International Handbook of Clinical Hypnosis


Психология и эзотерика

At the clinical level, the current open attitudes of society to problems that previously were brushed under the carpet, while solving some problems have sometimes raised as many new ones. There has been much heated controversy about repressed memories, but in the long term we gain from such controversies...



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Edited by

Graham D Burrows AO Robb 0 Stanley Peter B Bloom


International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley, P. B. Bloom

Copyright © 2001 John Wiley & Sons Ltd

ISBNs: 0-471-97009-3 (Hardback); 0-470-84640-2 (Electronic)

International Handbook of Clinical Hypnosis

International Handbook of Clinical Hypnosis

Edited by

Graham D. Burrows AO, KSJ

The University of Melbourne, Australia

Robb O. Stanley

The University of Melbourne, Australia

Peter B. Bloom

The University of Pennsylvania, USA


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International handbook of clinical hypnosis [edited by] / Graham D. Burrows, Robb O. Stanley, Peter B. Bloom

p. ; cm.

Includes bibliographical references and index. ISBN 0-471-97009-3 (cased)

1. Hypnotism. I. Burrows, Graham D. II. Stanley, Robb O. III. Bloom, Peter B. [DNLM: 1. Hypnosis. WM 415 H23551 2001] RC495 .H357 2001 616.89'162—dc21


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List of Contributors        ix

Preface        xi


1 Introduction to Clinical Hypnosis and the Hypnotic Phenomena ...         3

Graham D. Burrows and Robb O. Stanley

2 Training in Hypnosis        19

Peter B. Bloom


3 Patient Selection: Assessment and Preparation, Indications and

Contraindications        35

Julie H. Linden

4 Memory and Hypnosis—General Considerations        49

Peter W. Sheehan

5 Neuropsychophysiology of Hypnosis: Towards an Understanding

of How Hypnotic Interventions Work        61

Helen J. Crawford


6 Injunctive Communication and Relational Dynamics:

An Interactional Perspective        85

Jeffrey K. Zeig



7 Hypnosis and Recovered Memory: Evidence-Based Practice        97

Kevin M. McConkey

8 Hypnosis in the Management of Stress and Anxiety Disorders      113

Robb O. Stanley, Trevor R. Norman and Graham D. Burrows

9 Hypnosis and Depression      129

Graham D. Burrows and Sandra G Boughton

10 Hypnosis, Dissociation and Trauma      143

David Spiegel

11 Conversion Disorders      159

C. A. L. Hoogduin and Karin Roelofs

12 Personality and Psychotic Disorders      171

Joan Murray-Jobsis

13 Dissociative Disorders      187

Richard P. Kluft

14 Eating Disorders—Anorexia and Bulimia      205

Moshe S. Torem

15 Hypnotherapy in Obesity      221

Johan Vanderlinden

16 Hypnotic Interventions in the Treatment of Sexual Dysfunctions...     233

Robb O. Stanley and Graham D. Burrows

17 Hypnosis in Chronic Pain Management      247

Frederick J. Evans

18 Hypnosis and Pain      261

Leonard Rose

19 The Use of Hypnosis in the Treatment of Burn Patients      273

Dabney M. Ewin


20 Hypnosis in Dentistry      285

Dov Glazer

21 Dental Anxiety Disorders, Phobias and Hypnotizability      299

Jack A. Gerschman

22 Applications of Clinical Hypnosis with Children      309

Daniel P. Kohen

23 The Negative Consequences of Hypnosis Inappropriately

or Ineptly Applied      327

Robb O. Stanley and Graham D. Burrows

Index      335


Peter B. Bloom, MD    Department of Psychiatry, University of Pennsylvania, School of Medicine, c/o 416 Riverview Avenue, Swarthmore, PA 19081-1221, USA.

Sandra G. Boughton, DipClinPsych    Department of Psychiatry and Behavioural Science, University of Western Australia, Perth, Western Australia 6009, Australia.

Graham D. Burrows, AO KSJ MD    Department of Psychiatry, University of Melbourne, Austin and Repatriation Medical Centre, Heidelberg, Victoria 3084, Australia.

Helen  J.   Crawford,   PhD    Department  of Psychology,  Virginia  Polytechnic  Institute  and  State University, Blacksburg, VA 24061-0436, USA.

Frederick J. Evans, PhD    Pathfinders: Consultants in Human Behavior, 736 Lawrence Road, Law-renceville, NJ 08648-0412, USA.

Dabney M. Ewin, MD    Departments of Surgery and Psychiatry, Tulane University, c/o 318 Baronne Street, New Orleans, LA 70112-1606, USA.

Jack A. Gerschman, BDSc, PhD    School of Dental Science, University of Melbourne, c/o Suite 5, 3rd Floor, 517 St. Kilda Road, Melbourne, Victoria, 3004, Australia.

Dov Glazer, DDS    Lousiana State University School of Dentistry, 3525 Prytania Street, Suite #312, New Orleans, LA 70115-3566, USA.

C.A.L. Hoogduin, MD, PhD    Department of Psychology and Personality, University of Nijmegen, PO Box 9104, NL-6500 HE Nijmegen, The Netherlands.

Richard P. Kluft, MD    Department of Psychiatry, Temple University, c/o 111 Presidential Boulevard, Suite 231, Bala Cynwyd, PA 19004-1004, USA.

Daniel P. Kohen, MD    Behavioral Pediatrics Program, Department of Pediatrics - University of Minnesota, Gateway Center - Suite 160, 200 Oak Street SE, Minneapolis, MN 55455-2002, USA.

Julie H. Linden, PhD    Private Practice, 227 East Gowen Avenue, Philadelphia, PA 19119-1021, USA.

Kevin M. McConkey, PhD    School of Psychology, University of New South Wales, Sydney, New South Wales 2052, Australia.

Joan Murray-Jobsis, PhD    Human Resource Consultants, 100 Europa Center, Suite 260, Chapel Hill,

NC 27514-2357, USA.

Trevor R. Norman, PhD    Department of Psychiatry, University of Melbourne, Austin and Repatriation Medical Centre, Heidelberg, Victoria 3084, Australia.

Karin Roelofs, MA    Department of Psychology and Personality, University of Nijmegen, PO Box 9104, NL-6500 HE Nijmegen, The Netherlands.

Leonard Rose, MBBS    Melbourne Pain Management Clinic, 96 Grattan Street, Suite 14, Carlton, Victoria 3053, Australia.

Peter W. Sheehan, PhD, AO    Vice-Chancellor, Australian Catholic University, PO Box 968, North Sydney, New South Wales 2059, Australia.

David Spiegel, MD    Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Office 2325, Stanford, CA 94305-5718, USA.

Robb O.  Stanley, DClinPsych    Department of Psychiatry, University of Melbourne, Austin and Repatriation Medical Centre, Heidelberg, Victoria 3084, Australia.


Moshe S. Torem, MD    Center for Mind-Body Medicine, Northeastern Ohio Universities, College of Medicine, 4125 Medina Road, Suite 209, Akron, OH 44333-4514, USA.

Johan Vanderlinden, PhD    Department of Behavior Therapy, University Centre St-Josef, B-3070 Kortenberg, Belgium.

Jeffrey K. Zeig, PhD    The Milton H. Erickson Foundation, 3606 North 24th Street, Phoenix, AZ 85016-6500, USA.


The editors of this volume, the International Handbook of Clinical Hypnosis, first met to discuss the idea for it during the 13th International Congress of Hypnosis held in Melbourne, Australia, in 1994. During the Congress, sponsored on behalf of the International Society of Hypnosis by the Australian Society of Hypnosis and the Department of Psychiatry of the University of Melbourne, the presidency of the International Society of Hypnosis was passed from Graham D. Burrows AO to Peter B. Bloom, while Robb O. Stanley continued as secretary treasurer.

From that vantage point and following the publication of Contemporary International Hypnosis, the proceedings of the 13th Congress, we realized the need for a handbook authored by senior clinicians and researchers, who could present topics in greater length and depth that would substantially contribute to the field of hypnosis and its applications.

We hope that interested readers from many and varied disciplines who seek more definitive knowledge on how clinical hypnosis is used in a variety of medical, dental and psychological conditions will benefit from reading this volume. We also hope that health care professionals from many disciplines, whether they are experienced or inexperienced with the principles of clinical hypnosis, will find ways to better serve their patients or clients in the future.

The editors wish to thank our colleagues for their contributions to this handbook. Our contributors are experts in their fields and come with broad experience in medicine, dentistry, and psychology. Most are professors at major universities, some are chairman of their departments, and all are members of the leading hypnosis societies in their own countries. These societies, of which most of our authors have served as president, promote clinical training and research in the understanding of this immensely useful modality in the healing arts.

We sincerely thank Mrs Gertrude Rubinstein for her excellent editorial assistance; and we are grateful to our publisher, John Wiley & Sons, who has consistently helped us to shape these endeavors to the benefit of us all.

Graham D. Burrows, AO KSJ MD, Australia

Robb O. Stanley, DClinPsych, Australia

Peter B. Bloom, MD, USA

International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley, P. B. Bloom

Copyright © 2001 John Wiley & Sons Ltd

ISBNs: 0-471-97009-3 (Hardback); 0-470-84640-2 (Electronic)


The Nature of Hypnosis


 International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley, P. B. Bloom

Copyright © 2001 John Wiley & Sons Ltd

ISBNs: 0-471-97009-3 (Hardback); 0-470-84640-2 (Electronic)

Introduction to Clinical Hypnosis and the Hypnotic Phenomena


University of Melbourne, Australia

This volume presents a collection of brief monographs by specialists in various applications of hypnosis to the alleviation of chronic debilitating conditions. Hypnosis has an established role as an adjunct to the healing professions. The many societies and associations of hypnosis practitioners worldwide provide standards of training that enhance the learning, accreditation, and public trust in practitioners of hypnotic interventions in individuals seeking responsible health care.

The chapters range from general issues of training and choice of clients, through theoretical considerations of memory, the neurophysiology of hypnosis, and the psycho therapies. A generous admixture of clinical case histories is given. The more specific directions for applications of hypnosis techniques include cautions against problems encountered over years of clinical practice.

At a basic level, researchers are taking advantage of developments over the last decades in imaging the brain to gain a better understanding of the neurophysio-logical basis of hypnotic phenomena.

At the clinical level, the current open attitudes of society to problems that previously were brushed under the carpet, while solving some problems have sometimes raised as many new ones. There has been much heated controversy about repressed memories, but in the long term we gain from such controversies in wisdom as well as knowledge about the complexities of the human mind.


Like many psychological phenomena, intelligence, depression and anxiety, hypnosis is defined according to the subjective experience and report of participants and by the phenomena that accompany the 'hypnotic state.' The characteristics of this state include a redistribution of attention to an inward focus, a reduction of critical

International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley and P. B. Bloom © 2001 John Wiley & Sons, Ltd


judgment and reality testing, a suspension of forward planning, increased suggestibility, heightened imagery or involvement in fantasy, and hypnotic role behaviour. While there are many definitions of hypnosis, the most widely accepted is that proposed by the British Medical Association as a result of their investigation into the use of hypnosis in medicine in 1955 (BMA, 1955, 1982):

Hypnosis is a temporary condition of altered perception in the subject which may be induced by another person and in which a variety of phenomena may appear spontaneously or in response to verbal or other stimuli. These phenomena include alterations in consciousness and memory, increased susceptibility to suggestion, and the production in the subject of responses and ideas unfamiliar to him in his normal state of mind. Further phenomena such as anaesthesia, paralysis and the rigidity of muscles, and vasomotor changes can be produced and removed in the hypnotic state.


The use of hypnosis, under other names, for the treatment of clinical problems has a long history, being recorded in ancient scripts describing ritual and religious ceremonies. The phenomena of hypnosis have been used to account for miraculous cures that in the middle ages were attributed to sacred statues, healing springs and the 'laying on of hands' by those of high status or religious power. The more modern use of hypnosis began with the work of the Viennese physician Franz Mesmer, who achieved many spectacular cures which he attributed to the appropriate redistribution of invisible 'magnetic fluid' within the body. In 1784, a commission of Louis XVI could find no evidence of animal magnetism, and attributed Mesmer's successes to suggestion.

Despite Mesmer's fall from popularity following the Royal Commission, interest in the clinical application of hypnosis developed rapidly throughout the nineteenth century. The term hypnosis was coined in 1841 by James Braid, a Manchester surgeon, who believed that a psychological state similar to sleep accounted for the phenomena observed. The use of hypnosis by the French neurologist Charcot, and by Breuer and Freud in the 1880s, extended its use to the treatment of neurotic disorders broadly referred to as 'hysterical.' Freud subsequently abandoned the use of hypnosis in favour of psychoanalytic techniques (Sulloway, 1979).

The development of behavioural approaches in psychology in the early twentieth century saw a temporary lessening of interest in internal psychological processes such as hypnosis. Despite this, the use of hypnosis to induce relaxation in behavioural therapies for anxiety was frequently described (Beck & Emery, 1985; Clarke & Jackson, 1983; Marks, Gelder & Edwards, 1968; Rubin, 1972; Rossi, 1986). Hypnotic phenomena were also used to induce behavioural change (Hussain, 1964; Wolpe, 1958, 1973; Kroger & Fezler, 1976) but the nature of the hypnotic component was not always discussed. The more recent development of cognitive therapies which focus on altering the patient's perceptions and cognitions (Brewin,


1988) have all but ignored the use of hypnosis, in spite of the cognitive phenomena which have been demonstrated to accompany the hypnotic state.


A variety of phenomena accompany the hypnotic state, which may be induced on the instruction of a therapist or self-induced by the subject. The extent that the phenomena are experienced and observed depends upon the depth of the hypnotic state, which is a characteristic of the subject and commonly referred to as hypnotizability or hypnotic susceptibility.

During the hypnotic process the focus of attention is narrowed and shifted towards an internal cognitive focus. This leads to a reduction in awareness of the sensory input requiring a response. There is a relative reduction in arousal of sensory and response systems of the central nervous system, in contrast to the mobile shifting of attention which occurs as the anxious patient scans the environment for potential of imagined danger or threat.


Shor (1969) described the operation processes which characterize normal information processing. The 'generalized reality orientation' brings into play the frame of reference whereby the individual interprets and gives meaning to experience. In the hypnotic state this orientation is to a considerable degree suspended, resulting in concrete uncritical thought processes. Clarke and Jackson (1983) noted in their subjects, that 'ability to rouse oppositional self statements/beliefs is low [during hypnosis]' (p. 242).

Persuasive communications are a part of effective therapy interventions. Studies of hypnosis and hypnotizability are observed to produce a similar reduction in critical thinking. Malott, Bourg & Crawford (1989) demonstrated experimentally that hypnotized subjects generated fewer counter-arguments to persuasive communications, and that highly hypnotizable subjects experience more favourable thoughts and a positive attitude towards messages, whether hypnotized or not. Accompanying the suspension of critical thinking and the 'generalized reality orientation' is the readiness to accept as reality changes in perception and cognition that are suggested by the therapist.

In the hypnotic state, subjects, through their narrowed focus of attention, suspended thoughts of future actions or events. The contemporary focus of the hypnotic state encouraged this process.



The heightening of imagery or fantasy generation has been suggested to be an effect of the hypnotic procedure and a characteristic of hypnosis and hypnotiz-ability (Sheehan, 1979; Lynn & Rhue, 1987), and yet the correlations between imagery vividness and hypnotizability are moderate. With the internal/cognitive focus of attention and the suspension in critical judgment referred to earlier, it is likely that imagery experienced will be accepted and responded to as if it has greater reality rather than greater sensory vividness.


Subjects undergoing hypnotic induction procedures frequently report a sense of their behaviour as being under their normal control. Weitzenhoffer (1978) discussed this as a feature of the 'classic suggestion effect' that is a characteristic of hypnosis. This suggestion effect has two component criteria: (a) that there must be a response to a suggestion; (b) that the response must be experienced as avolitional. Relaxation, paralysis, automatic movements and rigid catalepsy may all be experienced as avolitional changes in response to hypnotic suggestion. Enhanced muscle performance may also be reported, but this may be due to reduced perception of muscle fatigue, rather than to actual improved performance.


Extensive experimentation and clinical accounts have demonstrated that many physiological processes assumed to be outside conscious control can be altered in response to hypnotic suggestions (Kiernan, Dane, Phillips & Price, 1995). (Whether these changes are due exclusively to hypnotic interventions or are modulated by hypnotic susceptibility remains to be demonstrated.) A recent experiment by Kiernan et al. (1995) has demonstrated such a physiological response to hypnosis.


While many phenomena associated with hypnosis are subtle and few are exclusively related to the hypnotic state, the alterations in sensation, particularly pain, have not been demonstrated to the same extent in nonhypnotic states when suitable subjects and techniques of hypnosis are used. Many descriptions have been given of major and minor surgery carried out with hypnotic anesthesia alone. While this approach is not suggested as the intervention of choice, given the ready availability


of chemical anesthesia, the procedures described confirm the effect of the hypnotic state.


Post-hypnotic amnesia, either suggested or spontaneous, is a common accompaniment of the hypnotic process. While the changes in cognitive functioning referred to earlier may suggest that this phenomenon is due to differences in encoding memories in the hypnotic state, research on memory distortions and enhancement suggests that the differences result from changes in retrieval rather than encoding (Barnier & McConkey, 1992; McConkey, 1997).


Given the generally held public beliefs and expectations of the 'magic' of hypnosis, the clinician may appropriately use these expectations to maintain patient motivations at the highest possible level and to diminish therapeutic resistance. The experience of the involuntary nature of responses to hypnotic suggestions further enhances motivation promoting success in its application to clinical problems.


Many psychotherapies utilize imagery and fantasy to facilitate the process of change. Certain patients in hypnotically assisted therapies may more readily respond to imagery and fantasy as reality, since the hypnotic process provides a powerful way of enhancing imagery. For the most effective and responsible use of this potent tool, members of the healing professions seek training in hypnosis to provide an adjunct to their own particular disciplines.


Training programs in using hypnosis differ from each other around the world. Each program strives for standards of training that enhance the learning, accreditation, and public trust in practitioners of hypnotic interventions in individuals seeking responsible health care. While many clinicians want to learn hypnosis in order to treat the more difficult cases which they encounter, true proficiency occurs over time and requires advanced workshops in subsequent months or years. Moreover, an important principle is that no one should treat those patients with hypnosis that one is not trained and comfortable treating without hypnosis. A final part of training is devoted to ethical principles, professional conduct, and certification. Joining national and international organizations ensures future personal and professional development.


Current controversies in hypnosis research and their applications to clinical practice raise major issues. Dr Bloom stresses the danger of accepting as literally true uncorroborated claims of perinatal and prenatal memories and recollections from past lives. The problems of accepting recovered memories of early childhood sexual abuse are of universal concern. While such abuse certainly does occur, there is the possibility that these memories may be due more to an artifact of the hypnosis than an indication that the abuse occurred. There are guidelines to aid the clinician in using hypnosis in uncovering memories of sexual abuse (Bloom, 1994), but in the final analysis, it is the clinician's own judgment with a particular case on how to proceed.

Dr Linden's chapter outlines a four-step process for establishing the hypnotic relationship with a client: evaluation, education of client, assessment of hypno-tizability, and the teaching of self-hypnosis phase, during which time positive expectancies about hypnosis and motivation of the client are enhanced. As the author points out, the public is more open to and more educated about hypnosis than in the past. Moreover, the criteria for patient selection have altered with increased understanding of the interactive nature of the treatment process and its relation to the doctor-patient partnership. Case histories reveal that often the client wants help not with the presenting problem but with an entirely different concern. Therefore diagnostic skills are no less important than hypnotic skills.

Several important but widely differing issues for concern may be mentioned here. Before initiating hypnotic intervention, the nonmedical clinician is advised to inquire of clients as to whether any medical evaluation of their condition has been performed. Many common presentations to the hypnotherapist may have organic etiologies which require surgical or pharmaceutical treatment. In obtaining the trauma history the clinician must be capable of dealing with abreactive material which may surface as normal psychological defenses are evaded. And when inquiry into childhood physical and/or sexual abuse is being made, it is crucial to avoid suggestive or leading questions which may compromise the validity of activated memories.

Some clinical presentations which are poorly suited to hypnotic intervention are listed. Forensic subjects also can pose a particular challenge to clinicians. Finally, when a client's presenting problem is outside the clinician's field of expertise the client should be referred elsewhere.

Chapter 4, on memory in hypnosis, is especially important in view of controversies about repressed memories. The author attempts to give unbiased consideration to the complexity of memory itself, as well as complications introduced by the interaction between client and therapist. The use of hypnosis provides no guarantee to assessing veracity; a degree of confidence (both in hypnosis and in the waking state) should in no way be taken as a reliable indicator of accurate memory. This chapter examines the association between hypnosis and memory by first exploring briefly the nature of both hypnosis and memory, and then looking specifically at


two relevant memory phenomena: pseudomemory, and the recovery of repressed memories of sexual abuse.

As Professor Sheehan points out, while hypnosis may increase the volume of material recalled, there is no dependable enhancement in the accuracy (vs inaccuracy) of the information retrieved. Demonstrations of increases in the accuracy of remembered material are, in fact, relatively rare. Moreover, it is probably very rare in the clinical or forensic setting to find any participant who can lay claim to be emotionally neutral.

The data to be collected must always be gathered in a way that shows respect for general clinical considerations affecting the welfare of those involved. The future welfare of the client concerned and those of others accused of the act of abusing, for example, depends on the strict enforcement of ethical guidelines which are now in place relating to the reporting of recovered memories (Bloom, 1994).

There are general clinical considerations that must be respected in the conduct of hypnosis. And these considerations can only be met if the appropriate guidelines are followed.

We have at last an opportunity to explore activity in the brain during hypnosis with neuroimaging techniques such as regional cerebral blood flow (rCBF), positron emission tomography (PET), single photon emission computer tomography (SPECT), and functional Magnetic Resonance Imaging (fMRI).

Dr Crawford reports how these techniques are addressing questions about psychological and physiological phenomena. There is evidence that hypnotic phenomena selectively involve cortical and subcortical processing. At a neurophy-siological level, highly hypnotizable subjects often demonstrate greater EEG hemispheric asymmetries in hypnotic and nonhypnotic conditions. Cerebral metabolism studies have reported increases in certain brain regions during hypnosis (see Chapter 5 for references). Given that increased blood flow and metabolism may be associated with increased mental effort, these data suggest hypnosis may involve enhanced cognitive effort.

This chapter also reports on preliminary neurophysiological research in the role of opioid and nonopioid neurotransmitters and modulators which may be involved in hypnoanalgesia. Recent fMRI research by the author (Crawford, Knebel & Vendemia, 1998) has certainly found shifts in thalamic, insular and other brain structure activity. Future neuroimaging and neurochemical studies will greatly contribute to our expanded knowledge of how hypnotic analgesia is so effective as a behavioural intervention for acute and chronic pain.

