your pace? Would that not have been better than quitting?’ Steve replied without any hesitation that ‘Oh, no, you really have to take pride in yourself to quit. You have be a real man … it takes guts to quit. Anybody can continue and turn in a lousy performance. I have too much pride to do that. I would rather quit’. Although this view can be judged as somewhat unusual, it is noteworthy that Steve had dropped out of more races than he had completed during the present season.

Steve was asked to clarify the meaning of selected terms or phrases he had used, and then he was asked the following question: ‘Would you like to have complete recall for all of this information, or would you prefer to forget about it, or perhaps, have it come back to you gradually?’ The decision to ask this question was based on the earlier demonstration by Johnson (1961a) that athletes sometimes do not wish to become aware of repressed material in the post-hypnotic state. The decision to ask whether he would prefer that this information gradually return was also based on Johnson’s case study, and it was intended to prevent Steve from becoming overwhelmed or further confused as a result of this previously repressed material. At any rate, Steve responded that he would like to have complete recall following the session. Hence, no effort was made to produce post-hypnotic amnesia. Steve was also asked in the hypnotic state whether he wished to continue with this program of insight training, and he replied that he would like to give this some thought. For this reason, post-hypnotic suggestions designed to ensure adherence to future hypnotic sessions were not administered. In other words, posthypnotic suggestions designed to produce amnesia regarding the previously repressed material, as well as motivating instructions designed to ensure continuation, could have, but were not, administered to Steve. This decision was based on our belief in the efficacy of nondirected approaches in such cases, as well as a priori contingency agreements with Steve. These agreements were of a generic nature, and they were decided on prior to intervention with hypnosis. This case serves to illustrate several points that practitioners in sport psychology or sports medicine might wish to consider prior to using hypnosis with an athlete. First, efforts designed to enhance physical performance with hypnosis should not be carried out within a unidimensional context. It is important first to obtain relevant information concerning the athlete’s physiological, psychological and medical state. Second, the decision to proceed with hypnosis should be made after obvious contraindications (i.e. pathophysiology and psychopathology) have been ruled out. Third, peak performance involving the transcendence of usual or customary levels can be associated with cognitive-perceptual

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processes of a remarkable nature. The recordsetting performance was found to be associated with considerable pain, but the sensation of pain had been repressed, i.e. Steve was unaware of this pain experience in the nonhypnotic state. However, the cognitive-perceptual experience was ‘replayed’ during hypnotic age regression, and Steve elected to have awareness of this experience in the post-hypnotic state. It is possible that conscious awareness of this previously repressed material may have provided Steve with insights he previously lacked. Steve subsequently elected to terminate insight training, and this decision was not congruent with his initial statement that he would do anything to return to his previous level of performance. It should be kept in mind that although he did possess the physiological capacity necessary to perform at a high level, to do so would have been associated with considerable pain. Also, despite the fact that his subsequent performance did not improve, our subjective impression was that he had ‘come to terms’ with the situation. In a sense, then, he did not terminate the insight training we were providing, but rather, the insight he gained resolved the problem—at least from his perspective. Fourth, it is noteworthy that Steve’s record performance was characterized by the cognitive strategy known as dissociation (Morgan et al., 1983; Morgan, 1984, 1997, 2001). Runners who use this strategy attempt to ignore sensory input (e.g. muscle pain and breathing distress) by thinking about other activities (i.e. distraction). Other runners have reported that they initiate ‘out-of-body’ experiences by entering the body’s shadow cast on the ground in front of them. These cognitive strategies have been labeled as dissociation. Although this strategy can clearly facilitate endurance performance (Morgan et al., 1983), it is not the preferred strategy of elite distance runners (Morgan and Pollock, 1977). Indeed, elite runners have been found to use a cognitive strategy known as association, which is based on systematic monitoring of physical sensations, rather than ignoring such input (Morgan and Pollock, 1977; Morgan et al., 1987b, 1988). There is a possibility that Steve could have been taught to use dissociation (1984), in either the hypnotic or the nonhypnotic state, in an effort to help him cope with the perception of

pain during competition. It is also possible that such an approach would have led to enhanced performance, because (1) laboratory research has shown that such an approach is ergogenic (Morgan et al., 1983); and (2) Steve had actually experienced a form of dissociation during his record-setting performance. However, ignoring sensory input while performing at a high metabolic level in a sport contest is not without risk, and such an approach can lead to heatstroke, muscle sprains or strains, and stress fractures (Morgan, 1984). Cognitive strategies designed to minimize or eliminate the sensation of pain and discomfort during athletic competition and training should be used judiciously and with caution.

28.3.2.3. Example 3 (Morgan, 2002) The case report described in the following example was published earlier in a chapter titled ‘Hypnosis in sport and exercise psychology’ (Morgan, 2002), and it is reproduced here with permission of the American Psychological Association. A 27-year-old competitive cyclist, hereafter referred to as ‘Max’, approached us with the request that hypnosis be used to resolve a problem he was experiencing with his training. Max was unable to complete routine training rides of 50–75 km, and he was concerned that he would not be able to compete effectively in a forthcoming national race. Max completed a standard battery of psychological questionnaires, and the results were remarkable in that he was found to be depressed and anxious. Because of the elevated scores on these measures, it was felt that his performance problem should not be addressed with hypnoanalysis. Max was referred to a clinical psychologist for evaluation and possible treatment. Not only did this assessment reveal that he was clinically depressed, but it also showed that crisis intervention was warranted. Therefore, Max was referred to an outpatient psychiatry clinic where he was treated for several months. Treatment consisted of time-limited psychotherapy in concert with antidepressant drug therapy. During the course of his psychotherapy, Max continued to visit our physiology of exercise laboratory, where he had previously completed a test of maximal aerobic power on the bicycle ergometer. This test revealed that