Despite the theoretical title, the chapter by Dr Zeig has a very practical touch, as befits one by a disciple of Milton Erickson. Erickson used multilevel communication, both within and outside trance, to stimulate the patient's own initiative in generating more desirable behaviour. As a first step, the therapist should make sure that the patient is responding. Therapeutic change is then promoted by the patient's ability to hear and respond to what the therapist has said indirectly. Moreover, since the change has appeared through the patient's own initiative, it will be more


complete and lasting. Table 6.1 gives a very clear exposition of how Erickson developed his strategy.

To obtain the best response, the therapist must understand that individuals may be working together in any of the following positions: one-up, one-down or equal. Zeig has given accounts of these different situations. These accounts are not only clear but entertaining, especially the metacomplementary relationships leading to secondary gain.

Erickson worked at modifying his technique where necessary to promote that responsiveness. Similarly, during induction, the therapist may need to experiment somewhat, before success is obtained in conveying covert messages to which the patient will respond and initiate self-change.

The first chapter of specific clinical applications of hypnosis is concerned with the currently relevant and controversial one of recovered memory in trauma victims. Clinicians must recognize that clients' remembrance of a previously forgotten trauma has clinical relevance; but recovered memories of abuse cannot be accepted as self-validating. Using hypnosis, it has been demonstrated that memory can be reconstructed (e.g. Barnier & McConkey 1992).

Clinicians working with individuals who report recovered memories of childhood abuse must display the sensitivity appropriate for dealing with any possibility of childhood abuse (McConkey, 1997). In doing so, however, they need to maintain and use justifiable methods of diagnosis and treatment. Because of its long history of misuse, clinicians when using hypnosis must be scrupulous in applying scientifically based and clinically sound therapeutic intervention.

Hypnosis is particularly suited to use as an adjunct in treatment of anxiety disorders; 95% of practitioners of hypnosis use it to assist in the treatment of anxiety. Hypnosis can be a powerful adjunct to desensitization and to coping rehearsal, since it attributes realism to imagined events. Arousal reduction and relaxation may be enhanced using hypnotic procedures. Self-hypnosis techniques or hypnotic interventions have proved useful in simple phobias, for panic patients and in the treatment of agoraphobia. As Frankel and Orne (1976) have noted, phobic patients tend to be more hypnotizable than other patients or the general population. Apart from general anxiety reduction, hypnotic techniques may be applied to re-establish a sense of self-worth and self-esteem.

Contrasted with the treatment of anxiety, there appears to be a widespread assumption that hypnosis is inappropriate for the management of depression because of the risk of suicide. Given our understanding that hopelessness is the best predictor of suicide risk, the clinician needs to decide whether to avoid the use of hypnosis with patients high on this variable, or to utilize hypnosis as a tool for its reduction.

Major depression remains a challenge to all treatment modalities, including pharmacotherapy, cognitive-behaviour therapy, and psychotherapy. The traditional prejudice against its use in depression has prevented a serious assessment of whether hypnosis has anything significant to contribute to this widespread disabling


problem. The authors of Chapter 9 present a series of arguments in favour of a trial of hypnotherapy augmenting cognitive-behavioural management of depression.

To complete the anxiety-depression spectrum, Spiegel's lucid and comprehensive presentation of PTSD symptoms and treatment approaches in Chapter 10 begins with an account of the vicissitudes undergone in developing the concept of post-traumatic stress disorder. It provides a cautionary tale that however confident we feel in the accuracy of our knowledge we can never know all the answers, and therefore should retain an open mind for opposing views.

Dr Spiegel notes the growing interest in the overlap between hypnotic and dissociative states and post-traumatic stress disorder, in particular a clear analogy between the three main components of hypnosis: absorption, dissociation, and suggestibility (Spiegel, 1994), and the categories of PTSD symptoms.

Like PTSD, conversion disorders are particularly suited for treatment using hypnosis. In 1986 Trillat made the hasty conclusion that hysteria was an illness that would no longer be seen, but conversion disorders still present neurologists, psychiatrists and psychotherapists with a considerable problem. Chapter 11 by Dr Hoogduin and Dr Roelofs views the relationship between conversion disorders and dissociative disorders from a modern cognitive psychological standpoint. Hyp-notherapeutic strategies are described and illustrated by case histories. Finally, it is emphasized that in an appreciable percentage of patients misdiagnosed as having a (psychological) conversion disorder, there may be an organic cause for the complaint.

A further note for caution is sounded. Is hypnosis an essential element in all the cases where treatment involving it leads to a favourable result? There is great need for controlled research in this area. On the other hand, there has been no controlled research relating to other treatment strategies, although some well-documented case descriptions indicate that behaviour therapy and physiotherapy achieve very positive results with conversion disorders.

As Dr Murray-Jobsis notes in Chapter 12, it is over a century and a half since hypnotic methods have been applied to the treatment of the extremely difficult conditions of psychosis and personality disorder. Most experimental work supports the conclusion that psychotic and personality disordered patients possess hypnotic capacity which can be used productively and safely.

The clinician dealing with the severely disturbed patient must have experience with this type of population, and also requires sensitivity. Moreover empathy in pacing is an essential in hypnotherapy of these psychologically fragile patients.

The conceptual framework of hypnotherapy in dealing with psychotic patients and personality disorder has a psychoanalytic framework. The aim is to redo life experiences and allow the disturbed patient to redevelop potential for healthy growth and development. Virtually all traditional psychotherapy techniques can be adapted for use with hypnosis in the treatment of these patients.

The use of hypnosis for dissociative trance disorder is also presented from a strongly psychoanalytical viewpoint. Treatment involves interrupting pathological


trance states and restructuring the dissociative experiences, often with the use of autohypnotic techniques, so that the patient can retain control over his or her proclivity for slipping into trance.

In considering the use of hypnosis with the dissociative disorders, we come again to current concerns about the contribution of hypnosis to pseudomemory formation. Firstly, can hypnosis contribute to the worsening of dissociative identity disorder? Secondly, it has been argued that trauma may not be at the root of many of these disorders, so that hypnotic searching for memories of childhood traumatizations may generate confabulations with far-reaching consequences.

Dr Kluft maintains in Chapter 13 that all perspectives have contributions to make to this complex area of study, and that a rational view of the subject precludes the complete or peremptory discounting of either perspective. Although there is concern about confabulations with this use of hypnosis, it is also possible for patients to recover well-being by working through a confabulated trauma. Since the recovery of the patient rather than the recovery of historical truth is the goal, this should not be a major concern in most instances.

Dissociation is a commonplace reaction to trauma in psychiatric patients and in nonpatient populations This chapter offers a detailed review of methods of treatment and clinical techniques are presented for hypnotic interventions in the dissociative disorders. In the absence of contraindications Dr Kluft considers most traumatized persons with major dissociative manifestations to be excellent candidates for the use of therapeutic hypnosis.

Both Dr Torem and Dr Vanderlinden comment that with anorexia nervosa and bulimia there has been remarkably little utilization of hypnosis as a therapeutic tool, whereas hypnotherapists have been intensively engaged in the treatment of obesity. Nevertheless, the effectiveness of hypnotic interventions in patients with eating disorders has been recorded in the literature over and over again since the time of Pierre Janet.

The clinical literature identifies a variety of psychodynamics attributed to the psychopathology of eating disorders. Many patients with these disorders feel helpless, hopeless, and ashamed of having to seek psychological help. Ego-strengthening suggestions are therefore an important part of most hypnotherapy interventions. Assignments which they are asked to complete are designed so that the patient will metaphorically and concretely experience a feeling of success, as well as a sense of gaining mastery, control, and exercising new choices and options. Ego State Therapy has become a frequent focus in the hypnosis literature.

While only psychological bases are at present considered to be operational in anorexia nervosa and bulimia, the picture is different for obesity. It is assumed nowadays that biological and psychological factors can function in combination as pathogenic factors in the development of obesity, therefore it is noted that hypnosis should always be part of a multidimensional approach.

Dr Vanderlinden offers a very practical commonsense overview of the problem. Thus, for a considerable group of patients, weight reduction is either not a realistic


goal, or the aim of treatment should be adapted; for instance they must learn to accept themselves as overweight, instead of pursuing weight reduction. The author's own approach (Vanderlinden, Norre & Vandereycken, 1992) contains, among others, behavioural, cognitive, and interactional components.

Most treatments are exclusively aimed at quick weight reduction and ignore the crucial goal, namely weight stabilization and prevention of relapse. A follow-up lasting 1 to 2 years is absolutely indicated to prevent possible relapse, with regular encouragement of the patient.

The treatment of sexual dysfunction can take a psychodynamic psychotherapy approach, a brief focused eclectic psychotherapy approach, or a cognitive-behavioural approach, and hypnotic assistance to each of these is advantageous. There is a surprisingly low degree of usage of hypnosis in sexual dysfunction. And yet, the involvement of thought, image and symbolism in sexual interest, arousal and behaviour cannot be overemphasized. Changing the information, associations, symbols and images that contribute to dysfunction is a primary goal of therapy. Hypnosis provides a powerful means of influencing all these cognitive levels in treatment.

The several chapters dealing with painful conditions highlight the differences between acute and chronic pain, and therefore the need for different strategies in their management.

Whereas acute pain is best managed by anxiety-reducing strategies, chronic pain requires strategies that deal with effective handling of one's psychological environment. In many cases chronic pain may have no clear organic basis, but secondary gain issues typically exist with the chronic pain patient and hypnotic strategies need to be developed which will not initially threaten these issues. Hypnotic intervention based on anxiety reduction will only frustrate the patient and the therapist, and will usually be unsuccessful.

As Dr Evans points out in Chapter 17, the clinical criterion of successful treatment outcome for chronic pain patients is far more complex than mere pain reduction. 'Multiple outcome measures need to consider decreased depression and medication and opioid use; improved sleep, social and family relations and quality of life; increase in range of motion and activity level; and return to work' (p. 249).

Dr Rose notes in Chapter 18 that, in keeping with modern approaches to patient care and autonomy, pain patients are encouraged to become more involved in their own management, both by selecting their own fantasies and maintaining a two-way communication with a hypnosis practitioner. Cues to the appropriate utilization of hypnotic approaches to treat pain are often given in the very terminology patients use to describe their pain. At a later stage, training in self-hypnosis gives patients a sense of mastery and control over their pain and they can become independent of the therapist. A case study reported by Dr Rose repeats the caution by Dr Vanderlinden that patients coming to hypnotherapists for alleviation of chronic conditions may have an organic etiology for the condition. In this case investigations prior to hypnosis had been unsuccessful in finding the organic cause.


The seriously burned patient needs psychiatric help from the time of injury to full recovery (Chapter 19). Opioids are the treatment of choice for pain relief, even though relief is seldom complete. Hypnosis can be a helpful adjunct, and should not be withheld even in patients who test low in hypnotizability.

In the first 2 to 4 hours postburn, hypnosis diminishes the inflammatory response. Later, it is helpful for resting pain, and especially effective for control of pain in those patients with the most excruciating procedural pain. Infection is minimized, suppressed appetite can be restored, and body image and active participation in rehabilitation are enhanced. A burned patient who has accepted the suggestion that his wounded area is 'cool and comfortable' is easy to treat, optimistic, and heals rapidly.

Commonly, the patient who enters the dentist's room is at some level of trance and the dentist has the opportunity to manipulate this hypnotic state to enhance patient comfort in the dental situation. The hypnotic interaction has begun before the first word is uttered.

Another area in which hypnotic strategies are utilized, but the concepts of hypnosis are not mentioned, is in the 3-minute smoking cessation interaction. This can take place at the conclusion of the oral examination and cancer screening, if there is an indication by the patient that there is a desire to 'quit.'

With the advent of stereophonic headphones, the dentist can offer positive hypnotic suggestions while taking care of the mouth. When preparing the patient tapes, it is recommended that the form of speech be primarily in the passive voice and the text be devoid of personal pronouns. For the listener, hearing just the ideas and suggestions is empowering. Note that Dr Glazer, in Chapter 20, in this way is using Ericksonian injunctive communication, as recommended by Dr Zeig. It should be noted that the words pain, hurt and discomfort are never introduced. Because the brain does not easily compute 'no' in the hypnotic state, it is more effective to offer positive suggestions.

The tape is used to teach patients not only to relax but to manage muscle tension headaches and to abort bruxism.

Fear of dentists is commonly listed in the top five commonly held fears and is among the ten most frequent intense fears. There are strong indications that a significant portion of the dental phobic population is hypnotizable and that the same high hypnotizability that allows them to develop a phobia is also a useful tool to help them overcome the phobia.

Implicit in these findings is a caution for dentists that they should be aware that a significant portion of the population is highly responsive to suggestion. Attention should therefore be given not to deliver suggestions to patients that may be counter-productive to treatment. Otherwise treatment difficulties and enduring problems may be created inadvertently.

During the 1970s research began to report both the clinical efficacy and psychophysiologic changes associated with self-hypnosis in children. At the same time the benefits of hypnosis training were recognized for children with chronic


illnesses such as cancer, haemophilia, and asthma. Successful applications of self-regulation include a focus on personal control and decision-making by the child, and specific attention to the child's preferences in using personal imagery skills.

For behavioural problems indirect approaches are used. These might include improved coping, allaying of anxiety, and facilitating improved self-esteem with the aid of self-hypnosis, rather than expecting problem resolution as one might reasonably expect in the treatment of habits. The biobehavioural disorders such as asthma, migraine, encopresis, Tourette's Syndrome, and inflammatory bowel disease, are all known to be exacerbated by psychological stress. Teaching self-hypnosis promotes a sense of self-control as well as providing a strategy for reducing symptoms. Clinicians should obtain appropriate training in paediatric clinical hypnosis to apply and integrate it within general or specialty paediatric care.

Since we know that hypnosis used properly by appropriately trained clinicians is safe and effective and has no adverse side effects (Kohen & Olness, 1993), it can become an important potential tool in managing a wide variety of clinical issues in child health care.


Hypnosis as an adjunct to traditional therapy has a special role in management of chronic debilitating conditions. To maintain ethical standards and responsible practice there are learned societies which offer accreditation to clinicians, offering guidelines in controversial areas.

In this volume we have been fortunate in obtaining contributions in many areas from authors who have achieved distinction in their fields of endeavour. Several caveats are stressed in their reports. Among others, there is a consensus that clinicians should treat with hypnosis only those patients that one is trained and comfortable treating without hypnosis. The nonmedical practitioner should be aware that many common presentations to the hypnotherapist may have organic etiologies which require surgical or pharmaceutical treatment. In obtaining the trauma history the clinician must be capable of dealing with abreactive material which may surface as normal psychological defenses are evaded. And when inquiry into childhood physical and/or sexual abuse is being made, it is crucial to avoid suggestive or leading questions which may compromise the validity of activated memories.

Hypnotic interventions have been particularly successful in managing both acute and chronic pain, reducing the need for medication and improving the quality of life in many ways. Hypnotherapy for burn patients can influence the immune response to the degree that there is no need for antibiotics, and a life-saving reduction in the need for fluid to retain blood pressure. From the psychological


angle, modern methods of induction and in particular use of self-hypnosis can improve self-esteem and feelings of mastery.

It is noteworthy that the authors are open-minded in their approach, and are willing to learn from all available techniques including old-style psycho therapies as well as new-style 'alternative medicine.' Hypnosis gives opportunities for creativity, and it is obvious that this makes for considerable satisfaction in both therapist and client.


Barnier, A. J. & McConkey, K. M. (1992). Reports of real and false memories: The relevance

of hypnosis, hypnotizability, and context of memory test. J. Abn. Psychol, 101, 521-527. Beck, A. T. & Emery, G. (1985). Anxiety Disorders and Phobias: A Cognitive Perspective.

New York: Basic Books. Bloom, P. B. (1994). Clinical guidelines in using hypnosis in uncovering memories of sexual

abuse: A master class commentary. Int. J. Clin. Exp. Hypn., 42(3), 173-198. Brewin, C. R. (1988). Cognitive Foundations of Clinical Psychology. London: Lawrence

Erlbaum. British Medical Association Report (1955). Medical use of hypnotism. Br. Med. J., 1,

Supplement, 190: cited in Hypnosis in Clinical Practice, Report of the National Health

and Medical Research Council, Canberra, 1982. Clarke, J. C. & Jackson, J. A. (1983). Hypnosis and Behaviour Therapy: The Treatment of

Anxiety and Phobias. New York: Springer. Crawford, H. J., Knebel, T., Kaplan, L., Vendemia, J., Xie, M., Jameson, S. & Pribram, K.

(1998). Hypnotic Analgesia: I. Somatosensory event-related potential changes to noxious

stimuli, and II. Transfer learning to reduce chronic low back pain. Int. J. Clin. Exp. Hypn.,

46,92-132. Crawford, H. J., Knebel, T. & Vendemia, J. M. C. (1998). Neurophysiology of hypnosis and

hypnotic analgesia. Contemporary Hypnosis, 15, 22-33. Frankel, F. M. & Orne, M. T. (1976). Hypnotizability and phobic behavior. Arch. Gen.

Psychiat, 33, 1259-1261. Hussain, A. (1964). The results of behaviour therapy in 105 cases. In J. Wolpe, A. Salter &

J. Reyna (Eds), Conditioning Therapies. New York: Holt Rinehart Winston. Kiernan, B. D., Dane, J. R., Phillips, L. H. & Price, D. D. (1995). Hypnoanalgesia reduces

r-III nocioceptive reflex: Further evidence concerning the multifactorial nature of hypnotic

analgesia. Pain, 60, 39-47. Kohen, D. P. & Olness, K. (1993). Hypnotherapy with children. In J. W. Rhue, S. J. Lynn &

I. Kirsch (Eds) Handbook of Clinical Hypnosis (pp. 357-381). Washington, DC: American Psychological Association. Kroger, W S. & Fezler, W D. (1976). Hypnosis and Behaviour Modification: Imagery

Conditioning. Philadelphia: Lippincott. Lynn, S. J. & Rhue, J. W (1987). Hypnosis, imagination, and fantasy. J. Mental Imagery, 11,

101. Malott, J. M., Bourg, A. L. & Crawford, H. J. (1989). The effects of hypnosis on cognitive

responses to persuasive communication. Int. J. Clin. Exp. Hypn., 37, 31. Marks, I. M., Gelder, M. G. & Edwards, G. (1968). Hypnosis and desensitization for phobias:

a controlled prospective trial. Br. J. Psychiat., 114, 1263. McConkey, K. M. (1997). Memory, repression, and abuse: Recovered memory and confident


reporting of the personal past. In L. J. Dickstein, M. B. Riba & J. M. Oldham (Eds),

American Psychiatric Press Review of Psychiatry, Vol. 16 (pp. 83-108). Chicago, IL:

American Psychiatric Press.

Rossi, E. L. (1986). The Psychobiology of Mind Body Healing: New Concepts, of Therapeutic Hypnosis. New York: Norton. Rubin, M. (1972). Verbally suggested responses as reciprocal inhibition for anxiety. J. Behav.

Ther. Exp. Psychiat., 3, 273. Sheehan, P. W. (1979). Hypnosis and processes of imagination. In E. Fromm & R. E. Shor

(Eds), Hypnosis; Developments in Research and New Perspective, 2nd edn. New York:

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Tart (Ed.), Altered States of Consciousness. New York: Wiley. Spiegel, D. (1994). In J. A. Talbot, R. E. Hales & S. C. Yudofsky (Eds), Hypnosis. American

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International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley, P. B. Bloom

Copyright © 2001 John Wiley & Sons Ltd

ISBNs: 0-471-97009-3 (Hardback); 0-470-84640-2 (Electronic)

Training in Hypnosis


University of Pennsylvania School of Medicine, USA


Training adult health care professionals to use hypnosis in their clinical practices or in their research laboratories is a complex undertaking. Well-trained dentists, non-psychiatric physicians, nurse specialists, psychiatrists, psychologists, clinical social workers, all seek training in hypnosis to provide an efficient adjunct to their healing disciplines. These clinicians insist that hypnotic interventions 'make sense' and be consistent with their basic training in their respective fields or they will not use them in their work. The principles of adult education become the foundation of all training in hypnosis to adult professionals (Bloom, 1993; Carmichael, Small & Regan 1972; Coggeshall, 1965; Dryer, 1962; Hawkins & Kapelis, 1993; Knowles, 1980; Rodolfa, Kraft, Reilly & Blackmore, 1983; Wright, 1991).

Training in hypnosis generates a wider view on how therapy works for most clinicians (Orne, Dinges & Bloom, 1995). Respect for the symptom and its treatment, willingness to delay obtaining insight into the 'deeper causes' of the illness, creating measurable outcomes as the goals for therapy, and understanding patients as evolving, self-generating 'open systems' are new perspectives available to the practitioner who studies hypnosis (Von Bertalanffy, 1968;Bloom, 1994a; Haley, 1963).

Training programs in using hypnosis differ markedly around the world. Some programs are designed to train unqualified 'therapists' who, without licensure, formal training, or accreditation in any primary discipline, use hypnosis as a therapy in of itself, which it is not. Other programs are created for highly qualified professionals who wish to add hypnosis to their therapeutic armamentarium. This chapter will discuss only the latter programs.

The purpose of this chapter is to present an 'ideal' training program in hypnosis which integrates the principles of adult education into teaching the methods of clinical hypnosis. Integration and applications of hypnotic principles into the core fabric of psychotherapy will 'make sense' to the experienced clinician who is willing to think creatively with each new individual patient. In such a training program, the clinician will broaden and enhance his or her own experience of being an effective healing agent in the lives of those who seek his or her care.

International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley and P. B. Bloom © 2001 John Wiley & Sons, Ltd



Andragogy, or adult education, combines new knowledge with the participant's previous professional experience. New information should make sense or it won't be used. Pedagogy, or student education, involves knowledge acquisition only. Students find out later whether the information is useful.

In a typical adult learning seminar, the entire group can be conceptualized as equal participants: the leader is a little more equal than the others because of his or her own advanced knowledge and experience; the participants are more equal than the leader in knowing their own life experiences and how they will incorporate what they learn into their practices.

From the leader's decision to address the participants as colleagues and not as students, respect for these principles of adult education begins. Each participant, now valued for his or her experience, shares in the teaching and learning. The leader learns as well. Most seminars with adults vary despite standard syllabi because of the unique contributions of the participants (Hawkins & Kapelis, 1993). These variations within a predetermined scheduling of topics ensure a creative context for maximal learning time and time again.


Several programs exist in the world that represent thoughtful responses to the need for quality training programs in hypnosis. While not exclusive, and certainly not the only ones worth mentioning, the American, Australian and the Netherlands programs are illustrative and outstanding in different ways. Each country has one or more Constituent Societies of the International Society of Hypnosis (ISH) founded in 1973 in Upsala, Sweden. Essential in each program is the determination to create standards of training that enhance the learning, accreditation, and public trust in practitioners of hypnotic interventions in individuals seeking responsible health care.