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. he had a peak VO2 of 66 ml/kg/min, i.e. maximal capacity was defined in terms of physiological capacity rather than a symptom-limited, or subjective, maximum. He was retested using the same protocol, and the test was performed by the same laboratory technician who performed the earlier assessment. Max’s maximal capacity had fallen to 53 ml/kg/min. Because a reduction of 20 percent in actual physiological capacity is both atypical and remarkable, Max was retested a week later to confirm these results. The second test yielded identical results, and these data served to confirm that the decision to use hypnosis in such a case was contraindicated, i.e. Max could no longer perform at his customary level, because he no longer had the physiological capacity to do so. The unexplained reduction in . VO2max warranted further assessment, and he was referred for a complete physical examination, including routine blood and urine chemistries. All results were negative, with the exception that he seemed to have some suspicious chest sounds. For this reason, Max was referred to a pulmonary function laboratory, where all test results were found to be negative. The psychotherapy and drug therapy led to a reduction in Max’s anxiety and depression, and he was eventually able to resume customary levels of training. However, the 20 percent decrement in physical capacity was not restored, nor was he able to return to competitive cycling at the national level. The purpose of elaborating on this case study is 3-fold. First, the ‘motivational’ problem was based on a profound and difficult to explain reduction in Max’s physiological capacity. Second, the use of hypnosis to treat this problem was contraindicated owing to the demonstration of both psychopathology (anxiety and . depression) and pathophysiology (reduced VO2max). Third, it is apparent in retrospect, and on theoretical grounds, that a multidisciplinary approach to problems was, and is, the only defensible course of action.

28.4. Summary Research studies involving the influence of hypnosis on physical performance in exercise and sport settings has relied almost entirely on quasiexperimental as opposed to true experimental designs. Too often designs confound treatment

condition (e.g. hypnosis versus control) with motivation (low motivation versus high motivation). The confounding of hypnosis with other factors influencing performance (e.g. rapport, suggestion, demand characteristics) has been a serious methodological problem in this literature. However, a careful review of the research literature indicates that hypnotic suggestion is superior to suggestion administered under nonhypnotic control conditions for selected physical tasks in highly hypnotizable individuals. Tasks involving prolonged efforts (i.e. endurance) are particularly responsive to hypnotic suggestion (Eysenck, 1941), whereas single, all-out efforts (i.e. strength, power) are not (Johnson, 1961b). The field has neglected reports of remarkable and compelling shifts in performance from both the group- and case-based literatures (Eysenck, 1941; Ikai and Steinhaus, 1961; Johnson, 1961b). Dismissing these ideographic data diminishes the discipline. The conclusions reached in this summary are largely similar to those advanced in earlier reviews dealing with the influence of hypnosis on human physical performance (Hull, 1933; Gorton, 1959; Johnson, 1961b; Morgan, 1972, 1985, 1993, 1996; Morgan and Brown, 1983). One exception to this generalization is the report by Ryde (1964) who described the successful use of hypnosis in the treatment of 35 individuals with various ailments commonly treated by sports medicine practitioners. These problems consisted of Achilles’ tendon sprains, arch sprains, bruised heels, shin splints, tennis elbow and other common ailments involving minor trauma often treated in the sports medicine clinic. The use of hypnosis in such cases to manage pain offers indirect evidence of its efficacy since the individuals described in Ryde’s report returned to regular physical activity earlier than otherwise would have been possible (Ryde, 1964). This report should be of interest to physicians, physical therapists, psychologists and athletic trainers involved in the treatment of sports injuries. This chapter differs from others published heretofore in that a case is made for the use of multidisciplinary approaches when applying hypnosis in efforts to enhance physical performance above baseline levels, as well as the restoration of previous performance levels that no

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longer appear to be possible. The case we make may seem daunting to the practitioner considering the application of hypnosis in exercise and sport settings, but we believe that such an approach is defensible from an ethical, moral, legal and scientific standpoint. It is our view that efforts to enhance performance to a level that exceeds an individual’s capacity can be problematic. The challenge, of course, is first to quantify the individual’s capacity in order to ascertain whether or not the performance goal is realistic. Advances in our understanding of hypnosis will be enhanced with the adoption of multidisciplinary models. This can be supported in exercise and sport settings on philosophical grounds alone, and there is compelling statistical theory and empirical evidence arguing against the use of unitary, narrow, disciplinary approaches. It is not sufficient to know whether or not hypnosis is effective in the enhancement of human physical performance, but it is also important to know how and why this intervention works.

References Barber, T. X. (1966) The effects of hypnosis and suggestions on strength and endurance: a critical review of research studies. British Journal of Social and Clinical Psychology, 5: 42–50. Barlow, D. H. and Hersen, M. (1984) Single case experimental designs. Pergamon Press, New York, NY. Benson, H., Frankel, F. H., Apfel, R., Daniels, M. D., Schniewind, H. E., Nemiah, J. C. et al. (1978) Treatment of anxiety: A comparison of the usefulness of self-hypnosis and a meditational relaxation technique. An overview. Psychotherapy Psychosomatics, 30: 229–242. Bergin, A. E. and Strupp, H. H. (1970) New directions in psychotherapy research. Journal of Abnormal Psychology, 76(1): 13–26. Ebbinghaus, H. (1913) Memory (H. A. R. a. C. E. Busenius, transl.). Teachers College: New York, NY. Eysenck, H. J. (1941) An experimental study of the improvement of mental and physical functions in the hypnotic state. British Journal of Medical Psychology, 18: 304–316. Evans, F. J. and Orne, M. T. (1965) Motivation, performance, and hypnosis. International Journal of Clinical and Experimental Hypnosis, 13: 103–116. Fechner, G. T. (1889) Elemente der Psychophysik. Breitkopf & Hartel, Leipzig. Garvin, A. W., Trine, M. R. and Morgan, W. P. (2001) Affective and metabolic responses to hypnosis, autogenic relaxation, and quiet rest in the supine and seated positions. International Journal of Clinical and Experimental Hypnosis, 49: 5–18.