There are two ISH Constituent Societies in the United States: the American Society of Clinical Hypnosis (ASCH) founded in 1957 has 2400 members; and the Society for Clinical and Experimental Hypnosis (SCEH) founded in 1949 has over 500 members. SCEH publishes quarterly the official ISH journal. Each US Society requires a minimal 20 hours of training at the introductory level for consideration of membership. Recently, ASCH established criteria for certification of training in hypnosis including: doctoral or selected master degree graduate training, state/ provincial licensure or alternate criteria if licensure does not apply to a particular discipline in a state/province, 40 hours of post-degree approved education divided evenly between introductory and intermediate training, 20 additional hours in 'one to one' training with an ASCH approved consultant, and 2 years of independent practice within their specialty area (Hammond & Elkins, 1994).

ASCH requirements for Approved Consultant in Clinical Hypnosis are even


more rigorous and include 100 hours of post-degree approved education, 20 hours of 'one to one' training with an Approved Consultant, and one of the following: Diplomate Status in one of the American Boards of Clinical Hypnosis, Fellowship in either ASCH or SCEH, 5 years membership in either the ASCH or SCEH, or evidence of equivalent membership or training such as in an appropriate component section of the American Psychological Association.

The American Boards of Clinical Hypnosis chartered by the Department of Education of the State of New York in 1958 are endorsed and recognized by ASCH and SCEH. They are comprised of the American Board of Hypnosis in Dentistry, the American Boards in Medical Hypnosis, the American Board of Psychological Hypnosis, and the American Hypnosis Board for Clinical Social Work. These Boards award diplomate status to those who document competency in hypnosis as opposed to certifying training in hypnosis. Applicants must be licensed, certified in their own primary specialty or the equivalent, and present videotape documentation of using hypnosis in actual patient care (accompanied with written release from the subject). He or she must then pass both written and oral examinations which include an actual demonstration of hypnotic and clinical skills. Both the ASCH program of certification/consultant status and the American Boards of Clinical Hypnosis build on the minimal requirements for membership in ASCH and SCEH. Clinicians who are recognized by the ASCH program and by the American Boards are without peer in the United States at this time and are equal in stature to graduates of any program in the world.

The Netherlands Society founded in 1931 is the oldest Constituent Society of the International Society of Hypnosis. The Nederlandse Vereniging voor Hypnosis (NVvH) has two levels of training requirements. First, a qualifying examination must be passed before acceptance into the bi-level training program. Level A requires 5 days @8 hours per day of basic training and standard procedures. Level B requires 12 days @8 hours per day of advanced courses in either psychotherapy or dental medicine. A paper which would be suitable for publication is required. In total, approximately 40 hours basic and 96 hours advanced is required for full membership in the society.

The Australian Society of Hypnosis (ASH) founded in 1971 has the largest representation in the ISH and has over 850 members. Requirements for membership include 80 hours of training over 2 years which include supervision, written and oral examinations. As is typical of each ISH Constituent Society, ASH has several membership categories including Associate, Trainee, Full, Honorary, Corresponding, as well as Fellows and Life Fellows. ASH sponsors a yearly scientific meeting in August/September and publishes a twice-yearly Australian Journal of Clinical & Experimental Hypnosis containing clinical and research papers, case reports, and theoretical discussions. ASH endorses a Formal Code of Behavior, and restricts its membership to certain qualified professional groups. These member benefits insure that training in hypnosis and its applications extends far beyond the initial rigorous introductory courses and seminars. In most ISH


Constituent  Societies,   similar programs  and common approaches to  member training and career enhancement prevail.


First, I will present two workshops, each given over 8 weeks in the evenings: one in the Fall and one in the Spring. Each workshop is 22 hours in length, lasting nearly 3 hours each evening. They are titled 'Clinical Methods in Hypnosis and Psychotherapy: Integration and Applications—Introductory Workshop (Fall) and Advanced Workshop (Spring).' Then, I will describe briefly an ongoing Senior Seminar which meets monthly throughout the year for graduates of the first two workshops.

While the introductory workshop imparts basic skills in hypnosis, the advanced workshop creates an environment encouraging its use in ongoing patient care. In both workshops, attention is given to helping the clinician change his or her attitude and receptiveness to using new skills in psychotherapy and, if possible, to widening and broadening the understanding of how psychotherapy works in both short-term and long-term treatment settings. While psychodynamic understanding of the patient and the therapist interactions is important, such understanding also rests on learning theories, cognitive therapy, and various principles of behavior therapies. A guiding principle in teaching these workshops is the understanding that the therapeutic alliance is foremost in importance (Binder, Bongar, Messer, Strupp, Lee & Peake, 1993). Creative interactions based on rigorous training in the participant's own discipline coupled with his or her intuitive inspirations constitutes the art of therapy and is encouraged throughout these workshops. Such therapy is always based on a thorough understanding of the patient's symptoms, history, diagnosis, and initial treatment planning.


All workshop announcements recruit adult participants. The word 'student' is never used. The learning objective enhances the concept of adult education by stating that 'experienced clinicians [will gain] a solid grounding in the principles and practices of hypnosis, and an understanding of how to integrate it into their own practice of psychotherapy' (Note that while this workshop is aimed at psychotherapists— licensed psychiatrists, psychologists, social workers, and others on special application—the principles described herein are directly applicable to workshops for anesthesiologists, dentists, non-psychiatric physicians, and those dealing with the more 'organic' pathologies of medicine and surgery.)


In the beginning, time is taken to introduce participants to each other and to the group leader. By sharing backgrounds together, the stage is immediately set for sharing professional experience. Learning from each other begins immediately with the group leader or faculty person facilitating the process. Each participant is considered an authority in his or her own work, who is coming to learn new skills. While it is beyond the scope of this chapter to discuss the training in hypnosis of psychiatric residents and psychological interns (Parish, 1975), these groups can be effectively integrated into these workshops if the majority of participants are already established in their postgraduate careers.

The first topic purposely introduces the historical figures in hypnosis. By sharing Mesmer's difficulties in treating the 18-year-old blind daughter of a wealthy and influential civil servant whose family lost her disability pension on return of her vision, the workshop participants can immediately relate to their own patients whose initial recoveries do not last when the consequences of recovery are outweighed by the loss of disability incomes. They can understand and relate to Mesmer's moving to Paris from Vienna for a 'deserved rest' following the controversy surrounding his initially successful intervention (Laurence & Perry, 1986). Each historical figure from Mesmer to Erickson is presented in personal terms that relate to the current clinical issues facing each of the participants. History becomes 'us' not 'them' and lives again.

After reviewing the myths and misperceptions of hypnosis and reminding the participants that hypnosis is not a therapy itself, but rather an adjunct to therapy, I demonstrate a typical induction using one of the participants who volunteers. The induction is simple and straightforward while at the same time quite complex and illustrative of hypnotic phenomena: eye fixation, internal absorption, relaxation of body, increasing quietness of mind, arm rigidity, imaging, and suggestions for further success in learning hypnotic techniques.

Members of the group are reminded that the workshop is an educational format and not a therapeutic one. Therefore, any interest in pursuing insights into personal problems while in trance is strongly discouraged. In fact, I state that such material, even if fresh from their own current therapist sessions, be 'parked' at the door. Participants welcome and value this important boundary reminder and understand that unless the context is appropriate, as it is in their own therapist's office, personal therapy has no place in an educational format. Abreactions seldom if ever occur, and are, in part, 'screened' out by pre-registration interviewing of each participant. Nonetheless, occasionally disturbing material surfaces and is handled by the leader privately if possible after the session. Rarely, participants are asked to avoid trancework during the remainder of the workshop or at least not to practice age regression if that exercise created the initial difficulty. Clinical judgment in the group leader, who should be an experienced psychotherapist, is always valued and useful. Such interventions are his or hers and not the responsibility of the group members despite the previous discussion on equality in adult educational experiences.


The next session begins with an introduction to the Harvard Group Scale of Hypnotic Susceptibility (Shor & Orne, 1962). Ever since Hilgard and Weitzenhof-fer's brilliant introduction of the concept of hypnotizability and scales for its measurement (Weitzenhoffer & Hilgard, 1959, 1962), most researchers have used them for experimental subject assessment (Bowers, 1976). However, since most clinicians rarely use hypnotizability scales in assessing patients/clients for hypnosis (Cohen, 1989), it seems appropriate to give introductory workshop participants the experience of assessing their own hypnotizability and thereby gaining familiarity with the scales that are available. More than a full hour is devoted to taking this standardized test and in sharing the graded response with the group. In teaching hypnosis to clinicians who treat a wide variety of patients requesting help, from simple pain control to complex dissociative disorders, the therapist's own hypnotizability can influence the patients they select and feel comfortable with. For instance, highly hypnotizable clinicians may feel very comfortable with highly hypnotizable patients who dissociate. These therapists may never take the time or have the patience to help a low hypnotizable subject go into trance to alleviate pain. Conversely, a low hypnotizable clinician will easily dismiss his role in guiding a dissociative disorder patient who seems to effortlessly go into trance and stay there indefinitely. When the clinicians learn how hypnotizable they are, they can take steps in the basic and advanced workshops to compensate for their own experience of hypnosis and learn to work more skillfully with a wider range of subjects. It is gratifying to see a highly hypnotizable therapist insist on working with a low hypnotizable patient step by step until trance is induced, no matter how long it takes.

Small group practice sessions begin during this second session. If the workshop is small in number (8-16), it is possible to divide the participants into groups of 2, 3, or 4 members each. In the beginning, one member 'performs' the hypnosis, one is the subject, and the other(s) watch and contribute to the post-hypnotic discussion afterwards. The faculty person(s) walk around the room, advising here and there, and then lead(s) a combined discussion when all the groups have finished practicing. This model has often been used at annual SCEH meetings in the United States. An alternative model is used frequently at annual and regional ASCH meetings. Group members, usually no more than 8, form a circle. One person induces the trance, one person experiences it, and all the others watch. The leader immediately shares, for the entire group: his or her observations, suggestions for improvement, and responses to questions from individual observers. When this is completed, the operator and subject are rotated around the circle so that on completion of the practice session each person has induced a trance, each has experienced one, and the leader has observed and discussed everyone's personal experience in both roles immediately after each individual experience. I personally like both methods and my choice depends in part on how comfortable the class is in working with less moment to moment supervision, and on how comfortable I am with the 'evenness' of the group skills. If the members are fairly similar in training


and risk-taking, I will often turn them loose, observe the multiple groups simultaneously, and save my discussion for the end. It gives the workshop members more actual practice that way. In any event, the most common complaint given in post-workshop evaluations is that not enough practice time is provided and every effort must be made to accommodate this important need for actual hands-on training.

The third and fourth sessions are devoted to discussing the evaluation and assessment of patients for hypnosis with special emphasis on ego function profiles. Hypnosis is very useful in ego strengthening before subsequent treatment of the presenting symptoms. Assessing ego strengths and deficits in addition to diagnostic considerations creates many additional opportunities for therapeutic interventions. The old caveat that symptom substitution will occur unless the underlying conflict is uncovered and understood is not always true (Bloom, 1994a). Therapists recognizing which patients can improve without such insight can offer effective short-term therapy for many seemingly complex problems. Ego function analysis with selected focused therapy to repair ego deficits has been a long-documented and described procedure (Bellak, Hurvich & Gediman, 1973), and is especially applicable to hypnotic interventions (Haley, 1973).

Additional topics include rapid induction techniques, imagery utilization, ideo-motor signaling and other communication techniques, age regression and affect bridging, abreaction management, and post-hypnotic suggestions. Despite the current controversy regarding the narrative versus historical truth (Spence, 1982) of recovered memories, age regression can augment psychotherapy for current problems. The use of common feeling states such as pleasure, anger, depression, or joy can facilitate age regression by forming an 'affect bridge' to times past (Watkins, 1971). In working with post-traumatic stress disorders, dissociative disorders, or in simple cases of lost objects, 'going back' in time may reveal feelings or even facts that may help the therapeutic process move forward. In teaching these techniques, it is useful to remind the clinicians that common sense and the tenets of their graduate training are even more crucial in assessing the recovered material. Too often practitioners of hypnosis unwisely accept as literally true uncorroborated claims of perinatal, prenatal, and past lives' memories on the one hand, while recognizing there has been nothing in their masters' level or doctoral training that would support such claims. The problems of accepting recovered memories of early childhood sexual abuse are of universal concern. While such abuse certainly does occur, hypnosis lends a credibility to these memories that may be due more to an artifact of the hypnosis than an indication the abuse occurred. Guidelines exist, however, to aid the clinician in using hypnosis in uncovering memories of sexual abuse (Bloom, 1994b). In the final analysis, it is the clinician's own judgment with a particular case on how to proceed. The participants in an introductory workshop will have a widely divergent experience and opinion on how to proceed in these cases. These differences must be respected if the controversial issues have been fully presented by the workshop leader.

Supervised small group practices occur for at least one hour each week. It is


useful to prepare a word-by-word transcription of the initially demonstrated induction for subsequent use by the workshop members in their own practice sessions. Such a script anchors the participants in an induction that they have already seen and which works. Once their partner/subject is in trance, the 'hypnotist' can actually read line by line the suggestions for deepening and imagery. As practice continues, confidence levels increase and the participants begin observing opportunities to tailor the induction to the particular needs of the moment. Gradually, further inductions are freer and more creative. It is also helpful to expose the members to the published inductions of others. Several texts are available that provide many good examples of useful induction and deepening techniques (Hammond, 1989; Hunter, 1994). Eventually, as therapeutic applications are introduced into the workshop, future inductions are gleaned from pre-hypnotic and post-hypnotic discussions with actual patients. While I use several standard inductions for the first time with all patients, I subsequently modify, expand, and create highly individualized suggestions for every patient. Even for the patients who usually tape record these initial experiences for practice purposes, I encourage their own creative and individual suggestions for their future clinical work. For both workshop members and patients, it is useful to start with a standard induction and then move from that as confidence and practice allow.

In introductory and advanced workshops, it is important to require reading of articles from the literature. With graduate professionals in dentistry, medicine, nursing, psychiatry, psychology, and social work, it is very useful to expose members to different points of view or to include topics for which little time is available in the actual sessions. I also believe that one faculty person for small workshops provides a model for learning how to use hypnosis in clinical practice. Workshops that have many faculty persons, each contributing a mini-lecture on single topics, fail to engage the group in an overall process of learning together. If a therapeutic alliance is important in patient care, an 'educational' alliance is critical in adult education and effective learning. Given my experience on teaching alone in small groups, it is doubly important that examples from the literature create additional perspectives. It is also a chance for me to expose the members to more in-depth discussions on particular topics that I have an interest in as well as, for example, the concept of Ericksonian Hypnotherapy (Bloom, 1991, 1994c).

During the fifth, sixth, and seventh sessions of the introductory workshop, the task of integrating hypnosis into clinical practice begins. Principles of short-term psychotherapy are reviewed and applications of hypnosis in treating phobias, performance anxieties, disorders of dyscontrol, psychosomatic illnesses, and pain management are introduced. Videotapes of surgical procedures using hypnosis as the sole anesthetic agent offer dramatic proof that the mind can control the body's sensations in a powerful way. Treatment planning with strategies for integrating hypnosis into short-term therapy is extended into long-term therapy. While hypnosis is an effective adjunct in treating so called 'untreatable' patients, a review


of transference and countertransference issues, managing resistance, and handling potential difficulties in forensic situations are discussed in detail.

It is tempting to allow workshop members to discuss the use of hypnosis in memory enhancement, post-traumatic disorders, and dissociative conditions too early in their learning rather than in more simple applications. Introductory workshops first teach 'how to get into trance' and then 'what to do when you get there.' The group needs to be reassured that using clinical hypnosis requires time: first, to experience one's own trance phenomena; second, to teach it to others. After these skills are learned, each clinician will then be able to learn what to do with an individual patient once the trance has been induced. While many clinicians want to learn hypnosis in order to treat these more difficult cases, true proficiency occurs over time and requires advanced workshops on each of the above topics alone in subsequent months or years.

During the small supervised group practice sessions, identification of slow or hesitant learners is essential if post-workshop use of hypnosis will occur. Participants who report early use of hypnosis with patients for simple relaxation and stress reduction do well in the future for more advanced cases. Those participants, however, who still hold on to scripts, and report little intersession use, may need some individual attention within the group framework. In general, those who understand that additional workshops may be helpful in ultimately claiming this modality for future use are encouraged to relax and accept their own rate of learning.

The last session is devoted to ethical principles, professional conduct, and certification (Bloom, 1995c). Maintaining training standards and advancing the field becomes an additional task of each workshop member on leaving the introductory course. Joining national and international organizations ensures future personal and professional development. Current controversies in hypnosis research and their applications to clinical practice raise major issues. Because of controversies in using hypnosis in memory retrieval, treating dissociative disorders, and understanding the 'false memory syndrome' movement, experimentalists contribute answers to important questions generated by clinical concerns. How does memory work, is repressed memory a proper subject of controlled studies, and how do investigating demands shape forensic hypnosis? (McConkey & Sheehan, 1995). There is a current danger that responsible clinicians will dismiss laboratory findings if they do not support their own perception of their patients' problems and responses to therapy. There is also a potential for serious misunderstanding if experimentalists do not appreciate that clinicians are licensed by the state/province to make independent responsible judgments on how to treat each individual patient. Two truths therefore seem to conflict: the truth of science, and the truth of clinical wisdom. Workshop members need to appreciate the inherent ambiguity of their work and learn to accept both truths at the same time. Human understanding is not advanced on clinical anecdote alone, but the wisdom of the healer is seldom dependent on the double blind study. Investigators and clinicians need each other and must find ways to share common ground.


A final note on enhancing creativity in one's practice is made, and future advanced workshops designed to cultivate these attributes in each participant, are presented and encouraged.


Four months later, an advanced workshop in Clinical Methods in Hypnosis and Psychotherapy: Integration and Applications is offered. The art of psychotherapy depends on the individual therapist as well as his or her individual patients. The advanced workshop as given is different from the workshops usually given in annual meetings of the National Constituent Societies of the International Society of Hypnosis. Usually an intermediate workshop is given to further one's experience with deepening techniques and using hypnosis in more complicated clinical cases, before advanced workshops in treating specific syndromes such as chronic pain, cancer, post-traumatic stress disorders, sexual problems, anxiety disorders, and dissociative identity disorders (formerly Multiple Personality Disorders) are presented. My own advanced workshop, presented here, shifts the emphasis from the problems of the patient/client to the professional development of the therapist. Let us examine what an 'ideal' advanced workshop might look like in this regard.

Creating a strong therapeutic alliance is the essential basis of successful psychotherapy. The context in which this relationship develops must be understood. The 'demand characteristics' described by Orne (1962) in the laboratory also contribute to the outcome of therapy in the clinical setting. With this in mind, I begin the first workshop session with a detailed examination of the setting of my own office: the location of the windows and doors, the arrangement of the chairs and bookshelves, and the creation of various visual lines to create a sense of comfort. It is not surprising, and in fact it was the specific requirement I had for creating my office, that each new patient would respond, when asked for the first word to come to their minds when sitting down, with 'comfortable'.

Once the context of the office is described, the personal styles of various therapists, both contemporary and historical, are discussed. While there should be no ideal style, emerging styles that are unique to each therapist should be recognized and encouraged as valuable. Finding one's voice as a therapist is a lifetime task (Bloom, 1995a,b). Selecting the 'right' patient and learning to treat the 'wrong' patient are challenges that can lead to therapist and patient growth. How to identify and strengthen the unique styles of each participant is the main task of the group's leader in collaboration with the other members of the workshop.

The next session examines the 'mind of the therapist', a concept originated by Bernauer W Newton, PhD (personal communication, 1988). By presenting our mutual cases, we elaborate what we were thinking as the therapy unfolded and clinical choices in therapy were made. When is hypnosis utilized, what is the nature of the interventions, what are the goals of treatment, and how are the results of


therapy understood and enhanced the next time? We all know that hearing audiotapes or seeing videotapes of our therapy with our patients evoke the same thoughts and words in our minds that occurred during the actual therapy—even if the therapy occurred years before. Unexpressed of course during the process of therapy, these inner deliberations can be shared in a small group setting devoted to examining the mind of the therapist. It is these inner deliberations, not solely the actual patient-therapist dialogues, that shed the most light on our work.

The third session focusses on treating the 'untreatable' patient. Difficult patients force the therapist to return to basic concepts of history, mental status, diagnosis, and treatment planning. Issues of transference and countertransference must be examined freshly and often by consultation with colleagues. I believe Carl Whitaker (1950) once said 'Every impasse is an impasse in the therapist.' Yet some patients are simply unable to summon sufficient motivation to change. Others, of course, experience symptoms derived from unknown biological disorders that resist psychological interventions. All patients benefit from a supportive therapeutic alliance which enhances ego building and coping mechanisms. Teaching self-hypnosis enables these simple goals to be accomplished in almost every case.

The next two sessions focus on using hypnosis in short-term and long-term therapy with special emphasis on problems with memory retrieval. In this advanced workshop, the participant's own case material is shared by the group and the direction of the workshop is shaped and refined by these particular interests. It is necessary to create a context of trust to facilitate this sharing, and yet it still remains difficult to encourage these presentations and thereby exposure of the participant's case material. This problem rests both in the persisting hesitancy to use hypnosis in clinical practice, and in discomfort in reviewing publicly one's basic psychotherapy skills. The leader must set the example by presenting his or her own difficult patients and the process of dealing with them (Bloom, in press). He or she must also be aware that the group will readily allow the allotted time to pass in this way without presenting their own cases. Occasionally an eager participant will monopolize all the time, again allowing other members the opportunity to remain silent. Experience in group dynamics and a clear understanding of the educational goals of the workshop helps the leader to navigate these seemingly conflicting agendas. These are the challenges and rewards of good adult education.

The sixth and seventh sessions go to the heart of the advanced workshop. In all creative therapy, true art occurs when science is fused with intuition (Bloom, 1990). Learning to rely on one's intuition or hunches takes time and willingness to trust oneself. Weaving these insights into the fabric of an individual's psychotherapy often advances the process of therapy in useful ways. When participants become more comfortable in finding responsible freedom to be creative in their work, they begin to find their style or 'voice' in their work. This path of learning leads to the knowledge that they are healers: it is the art and process of becoming a therapist. In learning hypnosis and psychotherapy, each workshop member is rewarded for examining his or her success and failures. However, while expanding


our flexibility to treat a wider array of individuals, it is also important to learn who not to treat. Some patients unduly demand time, energy, and effort that far exceeds our capacity to give. If our creative energies are depleted, we must refer these patients to colleagues more able to treat them.

No advanced workshop is complete without a review of current research findings and the relationship to clinical practice. Areas of mutual interest to the researcher and clinician include pain management in chronic illness, sickle cell anemia (Dinges, Whitehouse, Orne, Bloom, P.B. et al., 1997), and cancer. Also teaching self-hypnosis in patients who are dying can be a life-extending intervention (Spiegel, Bloom, J.R., Kraemer & Gottheil, 1989). Self-hypnosis techniques enhance self-control, increase coping, and increase freedom from discomfort in these patients. In establishing the therapeutic alliance with dying patients, a rich experience for both the patient and the clinician is created for the benefit of both.


Graduates of both the introductory and advanced workshops often express the wish to meet monthly throughout the year to discuss ongoing cases. These round table formats attract individuals who are pushing the limits of their understanding of how therapy works, and how they might enhance their art. Each evening is divided into: (a) a review of the current literature as determined by any participant who chooses to discuss an interesting article; and (b) a presentation of complex and interesting cases. More than in previous workshops, group members share deeper feelings and insights into their own work. While maintaining an adult educational format, these discussions lead to further shifts in becoming senior therapists. Upon completion of this seminar, participants must seek out other faculty leaders both locally, nationally, and internationally to meet as colleagues. For those who are interested, teaching in these wider settings becomes the next major step on the path of knowledge.


In this chapter, I have outlined several workshop programs for learning clinical hypnosis by graduate health care professionals. These workshops incorporate the principles of adult education and the standards required for certification by some national constituent societies of the International Society of Hypnosis and for diplomate status of the American Boards of Clinical Hypnosis. Inevitably, individual tailoring of such programs depends on the personality and style of the workshop leader and the participants' needs and interests. Basic principles of therapy, the experience of one's non-hypnotic practice, and common sense are emphasized before integrating hypnosis into practice. It follows that no one should treat those patients with hypnosis that one is not trained and comfortable treating without hypnosis. These workshops also help the participants identify their own style or voice, and


provide support for enhancing the special opportunities for creativity that come to therapists working with hypnosis. Finally, these workshops are devoted to helping clinicians learn new ways to treat patients more effectively and, by doing so, become more skillful therapists and clinicians in their own disciplines.


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Cohen, S. B. (1989). Clinical uses of measures of hypnotizability. Invited discussion with J. Barber, M. Diamond, F Frankel, E. Rossi & H. Spiegel. Am. J. Clin. Hypn., 32, 4-9,10-16.

Dinges, D. F, Whitehouse, W G., Orne, E. C, Bloom, P. B., Carlin, M. M., Bauer, N. K.,


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International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley, P. B. Bloom

Copyright © 2001 John Wiley & Sons Ltd

ISBNs: 0-471-97009-3 (Hardback); 0-470-84640-2 (Electronic)


General Clinical Considerations



International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley, P. B. Bloom

Copyright © 2001 John Wiley & Sons Ltd

ISBNs: 0-471-97009-3 (Hardback); 0-470-84640-2 (Electronic)

Patient Selection: Assessment and Preparation, Indications and Contraindications


Private Practice, Philadelphia, PA, USA

Advances in the field of hypnosis over the last two decades are reflected in many areas of hypnotic research and applicability. In this time period clinicians and researchers have come to appreciate and share the difficulty of defining this useful phenomenon we refer to as hypnosis, while simultaneously exploring its usefulness in a wide range of medical and psychotherapeutic settings. While debate about how to define hypnosis continues, so does its employment in many settings.

A perusal of the older texts on hypnosis portrays a poorly understood set of phenomena replete with warnings about the 'dangers and contraindications' of its use (ASCH, 1973). These texts were characterized by three common features. First, the format was often a cookbook approach to hypnotic applicability. Anyone could be a hypnotist if they simply followed the recipe. Second, there was a hint of a defensive posture on the part of authors, eager to convince their sometimes doubting or sceptical colleagues of the usefulness of hypnotic interventions (Hart-land, 1966). The public portrayal of hypnosis in the media, on TV or in the movies often reinforced myths and inaccurate stereotypes of hypnosis. More accurate public information was mostly unavailable. And finally, the hypnosis was often set apart from both the therapies and the therapists. Framed in a medical model, it was often portrayed as the necessary injection, without regard to the skill of the injector or the medicine injected.

Current texts portray a different picture. Hypnosis itself has come of age. It is a respected therapeutic modality, considered part of the clinician's full therapeutic armamentarium (Kroger, 1977; Crasilneck & Hall, 1975; Brown & Fromm, 1987; Northrup, 1998). As with so many new health alternatives, the public is more open to and more educated about hypnosis (Davis, McKay & Eshelman, 1980). Emphasis is both on the integration of hypnotic techniques into the clinician's existing orientation and on the skillfulness of the clinician in its use. Case studies no longer suggest a cookbook style, but rather the creative and individualized approaches to

International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley and P. B. Bloom © 2001 John Wiley & Sons, Ltd


applying hypnosis, which are tailored to the client's often complex presentation of symptomatology. A full discussion of patient selection must therefore include issues about hypnotic responsiveness, individual differences, and positive expectancies.

Establishing the hypnotic relationship with a client may be seen as a four-step process. First is the evaluation phase during which the building of rapport guides the clinician's every thought and action. Second is the educational phase during which the client is introduced to the concept of hypnosis and informed consent is garnered. Third is the assessment of hypnotizability, done either with formal or informal techniques. And fourth is the teaching of self-hypnosis phase, during which time positive expectancies about hypnosis and motivation of the client are further enhanced. These phases do not always occur in a linear fashion but are subject to the ebb and flow of the therapeutic relationship. However, it is a useful way for the clinician to organize his or her own experience of the unfolding of the hypnotic relationship. In addition, the four phases serve as a guide to the areas that should be covered in preparing the client for hypnotic treatment.



This new exposition of hypnosis changes the way we think about patient selection. No longer is it simply a matter of the doctor selecting what is best for the patient. This change in how we think about hypnosis, in combination with our increasing understanding of the interactive nature of the treatment process and the relational aspects (Miller, 1986; Surrey, 1984) of the 'doctor-patient' partnership alters the lens through which we view the suitability of hypnosis for clients.

In fact, patients are far more apt to present in our offices requesting an hypnotic intervention. We might then think of clients as falling into several categories. There is that group of clients who present with symptoms that are particularly amenable to an hypnotic intervention. Areas of increased use of hypnosis include stress reduction, pain management/welmess, and uncovering work in a psychodynamic relationship. Many of these clients are sophisticated in their knowledge of alternative health benefits and ask for information on hypnosis, while others are aware of the benefits of stress reduction techniques such as relaxation exercises, meditation and guided imagery, but are uninformed about their similarity to hypnosis. Still others are uninformed about hypnosis and ignorant of its application to their problem. Those who are actively resistant to the idea of hypnosis pose a particular challenge to clinicians. Resistance may come from several sources. Religious and cultural beliefs may influence a client's willingness to consider hypnosis (Marcum, 1994). Fear of the proposed procedure (of the unknown) may


render a client resistant, as well as fear of the clinician relationship (of a lack of safety).

Another group of clients seem to use the request for hypnosis as a way to get their proverbial foot into the therapist's door. They often request help with a discrete problem, such as the cessation of a smoking habit or the need to lose weight. Evaluation of the full clinical picture often reveals no conscious wish for help with the presenting problem, but rather help with an entirely different concern. The importance of the diagnostic skills of the practitioner is highlighted in these instances, rather than the hypnotic skills. The practitioner may be able to do a very credible job assisting the client with the 'presenting problem' but miss the underlying problems which the client may be unable to voice or explain.

Therefore when we conceptualize the process of introducing hypnosis to a patient population, we are reminded that patients are partners in their treatment and either partner may initiate the discussion about the suitability of hypnosis for the presenting problem. It follows from this relational perspective that both the client and the therapist variables are operative in the success of hypnotic application (Rhue, Lynn & Kirsch, 1993). However, 'patient acceptance of the hypnotic relationship is the primary determinant of the appropriateness of the patient for hypnosis' (Murray-Jobsis, 1993, p. 430).


The gathering of information about the presenting problem is of chief importance for the clinician. Research done by Torrey suggests that the client's motivation for improvement is determined by several factors of which the first is the 'degree to which the therapist's ability to name the disease and its cause agrees with the views of the patient' (Coe, 1993, p. 73). During the evaluation phase of treatment, the clinician will be establishing rapport, assessing the suitability of hypnosis for the presenting problem, and assessing the client's motivation for change, all the while that clinical data are being gathered. There are strong behavioural components in both the development and maintenance of illness. The clinician will want to identify these factors that affected the development of a condition as part of the assessment phase (Brown & Fromm, 1987).


The nonmedical clinician is advised to inquire of clients as to whether any medical evaluation of their condition has been performed prior to initiating an hypnotic intervention. Common presentations to the hypnotherapist such as headaches, insomnia, and back pain may have organic etiologies that require surgical or pharmaceutical treatment (Olness & Libbey, 1987). A hasty hypnotic intervention may delay proper diagnosis, cloud symptoms or actually worsen a client's condi-


tion. For example, a highly hypnotizable client presented with what he thought was a sprained ankle to an inexperienced therapist, and asked to be hypnotized so he could manage the pain. His responsiveness to the hypnotic suggestion that he would feel no pain, allowed him to walk on the injured foot for several days, after which time increased swelling led him to the Emergency Room, and an x-ray determined he had a broken ankle. This is not a danger inherent in hypnosis, but a danger in the clinician's faulty judgment. The skillfulness and clinical experience of the practitioner are operating variables that affect outcome of treatment and need to be separated from the value or success of hypnosis itself.


In making the determination as to whether an hypnotic intervention is suitable for a client, it is important to learn whether the client has had any prior experience with hypnosis or other alternative health approaches such as meditation, relaxation tapes or guided imagery. When there has been previous experience, inquiry about the client's experience as to depth of trance, reaction to suggestions, and the client's measure of the success or usefulness of the previous interventions, will provide the clinician with valuable data. This feedback will be useful in several areas: continuing to set positive expectancies for the client; tailoring the hypnotic intervention to the individual needs of the client; and correcting misinformation. Therapists report that when a previous experience with hypnosis has soured a client on the use of hypnosis, it may still be valuable to pursue the consideration of using hypnosis, patiently correcting misinformation and encouraging the client to reassess the previous 'bad' experience.


An increasingly popular practice among clinicians is the inclusion of questions about historical traumas (Linden, 1995). The relevance of traumas in the client's clinical history is the culmination of several factors that coalesced in the field of mental health. These were the Women's Movement of the 1970s and sociopolitical concerns about victimization of women, attention to the scope of child physical and sexual abuse and sociopolitical concerns about the victimization of children, the addition of the diagnostic category of PTSD to the 1980 DSM II nomenclature (Yehuda & McFarlane, 1995) and the rapid expansion of research in the area of dissociation during the decade of the 1970s (Lynn & Rhue, 1994) which grew out of the similarities between the trance behaviours of abused persons and hypnotic phenomena (Lynn Hilgard, 1986; Spiegel, 1986; Braun, 1986). Added to this, was the appreciation that little was understood about the nature of trauma in children, and that most knowledge came through retrospective studies of adults who experienced trauma in childhood (Eth & Pynoos, 1984). Most trauma models included predisposing factors of biology and temperament and prior trauma (Van


der Kolk, 1987; Burgess & Grant, 1988) in determining the development or severity of PTSD symptomatology. These models were mostly based on clinical case studies with traumatized adults. Emerging information on the neurobiology of PTSD is confirming the distinctness of this diagnostic entity (Yehuda & McFarlane, 1995; Van der Kolk, McFarlane & Weisaeth, 1996). Still unclear, is the impact of child development on the models for PTSD.

The need for obtaining the trauma history also grew from clinical experience with hypnosis which has taught us that abreactive material may surface as the client's usual means of psychological defense is circumvented (Fromm, 1980). In addition, current problems may be unconsciously associated with past traumas. The associative pathways for these stored memories may be activated during the hypnotic intervention.

A thorough trauma assessment asks about both large and small traumas a client may have experienced. Traumatic events are generally defined as those that render an individual overwhelmed or helpless. These may be physical in nature, such as car accidents, broken bones, hospitalizations, or minor trips to the Emergency Room. Or they may be psychological in nature, such as loss of a loved one, abandonment, or neglect. There is controversy over what is considered traumatic and the discussion of this controversy is beyond the scope of this chapter. Suffice it to say, the author's extensive experience treating children has taught her that trauma is a relative concept. Children are easily overwhelmed and rendered helpless, and without the benefit of an adult's coping mechanisms. Procuring an account of traumas, as the client defines them, will be useful.

How the clinician obtains a trauma history is a matter of some controversy. Central to this controversy is the concern that the clinician refrain from suggestive or leading questions during inquiry, especially when inquiry into childhood physical and/or sexual abuse is being made. The sensitive and seasoned clinician asks open-ended questions and knows that obtaining client histories is often an unfolding process rather than a linear process.

The clinician working with Post-Traumatic Stress Disorders or Dissociative Disorders will find hypnosis to be useful; however, it should not be considered a treatment in and of itself. It is a procedure that may both elicit or manage strong abreactive material, and the inexperienced clinician should proceed cautiously.


Assessing both conscious and unconscious motivation of a client is an integral part of the evaluation and treatment plan. Asking what brings the client in at this time, will often summon important motivational material. Asking what it will be like if the presenting problem is relieved, may also get at underlying contributors to symptomatology, and secondary gain factors. When motivation is low or absent, an effective treatment plan will include strategies to increase motivation. Once treatment has begun, and consent for hypnosis has been obtained, hypnosis may be


utilized to both assess and increase motivation. For example, ideomotor signalling may lead to underlying factors that compromise motivation. Ego-strengthening inductions can help to rebuild or restore hope.


Hypnosis is applicable in almost every area of medicine, dentistry, and psychotherapy either as a primary treatment choice or as one that is used adjunctively. The clinician's familiarity with treating the presenting problem nonhypnotically is preeminent. Knowledge of hypnosis is like the buttress of the central structure— one's specialty field. The clinician must stay within his or her area of expertise when utilizing hypnosis.

Moreover, it is not so much whether or not to apply a hypnotic procedure that the clinician will ponder, but rather the responsiveness of a client to such a procedure that will be a decisive factor in whether to use hypnosis or not. This leads to the inquiry about hypnotizability of a client that is discussed under phase III of patient preparation.

Research has shown hypnotic responsiveness to be unrelated to gender (Spiegel & Spiegel, 1978), and of some relationship to age. Children are particularly good subjects, with their hypnotic ability peaking between ages 9-12 (LeBaron & Hilgard, 1984). Their hypnotic responsiveness seems related to their ready ability to use fantasy and imagination (Wicks, 1995).

Since most people can be considered as candidates for hypnosis, it may be that judicious timing of the introduction of hypnosis is a factor in outcome. Timing of an hypnotic intervention, as its own variable, has received little attention from researchers, and timing of the introduction of the idea of hypnosis has received none, to my knowledge, perhaps because it is such a complex matter of clinical judgment and patient variables such as readiness, pathological presentation, and expectations.

On some occasions, hypnosis may be applied in an emergency situation without following all of the steps suggested in preparing the client. Examples of such rapid interventions mostly include pain management of serious physical injuries. Such interventions are best left in the hands of the experienced clinical hypnotherapist.


The way in which clients describe and report their presenting problem is useful information for the hypnotherapist. Hypnosis is about communication, and, some would say, about communication with the unconscious aspects of the individual (Rossi & Cheek, 1988; Weil, 1995, pp. 93-97)). While proven models for empirical investigation of how metaphoric information produces change are still lacking, the literature abounds with case examples of positive outcomes both


somatically and psychologically with the use of client's metaphors in hypnosis (Hammond, 1990; Malmo, 1995).



The transition between evaluating the client (phase I) and educating the client (phase II) occurs as the clinician begins to determine the client's understanding of hypnosis. Research in the area of positive expectancies has taught us that the responsiveness of a client to any treatment will be affected by their expectations. Therefore, the preparation of our clients for hypnosis is a process of educating them and building positive expectations (Coe, 1993). Kirsch has interpreted the results of several of his studies as suggesting that, with sufficiently strong expectation, anyone is hypnotizable (Rhue, Lynn & Kirsch, 1993, p. 89). This parallels Hilgard's (1968) observation that laboratory studies of hypnotic ability and susceptibility are often unable to mirror the demands of the clinical setting where the client's expectations and motivation may render the results on the tests of hypnotizability less important.

An educational discussion about hypnosis prefaces any induction procedure. This pre-induction talk covers the myths, the misperceptions, the uninformed constructs that the individual may hold about hypnosis. Some of the common beliefs held about hypnosis include but are not limited to the following:

Hypnosis is something done to a person. The client may say 'Put me under,
Doc' This idea that the hypnotist has some power to control the client is partly
rooted in the much larger sociopolitical view of the medical model as a non-
egalitarian relationship. In addition, this notion of having something done to you is
comparable to the surgical paradigm of the client who is unconscious on the
operating table and literally in the hands of the doctor. It is important early in the
educational process to clarify that all hypnosis is self-hypnosis and that client and
clinician are partners in the endeavour. The client is thus encouraged to actively
participate in the exploration of his or her own hypnotic abilities.

Hypnosis is sleep, loss of consciousness or amnesia. The client may ask 'How
will you wake me up?', or 'How come I heard everything you said?' The origin of
the word hypnosis is the Greek word for sleep. Many accounts of hypnosis describe
it as similar to the early stage of sleep when one is drifting in and out of conscious
awareness but still awake. Clients' confusion about hypnosis being a state of sleep
is further compounded by their knowledge that sleepwalking occurs in the
hypnagogic stage of sleep. Our semantic difficulties in describing the experience of
trance, of hypnosis, have contributed to this misconception about hypnosis. Clients
usually find it helpful when they can recall an experience of profound concentration


or fixed attention. Such an experience can then be compared to their hypnotic trance. It is also helpful to share with clients that brain wave studies of subjects 'under hypnosis' show an alert brain wave pattern, and not that of a deep sleep state.

The trance will be irreversible. The client may ask 'Can I come out of this?'
This fear that once in a trance state the client will be unable to terminate the trance
is founded on the belief that something is being done to him or her. It suggests
there is an external locus of control for the hypnotic process. It is useful to compare
the hypnotic partnership to the roles of guide and pioneer. The hypnotist is a
teaching guide, the client may choose whether and when to follow, and the client
rapidly learns the terrain already familiar to the clinician.

The hypnotist will have power over the client, over their behaviour, their
thoughts, over their wills. The client may fear that a suggestion will violate a moral
or ethical code. 'Will I bark like a dog?' 'Will I talk about something I don't want
to talk about?' These concerns often reflect the client's exposure to the portrayal of
hypnosis in the entertainment industry. Lay hypnotists, unlike hypnotists in the
professional health fields, lack clinical training and all too often lack concern for
the subject's privacy, psychological well-being or moral codes. It is the clinician's
responsibility to teach hypnosis adhering to the codes of ethics of his or her
profession and to teach the client to discriminate between the ethical and unethical
uses of hypnosis.

Each of these beliefs carries a concern about who is in control. This underlies the important clinical construct that all hypnosis is self-hypnosis. It is useful to teach this to clients and it may serve to lay the foundation for the later teaching of self-hypnotic procedures.

Some other valuable constructs which are important to explain to the client include defining and describing absorption, concentration, focused attention, and dissociation. The commonness of absorption or what is termed the 'everyday trance' can be illustrated by experiences of automaticity shared by many, such as automobile driving behaviours, tooth brushing and other repetitious behaviours. The focused attention or concentration of hypnosis may be compared to the state one experiences while at prayer, or while reading a highly absorbing novel. The state of shock one is in following an injury or accident can be likened to the experience of dissociation.

There is variability in hypnotic talent and skill. Discussion of this point is helpful in building positive expectancies that practice will make a difference in hypnotic responsiveness over time. Hypnotizability scales may be used to assess degree of hypnotizability.

Discussion about memory and hypnosis is an important requirement of the pre-induction talk. Memory is imperfect, productive, and reproductive both in and outside of hypnosis. Some hypnotic techniques metaphorically suggest that events in memory will be retrieved as they happened or were encoded (e.g. the TV screen


or movie technique). It is important to distinguish between this metaphorical exploration of memory and what research tells us about the nature of memory. This is similar to the distinction that is made between narrative truth and historical truth. Educating the client about these distinctions will be beneficial.

A final area for consideration by the clinician is that of informed consent. The clinician will document the evaluation and treatment plan for a client according to the standards of care determined by his/her profession. In addition, if a case involves or may involve forensic testimony, clients need to know about any issues related to admissibility of testimony gathered with hypnosis.


The assessment of hypnotizability is phase III of patient preparation. Standard measures may be used, although increasingly these are limited to research settings. The most common measurement instruments are: The Stanford Hypnotic Clinical Scales for Adults and Children, The Hypnotic Induction Profile, the Harvard Group Scale of Hypnotic Susceptibility, the Stanford Hypnotic Susceptibility Scale, Forms A, B, and C, and the Children's Hypnotic Susceptibility Scale. Other research instruments include the Stanford Profile Scales of Hypnotic Susceptibility, the Barber Suggestibility Scale, the Creative Imagination Scale, the Wexler-Alman Indirect Susceptibility Scale and the Waterloo Stanford Group C Scale of Hypnotic Susceptibility.

It is important to note that the client who is low hypnotizable on a standard measure may in fact achieve great benefit from learning hypnotic skills. Issues of ability and susceptibility, while extensively studied in the laboratory, pale in significance in the clinical setting next to the client's expectations and motivation.

Nonstandard measures of hypnotizability may also be used to assess a client's responsiveness. Many clinicians use a simple induction procedure for this purpose. Usually, it is one they have used with many other clients, so that they have gathered data for comparative purposes. These same inductions can be used as part of the building of positive expectations, to set up success experiences and to establish motivation.


Generally, once the evaluative and educational phases are complete, and hypnotizability has been assessed, the clinician is ready to teach the client self-hypnosis. This is phase IV of the preparation process. A principle for success is to separate the teaching of hypnosis from the presenting problem. For example, the client who presents with a headache should not receive a first intervention for symptom relief until basic hypnotic principles have been taught. Otherwise, the clinician risks the


client viewing hypnosis as a failure, should the headache not be relieved. In addition, because hypnosis is considered a skill, it is subject to improvement with practice. Clients can be instructed to practice self-hypnosis, thereby increasing their skills while simultaneously validating their altered state, thus increasing positive expectancies.


There are only a few instances in which hypnosis should not be used, and these mostly have to do with the skill of the therapist. Hypnosis should not be used with any presenting problem that the clinician is unprepared to treat without hypnosis. When a client's presenting problem is outside the clinician's field of expertise the client should be referred elsewhere. Every clinician has had the experience of meeting a client they would rather not treat. It is advisable to refer them elsewhere, as well. While the literature contains case reports of successful hypnotic applications with almost every DSM category, most clinicians have delineated a narrower field of practice and will find they can easily apply hypnosis within their defined domain.

Some clinical presentations are poorly suited to hypnotic intervention. Organic brain syndromes is one such category. Clients who present as suicidally depressed or as paranoid schizophrenics are generally not good candidates for hypnosis, at least in the beginning of treatment. The rapidity with which hypnosis may bring forth repressed material, or unravel the already fragile psychic structure, are unwanted repercussions with such clients.

Similarly, in uncovering work, caution must be taken when working with clients with fragile ego structure, thought disorders, or borderline psychotics where there may be further decompensation with hypnosis. Paranoid clients may also feel an intensification of hostile feelings related to feeling controlled following hypnosis (Frauman, Lynn & Brentar, 1993).