Gorton, B. E. (1959) Physiologic aspects of hypnosis. In J. M. Schneck (ed.) Hypnosis in Modern Medicine, pp. 246–280. Charles C. Thomas, Springfield, IL. Hull, C. L. (1933) Hypnosis and Suggestibility. AppletonCentury-Crofts, New York. Ikai, M. and Steinhaus, A. H. (1961) Some factors modifying the expression of human strength. Journal of Applied Psychology, 16: 157–163. Johnson, W. R. and Kramer, G. F. (1961) Effects of stereotyped non-hypnotic, hypnotic, and posthypnotic suggestions upon strength, power, and endurance. Research Quarterly of the American Association for Health, Physical Education, and Recreation, 32: 522–529. Johnson, W. R. (1961a) Body movement awareness in the non hypnotic and hypnotic states. Research Quarterly, 32: 263–264. Johnson, W. R. (1961b) Hypnosis and muscular performance. Journal of Sports Medicine and Physical Fitness, 1: 71–79. Kazdin, A. E. (1982) Single-case research designs: Methods for clinical and applied settings. Oxford University Press, New York. Kazdin, A. E. (1992) Research design in clinical psychology, 2nd edn. Allyn and Bacon, Boston, MA. Kohler, W. (1925) The mentality of apes. Harcourt, New York, NY. Mittleman, K. D., Doubt, T. J. and Gravitz, M. A. (1992) Influence of self-induced hypnosis on thermal responses during immersion in 25°C water. Aviation, Space, and Environmental Medicine, 68: 689–695. Morgan, W. P. (1972) Hypnosis and muscular performance. In W. P. Morgan (ed.) Ergogenic Aids and Muscular Performance, pp. 193–233. Academic Press, New York. Morgan, W. P. (1980a) Hypnosis and sports medicine. In G. D. Burrows and L. Dennerstein (ed.) Handbook of Hypnosis and Psychosomatic Medicine, pp. 359–375. Elsevier/North-Holland Biomedical Press, Amsterdam, The Netherlands. Morgan, W. P. (1980b) The trait psychology controversy. Research Quarterly for Exercise and Sport, 51: 50–76. Morgan, W. P. (1981) Psychophysiology of self-awareness during vigorous physical activity. Research Quarterly for Exercise and Sport, 52: 385–427. Morgan, W. P. (1984) Mind over matter. In W. F. Straub and J. M. Williams (ed.) Cognitive Sport Psychology, pp. 311–316. Sport Science Associates, Lansing, NY. Morgan, W. P. (1985) Psychogenic factors and exercise metabolism. Medicine and Science in Sports and Exercise, 17: 309–316. Morgan, W. P. (1993) Hypnosis and sport psychology. In J. Rhue, S. J. Lynn and I. Kirsch (ed.) Handbook of Clinical Hypnosis, pp. 649–670. American Psychological Association, Washington, DC. Morgan, W. P. (1997) Mind games: the psychology of sport. In D. R. Lamb and R. Murray (ed.) Perspectives in Exercise Science and Sports Medicine (Vol 10): Optimizing Sport Performance, pp. 1–62. Cooper Publishing Company, Carmel, IN.

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Morgan, W. P. (2001) Psychological factors associated with distance running and the marathon. In D. Tunstall Pedoe (ed.) Marathon Medicine 2000, pp. 293–310. Royal Society of Medicine, London. Morgan, W. P. (2002) Hypnosis in sport and exercise psychology. In J. L. Van Raalte and B. W. Brewer (ed.) Exploring Sport and Exercise Psychology, pp. 151–181. American Psychological Association, Washington, DC. Morgan, W. P. and Brown, D. R. (1983) Hypnosis. In M. L. Williams (ed.) Ergogenic Aids and Sports, pp. 223–252. Human Kinetics, Champaign, IL. Morgan, W. P. and Pollock, M. L. (1977) Psychologic characterization of the elite distance runner. Annals of the New York Academy of Science, 301: 382–403. Morgan, W. P., Raven, P. B., Drinkwater, B. L. and Horvath, S. M. (1973) Perceptual and metabolic responsivity to standard bicycle ergometry following various hypnotic suggestions. International Journal of Clinical and Experimental Hypnosis, 31: 86–101. Morgan, W. P., Hirota, K., Weitz, G. A. and Balke, B. (1976) Hypnotic perturbation of perceived exertion: ventilatory consequences. American Journal of Clinical Hypnosis, 18: 182–190. Morgan, W. P., Horstman, D. H., Cymerman, A. and Stokes, J. (1983) Facilitation of physical performance by means of a cognitive strategy. Cognitive Therapy and Research, 7: 251–264. Morgan, W. P., Brown, D. R., Raglin, J. S., O’Connor, P. J. and Ellickson, K. A. (1987a) Psychological monitoring of overtraining and staleness. British Journal of Sports Medicine, 21: 107–114. Morgan, W. P., O’Connor, P. J., Sparling, B. P. and Pate, R. R. (1987b) Psychological characterization of the elite female distance runner. International Journal of Sports Medicine, 8: 124–131. Morgan, W. P., O’Connor, P. J., Ellickson, K. A. and Bradley, P. W. (1988) Personality structure, mood states, and performance in elite male distance runners. International Journal of Sport Psychology, 19: 247–263.

Pavlov, I. P. (1927). Conditioned reflexes. University Press, New York. Peterson, D. R. (2004) Science, Scientism, and professional responsibility. Clinical Psychology: Science and practice, 11: 196–210. Ryde, D. (1964) A personal study of some uses of hypnosis in sports and sports injuries. Journal of Sports Medicine and Physical Fitness, 4: 241 246. Skinner, B. F. (1938). The behavior of organisms. AppletonCentury-Crofts: New York, NY. Wang, Y. and Morgan, W. P. (1992) The effect of imagery perspectives on the psychophysiological responses to imagined exercise. Behavioral Brain Research, 52: 167–174. Watson, J. B. (1925). Behaviorism. W. W. Norton, New York, NY. Watson, L. (1973) Super Nature. Anchor Press/Doubleday, New York. Williamson, J. W., McColl, R., Mathews, D., Mitchell, J. H., Raven, P. B. and Morgan, W. P. (2001) Hypnotic manipulation of effort sense during dynamic exercise: Cardiovascular responses and brain activation. Journal of Applied Physiology, 90: 1392–1399. Williamson, J. W., McColl, R., Mathews, D., Mitchell, J. H., Raven, P. B. and Morgan, W. P. (2002) Brain activation by central command during actual and imagined handgrip under hypnosis. Journal of Applied Physiology, 92: 1317–1324. Williamson, J. W., Mitchell, J. H. and Raven, P. B. (2005) Cardiorespiratory control: hypnosis and perceived exertion. International Journal of Sport and Exercise Psychology, 4: 518–526. Young, P. C. (1925) An experimental study of mental and physiological functions in the normal and hypnotic states. American Journal of Psychology, 36: 214–232.

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Clinical hypnosis: the empirical evidence Mark Moore and Anthony F. Tasso

29.1. Introduction At present, clinical research has little or no influence on clinical practice. This state of affairs should be particularly distressing to a discipline whose goal over the past 30 years has been to produce professionals who would integrate the methods of science with clinical practice to produce new knowledge (Barlow, 1981, p. 147). The 30 years to which Barlow refers mark their beginning with the Boulder conference held in 1949, a conference which was the culmination of growing concern for the standards of clinical training in a time of increasing need for professional psychologists in the public sector. From the beginning, however, there were concerns as to how research and practice were to be brought together in a fruitful alliance. Yet seemingly by the end of the conference ‘the original chasm had disappeared’ (Raimy, 1950, p. 23) and the majority of attendees accepted the importance of including research training in clinical programs. What, you may wonder, has this to do with the chapter at hand, and hypnosis in particular? Over 220 years ago, had Mesmer and his colleagues considered the relevance of Enlightenment thinking and the development of scientific inquiry to their practice of hypnosis, the history of our field might look quite different. Instead of engaging the members of the Royal Commission, who were to investigate the merits of mesmerism, in a consideration of the clinical importance of

distinguishing efficacy from effectiveness, the Commission were left to focus their evaluation of Mesmer’s treatment on mechanism only. The final report (Franklin et al., 1785) dismissed the effects of mesmerism as due only to the effects of the imagination. Yet what an effect! Clinical hypnosis, as both art and science, was the tragic victim of the willful blindness of the mesmerists and the myopic vision of the Royal Commission for over 150 years, as hypnosis was summarily dismissed from the realm of worthy scientific investigation. One wonders what would have happened if those practicing mesmerism had had sufficient insight into the scientific method utilized by the Commission. Perhaps in addition to accepting the conclusiveness of the Commission’s findings that treatment effects had nothing to do with animal magnetism, they could have persuasively argued that a study of mechanism is quite different from a study of effect, thus preventing the throwing out of the infant child that was hypnosis with the sullied waters of animal magnetism. It can be argued that it is of mutual benefit for both the fields of clinical hypnosis and psychotherapy in general that we (as clinicians who use hypnosis) both understand and appreciate the value of outcome research in evaluating and improving our work. However, in drawing an analogy to the elegant work of the Royal Commission (Franklin et al., 1785) on mesmerism, it would be remiss of me

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not to acknowledge the continuing controversies that rack the field of outcome research in psychology. Fifty-three years on from the Boulder conference, it might appear that few, if any, of the bridges of understanding originally thrown across that ‘chasm’ remain. Even modern, more carefully engineered edifices (thrown from either side of the chasm) have apparently failed to connect both sides securely. The literature is rife with debate on the scientist–practitioner divide, and the sense of division is evident in the titles given to articles in the area such as ‘Psychotherapy: Can the practitioner learn from the researcher?’ (Strupp, 1989); ‘Are the results of randomized controlled trials useful to psychotherapists?’ (Persons and Silberschatz, 1998); and ‘Psychotherapy practice and research: Repairing a strained alliance’ (Goldfried and Wolfe, 1996). The same question may be asked of the utility of clinical research for hypnosis. Why should the field of hypnosis place an emphasis on research? Looking again to the broader field of psychotherapy research, one answer may be found in Larry Beutler’s (1998) argument that clinical research is a necessary response to recent legal and economical factors. From the late 1970s on, the law courts used two standards for determining psychotherapeutic effectiveness: the principle of the community standard and the doctrine of the respectable minority. The principle of the community standard reduces effectiveness to the popularity and common usage of a given treatment among professionals within a given region. Obvious problems occur with such a standard: one only has to reflect on how an unchallenged standard of popular belief would still have us believing the earth to be flat. To make matters worse, the doctrine of the respectable minority, put forward to counter difficulties associated with the development of a clear community standard, holds that a clinician may also be judged according to the principles of the school he claims to adhere to. A school must be ‘the line of thought of a respectable minority of professionals’ (Beutler, 1998, p. 115), but case law has established that this minority could be composed of as few as six individuals! A lack of empirical, research-based standards of effectiveness would clearly leave the profession in a precarious position whereby legal experts rather than psychologists would define the types of therapy that could be practiced and reimbursed.