Forensic subjects can pose a particular challenge to clinicians. Recent recommendations (Hammond, Garver, Mutter et al., 1994) clarify the state and federal models for forensic hypnosis. Training in forensic applications of hypnosis and nonsuggestive or nonleading interviewing techniques are recommended for professionals working with forensic subjects. It is the clinician's responsibility 'to reject the use of hypnosis in any case in which' the client (the witness) is not competent to give or refuses to give written informed consent, or where the mental, emotional or physical health of the person will be at risk of harm with the use of hypnosis, or when 'the witness was not in a position to realistically perceive the events in question' (ibid, p. 39). In the aggregate, when forensic guidelines have not been properly followed by a forensic subject, the use of hypnosis is ill-advised.

As noted earlier, indiscriminate removal of organic pain may lead to complications. This is a particular problem with highly hypnotizable clients whose talents in


the area of pain relief are enviable. Such complications are not the result of hypnosis, but rather a failure on the part of the clinician to adequately assess hypnotizability and carefully construct hypnotic suggestions.

When Fromm (Frauman, Lynn & Brentar, 1993) looked at therapists' styles and values, she found that the coercive, omnipotent stance tended to produce negative reactions in the client, while a more permissive, respectful, and collaborative stance was unlikely to encounter complications. This research again highlights clinician characteristics, such as style and competence, as limiting factors in the hypnotic relationship, rather than hypnosis itself as having any inherent dangers.

A final area of concern is the potential for abuse of the hypnotic technique by the client. It is the task of the clinician to teach clients that self-hypnosis is solely for their own use. Children, in particular, must be reminded that the new skill they are learning is for them alone, and not for them to teach to their classmates and friends. There are stories shared among clinicians about individuals who have misused their hypnotic skills with others. Most of these cautions, again, have to do with the risks for highly hypnotizable subjects, and not with dangers inherent to hypnosis.

In the final analysis it is the clinician's own judgment and experience that determines whether or not hypnosis should be employed and when to introduce the notion of hypnosis. If a client is unwilling to learn about hypnosis he or she has the conclusive say in determining this. As has been outlined in the preceding comments, the issues of trust and control in the therapeutic relationship are the cornerstones of good rapport, and the client's wishes must be respected.


In summary, the selection of the client for hypnosis is a relational process in which both the client and clinician bring many variables to the therapeutic table. The hypnotic responsiveness of the client, individual differences and the positive expectancies the client holds, or those which are established with the client, are all important variables in the assessment and preparation of a client. There are no known dangers inherent to hypnosis, but contributing factors to 'negative effects' are found within the therapist and client characteristics and within the relationship they form.

There are four phases to the assessment and preparation of the client. The first is the evaluation phase, the second is the educational, the third is the assessment of hypnotizability, and the fourth is the teaching of self-hypnosis.

This chapter has emphasized that hypnosis is a valuable technique to utilize in a variety of settings. With an appropriate introduction and education about hypnosis and hypnotic phenomena clinicians are likely to experience much success in the use of hypnotic techniques within their individual fields. The chapters that follow will explore in detail the diverse applications of hypnosis.



American Society of Clinical Hypnosis (ASCH) (1973). A Syllabus on Hypnosis and a

Handbook of Therapeutic Suggestions. Chicago: ASCH-ERF. Braun, B. (1986). Treatment of Multiple Personality Disorder. Washington, DC: American

Psychiatric Press. Brown, D. & Fromm, E.  (1987).  Hypnosis and Behavioural Medicine. Hillsdale, NJ:

Lawrence Erlbaum. Burgess, A. & Grant C. (1988).  Children Traumatised in Sex Rings. Washington, DC:

National Center for Missing and Exploited Children. Coe, W (1993). Expectations and hypnotherapy. In J. W Rhue, S. J. Lynn & I. Kirsch (Eds),

Handbook of Clinical Hypnosis (pp. 73-93). Washington, DC: American Psychological

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'negative effects' in hypnotherapy. In J. W Rhue, S. J. Lynn & I. Kirsch (Eds), Handbook

of Clinical Hypnosis. Washington, DC: American Psychological Association. Fromm,  E.  (1980).  Values  in hypnotherapy.   Psychotherapy:  Theory,  Res.  Pract.,  17,

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Guidelines for Clinicians and for Forensic Hypnosis. Des Plaines, IL: American Society

of Clinical Hypnosis Press. Hartland, J. (1966). Medical and Dental Hypnosis, 2nd edn. Baltimore, MD: Williams &


Hilgard, E. (1968). The Experience of Hypnosis. New York: Harcourt, Brace & World. Hilgard, E.  (1986). Divided Consciousness: Multiple Controls in Human Thought and

Action. New York: Wiley.

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Altos, CA: William Kaufmann. Linden, J. (1995). When mind-body integrity is tramatised by problems with physical

health: The woman's response. In G. D. Burrows, & R. O. Stanley (Eds), Contemporary

International Hypnosis. New York: Wiley.

Lynn, S. & Rhue, J. (1994). Dissociation. New York: Guilford Press.

Malmo, C. (1995). Drawings in MPD and therapy of childhood trauma. Hypnos, 23(2), 60-72. Marcum, J. (1994). Jackhammering the concrete—or working in the buckle of the Bible Belt.

Paper presented at the 36th Annual Scientific Meeting of the American Society of Clinical

Hypnosis, San Diego, CA.

Miller, J. B. (1986). Toward a New Psychology of Women. Boston: Beacon Press. Murray-Jobsis, J. (1993). The borderline patient and the psychotic patient. In J. W Rhue,

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Northrup, C. (1998). Women's Bosies, Women's Wisdom. New York: Bantam Books.

Olness, K. & Libbey, P. (1987). Unrecognised biologic bases of behavioural symptoms in patients referred for hypnotherapy. Am. J. Clin. Hypn., 3, 1-8.

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Spiegel, D. (1986). Dissociation, double binds, and posttraumatic stress in multiple personality disorder. In B. Braun, (Ed.), Treatment of Multiple Personality disorder (pp. 61-78). Washington, DC: American Psychiatric Press.

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International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley, P. B. Bloom

Copyright © 2001 John Wiley & Sons Ltd

ISBNs: 0-471-97009-3 (Hardback); 0-470-84640-2 (Electronic)

Memory and Hypnosis-General Considerations


Australian Catholic University

This chapter concerns itself with hypnosis and memory, and the relationship between them. At the outset, it seems most appropriate to define the nature of both, and then to briefly review the association that exists between them. The concern of this chapter is primarily with memory distortion, rather than accuracy, as the distorting effects of what people remember are often clinically relevant.



The nature of hypnosis has been much debated in the literature (Orne, 1959; Kihlstrom, 1985; Lynn & Rhue, 1991). Nevertheless, there is reasonable consensus about some of its defining properties. Although distortions typically occur, hypnosis can be said to occur when one person (the subject) experiences alterations in perception, memory, or mood in response to suggestions given by another person (the hypnotist). Although distortions typically occur, hypnosis is essentially an experiential phenomenon where the hypnotist typically guides the subject to create a favorable situation for the display of his or her special capacities and skills. Substantial reliance has to be placed therefore on the subject's self-report as to the nature of his or her experience.

If a subject is motivated to fake hypnosis (i.e. to report an experience that he or she is not having), then it is possible to do so. In such a case, subjects typically base their performance on the information that has been given about hypnosis before the hypnosis session and on the cues that are given during the hypnosis session itself. This is not a view that is compatible with hypnosis recovering traces of original perception, and sits most comfortably with the perspective that memories retrieved in hypnosis are products of hypnotized subjects' imaginative capacities at work. It does not say, however, that hypnosis is inherently distorting.

International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley and P. B. Bloom © 2001 John Wiley & Sons, Ltd



Memory is equally a complex process. It is a labile phenomenon and its inherent plasticity is clearly acknowledged in the literature (e.g., Annon, 1988). It is influenced strongly by pre-existing representations (Echabe & Rovira, 1989), but postevent misinformation is also effective and known to lead to distortion of memory in both adults and children (e.g., Ceci, Ross & Toglia, 1987).

In general, memory is a constructive and reconstructive process. There is substantial evidence that it changes over time to accommodate alterations in feelings toward or information about the event(s) being remembered. Hypnosis may lead to an increase in the amount of material reported as memory. However, whereas some of the additional material may be accurate, other aspects of it may be inaccurate; and this is despite the fact that the person may be substantially confident about the accuracy of the material that is reported.


By way of illustration, it seems most instructive to single out pseudomemories, and memories of past, personal events recorded in the clinical setting by use of hypnosis. These two phenomena are selected because they both illustrate the rich variety of the complex processes and factors that are frequently at work.


The phenomenon of pseudomemory is tied necessarily to subjects' acceptance of postevent misinformation. In operational terms, the conditions for establishing it in the hypnotic setting typically involve the administration of suggestions giving false information to subjects following the induction of hypnosis. Routinely, subjects are awakened subsequently and then tested for how well they remembered the events that they saw earlier.

Empirically, there is a range of parameters that has been shown to be related to hypnotically induced pseudomemory, but not all of them have produced reliable results. Incidence of the phenomenon is variable, the most consistent evidence that has emerged being that level of hypnotic susceptibility is related positively to the phenomenon, with high susceptible subjects showing greater evidence of pseudo-memory than low susceptible subjects.

The evidence for the relevance of hypnotic skill comes from a variety of studies that have now used a range of paradigms for studying pseudomemory. Labelle, Laurence, Nadon & Perry (1990), for instance, found that pseudomemories were reported most often by highly susceptible subjects, and not at all by low susceptible subjects: and this pattern of findings was largely replicated by McConkey, Labelle, Bibb & Bryant (1990). Relatively few studies have used nonhypnotic comparison


groups in studying pseudomemory, comparison rarely being made between waking and hypnotic instructions. The study by Labelle et al. (1990) did not include waking comparison, while McConkey et al. (1990) and Barnier & McConkey (1993) did so, and where the comparison was provided results have generally failed to demonstrate a hypnotic instruction effect. Other studies (Sheehan, Statham & Jamieson, 1991), however, have indicated increased pseudomemory effect for hypnotic instruction, with high susceptible subjects showing greater acceptance of the false information under hypnotic as opposed to waking instruction.

Contextual factors as they affect pseudomemory have been studied in a variety of ways and have yielded relatively consistent results. Their influence is widely evident across other memory phenomena as well. Factors relevant to pseudomemory (and other memory phenomena as well) include type of stimulus event, the setting in which suggestion is tested, mode of memory test, presence of reward, and other contextual influences (see Spanos, Gwynn, Comer, Baltruweit & de Groh, 1989). Also, Spanos & McClean (1986) studied the influence of the cues available in different testing contexts as they affected the incidence of reported pseudo-memories and found that pseudomemory varied positively as a function of the type of expectation given to subjects, though not all expectancies in terms of prehypno-tic information have been shown to be effective (Lynn, Weekes & Milano, 1989).

Contextual factors obviously play a part in influencing the phenomenon of pseudomemory, but the mix of possible mediating factors requires exploration of a much wider range of parameters than has been conducted to date. In particular, interpersonal parameters, such as rapport, are also relevant. Rapport has been claimed by a number of theorists (Sheehan, 1971, 1980; Shor, 1962) to be integrally related to hypnosis, and demonstrating the importance of rapport in maximising the occurrence of hypnotic phenomena has been the primary aim of a number of studies in the past (e.g., Gfeller, Lynn & Pribble, 1987; Matheson, Shue & Bart, 1989; Sheehan & McConkey, 1988).

Rapport appears widely in the hypnosis literature under a range of alternative labels and they are all clinically related. These include archaic involvement (Shor, 1962, 1979), social relationship factors (Sarbin & Coe, 1972), transference (Gill & Brenman, 1961), and fusional or symbiotic alliance (Diamond, 1988). Viewed within the hypnotic setting, the concept normally expresses the positive interaction of hypnotist and subject, predictably resulting in strong feelings of relaxation and comfort in the subject who is hypnotized. Specifically, Shor has asserted that rapport (or archaic involvement) is one of three major factors that mediates hypnotic response, arguing that the hypnotist is infused with importance to the extent that the hypnotized subject has a special wish to please, the core of the subject's personality being bound up in the relationship that is formed with the hypnotist. Sheehan (1971, 1980) studied the implications of Shor's theorising and found strong support for this process as a primary determinant of hypnotic response. Of particular significance for the clinical relevance of hypnosis was the finding that as rapport diminished between the hypnotist and subject, susceptible


subjects in hypnosis were appreciably less inclined to do as the hypnotist wanted (Sheehan, 1980). If this finding can be generalized to the pseudomemory test situation, then pseudomemory might be expected to be less under reduced conditions of rapport when the relationship between hypnotist and subject is appreciably reduced or has broken down.

Generality of Findings

With these specific findings on pseudomemory aside, evidence across multiple methodologies investigating memory distortion indicates sporadic effects for state instruction, but very reliable effects for level of susceptibility, and some evidence of an interaction between state instruction and aptitude for hypnosis. The effects are quite pervasive for pseudomemory, for instance, across different experiments using the same paradigm and the same basic sets of procedures. Table 4.1 sets out the major inferences from the literature reviewed across different paradigms and illustrates how some quite specific conclusions evidenced from pseudomemory do generalize to other kinds of memory reporting as well (see Sheehan, 1994).

For instance, it is clear across paradigms that hypnosis provides no guarantee to assessing veracity. Although hypnosis is not inherently distorting, it can easily lead to falsification, error and confabulation. Hypnosis is likely to produce more information, but it is not possible to determine in hypnosis, without later independent verification, which facts being recalled are true. Additional facts recalled, however, may be useful clinically and forensically. The act of reporting, separate to the accuracy of what is remembered, is typically one in which the hypnotized person is confident, but confidence (both in hypnosis and in the waking state) should in no way be taken as a reliable indicator of accurate memory. Overall, a subject's level of hypnotic skill is a powerful determinant of the hypnotic creation of memory, and hypnotizability often (in pseudomemory, at least) interacts with the use of hypnotic instruction.

Past data clearly indicate that phenomena involve a mix of mediating processes. Looking at the general program of work on memory in the hypnotic literature as

Table 4.1.    Major inferences from experimental data drawn on the association between memory and hypnosis

No reliable memory enhancement effects occur either within single paradigms or across

Memory distortion effects are not unique to hypnosis

A number of variables exist (adhering to context) that are influential in determining

Patterns of effects depend on the means by which false information is communicated in
the test situation

Hypnotic skill is especially influential across different methodologies

Confidence, in particular, is influential across paradigms with distorted memories
frequently being reported confidently

Source: Adapted from Sheehan (1994).


a whole, level of suggestibility, type of memory test, and stimulus pull are all necessary, though not sufficient, factors in determining the occurrence of hypnotically induced memory distortion.

There are several theoretical implications of such findings for the role of hypnosis in its association with memory. First, the research reported as a whole does not determine whether hypnosis per se was responsible for memory distortion effects observed among hypnotic subjects, but data are nevertheless consistent with the position that contextual variables are important determinants of the strength of effects that are created in hypnosis for highly susceptible subjects.

In highlighting the particular relevance of contextual variables, the implication can also be drawn that clinical memory reporting does not necessarily involve (indeed, often may not) genuine memory distortion. To the extent that genuine memory distortion would not be expected to be reversed by the influence of interpersonal factors, one implication of the evidence is that phenomena (for some subjects at least) more likely reflect goal-directed performance which is motivated by an intent to please the hypnotist. Far from being an example of behavioural conformity, however, such may signify genuine hypnotic effects, albeit not ones that necessarily reflect durable impairment of memory. There are major theoretical implications of these data that perhaps deserve emphasis. One is that hypnotically induced pseudomemory may well be a particular instance of posthypnotic responding. Memory distortion, for example, occurs in a postinduction setting that is clearly related to hypnosis.

On the basis of any of the experiments discussed here it would be difficult to argue that hypnosis provides a unique environment for special memory effects to manifest themselves. The assertion that memories can, under some circumstances, be altered or even changed completely is a serious one, especially when viewed in the forensic context (see Orne, 1979). Countenancing the possibility of serious distortion in the memories that are reported is a notion that may not rest easily with the general public and that is one reason why the accomplishment of systematic empirical work in the area is so important.


One of the key contemporary questions or issues in relation to memory and hypnosis, is that of recovered memories. This topic is pursued in greater detail in chapter 8 of this book. Such is the relevance of this topic to the relationship of memory to hypnosis that it is pursued here to illustrate the complexity of the many factors affecting the association between memory and hypnosis.

Evidence on Recovered Memories

Returning to the opening remarks of this chapter, about memory being a constructive and reconstructive process, there are some important implications for the


nature of memory. What is remembered about an event is shaped by what was observed of that event, by conditions prevailing during attempts to remember, and by events occurring between the observation and the attempted remembering. It is essential therefore to recognize that memories can be altered, deleted, and created by events that occur during and after the time of encoding, during the period of storage, and during attempts at retrieval.

Repression and dissociation are key processes in some theories and particular approaches to therapy. According to these theories, memories of traumatic events may be blocked out unconsciously and this leads to a person having no memory of the events. However, memories of traumatic events may become accessible at some later time. It is important to recognize that the scientific evidence does not allow precise statements to be made about a definite relationship between trauma and memory (McConkey & Sheehan, 1995). The evidence tells us more that memories reported spontaneously or following the use of special procedures in therapy may be accurate, inaccurate, fabricated, or a mixture of these. Belief can often be strong but it is not the yardstick of veracity; and neither is the level of detail diagnostic of the truth of the recollections.

We know that sexual and/or physical abuse against children and adults is destructive of mental health, self-esteem and personal relationships. It is a fact also that reports of abuse long after the events are reported to have occurred are difficult to prove or disprove in the majority of cases. Independent corroboration is for the most part impossible. It is therefore essential that clinicians exercise special care in dealing with clients, their family members, and the wider community when allegations of past abuse are made.

Looking summarily at the evidence, there is increasing testimony now that there are individuals entering therapy with no specific recollection of incest or molestation who, during the course of therapy, uncover detailed recollections of repeated sexual abuse by family members. Many of these people believe their recovered memories are veridical, and have taken legal action on the basis of these memories which have sometimes been recovered through hypnosis. There is now full-scale debate about the issues in the scientific, professional, and mass-market literature.

Serious questions exist in the literature about the validity of recovered memories (see research by Loftus and her associates Loftus & Ketcham, 1994, for example). Major issues at stake include the validity of repression as a psychological mechanism, where there is substantial evidence that people can be very confident about the accuracy of their memories of past events even when those memories are wrong. Neisser's work with Nicole Harsch (Neisser & Harsch, 1992; see also Neisser, 1993) on the Challenger space shuttle disaster compellingly illustrates that memory for emotionally charged events is widely inaccurate, despite the conviction people might hold about these events. That work convincingly demonstrates that personally memorable events occurring in the past are often not what they seem and can be entirely misleading in the manner in which they are reported. Memories of


distant events, and particularly memories of early childhood, appear to be very susceptible to distortion and error. Further, it is the case that many victims of traumatic events do not repress events, but remember them and often report uncontrollable, intrusive memories about them. What then distinguishes for traumatized people, memories that can be retrieved (if sufficient effort is made), from memories that are seemingly permanently blocked (despite efforts at retrieval)? Evidence reported by Lindsay & Read (1994), for example, implies that complete forgetting of childhood sexual abuse, whether through repression, dissociation, or normal forgetting, never actually occurs; rather, necessary caution is advocated in assuming any particular incidence rate for amnesia and in accepting or rejecting the recovered memories of an individual. As Loftus and her associates claim, although sexual abuse may be tragically common, the emerging culture of unearthing traumatic repressed memories may be creating as many problems as it is claimed to be solving.

The term 'Recovered Memory Therapy' (the relevant experimental evidence is discussed in detail in chapter 8) profiles a form of therapy that does not formally exist. As a term it really refers to the recovery for therapeutic purposes of repressed memories of sexual abuse, such memories often being associated with reported satanic rituals and manifestations of Multiple Personality Disorder. It is a label that essentially has come to denote poor practice across a range of therapies, forgotten memories being the natural target of many different modes of treatment.

A forgotten instance of abuse in a history of abuse is not necessarily evidence of repression at work, and a number of issues are implicated: memories may be avoided, not just remain temporarily inaccessible, and some people may be more successful than others in that process of avoidance. Equally, there are reports in therapy that can be trusted and reports which cannot. The professional's problem is to know which is which and we have no precise way of making that discrimination—a problem that is exaggerated in its significance when many of us accept routinely that the important matter in therapy is the client's personal account of what has happened and what he or she is feeling about that now.

Therapy certainly can facilitate access to memories and produces memory reports, but it is also a mode of influence that inevitably transmits specific cues and suggestions about what is fitting, wanted or appropriate to report. Therapy (like other influence techniques) can produce significant memory distortion while at the same time fresh memories can be retrieved that are true and reported. The essential problem is that we have no easy guarantee of the veracity of verbal reports offered in therapy, and past emotional events can rarely be corroborated independently to establish their truth value.

Because of the risks of suggestion and the many possibilities of distortion, special professional obligations exist when the memories being explored in therapy are associated with possible past abuse. This leads one to a major matter for consideration—the need for guidelines for practice.


Proper Professional Practice

Guidelines are now in place relating to the reporting of recovered memories. They have been accepted by the Australian Psychological Society and have been used in the conduct of actual cases that have come to a conclusion.

Essentially, in summary of them, it is important to: obtain informed consent regarding the therapeutic procedures; record intact memories at the beginning of therapy; be familiar with research in memory (and hypnosis, if used); clarify that the client is responsible for the reported accuracy of memories and not the therapist; and be aware of possible biases regarding the accuracy of recovered memories of traumatic events.


Special concluding comment is needed on the complexity of what one is addressing here in the light of the comments that have been made. The level of that complexity can be prodigious.

Consider, for a moment, a man who remembers in therapy that he was abused sexually and recovers that recollection in therapy. His memory may be genuinely very difficult to retrieve. The events themselves, however, may have taken place in a state of normal or dissociated consciousness. Events that were encoded in an altered state of consciousness may be especially difficult to retrieve. If they are not, there are enormously strong motivations that exist for that person not to want to recall them.

Intervening between the original trauma and therapy is often a lifespan of experiences and other recollections that return to this chapter's opening comments on memory. The person has been exposed to a myriad of events, suggestions and experiences which have the potential to reshape and later correct recollections of what has, in fact, previously occurred. In therapy there may be a grain of truth, as it were, in what is eventually remembered, but the facts could well be distorted, reshaped, embellished or confabulated. What occurs makes eventual reporting far from the absolute truth.

Into the act of retrieval comes a therapist, years later, who in the task of interrogating (albeit supportively) is unwittingly influential in altering further recollections of those past events. Those events are then explored in a context where there are implicit or explicit cues about what should be remembered. That suggestion will occur is incontrovertible. And it is for this reason that guidelines for proper professional practice must be adopted, understood and practised.


In the application of hypnosis, there are general considerations that must be respected and these relate primarily to locating the correct balance between


technical and clinical concerns. As argued elsewhere (see McConkey & Sheehan, 1995), this is often a matter of professional judgement and such a judgement must be guided by familiarity with relevant ethcial principles and the application of professional competency.

Consider, for a moment, two specific instances, one in the clinical setting and one in the forensic setting, where the issue of memory accuracy is often of paramount importance.

In clinical practice, hypnosis typically relates to a range of applications which can involve major issues for practitioners when hypnosis is used in a therapeutic way. Factors requiring attention relate to the perceived association between emotion and recall in hypnosis, the implication of falsifications occurring in hypnosis, the possibility that confirmation or suggestions of abuse may be inadvertently communicated to the client, and interpretations of the 'evidence' of a session being drawn which could be inconsistent with scientific data. Clinical concern can be wider than the pursuit of client 'improvement.'

In other settings, such as the forensic one, similar factors are involved. They primarily relate to the choice of the person to be hypnotized, the role of emotion in recall (again), the possibility of deception, and the civil rights of the person being hypnotized. Each of these factors is relevant to both settings but takes on a particular appearance in different social contexts. The role of emotion is distinctly important in the forensic setting, for instance, where the welfare of a client (the person being hypnotized) can be threatened by the forensic procedures the practitioner adopts. A person who is severely distressed at the point of retrieving (possibly) relevant information, for instance, raises the problem of whether further stress is justified to retrieve more information that may or may not have a useful legal purpose.

These general professional considerations are nearly always relevant, but have particular relevance to some cases. Legitimate questions can often be raised as to whether the use of hypnosis has a timely investigative purpose and where the balance of technical versus clinical concerns is critical. Decisions to proceed to explore the association between hypnosis and memory can often be quite difficult, and if hypnosis is used clear support for moving ahead must be reliably evident or forthcoming.

Where the association between memory and hypnosis is concerned, a special consideration (both technically and clinically) is the reliability of the memory reporting. In a technical sense, there are specific procedures which can aim to determine whether reporting is reliable (independent checking of memory events reported in hypnosis, for example), but clinical and professional factors are also relevant. Where personal reputations can be damaged, for instance, by a recovered recollection of sexual abuse the practitioner must make every effort to ensure that the memory retrieved is accurate. The future welfare of the client concerned and that of others accused of the act of abusing, for example, depends on the strict enforcement of ethical guidelines for recovering the memory in question. For


explication of these, see the Chapter 7 in this book (and also, McConkey & Sheehan, 1995).


As argued above (see also Sheehan & McConkey, 1993), hypnosis is not communication in the usual sense of the word. It frequently involves a close interpersonal relationship, and can involve radical changes in ways of thinking which can occur in a range of different social contexts—including therapy. Hypnotized people do not in general critically analyze incoming detailed information (Kihl-strom, 1985), and this has major implications for the use of hypnosis in the clinical and forensic setting. Furthermore, beliefs of the hypnotist and of clients reliably influence the manner in which hypnotized people respond. Looking at memory, in particular, although hypnosis may increase the volume of material recalled, there is no dependable enhancement in the accuracy (vs inaccuracy) of the information retrieved. Demonstrations of increases in the accuracy of remembered material, are, in fact, relatively rare (e.g., Crawford & Allen, 1983; McConkey & Kinoshita, 1988; Stager & Lundy, 1985).

In this chapter, two sample phenomena have been analyzed and general conclusions drawn about the association between hypnosis and memory.

Clinically speaking, in relation to memory and its association with hypnosis, if the decision has been made to proceed with hypnosis then it must be assumed by the practitioner that benefits are likely to occur. Such benefits may be the promise of therapeutic cure, events that will take the form of refreshed memory on the part of the client which can be checked independently, or the determination of the state of consciousness of an involved participant when some event took place. A whole complex set of motivational factors comes into play once the decision to use hypnosis has been taken and the link with the relevant laboratory evidence has been made. There may be, if the person is truly hypnotized, motivational factors associated with hypnosis, such as a desire to please the hypnosist; but there may be other extrinsic motivational factors at work as well that are related to the context in which hypnosis is embedded. In clinical hypnosis, for example, these cues are often salient and powerfully motivational in character. In the case of forensic hypnosis, victims may in some cases have reasons for wanting innocent people convicted, and this is vividly illustrated in the cases discussed by Orne (1979). Suspects may have a very strong need to demonstrate their innocence (or guilt) and a large number of motivating forces can be present. It is probably very rare in the clinical or forensic setting to find any participant who can lay claim to be emotionally neutral.

The question of hypnotizing a person who is involved in an actual memory event (to be later retrieved) has many potential difficulties. The laboratory evidence tells us that aptitude for trance is clearly a highly relevant variable, state instruction may


be relevant, and lying is a possibility. Some theorists believe that it is possible to lie while under hypnosis while others are more cautious about making a definite judgement in the matter.

Emotional involvement is clearly implicated in analyzing the association of memory and hypnosis, and one major issue which is raised in this chapter is how emotion can be handled in real-life settings when recovered memories are reported. Memories that are recovered are often given spontaneously and when they are associated with hypnosis they occur in a context where therapeutic questions may also be suggestive. These memories can be accurate, in error, or show a combination of both; and confidence in the memories, and the level of affect associated with them, offers no real proof of literal accuracy.

Situations that attempt to retrieve past memories obviously require complete ethical response. There are general clinical considerations that must be respected in the conduct of hypnosis. And these considerations can only be met if the appropriate guidelines are followed.


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International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley, P. B. Bloom

Copyright © 2001 John Wiley & Sons Ltd

ISBNs: 0-471-97009-3 (Hardback); 0-470-84640-2 (Electronic)

Neuropsychophysiology of


Towards an Understanding of

How Hypnotic Interventions



Virginia Polytechnic Institute and State University, USA

No longer can one hypothesize hypnosis to be a right-hemisphere task, a commonly espoused theory popular since the 1970s (e.g., Graham, 1977; MacLeod-Morgan, 1982), or that highly hypnotizable individuals exhibit greater right hemisphericity (Gur & Gur, 1974). Rather there is growing evidence (Crawford, 1994a; Crawford & Gruzelier, 1992; Gruzelier, 1988) that hypnotic phenomena selectively involve cortical and subcortical processes of either hemisphere, dependent upon the nature of the task, as well as shifts in attention and 'disattention' processes ... Thus, hypnosis instructions 'can be seen to trigger a process that alters brain functional organizationa process that at the same time is dependent on individual differences in existing functional dynamics of the central nervous system! (Crawford & Gruzelier, 1992, p. 265; Crawford, 1996, p. 254)

During the transition from the 1990s, labeled the 'Decade of the Brain,' into the twenty-first century, new discoveries about the neuropsychophysiological bases of hypnosis are being made. The excitement is high as interdisciplinary approaches address old and new questions about psychological and physiological phenomena with ever-refined electrophysiological and neuroimaging techniques. Hypnosis and its various phenomena, should have neuropsychophysiological correlates if one takes to heart a quote from Miller, Galanter and Pribram's (1960) seminal book, Plans and the Structure of Behavior: 'There is good evidence for the age-old belief that the brain has something to do with ... mind' (p. 196).

The present chapter looks back and forth between the phenomena of hypnosis and neurophysiology in a quest to help understand how and when hypnotic interventions work effectively in clinical and medical settings. (Due to limited

International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley and P. B. Bloom © 2001 John Wiley & Sons, Ltd


space, only those studies of greater relevance to this clinical handbook of hypnosis are addressed herein. The reader is referred to other reviews: Crawford, 1994a,b, 1996; Crawford & Gruzelier, 1992; Crawford, Horton, McClain-Furmanski & Vendemia, 1998; Crawford, Knebel, Vendemia & Horton, 1999; Gruzelier, 1988; Perlini & Spanos, 1991; Perlini, Spanos & Jones, 1996; Spiegel, 1991; and Spiegel & Vermutten, 1994). While hypnotic susceptibility level is sometimes considered irrelevant in a clinical context, it has been shown to be a highly relevant moderator in many clinical and neurophysiological studies and is thus considered within the chapter. It is hoped that knowledge of these neurophysiological findings will help the practicing clinician to communicate to the medical and psychological communities, as well as to the patient and his/her family, as to how hypnosis works as an important therapeutic technique in behavioral medicine and psychotherapy. Furthermore, evidence presented herein supports hypnosis being an integral part in the development of medical treatment plans for pain management.


Hypnosis involves an amplification of focused attention either towards or away from an internal or external event (e.g., Hilgard, 1965, 1986; Krippner & Bindler, 1974). Since the nineteenth century hypnotically responsive persons commonly report profound physical relaxation (for exceptions, see Banyai & Hilgard, 1976) and alterations in perception following a hypnotic induction. In this physically relaxed state, they report their experiences as being more involuntary and effortless (e.g., Bowers, 1982-83), yet, somewhat paradoxically, at the same time more intense and involving than in a nonhypnotic condition. Such paradoxical reports suggest a dissociation between awareness of attentional effort (perceived workload) and perceptual awarenesses. If we view hypnotizable persons as active and 'creative problem-solving agents' (Lynn & Sivec, 1992) who can draw upon their abilities (including absorption, imagery, giving up of reality testing and focused and sustained attention) during hypnosis, then the paradox is eliminated. Contrary to common conceptions in the clinical and experimental literature, recent EEG and cerebral metabolism research supports the view that hypnosis may take cognitive effort that demands further allocations of attention and disattention (Crawford, 1994a,b; Crawford & Gruzelier, 1992; Hilgard, 1986).


In studies of EEG brain wave activity, a robust finding is that theta power (3-7 Hz), hypothesized to be associated with focused attention (e.g., Schacter, 1977), is positively related to hypnotic susceptibility (e.g., Akpinar, Ulett & Itil, 1971;


Crawford, 1990; Galbraith, London, Leibovitz, Cooper & Hart, 1970; Graffin, Ray & Lundy, 1995; Sabourin, Cutcomb, Crawford & Pribram, 1990; Tebecis, Provins, Farnbach & Pentony, 1975; Ulett, Akpinar & Itil, 1972a,b; for review, see Crawford & Gruzelier, 1992). In a nonhypnotic state, highly hypnotizable persons (referred to as 'highs') are likely to generate more theta power than the low hypnotizable persons ('lows'). This is supportive of behavioral research that finds highs have greater extremely focused and sustained attentional abilities, as measured by the Tellegen Absorption Scale (e.g., Crawford, Brown & Moon, 1993; Tellegen & Atkinson 1974; for review, see Roche & McConkey 1990) or the Differential Attentional Processes Inventory (Crawford, Brown & Moon, 1993), and by performance measures involving attentional processing. Highs have shown superior performance on attentional tasks such as visual search (Wallace & Patterson, 1984), gestalt closure (Crawford, 1981; Wallace, 1990), reversible figures and visual illusions (e.g., Crawford, Brown & Moon, 1993, Wallace, 1986, 1988) and other attentional tasks (for review, see Crawford, 1994b).

As individuals enter into hypnosis, EEG theta power often increases, sometimes in both lows and highs. Highs continue to generate more theta than lows in various brain regions (e.g., Crawford, 1990; Graffin, Ray & Lundy, 1995; Sabourin et al., 1990). Sabourin et al. (1990) noted theta power increases in both hemispheres of frontal, cenfral and occipital regions during hypnotic induction and a subsequent series of standardized hypnotic suggestions provided by the Stanford Hypnotic Susceptibility Scale, Form C (Weitzenhoffer & Hilgard, 1962). Graffin, Ray and Lundy (1995) reported that during an induction theta power increased in the posterior areas, while during a subsequent passive hypnotic condition theta decreased for highs. Within hypnosis, Crawford (1990) found highly hypnotizable persons generated significantly more high theta (5.5-7.5 Hz) than did lows at frontal, temporal, parietal and occipital regions. Highs showed asymmetrical EEG high theta power shifts, particularly in the temporal region, during cold pressor pain when focusing on pain (left hemisphere dominant) or experiencing hypnotic analgesia (right hemisphere dominant), suggesting differential involvement of possibly the hippocampal system from which theta may be generated, particularly during vigilant conditions (e.g., Crowne, Konow, Drake & Pribram, 1972; Michel, Lehmann, Henggeler & Brandeis, 1992).

The so-called '40-Hz band' is a high frequency, low amplitude EEG rhythm centered around 40 Hz that has been found to be a covariate of focused arousal (e.g., Sheer, 1976). It appears to be from localized cortical neurons that receive thalamic afferents (Steriade, Gloor, Llonas, Lopes da Silva & Mesulam, 1990) and has 'been taken to be indicative of a mechanism linking or temporally coordinating the distributed cortical representation of stimuli' (Barlow, 1993, p. 165). Akpiner, Ulett and Ital (1971) reported more 40-50 Hz-activity during nonhypnotic rest and reaction time tasks in highs than lows. De Pascalis and Penna (1990) found highs showed greater right-hemispheric 40-Hz production during hypnosis, while lows showed reduced activity in both hemispheres. In line with the hypothesis that highs


become more deeply involved in their emotional states, highs, but not lows, showed greater 40-Hz density at both left and right parieto-occipito-temporal cortex junctions during emotional states compared to rest in both nonhypnotic (De Pascalis, Marucci, Penna & Pessa, 1987) and hypnotic (De Pascalis, Marucci & Penna, 1989) conditions. Using mean magnitude 40-Hz, Crawford, Clarke and Kitner-Triolo (1996) did not find differences between lows and highs during self-generated happy and sad emotions. Interestingly, Schnyer and Allen (1995) found highs who experienced recognition amnesia generated significantly more 40-Hz power in preinduction but not postinduction conditions than highs not experiencing recognition amnesia or lows.


High hypnotizable persons have a greater disposition for more sustained attention and deeper involvement. In addition, they appear to have greater cognitive flexibility, the ability to shift from one strategy to another and from one alternative state of consciousness to another (e.g., Crawford, 1989; Crawford & Allen, 1983; Crawford & Gruzelier, 1992). Similarly, at a neurophysiological level, highs often demonstrate greater EEG hemispheric specificity in hypnotic and nonhypnotic conditions.

MacLeod-Morgan and Lack (1982) noted highs shifted in EEG alpha power hemispheric dominance when performing analytical and nonanalytical tasks while lows did not. Greater hemispheric specificity in certain EEG frequency bands, in nonhypnosis and hypnosis conditions, among highs has been noted elsewhere (e.g., Crawford, 1989; Crawford, Clarke & Kitner-Triolo, 1996; De Pascalis & Palumbo, 1986; Meszaros & Banyai, 1978; Meszaros, Crawford, Szabo, Nagy-Kovacs & Revesz, 1989; Sabourin et al., 1990).

Hypnosis facilitates access to and involvement in emotional material and for this reason is often seen as a facilitator of hypnotherapy. Quite relevant to hypnotherapy, highs generally report more intense affect when viewing violent films (Crowson, Conroy & Chester, 1991) and experiencing positive and negative emotions (Crawford, 1989; Crawford, Clarke & Kitner-Triolo, 1996; Crawford, Kapelis & Harrison, 1995) during nonhypnotic conditions. During hypnosis, possibly due to greater focused attention and decreased generalized reality orientation, highs report enhanced intensity and vividness of emotionally laden imagery (e.g., Crawford, Clarke & Kitner-Triolo, 1996). This may help explain why hypnoprojective and abreactive techniques (e.g., Brown & Fromm, 1986; Watkins, 1993), often utilized in therapy to elicit, titrate and metabolize traumatic material, can be useful for some patients. Furthermore, it may help us understand why desensitization techniques are often facilitated by hypnosis.

At a neurophysiological level, when presented with emotional stimuli (Crawford, Kapelis & Harrison, 1995), or asked to generate emotional memories (Crawford, Clarke & Kitner-Triolo, 1996), highs show, respectively, greater visual field and


EEG hemispheric differences in both hypnotic and nonhypnotic conditions. Highs were significantly faster than lows in recognizing angry and happy affect in the discrimination of faces presented to the left or right visual field (Crawford, Kapelis & Harrison, 1995). For highs only, angry faces were identified faster when presented to the right (left visual field) than left (right visual field) hemispheres, while lows showed no significant asymmetries. During self-generated happy and sad emotions in hypnosis and nonhypnosis conditions, in comparison to lows, highs showed significantly greater hemispheric asymmetries (greater right than left) in the parietal region, in high theta, high alpha and beta activity between 16 and 25 Hz, all frequency bands that are associated with sustained attentional processing (Crawford, Clarke & Kitner-Triolo, 1996). Taken together, these two studies suggest that highs have more focused and sustained attention. Greater right parietal activity, as indicated by faster reaction times and more EEG activity, is suggestive of greater emotional arousal (e.g., Heller, 1993) and/or sustained attention among the highs.


Our work suggests that highly hypnotizable persons have more effective and flexible frontal attentional and inhibitory systems (Crawford 1994a,b; Crawford, Brown & Moon, 1993; Crawford & Gruzelier, 1992; Gruzelier & Warren, 1993). Consistent with the above discussed research showing a relationship between hypnotizability and sustained attentional processing, an intriguing neurochemical study by Spiegel and King (1992) suggests that frontal lobe activation is related to hypnotizability. In 26 male psychiatric inpatients and 7 normal male controls, levels of the dopamine metabolite homovanillic acid were assessed in the cerebrospinal fluid. While preliminary in nature, the results suggested that dopamine activity, possibly involving the frontal lobes, was necessary for hypnotic concentration.

Gruzelier and Brow (1985) found highs showed fewer orienting responses and increased habituation to relevant auditory clicks during hypnosis, suggesting increased activity in frontal inhibitory action (Gruzelier, 1990). Gruzelier and his colleagues (Gruzelier, 1990; Gruzelier, 1999; Gruzelier & Warren, 1993; for review, see Crawford & Gruzelier, 1992) proposed that during the hypnotic induction there is an engagement of the left frontal attentional system and then a significant decrease of left frontal involvement with a shift to other regions of the brain, dependent upon the hypnotic task involved. Our hypnotic analgesia work reviewed below also strongly implicates the active involvement of the frontal inhibitory processing system.


Only recently have we been able to begin to explore cortical and subcortical processes during hypnosis with neuroimaging techniques such as regional cerebral


blood flow (rCBF), positron emission tomography (PET), single photon emission computer tomography (SPECT) and functional Magnetic Resonance Imaging (fMRI).

Consistently, regional cerebral metabolism studies [unlike EEG studies reviewed above] have reported no waking differences between low and highly hypnotizable persons. A robust finding has been that highs show increases in cerebral metabolism in certain brain regions during hypnosis (for reviews, see Crawford, 1994a,b, 1996; Crawford & Gruzelier, 1992). This has been found in normally healthy (Crawford, Gur, Skolnick, Gur & Benson, 1993; De Benedittis & Longostreui, 1988; Meyer, Diehl, Ulrich & Meinig, 1989) and psychiatric (Walter, 1992; Halama, 1989, 1990) populations. Given that increased blood flow and metabolism may be associated with increased mental effort (Frith, 1991), these data suggest hypnosis may involve enhanced cognitive effort.

Among healthy individuals, De Benedittis and Longostreui (1988) found highs but not lows showed increases in brain metabolism during hypnosis. Using the xenon inhalation method, Crawford, Gur et al. (1993) found substantial increases in rCBF during hypnosis (rest; ischemic pain with and without suggested analgesia) in highs but not lows. During rest while reviewing past memories of a trip taken, fCBF enhancements in the anterior, parietal, temporal and temporo-posterior regions ranged from 13 to 28%, with the largest being in the bilateral temporal area in highs (unpublished data). Among hypnotically responsive individuals, Meyer et al. (1989) found global increases of rCBF in both hemispheres during hypnotically suggested arm levitation. An additional activation of the temporal centers was observed during acoustic attention. Under hypnotically narrowed consciousness focus, there was 'an unexplained deactivation of inferior temporal areas' (p. 48). Discussed in greater detail below, Crawford, Gur et al. (1993) found further rCBF enhancements of orbito-frontal and somatosensory regions during hypnotic analgesia among highs only.

Within a psychiatric population (16 neurotic, 1 epileptic) using SPECT, Halama (1989) reported a global blood flow increase during hypnosis, with those more deeply hypnotizable showing greater CBF increases than the less hypnotically responsive. During hypnosis 'a cortical "frontalization," takes place particularly in the right hemisphere and in higher areas (7 cm above the meato-orbito-level) more than in the deeper ones (4 cm above the meato-orbital-level)' (p. 19). Frontal region increases included the gyrus frontal, medial and inferior, as well as the superior and precentral gyrus regions. These are suggestive of greater involvement of the frontal attentional system during hypnosis. By contrast, there was a significant decrease in brain metabolism in the left hemisphere in the gyrus temporalis and inferior region, as well as in Brodmann areas (BA) 39 and 40.

Hypnotic instructions (i.e., inductions and suggestions) trigger a process that alters brain functional organization, a process that is moderated by hypnotic susceptibility level. No longer can we hypothesize hypnosis to be a right-hemisphere task, a commonly espoused theory popular since the 1970s (e.g.,


Graham, 1977; MacLeod-Morgan, 1982). The studies reviewed here suggest that hypnosis is much more dynamic, activating differentially regions in either the left or right hemispheres, or both hemispheres dependent upon the attentional, perceptual and cognitive processes involved. Since pain management is perhaps the most dramatic and clinically useful application of hypnosis, the neurophysiological evidence for hypnotic analgesia effects are examined in greater detail in the following section.


Hypnosis is one of the best documented behavioral interventions for controlling acute and chronic pain in adults and children (for reviews, see Barber & Adrian, 1982; Chaves, 1989, 1994; Crawford, 1994a, 1995a,b; Crawford, Knebel & Vendemia, 1998; Crawford, Knebel, Vendemia, Horton & Lamas, 1999; Evans, 1987; Evans & Rose, chapters 18a, 18b this volume; Ewin, chapter 19 this volume; Gardner & Olness, 1981; Hilgard & Hilgard, 1994; J. R. Hilgard & LeBaron, 1984). The reader is referred to two special issues (October 1997; January 1998) on 'Hypnosis in the Relief of Pain' in the International Journal of Clinical and Experimental Hypnosis (Chaves, Perry & Frankel, 1997, 1998). This section will address: (a) recent advances in the understanding of the neurophysiology of pain relevant to our understanding the effectiveness of hypnotic analgesia interventions; and (b) neurophysiological studies of hypnotic analgesia.

Pain is a mulitidimensional and multifaceted experience. Several models of pain processing (e.g., Melzack, 1992; Pribram, 1991; Price, 1988) differentiate between the sensory and affective aspects of pain. While the role of subcortical processes is well known, only recently have we begun to appreciate the role of the cerebral cortex in pain perception. Findings from PET (Casey, Minoshima, Berger, Koeppe, Morrow & Frey, 1994; Jones, Brown, Friston, Qi & Frackowiak, 1991; Talbot, Marrett, Evans, Meyer, Bushnell & Duncan, 1991), SPECT (Apkarian, Stea, Manglos, Szeverenyi, King & Thomas, 1992; Stea & Apkarian, 1992) & fMRI (Downs, Crawford et al., 1998; Crawford, Horton et al., 1998; Davis, Wood, Crawley & Mikulis, 1995; Davis, Taylor, Crawley, Wood & Mikulis, 1997) studies using painful heat or cold stimuli, have identified cortical and subcortical brain regions which seem likely to be involved in affective and sensory processing of pain.