Beutler (1998) also noted how the Task Force on Promotion and Dissemination of Psychological Procedures was developed in 1992 in response to the Managed Health Care (MHC) system’s view of psychotherapy as a homogeneous treatment and practitioners as interchangeable. The MHC system emphasized effectiveness based on cost and access rather than actual clinical benefit. However, MHC programs are beginning to shift their focus from cost onto empirical proof (Aaron, 1996), thus furthering the need for empirical standards within the field. One source for empirical standards for treatment comes from the results of well designed randomized controlled trials (RCTs). Their use by the APA Division 12 Task Force in deciding what therapies can be categorized as empirically supported therapies has been described by Chambless and Hollon (1998). Chambless and Hollon (1998) propose that treatment efficacy is best demonstrated by controlled research (as exemplified by RCTs) that allows one to conclude that outcome gains are due to treatment effects rather than chance events such as patient differences, the passage of time or initial problem severity. A list of the criteria developed by Chambless et al. (1998) to evaluate the level of empirical support for a treatment is given in Table 29.1. RCTs compare experimental psychotherapy treatments with control or comparison treatments, and factors that may obscure treatment effects are reduced or eliminated. As such, they are: (1) ‘often single-blinded’ so that participants are unaware of which treatment condition they are in; (2) ‘use restrictive inclusion and exclusion criteria’ so that participants are accurately categorized thus allowing a link between treatment and specific diagnosis to be made; (3) participants ‘are commonly randomly assigned to experimental and control or comparison conditions’ so that differences between groups can be more confidently attributed to treatment differences rather than initial group differences; and (4) ‘typically use clinicians who are rigorously trained in the treatment they are to provide’ so that the treatment is actually given in the form intended (Nathan et al., 2000, pp. 964–965). The advantage of applying such a design to the study of psychotherapy is that it allows for greater internal validity than do poorly controlled studies. Ironically, the central problem for many practitioners is that the bulk of such psychotherapy

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Table 29.1 Criteria for empirically supported treatments (from Chambless et al., 1998) Well-established treatments I.

II. At least two good between-group design experiments must demonstrate efficacy in one or more of the following ways: A. Superiority to pill or psychotherapy placebo, or to another treatment B. Equivalence to already established treatment with adequate sample sizes.

A large series of single case design experiments demonstrating efficacy with: A. Use of good experimental design and B. Comparison of intervention with another treatment

Further criteria for well-established treatments III. Experiments must be conducted with treatment manuals or equivalent clear description of treatment IV. Characteristics of samples must be specified. V. Effects must be demonstrated by at least two different investigators or teams. Probably efficacious treatments I. Two experiments must show that the treatment is superior to waiting-list control group. or II. One or more experiments meeting the well-established treatment criteria IA or IB, III and IV above but V is not met. or III. A small series of single case design experiments must meet well-established treatment criteria. Experimental treatments Treatment not yet tested in trials meeting task force criteria for methodology.

research, which utilizes RCT’s as the sine qua non of empirical design, appears to consist of ‘impeccable studies of nothing very much’ (Spence, 1994). In other words, the cost of such high internal validity is lowered external validity or generalizability: RCTs address questions of efficacy over effectiveness (Seligman, 1995). For example, statistically significant outcome differences in RCTs are often not equivalent to clinically meaningful change in symptomatology or quality of life for participants (Jacobson and Truax, 1991). Also, RCTs typically focus on uncomplicated diagnostic groups that are not representative of the complex, typically co-morbid patient groups seen in actual practice (Silverman, 1996); and the use of treatment manuals do not adequately capture psychotherapy as it is practiced (Smith, 1995). Psychotherapy research, of course, is not limited to RCTs, and several authors (e.g. Howard et al., 1996; Seligman, 1996) have argued that effectiveness studies, which aim to ‘determine whether treatments are feasible and have measurable beneficial effects across broad popula-

tions and in real-world settings’ (Nathan et al., 2000, p. 965), have an important role to play in the empirical study of psychotherapy. Substantial numbers of effectiveness studies have yet to emerge, however; and, in the meantime, practitioners have taken umbrage with what is considered to be the premature creation of a list of empirically validated therapies that rests predominantly on the results of RCTs (Task Force on Promotion and Dissemination of Psychological Procedures, 1995; Chambless et al., 1996; Beutler, 1998; Chambless and Hollon, 1998; Henry, 1998). Fears that such a list will be used by HMOs to justify the type and duration of treatment offered to clients are warranted (Steenbarger et al., 1996) and the list will also have important implications for the training of future clinical psychologists (Calhoun et al., 1998). Yet what is the alternative? Few would disagree that clinical psychology, as both art and science, has at its heart a desire for greater understanding of psychopathology, assessment and treatment; an understanding hopefully

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unencumbered by personal interest, bias or the mistaken perception of order amidst random chaos. The greatest hope for such an understanding is through empirical study. This chapter will thus begin with a consideration of what constitutes the current empirical approach to evaluating psychotherapy, and then consider examples of how this approach has been applied to clinical hypnosis.

29.2. Empirical approaches

to outcome research Efficacy is the key focus of RCTs, with their emphasis on determining if observed benefits are due to the effects of a treatments, or to confounding factors such as the type of patients assigned to the treatment or control conditions, biases or error in the outcome measures, and the impact of maturation and historical events. RCTs overcome such confounding factors through the random assignment of patients to the treatment condition and the control conditions. All things being equal, randomization ensures that each group of patients assigned to a particular condition is on an equal footing on average with all other groups, both before treatment and over the course of time, with the only difference being the particular treatment applied to that group. In addition to the need for random assignment as an element of research designed to evaluate a treatment’s efficacy, Chambless and Hollon (1998) also stress the need for replication of studies, particularly by independent research teams, if incorrect conclusions on the basis of single aberrant results are to be avoided. Chambless and Hollon (1998) emphasize the need for sound methodology as a feature of efficacy research. While there is much debate as to what constitutes sound methodology, the minimal threshold of ‘soundness’ put forward by Chambless and Hollon is a design that compares a treatment with some form of ‘minimal or notreatment condition’ (e.g. wait-list or assessment-only control). They consider a treatment to be efficacious if it is found by at least two teams of researchers to be of greater benefit than no treatment. In essence, while we may not know why it is that such a treatment works, we can easily see that it has some clinical utility and

that it is worth using. A more sound design is one in which a treatment is compared with a placebo or other treatment. If the effect of a treatment is found to be superior to alternative treatments or to conditions that control for placebo effects, i.e. the effects are due to more than simply positive expectations or receiving attention, then a treatment can be said to be efficacious and specific. A comparison with an alternative established treatment is often the most conclusive design, if equivalence can be sufficiently demonstrated. Thus, Chambless and Hollon (1998) note that it is often tempting for researchers simply to compare a new treatment with an established treatment and to omit a control condition, as it is less timeconsuming and seemingly easier to obtain an adequate sample size. However, such a design requires that the well-established treatment is implemented correctly and that there is also adequate statistical power, as approximately 50 patients are required for a significance test of a medium difference between two conditions if a conventional power level of 80 percent is to be achieved (Cohen, 1988, cited by Chambless and Hollon, 1998, p. 8). Therefore, the authors suggest that ‘equivalence is always easier to interpret if it occurs in the context of a design that compares the established efficacious treatment with the kinds of control conditions against which it was initially established’ (pp. 8–9). In considering the issue of equivalence and how to interpret efficacy on the basis of null results, Chambless and Hollon suggest that treatments may be considered equivalent when ‘(a) investigators have a sample size of 25–30 per condition, (b) the unproven treatment is not significantly inferior to the established efficacious treatment on tests of significance, and (c) the pattern of the data indicates no trends of the established efficacious treatment to be superior’ (p. 9). RCTs also typically have the advantage of clearly defining the population for which a treatment is designed. The majority of recent research has relied on nomenclature provided by the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994). Chambless and Hollon argue that this is advantageous because it ‘ties treatment research to a large body of descriptive psychopathology literature based on the same definitions, and

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there are standardized diagnostic interviews that allow reliable diagnoses to be made’ (1998, p. 10). The authors also point out that many clinicians are familiar with this diagnostic system because of its use by third-party payers. Alternative means are available to identify a population for which treatment is intended—examples include use of cut-off scores on questionnaires or interviews, but the important point is that the method used to do so is reliable and valid. Chambless and Hollon also advise that researchers describe other relevant sample characteristics, such as age range, socio-economic status, ethnicity and co-morbid conditions. Of course, in order to determine that a given treatment produces an effect, it is necessary to assess the impact of that treatment on a particular problem. Thus the need for valid and reliable outcome assessment tools in RCTs and, if interviewers are used, the demonstration of reliability for the interview-based measures. Measures should be selected that are not only pertinent to the problem being treated, but that are also capable of addressing multiple facets of a problem. An example is the assessment of pain reduction, which might not only be assessed in terms of patient self-report but also in terms of reduced pain medication use, increased frequency of use of an affected limb and/or changes in autonomic arousal. It is also desirable to have follow-up data in order to ascertain the stability of treatment effects over time. However, obtaining follow-up data is complicated by the fact that many problems of interest to researchers, e.g. depression, have naturally varying courses over time, and so single-point follow-up assessments may be misleading. On the issue of how long to maintain follow-ups, Chambless and Hollon (1998, p. 10) suggest that ‘those disorders that tend to follow a more variable course require longer follow-ups … [and] strong effects are likely to require less time to be detected than weak ones, particularly if they are stable over time’. A final advantage of RCTs is their reliance on manualized treatments. The use of treatment manuals in supporting research has been adopted by the APA Task Force on Promotion and Dissemination of Psychological Procedures as a requirement for a therapy to be considered for the list of empirically supported therapies (Chambless et al., 1996). Use of manuals ensures

better research design and interpretable results, and also allows others to know what the treatment actually entailed. Chambless et al. (1996) provide an example of the problem of classifying a treatment as ‘psychodynamic’—does that refer to Supportive Expressive Psychotherapy as described by Luborsky (1984) or Davanloo’s (1980) short-term dynamic therapy? Without the existence of a manual it is unclear what is meant by the names given to particular treatments—or as Chambless et al. (1996, p.11) express it: ‘the brand names are not the critical identifiers … the manuals are.’ Chambless and Hollon (1998, p. 11) also allow for one exception for the requirement of a manual: when a treatment ‘is relatively simple and is adequately described in the procedure section of the journal article testing its efficacy’. While manuals may contain detailed sessionto-session descriptions of technique, it is not necessary. For example, a manual may also consist of a description of broad principles of treatment and examples that clarify those principles. However, regardless of the form of manual used, it will typically need to be supplemented by supervision and training. In addition to initial training, there is a need to determine if the treatments were administered adequately, particularly if a therapist is inexperienced with a particular treatment modality or has allegiance to another school of therapy. Ideally, one would want to evaluate a therapist’s adherence to a treatment protocol and his or her competence in delivering it. Unfortunately, competence (or the quality of treatment) is markedly more difficult to assess than adherence, and currently the inclusion of tests for either adherence or competence is not a requirement for the determination of a treatment’s efficacy. Chambless and Hollon (1998) noted other important factors to consider when determining if there was evidence to label a treatment as ‘empirically supported’. Caveats on data analysis included the need for an a priori rationale for statistical tests, the importance of intentionto-treat analyses when there are differing rates of attrition from conditions, and the need to test for therapist or site effects so as to enhance the generality of findings. In the not-infrequent case of contradictory findings, they allowed for welldesigned studies to ‘carry the day’ if they point