Magnetoencephalographic (MEG) studies of electrical tooth stimulation (Hari, Kaukoranta, Reinikainen, Huopaniemie & Mauno, 1983) and electric finger shock (Howland, Wakai, Mjaanes, Balog & Cleeland, 1995) point to involvement of several cortical regions: SI and SII regions traditionally associated with somatosen-sory processing, as well as frontal (frontal operculum) and parietal (posterior insula) regions associated with affective processing. Bromm and Chen (1995), using the brain electrical source analysis program with 31 EEG leads, found laser


evoked potentials in response to painful trigeminal nerve stimulation to have several generators: bilaterally in the secondary somatosensory areas of the trigeminal nerve system, in the frontal cortex probably related to attention and arousal processes & in a more central region (e.g., cingular gyrus) probably associated with perceptual activation and cognitive information processing.

Our first fMRI research (Downs et al., 1998) using stimulation of the left middle finger with a painful electrical stimulation found all participants showed activation of primary somatosensory SI either unilaterally or bilaterally, supplementary motor area bilaterally and primary motor area bilaterally or right only. Posterocentral activation occurred inconsistently. Unilateral or bilateral activation occurred in superior and inferior parietal areas, precuneus and dorsolateral frontal cortex. Frontal pole activation was visible in some. All showed unilateral or bilateral activation in the cingulate cortex, although specific areas differed. Anterior and/or posterior insular, as well as thalamic, activity was observed in some participants. Thus, like prior research, we found a widespread neuronal network involving evaluative and sensory-discriminative pain was activated.

The anterior frontal cortex is known to gate or inhibit somatosensory input, operating at early stages of sensory processing on both cortical and subcortical structures, from 'the periphery through dorsal column nuclei and thalamus to the sensory cortex' (Yamaguchi & Knight, 1990, p. 281). Thus, the frontal region is a prime candidate to become involved during disattention and active inhibition of pain during successful hypnotic analgesia. Studies of dynamic changes in regional cerebral blood flow, EEG activity, somatosensory event-related potentials and even peripheral reflexes during hypnotic analgesia lend credence to the hypothesis that the frontal attention system is actively involved in the inhibition of incoming somatosensory information coming from the pain source during hypnotic analgesia and works by way of its connections with the thalamus and possibly other brain structures to regulate the perception of the intensity of pain (e.g., Crawford, 1994a,b; Crawford, Gur et al., 1993; Crawford, Knebel et al., 1996, 1997).

Using the 133-xenon inhalation method during attention and hypnotic analgesia to ischemic pain applied to the arms, Crawford, Gur et al. (1993) found different rCBF activation patterns in low and high hypnotizable subjects. Using the sub-tractive technique, only highs showed further substantial increases in rCBF in the anterior frontal orbito-frontal and somatosensory regions during successful hypnotic analgesia. This was interpreted as being supportive of the view that hypnotic analgesia involves the supervisory, attentional control system (Hilgard, 1986) of the anterior frontal cortex in a topographically specific inhibitory feedback circuit that cooperates in the regulation of thalamocortical activities (e.g., Birbaumer, Elbert, Canavan & Rockstroh, 1990). It also suggests that mental effort occurred during the inhibition of painful stimuli. Thus, hypnotic analgesia and dissociation from pain requires higher cognitive processing and mental effort—and the involvement of the frontal attentional system.

Further research employing fMRI, PET and SPECT neuroimaging techniques


will permit us to understand how hypnotic analgesia affects both cortical and subcortical processes. For instance, the first fMRI study (Crawford et al., 1998; Crawford, Horton, Harrington, Hirsh-Downs, Fox, Daugherty & Downs, 2000) that examined hypnotic analgesia in highly hypnotizable individuals showed dramatic activation shifts between attend and hypnotic analgesia in response to noxious stimuli presented to the left middle finger. In the cingulate cortex, there was bilateral or right hemisphere activation during attend, whereas in hypnotic analgesia only left hemisphere activation remained. Among other findings, we also observed reductions of insular and shifts in thalamic activity during hypnotic analgesia.

Human pain responses have been successfully studied through the analysis of brain somatosensory event-related potentials (SEPs). Hypnotically suggested analgesia results in significant decreases in the later SEP components (100 msec or later after stimulus) at certain scalp leads using painful electrical (e.g., Crawford, 1994a; Crawford, Clarke & Kitner-Triolo, 1996; De Pascalis, Crawford & Marucci, 1992; Meszaros, Banyai & Greguss, 1978; Spiegel, Bierre & Rootenberg, 1989; but see Meier, Klucken, Soyka & Bromm, 1993), laser heat (e.g., Arendt-Nielsen, Zachariae & Bjerring, 1990; Zacharie & Bjerring, 1994) or tooth pulp (Sharav & Tal, 1989) stimulation. Earlier studies, often plagued by methodological flaws, provide mixed evidence (for reviews, see Crawford & Gruzelier, 1992; Spiegel, Bierre & Rootenberg, 1989).

Multiple intracranial electrodes temporarily implanted in the anterior cingulate cortex, amygdala, temporal cortex and parietal cortex of two patients undergoing evaluation and treatment of obsessive-compulsive disorder permitted Kropotov, Crawford & Polyakov (1997) to conduct a unique evaluation of pain processes. We investigated changes in SEPs accompanying electrical stimulations to the right finger during conditions of attention and hypnotically suggested analgesia. Only in the hypnotically responsive patient was reduced pain perception during suggested hypnotic analgesia accompanied by a significant reduction of the positive SEP component within the range of 120-140 msec. In the left anterior temporal cortex, a significant enhancement of the negative SEP component in the range of 210-260 msec was observed. Enhancement of the N200 component is thought to be indicative of increased active and controlled inhibitory processing. No significant changes were observed at the amygdala or at Fz. Rainville, Duncan, Price, Carrier and Busline 11 (1997), using hypnotically suggested reduction of affective but sensory pain to cold pressor pain during PET recordings, reported a relationship between the degree of affective pain experienced and activation of the anterior cingulate cortex. Considered together, Crawford et al. (1998), Kropotov et al. (1997) and Rainville et al. (1997) demonstrate changes in the activation of the anterior cingulate during hypnotic analgesia, a region known to show increased activation during attention to pain (e.g., Bromm & Chen, 1995; Jones etal., 1991; Talbotetal., 1991).

In our laboratory, we evaluated SEPs in two populations: (a) normal college undergraduates who were either low or 'virtuoso' highs, the latter of whom could


completely eliminate all perception of pain or distress during cold pressor pain training with hypnotic analgesia (Crawford, 1995b; Crawford et al., 1996, 1997; in preparation); and (b) adults with enduring chronic low back pain who, as a group, were able to reduce their pain by 90% in cold pressor training with hypnotic analgesia (Crawford, Knebel, Kaplan et al., 1998). After training with cold pressor pain, subjects returned the next week for the SEP study. Blocks of 30 electrical stimuli were delivered to the left middle finger, the intensity of which was titrated to each subject to be rated as strongly painful but bearable (7-8 on 0-10 point scale). During hypnosis, an A-B-A design was employed: (a) normally attend to stimuli; (b) hypnotically suggested analgesia; and (c) normally attend to stimuli.

Among the college students, highs had a significantly higher P70 in the right anterior frontal (Fpl) and parietal regions during attend, yet during hypnotic analgesia there was a dramatic reduction of P70 only at the right anterior frontal region. During hypnotic analgesia, only highs showed significant reductions of P200 in central and parietal regions & of P300 in the central region. The N140 and N250, both possibly reflective of greater inhibitory processing, were enhanced during hypnotic analgesia.

The participants with chronic low back pain showed significant reductions in P200 (bilateral midfrontal and central and left parietal regions) and P300 (right midfrontal and central regions) during hypnotic analgesia. Furthermore, hypothesized inhibitory processing was evidenced by enhanced N140 in the anterior frontal region and by a pre-stimulus positive-ongoing contingent cortical potential at left anterior frontal (Fpl) region only during hypnotic analgesia. These findings suggest that two pain processes are affected by hypnotic analgesia: one dealing with the allocation of attention to pain (frontal attention system) and one dealing with the perception of the intensity of pain (frontal attention system working via connections with the thalamus and possibly other cortical and subcortical regions).

Furthermore, of particular relevance to clinicians, we documented the development of self-efficacy through the successful transfer of the newly learned skills of experimental pain reduction to the reduction of the participant's own chronic pain (Crawford, Knebel et al., 1998). Over three experimental sessions, they reported significant reductions of experienced chronic pain, increased psychological well-being and increased sleep quality. We argue that 'the development of "neurosigna-tures of pain" can influence subsequent pain experiences (Coderre, Katz, Vaccarino & Melzack, 1993; Melzack, 1993) and may be expanded in size and easily reactivated (Flor & Birbaumer, 1994; Melzack, 1991, 1993). Therefore, hypnosis and other psychological interventions need to be introduced early as adjuncts in medical treatments for onset-pain before the development of chronic pain' (p. 92).

In a patient undergoing dental surgery with hypnosis as the sole anesthetic, Chen, Dworkin and Bloomquist (1981) found total EEG power decreased with a greater diminution in the left hemisphere in alpha and theta EEG bands. Karlin, Morgan and Goldstein (1980) reported hemispheric shifts in total EEG power during hypnotic analgesia to cold pressor pain that were interpreted as greater


overall right hemisphere involvement at the bipolar parieto-occipital derivation. In an EEG study of cold pressor pain, with and without hypnotic analgesia, Crawford (1990) found hemispheric shifts in theta power production during hypnotic analgesia only among highs, while lows showed no hemispheric asymmetries. In the temporal region the highs were significantly more left hemisphere dominant during the pain dip while concentrating on the pain, but during hypnotic analgesia there was a shift to right hemisphere theta power dominance. This was interpreted as further evidence for the involvement of the frontal attentional system and possibly the hippocampal region during pain inhibition (Crawford, 1990; 1994a,b).

Typically there is continuing autonomic reactivity (increases in galvanic skin responses, blood pressure and pulse) to acute pain during hypnotic analgesia, although some exceptions have been noted in well-trained, highly hypnotizable persons (Hilgard & Hilgard, 1994). Dynamic pupillary measurements revealed that the reduction of pain through hypnotic suggestions was accompanied by an autonomic deactivation (Grunberger, Linzmayer, Walter et al., 1995).

Biochemical studies of hypnotic analgesia are thus far very limited, but encouraging. The role of endorphins in hypnotic analgesia has been explored since these endogenous substances were implicated in analgesia effects produced by acupuncture (e.g., Kisser et al., 1983) and placebo (Grevert, Albert & Goldstein, 1983). The opiate antagonist naloxone typically does not reverse hypnotic alleviation of chronic (Spiegel & Albert, 1983) or acute (Goldstein & Hilgard, 1975; Joubert & van Os, 1989; Moret, Forster, Laverriere et al., 1991) pain. Yet, Stevenson (1978) reported such a reversal in a single subject and Hilgard (personal communication, 1976) observed a reversal in a pilot subject. Only under conditions of environmental stress did Frid and Singer (1980) find naloxone could significantly reverse hypnotic analgesia levels.

Preliminary research (e.g., Domangue, Margolis, Lieberman & Kaji, 1985; Sternbach, 1982) suggests other neurochemical processes may be involved in hypnosis. Arthritic patients who reported significant reductions in pain after hypnoanalgesia showed significant posttreatment enhancement of the mean plasma level of beta-endorphin-immunoreactivity but no changes in plasma levels of epinephrine, dopamine or serotonin (Domangue et al., 1985). There is recent neurophysiological evidence that some descending inhibitory control systems are responsive to naloxone while others are not. Noradrenaline, acetylcholine and dopamine are non-opioid transmitters that are involved in analgesia and possibly hypnotic analgesia. Which of these non-opioid transmitters and descending inhibitory systems may be affected by hypnotic analgesia is worthy of investigation.

At the peripheral nervous system, the effect of hypnosis per se and hypnotic analgesia on reflex activity has been considered. Motor-neuron excitability, as measured by the Hoffman reflex amplitude of the soleus muscle, was decreased significantly during hypnosis in high but not low hypnotizables, yet manipulations of suggested analgesia or paralysis had no further effect (Santarcangelo, Busse & Carli,   1989).   Kiernan,  Dane,  Phillips  and Price  (1995)  found that hypnotic


analgesia can reduce the R-III nociceptive reflex, which implicates inhibitory processes at the spinal level.

In summary, evidence is strong that the more highly hypnotizable persons possess stronger attentional filtering and inhibitory abilities that are associated with the frontal attention system. The importance of the anterior frontal attention system in the control of pain is supported by independent studies of EEG, evoked potentials, and cerebral metabolism. Regional cerebral blood flow increases found in the orbito-frontal and somatosensory cortical regions suggested cognitive activity of an inhibitory nature (Crawford, Gur et al., 1993). Active inhibition involves both a search and subsequent ignoring of irrelevant stimuli (Crowne et al., 1972). Changes in the involvement of the anterior cingulate cortex (Kropotov, Crawford & Polyakov, 1997; Rainville et al., 1997) and decreases in P70 mean amplitude in the right anterior frontal region suggest a change in the allocation of attention during hypnotic analgesia (Crawford, Clarke & Kitner-Triolo, 1996). Furthermore, if we view the human body as a feedback loop, as electrical engineers do, then it is not surprising that hypnotic interventions can even affect peripheral reflex activity (e.g., Kiernan et al., 1995). While we hypothesize the frontal attention system can work by way of its connections with the thalamus and other brain structures to regulate the perception of the intensity of pain (Crawford, Clarke & Kitner-Triolo, 1996), this has yet to be demonstrated fully. Our recent fMRI research (Crawford et al., 1998) certainly found shifts in thalamic, insular and other brain structure activity. Future neuroimaging and neurochemical studies will greatly contribute to our expanded knowledge of how hypnotic analgesia is so effective as a behavioral intervention for acute and chronic pain.


In light of current interest in psychoneuroimmunology and mind-body connections, a somewhat neglected area of hypnotherapy research of major theoretical and practical interest is the underlying neurophysiological processes that might mediate hypnosis in its contribution to immunomodulation. Interpretation of earlier research is hindered by methodological shortcomings; these shortcomings are now being addressed and overcome with the most recent wave of research. It is suggested that the reduction of stress, enhancement of positive emotional states and enhanced imaginal processing that often occur during clinical applications of hypnosis may be contributing factors. Spiegel (1993) suggests that self-hypnosis may enhance feelings of control which, in turn, produce reduced pain and increased immune functioning for highly hypnotizable individuals and, perhaps, lows as well. Whether physiological reactivity, hypnotic responsiveness, mood state, or some other factor mediates these hypothesized connections between hypnosis and immunomodulation needs further investigation.

A review of the literature (Laidlaw, Richardson, Booth & Large, 1994) points out


that the combination of hypnosis and skin reactivity has been investigated for over 50 years, first beginning with work by Clarkson (1937), Zeller (1944) and the early studies by Black and Mason in England (e.g., Black, 1963a,b, 1969; Black, Humphrey & Niven, 1963; Mason & Black, 1958) and continuing to a resurgence of interest in the past 10 years (e.g., Laidlaw, Booth & Large, 1994, 1996; Laidlaw, Large & Booth, 1997; Laidlaw, Richardson, Booth & Large, 1994; Zacharie & Bjerring, 1993; Zachariae, Bjerring & Arendt-Nielsen, 1989). The Mantoux reaction to tuberculin was inhibited by highly hypnotizable subjects who were Man-toux-positive (Black, Humphrey & Niven, 1963; Zachariae, Bjerring & Arendt-Nielsen, 1989), yet two other studies (Beahrs, Harris & Hilgard, 1970; Locke, Ransil, Covino et al., 1987) were unable to replicate. Asthmatic patients reduced reactions to histamine more so in hypnosis than nonhypnosis conditions (Laidlaw et al., 1994). Further work from New Zealand found that subjects given hypnotic suggestions were able to decrease their reactivity to histamine reactions (Laidlaw, Booth & Large, 1996) and allergen reactions (Laidlaw, Large & Booth, 1997). Those who produced the largest effects tended to be more hypnotizable (Laidlaw, Large & Booth, 1997). Of great interest is that mood was an important correlate: low irritability rating was associated with smaller wheals (Laidlaw, Booth & Large, 1994, 1996). Hypnotic treatment of warts was found to be more successful than topical medication or placebo medication (e.g., Spanos, Williams & Gwynn, 1990). Beyond the space of this chapter are other important physiological changes accompanying waking and hypnotic suggestions that are worthy of further investigation. Suggestions of cooling and imagery have assisted burn patients, particularly those who were noted to image well, within hours of the burn incident (Margolis, Domangue, Ehleben & Shrier, 1983; for a review, see Patterson, Adcock & Bombardier, 1997). Suggestions have led to reduced blood loss in spinal (Bennett, Benson & Kuiken, 1986) and maxillofacial (Enqvist, von Konow & Bystedt, 1995) surgery patients, possibly because of the reduced anxiety and lowered blood pressure accompanying the suggestions. Suggestions have enhanced blood clotting in severe hemophilia (Swirsky-Sacchetti & Margolis, 1986). Increased blood volume was increased in Raynaud's disease (Conn & Mott, 1984). Hypnosis in the successful treatment of asthma has been demonstrated (e.g., Collison, 1975; Ewer & Stewart, 1986). The possible effect of hypnosis on T and B cell functioning, neutrophil adhesiveness and other immunological factors may have important implications for cancer and the psychology of healing (e.g., Hall, 1982-83, Hall, Minnes, Tosi & Olness, 1992; Hall, Mumma, Longo & Dixon, 1992; Ruzyla-Smith, Barabasz, Barabasz & Warner, 1995).


Hypnosis has been shown to be a viable adjunct, alone or combined with other psychological interventions, for the treatment of a number of physiological and


psychological disorders. Experimental evidence shows that more highly hypnotiz-able persons have greater cognitive and physiological flexibility than do lows (e.g., Crawford, 1989). Highs shift more easily from detail to holistic strategies (e.g., Crawford & Allen, 1983), from left to right anterior functioning as demonstrated by neuropsychological tests (e.g., Gruzelier & Warren, 1993) and from one state of awareness to another. Evidence was reviewed that these cognitive strategy shifts are evidenced by greater neurophysiological hemispheric specificity or dominance across tasks, as seen in EEG and visual field studies.

EEG, evoked potential and neuroimaging (pET, SPECT, rCBF, fMRI) data provide evidence that hypnotic phenomena selectively involve cortical and subcor-tical processes of either hemisphere, dependent upon the nature of the task. No longer can one call hypnosis a right hemisphere task. The more highly hypnotizable persons appear to possess stronger attentional filtering and inhibitory abilities that may be associated with the frontal attentional system. Dissociated control during hypnosis, such as that seen in hypnotic analgesia for pain, requires higher order cognitive and attentional effort, as evidenced by shifts in EEG theta power (e.g., Crawford, 1990) and increased cerebral metabolism in neuroimaging studies (e.g., Crawford, Gur et al., 1993; Halama, 1989). The lack of perceived control and a decreased self-concept (Kunzendorf, 1989-90) does not negate processes still occurring that involve higher cognitive processing and the executive control system.

Brain research is validating and extending clinical and experimental observations of hypnotic phenomena. It is demonstrating that 'There is good evidence for the age-old belief that the brain has something to do with ... mind' (Miller, Galanter & Pribram, 1960, p. 196). This knowledge will help us communicate to the medical and psychological communities, as well as the patient and family, why and how hypnosis is such an important therapeutic technique in behavioral medicine and psychotherapy.


To my many clinical colleagues, your informal discussions at meetings and excellent case studies and experimental clinical intervention studies are much appreciated. From you I learned to appreciate the intricacies of hypnotic interventions and was alerted to clinical phenomena and issues that could be investigated in the laboratory. Research reported herein was supported by the National Institutes of Health (1 R21 RR09598), The Spencer Foundation, National Institutes of Health Biomedical Research Support grants and intramural grants from Virginia Polytechnic Institute and State University and the University of Wyoming to the author.


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attention-specific cognitive tasks. J. Personal. Soc. Psychol., 47, 175-181. Walter,  H.   (1992).   Hypnose:   Theorien,   neurophysiologische Korrelate  und praktische

Hinweise zur Hypnosetherapie [Hypnosis: Theoreis, neurophysiological correlations and

practical tips regarding hypnotherapy]. Stuttgart, Germany: Georg Thieme Verlag. Watkins, J. G. (1993). Hypnoanalytic Techniques: The Practice of Clinical Hypnosis, Vol. 2.

New York: Irvington Publishers. Weitzenhoffer, A. M. & Hilgard, E. R. (1962). Stanford Hypnotic Susceptibility Scale, Form

C. Palo Alto, CA: Consulting Psychologists Press. Yamaguchi, S. & Knight, R. T. (1990). Gating of somatosensory input by human prefrontal

cortex. Brain Res., 521, 281-288. Zachariae, R. & Bjerring, P. (1993). Increase and decrease of delayed cutaneous reactions

obtained by hypnotic suggestions during sensitization. Studies on dinitrochlorobenzene

and diphenylcyclopropenone. Allergy, 48, 6-11. Zachariae, R. & Bjerring, P. (1994). Laser-induced pain-related brain potentials and sensory

pain ratings  in high and low hypnotizable  subjects during hypnotic  suggestions of

relaxation, dissociated imagery, focused analgesia & placebo. Int. J. Clin. Exp. Hypn., 42,

56-80. Zachariae, R., Bjerring, P. & Arendt-Nielsen, L. (1989). Modulation of Type I and Type IV

delayed immunoreactivity using direct suggestion and guided imagery during hypnosis.

Allergy, 44, 537-542. Zeller, M. (1944). The influence of hypnosis on passive transfer and skin tests. Ann. Allergy,


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Copyright © 2001 John Wiley & Sons Ltd

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The Psychotherapies



International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley, P. B. Bloom

Copyright © 2001 John Wiley & Sons Ltd

ISBNs: 0-471-97009-3 (Hardback); 0-470-84640-2 (Electronic)

Injunctive Communication and Relational Dynamics: An Interactional Perspective


Milton H. Erickson Foundation, Phoenix, AZ, USA

Erickson's therapeutic communication relied heavily on indirection to guide his patient's associations. Employing his multilevel interspersal technique, Erickson (1966) could, on one level, speak about common everyday phenomena—the growth of a tomato plant from a seed—while on another, indirectly intersperse suggestions about controlling discomfort. These covert messages were meant to stimulate enough memories and associations of experiential learnings to 'drive' more effective patient behavior.

This ideodynamic effect, whereby associations drive behavior, is well known to practitioners of hypnosis. All of us have experienced ideodynamic activity in our everyday lives, such as when we find ourselves salivating while someone describes an especially tantalizing meal or dish. Eliciting ideodynamic effects is one of the hypnotherapist's key tasks. Erickson used multilevel communication, both within and outside trance, to stimulate constructive associations that could generate, through the patient's own initiative, more desirable behavior.