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in one direction and poorly designed studies point in another (p. 13). If studies are equally rigorous, then it is necessary to consider the preponderance of the evidence, but, if results are truly mixed, a conservative conclusion is advised. Meta-analyses may also shed further light on conflicting results. However, despite the obvious strengths of RCTs as a means of evaluating the efficacy of various treatments, concerns have been raised regarding the need also to consider the effectiveness of a treatment. Seligman (1995, 1996) has argued that RCTs capture neither the reality nor the richness of actual clinical practice. He states that ‘the efficacy study is the wrong method for empirically validating psychotherapy as it is actually done, because it omits too many crucial elements of what is done in the field’ (1995, p. 967). Specifically the ways that psychotherapy as practiced in the field differs from psychotherapy in efficacy studies are that (1) it is generally not of fixed duration; (2) it is self-correcting and not confined to a limited number of techniques; (3) patients enter therapy by active shopping rather than random assignment; (4) patients usually have multiple problems; and (5) therapists are typically concerned with improvement in general functioning rather than solely symptom reduction. Many practitioners who are presented with the results of RCTs and effectiveness studies may feel that research findings tell them little of value for their actual daily practice. Critics of current research often raise the question of whether or not there are immediate practical benefits to the pursuit of psychotherapy research. If our goal is to apply our knowledge to the assessment and treatment of patients’ presenting problems, then is the proof not in the pudding? Do experienced clinicians need research findings to tell them how to do a better job? Can the nomothetic emphasis in outcome research provide meaningful and practical advice pertinent to an actual client presenting with a particular problem to a specific therapist? It is easier for clinicians, after years of practice, to feel confident in claiming that they know what works ‘on the basis of experience’. Unfortunately, assessing outcome and making causal attributions regarding what elements of therapy were responsible for change is wide open

to human error. Clinicians are human and thus prone to common biases in judgment, attribution, decision-making, inferences and perception (Kahneman et al., 1982; Fiske and Taylor, 1995). Continued success over the years may lead clinicians, in the absence of control comparisons, to mistakenly attribute client improvement to specific therapist skills and techniques rather than, for example, client variables, initial severity of the presenting problem, historical and social factors and general therapeutic factors such as provision of hope and empathy (Kendall, 1998). With these points in mind, the field of research on clinical hypnosis will now be brought into focus through consideration of a sample of the outcome research that has been done to date. The scope of this chapter is not wide enough to provide an overview that would be both comprehensive and satisfying, so areas have been selected that are broadly representative of the wider body of research on hypnosis. The reader is thereby offered the benefit of greater detail and some room for the finer subtleties inherent in clinical research. The three general areas of study that will be focused on are: pain, health and (to some degree) psychotherapy. Pain is representative of a widely studied problem; health is an area of fast-developing application and study; and psychotherapy, unfortunately, is an example of how much remains to be done. What has been answered and what lies unanswered in these three research areas is true of other areas of study on clinical hypnosis, and so hopefully the following overview will illuminate a way forward for future researchers.

29.3. Pain The use of hypnosis in alleviating pain has a history of extensive study and application. In 2001 Russell Hawkins published a systematic meta-review on the effectiveness of hypnosis in pain relief, and in this paper he concentrated on review articles in order to draw conclusions about the efficacy of hypnotic analgesia. Review articles were subjected to a quality assessment algorithm developed by Oxman and Guyatt (1991). This assessment consisted of 10 criteria applied to reviews; however, Hawkins omitted the tenth question due to its subjective component

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regarding the overall quality of the review. The other nine questions require a simple yes/no answer and so result in a quality ‘score’ ranging from 0 to 9. The questions are presented in Table 29.2. Of the 23 reviews of the pain literature that Hawkins included in his meta-review, only 6 obtained a quality score of 7 or greater: five studies (Kirsch et al., 1995; Sellick and Zaza, 1998; Milling and Costantino, 2000; Montgomery et al., 2000; Pan et al., 2000) obtained a score of 7, and Talley et al. (1996) obtained a score of 8. The remaining quality scores were one 4, two 3s, one 2, ten 1s and three 0s. Using an arbitrary cutoff score of 7 to assess the reviews, Hawkins concluded that ‘level I evidence (evidence from a systematic review of all relevant trials) exists for the efficacy of hypnosis on pain’ and ‘also exists for the effects of hypnosis on pain related to cancer/invasive medical procedure’, but that there was a ‘conspicuous lack of Level I evidence for the application of hypnosis in the treatment of … low back pain, headache, childbirth and burn pain’ (p. 67). Some of the high-quality reviews that he cites are worth further scrutiny.

Table 29.2 Criteria from the Oxman and Guyatt (1991) index for assessing the quality of review articles (taken from Hawkins, 2001) 1. Were the search methods used to find the evidence on the primary question(s) stated? 2. Was the search for evidence reasonably comprehensive? 3. Were the criteria used for deciding which studies to include in the review reported? 4. Was bias in the selection of studies avoided? 5. Were the criteria for assessing the validity of the included studies reported? 6. Was the validity of all studies referred to in the text assessed using appropriate criteria? 7. Were the methods used to combine the findings of the relevant studies reported? 8. Were the findings of the relevant studies combined appropriately relative to the primary question? 9. Were the conclusions made by the author supported by the data and/or analysis reported in the overview?

29.3.1. Sellick and Zaza From the results of a search (and utilizing the terms hypnosis, pain and cancer) of the MEDLINE, CINAHL and PsychoINFO Lit databases for RCTs of nonpharmacological treatments of cancer pain, Sellick and Zaza (1998) were able to find six studies of hypnotic analgesia for cancer pain. Three of the studies were on adult patients with cancer-related pain: Spiegel and Bloom (1983) and Syrjala et al. (1992, 1995); and three were with children or adolescents with cancerrelated pain: Zeltzer and LeBaron (1982), Katz et al, (1987) and Wall and Womack (1989). The Spiegel and Bloom (1983) study focused on chronic pain, but the remaining five studies considered acute procedural pain. Sellick and Zaza evaluated these studies using criteria developed by Detsky et al. (1992). Their evaluation indicated that all six studies randomly assigned patients and also adequately described the randomization. They also concluded that there was no bias in the treatment assignment. All six studies included a description of the criteria for measuring outcome and those criteria were partially objective. In only two studies (Katz et al, 1987; Wall and Womack, 1989) were the outcome assessors blind to the treatment received. Inclusion/ exclusion criteria were clearly defined for five studies and partially defined for the Zeltzer and LeBaron (1982) study. For all the studies, the authors were able to determine how many patients were excluded from the trial, and all six studies fully described the therapeutic regimen for treatment and control groups. The statistical analyses were also deemed appropriate for all the studies, although none of the studies offered a sample size justification before the research was conducted. The Spiegel and Bloom (1983) study involved 54 female patients with metastatic breast cancer, and the results of the study indicated that patients who conducted 5–10 min of selfhypnosis reported the lowest mean pain sensation relative to a control group and a second treatment group (supportive group therapy without hypnosis). Both treatment groups reported lower pain and suffering, and there was no significant difference between the treatment groups for frequency and duration of pain.

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Syrjala et al. (1992) randomly assigned 45 patients undergoing bone marrow transplant to one of four groups: usual treatment, therapist contact control, cognitive-behavioral training without imagery, and hypnosis. Relative to all other groups, the patients in the hypnosis group reported significantly less oral pain. Syrjala et al. (1995) again looked at patients undergoing bone marrow transplant. Ninety-four patients were assigned to one of four groups: usual treatment, therapist contact, cognitive-behavioral therapy (CBT) with imagery, and hypnosis (relaxation and imagery). Only patients in the CBT group and the hypnosis group reported a significant reduction in pain. While the authors concluded that CBT ‘did not provide any additional benefit beyond that of the relaxation and imagery component alone’ (p. 13), it could also be argued that hypnosis failed to deliver any additional effect beyond that of CBT. Zeltzer and LeBaron (1982) randomly assigned 27 children and adolescents undergoing bone marrow aspirations and 22 children and adolescents undergoing lumbar puncture to either a hypnosis treatment group or a nonhypnotic behavioral distraction group. For the bone marrow aspirations, both treatment groups achieved a reduction in pain, but the hypnosis treatment produced a larger effect (decrease of 1.5 versus 0.66 on a 5-point scale). Also significant anxiety reduction was only evident in the hypnosis treatment group. For the lumbar puncture patients, only the hypnosis treatment group (decrease of 1.71) achieved a significant decrease in pain. Both treatments produced a decrease in anxiety, although again the participants in the hypnosis treatment group achieved a greater reduction in anxiety (decrease of 1.36 versus 0.66 on a 5-point scale). Katz et al. (1987) studied 36 children undergoing bone marrow aspirations. The children were randomly assigned to one of two groups: hypnosis or play. These two treatments were equally effective in reducing pain and fear, although there was an interaction effect for gender and treatment, with boys benefiting more from play and girls more from hypnosis. Wall and Womack (1989) found in a study of 20 pediatric patients undergoing bone marrow aspirations or lumbar puncture that there was a significant decrease in pain for both the hypnosis treatment group and

the active cognitive strategy treatment group. Sellick and Zaza concluded that there was ‘much support for the specific use of hypnosis in managing pain associated with medical procedures and some support for its use in managing chronic cancer pain’ (p. 13).

29.3.2. Montgomery et al.’s

meta-analysis Montgomery et al. (2000) conducted a metaanalysis of 18 studies, that included both clinical and patient samples. The stated aims of their study were: ‘(a) to determine the percentage of people who benefit from hypnoanalgesic suggestions, (b) to explore whether results based on empirical work in the laboratory generalize to medical settings and whether the effects of hypnosis are limited to a particular segment of the population (e.g., highly suggestible individuals), and (c) to explore whether the effects of hypnoanalgesic suggestions are less effective, equally effective, or more effective than other psychological interventions (e.g., relaxation training) in providing pain relief ’ (p. 138). In pursuing the first two aims, they limited the sample to studies ‘that directly compared hypnotherapy to no-treatment, wait list, or standard-treatment control groups on measures of pain’ (p. 139). Twenty-seven effect sizes derived from 18 studies were used to achieve their first aim; and the second aim of comparing clinical and student samples compared 10 and 17 studies, respectively. For the comparison to other psychological interventions, they included studies without control groups, requiring an additional 27 effect sizes to be calculated. In selecting their studies, the authors relied on previous reviews (Spinhoven, 1988; Ellis and Spanos, 1994; Genius, 1995; Holroyd, 1996; Chaves and Dworkin, 1997) and on a PsycLIT database search using the search terms hypnosis and pain, hypnosis and analgesia, hypnotherapy and pain, and hypnotherapy and analgesia. To the studies obtained from their search, they applied the following criteria: ‘(a) a hypnotic intervention intended to reduce pain was administered to at least one group of studies; (b) the inclusion of a no-treatment or standard-treatment control group; and (c) sufficient data … to allow calculation of effect sizes’ (p. 139). This resulted in the

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calculation of 41 effect sizes from a total of 18 studies and 933 participants. Random assignment was utilized in nearly all the studies, and the exceptions were sequential assignment to counter-balance for order of group assignment between therapists (Edelson and Fitzpatrick, 1989); alternate placement in one of three treatment groups (Elton et al., 1988); and use of odd and even medical chart numbers for group assignment (Weinstein and Au, 1991). On the basis of their analysis, the authors calculated that there was a moderate to large effect size, d = 0.74 and even with the use of a conservative estimate of effect size whereby individual effect sizes were weighed by the size of the sample, the effect remained significant (D = 0.67, VarD = 0.26, P