A number of theorists have contributed to our understanding of multilevel communication. Bateson (Bateson & Ruesch, 1951) led the way with his identification of the dual nature of all communication. He postulated that all messages contain a report and a command. Even as information is transmitted (the report), a simultaneous, but covert, message is relayed, 'Do something with this information!' This command can take the form of a subtle imperative, for example 'Learn!, Appreciate!, Utilize!, or Move Closer!'

Berne (1966), in developing Transactional Analysis, argued that every communication consists of a social level and a psychological level. A cliche example of

International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley and P. B. Bloom © 2001 John Wiley & Sons, Ltd


this is the Lothario who says, 'Come up and see my etchings.' The social level appears to be a straightforward interest in fine art: the psychological level of this communication suggests something else entirely. For Berne, the outcome of communication was determined on the psychological level.

Chomsky (Bandler & Grinder, 1975) offered still another variation on communication dualities, suggesting that every communication has both a surface structure and a deep structure. Often, multiple transformations of surface structure can share the same underlying deep structure. It is the task of the receiver to decipher deep structure.

Finally, Watzlawick (1985) posited that communication is both indicative and injunctive, consisting of both denotation and connotation. He maintained that the injunctive aspect of communication promotes change. It is this prospect that Ericksonian therapists find most intriguing and pertinent to their work.


Erickson was a master of injunctive language. In fact, his style of therapy, and especially hypnosis, can be characterized as building responsiveness to injunctive communication. Applying Watzlawick's ideas to Erickson's work affords a useful insight into the mechanisms activated in a typical induction. A good illustration of this is Erickson's well-known early learning set induction (Erickson & Rossi, 1979). A close reading of the induction reveals an indicative level (how a child learns to write the alphabet), and an injunctive level (Erickson's implied instructions about hypnosis directed to the patient). Table 6.1 illustrates this.

The reader should note that in Table 6.1, the message sent is not necessarily the message received. Influence communication should be judged by the response it elicits, not by the cleverness of its structure. In his inductions, Erickson worked to develop responses to injunction. If the patient did not respond to his alembicated methods, he would modify his technique to promote that responsiveness.

Let's consider the covert messages contained in the early learning set induction to which the recipient could respond. The overall injunction, 'Go into a trance!' is presented nonverbally. Erickson offered this injunction by changing the locus and tone of his voice. When speaking to the floor in a 'hypnotic' style, Erickson indicated, 'The time for trance is now!' The allusion to the difficulty in learning to write is a parallel communication in which the patient could associate the difficulty of learning to write with perceived difficulty in achieving trance. At one time, learning to write was difficult; now it is second nature. In parallel, the same can be true of trance.

Questioning whether the child dotted the 't' or crossed the 'i' can confuse the patient. Confusion is part of every hypnosis induction (Haley, 1963), and is used to depotentiate conscious sets (Erickson & Rossi, 1979).

When Erickson queried, 'How many bumps are there in an "n" and an "m"?' he



Table 6.1    The early learning set induction

Indicative level

 Injunctive level

Hypnosis may seem difficult at first, but it will become second nature!



Erickson looks to the floor, softens his      1.    Go into trance!
voice, and slows his tempo.

'I am going to remind you of something   2.    Remember!
that happened a long time ago ...'

'... when you first learned to write the
letters of the alphabet, it was an awfully
difficult task ...'

'Did you dot the "t" and cross the "i"?'   4.

'How many bumps are there in an "n"      5.
and an "m"?'

'Although you didn't realize it, slowly       6.
and gradually you formed mental images
of those letters that were stored
somewhere in your brain cells and stored
there permanently.'

'And while I have been talking with you,  7.
your pulse rate has changed, your blood
pressure has changed, your motor tone

has changed ...'

 Be confused!

Be absorbed in the memory! The order of things may be unexpected and confusing!

You will have permanent unconscious learnings as a result of this experience! Visualize!

You are responding correctly! You are demonstrating hypnotic patterns!

elegantly changed the injunction from 'Remember!' to 'Be absorbed in memory!' This was accomplished by the subtle shift in tense from past to present. Initially, he talked about the past, for example 'It was a difficult task' and 'Did you dot the "t" ...?' Abruptly, he began speaking in the present, 'How many bumps are there ...?' as if the patient were reliving the childhood learning process. Subsequent injunctions covertly remind the patient that hypnotic learning can be gradual but permanent in a manner similar to learning to write. The patient is also encouraged to develop visual images.

Next, Erickson ratified the occurrence of physiological changes, thereby confirming the patient's ability to experience trance and hypnotic effects. Ratification is the process of reflecting back in simple declarative sentences the changes that occur as the patient becomes absorbed in the induction, for example, 'While I've been talking to you your pulse rate has changed ...' The injunction to the patient is 'You're responding!,' 'You're responding correctly!,' 'You are demonstrating hypnotic patterns!'

Please note that the above injunctions are deliberately written with exclamation points rather than as statements or questions. By their very nature, injunctions are subtle imperatives. The deliberate use of injunctions parallels the patient complaint, because patients customarily tell their stories to therapists with both overt


and covert exclamation points, for example 'I am depressed! Relieve my problem! I am helpless!' By communicating with imperatives through indirect injunctions, the therapist fights fire with fire. A primary injunction that should be communicated to all patients is, 'You can find within the resource you need to change or cope!' (For more information about the grammar of change, see Zeig, 1988a.)

Merely presenting injunctions is not therapy. The therapist must first elicit and build responsiveness to offered injunctions. For instance, in attempting to produce an arm levitation during trance, the therapist might enjoin the patient, 'Lift your arm.' But, even if the patient responds, this is no guarantee that hypnosis has occurred. On the other hand, if the therapist says to the patient, 'I want you to realise in a way that is handy, that hypnosis is an uplifting experience, in a way that is right for you,' and the patient lifts her or his right hand in a dissociated manner, the injunction has been understood and accepted. Because of the dissociated response garnered by the use of injunctive communication, the existence of hypnotic responsiveness can be surmised. The therapist's words and data do not so much promote therapeutic change, as does the patient's ability to hear and respond to what the therapist has said indirectly (Zeig, 1985a).

Hypnotic induction is essentially the elicitation of dissociative responsiveness to injunctions (Zeig, 1988b). During induction, the therapist maximally builds the patient's response to injunction. Once the patient consistently responds to injunction, the patient in effect communicates to the therapist, 'Okay, I am open to your influence.' At this point, the door to the constructive unconscious is unlocked and the treatment phase can begin. Subsequent hypnotherapeutic injunctions access the resources of the constructive unconscious (Zeig, 1985a, 1988b). Once responsiveness to injunction is developed by the hypnotic induction, then injunction-rich therapeutic communication can be used to help patients elicit constructive associations that 'drive' more effective behavior.

Injunctions per se are not therapeutic. Again, while the structure of injunctions may be interesting, it is the response to the injunction that must be elicited during induction before hypnotherapy can begin. The more responsiveness to injunction which can be established, the more effective the therapy. As I have previously argued, 'The success of hypnotherapy in general is proportional to the degree of responsiveness to minimal cues (injunctions) developed within the patient' (Zeig, 1988b, p. 358).

Communications not only contain underlying injunctions, they also possess a covert message about relationships.


Building on Bateson's work, Watzlawick, Beavin & Jackson (1967) defined how interactions tend to follow one of two patterns: symmetry or complementarity. 'Symmetric  interaction is characterized by equality and the minimisation of


difference. Potential pathologies can be seen as an escalation in symmetry and/or rigidity in complementarity. In a complementary relationship, one participant is in the superior or "one-up" position, and the other is in corresponding "one-down" position' (pp. 68-70). Since complementary relationships are far more common than symmetric, I will describe them first.


According to Haley (1963), a complementary relationship involves two people exchanging different types of behaviors. 'One gives and the other receives. One teaches and the other learns' (p. 111). One-up people take charge, making decisions based on their own, internal preferences. One-down people, on the other hand, monitor their environment for cues before acting. They base their decision on external information, often responding to the overt and covert directions of the one-up individual. The observable manifestations of these traits include the steadier eye contact and bolder stance of the one-up individual, in contrast to the more tentative mannerisms of the one-down individual.

Essentially, the one-up person controls and defines the relationship. The implicit injunction of the interaction is: 'I will determine the direction that the relationship takes ... In this relationship, we will have fun (learn/be intimate/etc.)!' The one-down person responds to the demands of the injunction.

Ideally, one takes either role depending on circumstances: flexibility is beneficial to a socially effective existence. For instance, a school teacher may assume a one-up position in the classroom during the day, but unconsciously switch to a one-down posture when taking a night course in a new subject.

We are not specifically taught this swing from one role to another. Neither do we customarily discuss or negotiate which position in the relationship we will assume. Rather, we automatically adopt one position or the other, entering into an unspoken interpersonal contract that is determined within seconds of an encounter. Couples quickly settle into complementary roles, but they can alter their roles depending on context. One partner, for instance, might be generally one-up in the social sphere, while the other may take command in financial matters. Complementary roles tend to be relatively stable, although they can be modified by circumstances.

A person's inability to flexibly assume either one-up or one-down roles dependent on the contextual demands can pose difficulties for that individual, particularly if the individual has the habit of rigidly assuming one role under all circumstances. When an individual insists on maintaining a particular position, change can be impeded or even impossible to achieve. Telling a one-up person that he or she is inflexibly one-up is usually ineffective in bringing about change. Most rigidly one-up individuals have developed skillful manoeuvers for parrying overt challenges to their position.

Conversely, some people insist on being one-down, presenting themselves as


long-suffering victims of exaggerated shortcomings or the insensitivities of others. Notice the underlying dynamics in this hypothetical exchange:

grandson:    Grandma, how are you doing?

grandma: Oh, I'm lonely.

grandson:    Why don't you go out and meet some people?

grandma: Oh, my bones ache and it's too far to walk down the stairs.

grandson:    Why don't you call some people and have them come over?

grandma:    I would, but the house is such a mess and I don't have the energy to clean it up.

grandson:    Why don't you call people and just talk on the phone? grandma:    I would, but I can't hear too well. Why bother?

While Grandma presents herself in a clearly one-down role, she is, however, controlling and defining the relationship in much the same way as a one-up person might. Bateson described this position as metacomplementary (Haley, 1963). A metacomplementary bind occurs when a person goes one-down in order to get one-up. It is a bind because these individuals do not experience themselves as one-up. All symptoms are to some extent metacomplementary binds. In traditional psychiatric nomenclature, this process is known as 'secondary gain.'

As is true in the one-up situation, discussing secondary gain with the patient does not seem to produce therapeutic change. During a graduate school internship, I treated a woman who was afraid of venturing into stores. Her fear put her one-down, but because her condition prevented her from doing the family shopping, a task her husband had to assume, she gained a measure of control in her marital relationship, and on this issue at least, she was the defining partner. When I confronted her about secondary gain, she replied, 'I don't want control. I just want to be able to shop.'

The one-up person not only controls and defines the relationship, but also induces roles in the one-down person which can be functional or maladaptive. The permitted roles for the one-down person could include martyr or helper, being stupid or ineffective. By assuming the one-up position, the clinician can direct therapy and elicit effective roles.


Some people rigidly insist on an equal status in their relationships. Such a symmetrical relationship can, however, escalate and become problematic. Interaction can be tenuous and unsteady as the two parties attempt to resolve whether


one will dominate or attain a one-up status. Consider the following imaginary dialogue:

person a :    I've been studying Erickson's work. person b:    Well, I've been studying Erickson.

persona: I understand that Erickson's most important contribution to hypnosis is the development of the confusion technique.

person b: But my understanding of Erickson suggests his most important contribution is the interspersal technique

person a: Jay Haley says that confusion is a part of every hypnosis induction ...

Or consider the couple who keeps a list on the refrigerator door of how much money each has spent. At the end of the week, they tally up the totals to ensure a fair exchange. Potentially conflicting conversation between this couple might sound like this:

he: All right, last time we went out, you decided on the movie and I decided where to go to dinner. So this time, you decide where we go to dinner, and I'll decide on the movie.

she: Are you sure about that? I think you decided on both the movie and the dinner, now it's my turn.

This kind of relationship can be volatile, with frequent clashes and conflicts. Since many aspects of the relationship are open to negotiation, struggles become pervasive, spreading to mundane details of life.

Escalating symmetry can end in one of three ways:

By resolving itself into a complementary relationship whereby one person
becomes one-up, the other one-down.

With an 'explosion' that breaks-off the relationship, sending the participants in
separate directions. Explosions in marital relationships sometimes escalate to
physical violence.

With the intervention of a 'governor' which allows conflict to escalate only to a
certain level. The governor may be a simple nonverbal gesture, such as
scratching one's head or scowling. Once the governor is activated, tensions
diminish and participants revert to the beginning stages of symmetry.

A functional relationship between two high-powered individuals almost always contains a governor, although it may not be consciously recognized. The governor's existence is revealed through observable behaviors that are unconsciously understood. For instance, one partner may always light a cigarette at the point in which a symmetric escalation begins to verge on a serious communication breakdown.


Many therapists have difficulty working with couples in these sometimes explosive, symmetric relationships since the clinician essentially encounters a couple who bicker incessantly. Any suggestions that a couple are involved in a power struggle usually falls on deaf ears. One of the pair might respond with 'Power struggle? I'm not involved in a power struggle. She (he) may be in a power struggle, but not me!' Subsequently, the therapist might become embroiled in an escalating symmetrical relationship with one of the partners.


Madanes (1984) has demonstrated that strategic therapy that modifies disturbed family hierarchies can remove symptoms. Straightforward discussions are usually of little value in changing relational power dynamics, primarily because the duel does not occur on the conscious, verbal level, but on an extraverbal level. People do not say to each other, 'Well, in this situation, I'm going to be one-up or one-down.' Nonverbal behavior such as demeanor, tone and posture signal these roles within the first few seconds of an encounter.

As a result, psychotherapy should be effected at the level of experience at which the problem is generated. If a problem is generated at a verbal level, it may be solved through discussions. If the problem is generated at extraverbal levels, therapy should be directed extraverbally. Because most problems are generated at the level of preconscious associations, 'right hemisphere' methods such as tasks and metaphors which pattern new associations and disconnect old rigid sets are the most effective psycho therapeutic techniques in cases with disturbed power balances.

Consider the case in Uncommon Therapy (Haley, 1973) of the couple who were involved in a rigid complementarity. The wife complained bitterly that her husband was incompetent, forcing her to tend to both the family and the family business. Erickson offered the wife a directive. He commented that she deserved some rest, a statement with which she would likely agree. Then he suggested that she could arrive at work 30 minutes late, indicating that her husband 'could not possibly do much damage in 30 minutes.' The wife arrived at the instructed later time and discovered that the husband had done a competent job without her presence. Over time, she went to the business later and later, and the relationship improved. The use of directive tasks to rearrange problematic hierarchies has been elaborated by Madanes (1984).

Erickson was acutely attuned to styles of complementarity and symmetry and he used strategic tasks, jokes and confusion techniques to disrupt inflexible patterns of behavior. Erickson also was consistently one-up in his relationships with patients because he held that it was essential for the clinician to be in control of the therapeutic relationship.



One of the therapist's main goals is to induce more effective roles. As a result, it is important to diagnose rigid power dynamic styles, keeping in mind the power dynamics of the clinician-patient relationship itself. To induce change, the therapist must be one-up. If the patient is one-up, the therapy will not be successful. 'Right hemisphere' techniques are valuable for this because they work to unexpectedly disconnect habitual sets. The therapist can cripple his or her therapeutic effectiveness by adhering to inflexible, preordained expectations for change which can concede the one-up position to the patient. If the patient is consistently one-up, therapy should be terminated since there will be no leverage for change.

I am not promoting a Machiavellian stance for the therapist. The job of the therapist is to work on the patient's behalf to elicit change. This can only be accomplished when the therapist controls, defines and induces different roles by assuming the one-up position.


Keep in mind that it is the injunctive nature of the communication, not the actual words and actions of the therapist, that provides the pivotal stimulus for patient change. The therapist must work to develop an understanding of the covert messages to which the patient will respond.


The author wishes to acknowledge the assistance of Brent Geary, PhD, and Jean M. Emery, MA, MFA, in the preparation of this chapter.


Bandler, R. & Grinder, J. (1975). The Structure of Magic, Vol. 1. Palo Alto, CA: Science and

behavior Books. Bateson, G. & Ruesch, J. (1951). Communication: The Social Matrix of Psychiatry. New

York: W. W. Norton.

Berne, E. (1966). Principles of Group Treatment. New York: Grove Press. Erickson, M. H. (1966). The interspersal technique for symptom correction and pain control.

Am. J. Clin. Hypn. 8, 198-209. Erickson, M. H. & Rossi, E. L. (1979). Hypnotherapy: An Exploratory Casebook. New York:

Irvington. Fisch, R., Weakland, H. H. & Segal, L. (1982). The Tactics of Change: Doing Therapy

Briefly. San Francisco: Jossey-Bass. Haley, J. (1963). Strategies of Psychotherapy. New York: Grune & Stratton.


Haley, J. (1973). Uncommon Therapy. New York: W. W. Norton.

Madanes, C. (1984). Behind the One Way Mirror: Advances in the Practice of Strategic

Therapy. San Francisco: Jossey-Bass. Watzlawick, P., Beavin, J. H. & Jackson, D. (1967). Pragmatics of Human Communication.

New York: W. W. Norton. Watzlawick, P., Weakland, J. & Fisch, R. (1974). Change: Principles of Problem Formation

and Problem Resolution. New York: W. W. Norton. Watzlawick, P.  (1985). Hypnotherapy without trance. In J. K. Zeig (Ed.), Ericksonian

Psychotherapy, Vol. 1: Structures. New York: Brunner/Mazel. Yapko, M. D. (1985). The Erickson hook: Values in Ericksonian approaches. In J. K. Zeig

(Ed.), Ericksonian Psychotherapy, 1: Vol I: Structures. New York: Brunner/Mazel. Zeig, J. K. (1982). Ericksonian approaches to promote abstinence from cigarette smoking. In

J. K. Zeig (Ed.), Ericksonian Approaches to Hypnosis and Psychotherapy. New York:

Brunner/Mazel. Zeig, J. K. (1985a). Experiencing Erickson: An Introduction to the Man and his Work. New

York: Brunner/Mazel. Zeig, J. K. (1985b). Ethical issues in Ericksonian hypnosis: Informed consent and training

standards. In J. K. Zeig (Ed.), Ericksonian Psychotherapy, Vol. 1: Structures. New York:


Zeig, J. K. (1988a). The grammar of change. Int. J. Eclectic Psychother, 7(4), 410-414. Zeig, J. K. (1988b). An Ericksonian phenomenological approach to therapeutic hypnotic

induction and symptom utilization. In J. K. Zeig & Stephen Lankton (Eds), Developing

Ericksonian Therapy: State of the Art. New York: Brunner/Mazel.

International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley, P. B. Bloom

Copyright © 2001 John Wiley & Sons Ltd

ISBNs: 0-471-97009-3 (Hardback); 0-470-84640-2 (Electronic)


Specific Disorders and Applications



International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley, P. B. Bloom

Copyright © 2001 John Wiley & Sons Ltd

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Hypnosis and Recovered Memory: Evidence-Based Practice


University of New South Wales, Australia


Memories can be accurate, inaccurate, incomplete, and malleable. They are sometimes detailed and specific, and sometimes fragmentary and vague. People sometimes remember things they had forgotten, and sometimes create accounts of things that never happened. We know that memory is influenced by cognitive and social events and that influence can occur during encoding, storage, and retrieval. As Bartlett (1932/1995) argued: 'Remembering is not the re-excitation of innumerable fixed, lifeless, and fragmentary traces. It is an imaginative reconstruction, or construction, built out of the relation of our attitude towards a whole active mass of organized past reactions or experience' (p. 213).

Memories reported in the clinical setting are usually autobiographical in nature. That is, they usually involve events or experiences that have played a significant part in the life of the individual. If we are to understand such memories, then we have to consider the purposes, processes, and products of autobiographical remembering, and we have to embed that remembering within its biological, affective, interpersonal, sociocultural, and historical contexts (Bruner & Feldman, 1996; Hirst & Manier, 1996; Rubin, 1996). In other words, remembering past experiences is a pervasive part of life, and changes in an individual's life can be associated with changes in remembering (Fivush, Haden & Reese, 1996; Neisser & Fivush, 1994). The critical place of memory in human experience is clear when we examine individual lives in their social context, and that point needs to be kept in mind when we consider the impact of hypnosis on memories reported in the clinical setting (McConkey, 1995).

There has been substantial debate about recovered memory in the clinical setting (e.g., Freyd, 1996; Herman, 1992; Loftus & Ketcham, 1994; Lynn & McConkey 1998; McConkey & Sheehan, 1995; Ofshe & Watters, 1994; Pezdek & Banks,

International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley and P. B. Bloom

© 2001 John Wiley & Sons, Ltd


1996; Pope & Brown, 1996; Schacter, 1996; Spanos, 1996; Terr, 1994; Yapko, 1994), and I focus on the reporting of recovered memories of childhood abuse by adults who had not previously reported such memories. This type of reporting can be argued to involve the therapeutic recovery of repressed, true memories (Briere & Conte, 1993; Courtois, 1992; Freyd, 1994; Herman & Schatzow, 1987; Olio, 1989; Pope, 1996; Williams, 1994, 1995). This type of reporting, however, can be argued to involve the creation of false memories (Brenneis, 1994; Garry & Loftus, 1994; Lindsay & Read, 1994; Loftus, 1993; Lynn & Nash, 1994; Ofshe & Singer, 1994). As McConkey (1997; McConkey & Sheehan, 1995) pointed out, there are difficulties involved in achieving a balanced and practical position on the issues associated with recovered memory of childhood abuse. Nevertheless, it is important to work with clients in a way that is professionally defensible and therapeutically beneficial. To help in this, I comment on: (a) memory, repression, and recovered memory; (b) hypnosis and memory; and (c) guidelines for evidence-based practice.


There is extensive evidence that memory is extremely susceptible to the influence of suggestion, postevent information, and source confusion (Belli & Loftus, 1996; Brainerd & Reyna, 1996; Conway, Collins, Gathercole & Anderson, 1996; Hyman & Pentland, 1996; McDermott, 1996; Mitchell & Zaragoza, 1996; Payne, Elie, Blackwell & Neuschatz, 1996; Read, 1996; Roediger, Jacoby & McDermott, 1996; Zaragoza & Mitchell, 1996). For instance, Zaragoza & Mitchell (1996) showed people a video of a burglary and then asked questions containing misleading suggestions, some of which were repeated; then, they tested memory for the source of the suggestions. Zaragoza & Mitchell (1996) found that, in comparison to subjects exposed to the suggestion only once, those exposed repeatedly were more likely to confidently remember the suggested events from the video and to claim they could recall witnessing the suggested events.

Despite the consistency and reliability of this type of finding, laboratory research has been rejected by some as irrelevant to the debate about recovered memory. For instance, Freyd & Gleaves (1996; Kristiansen, Felton & Hovdestad, 1996; van der Kolk, 1994; but see Roediger & McDermott, 1996) argued that laboratory research on memories of benign, artificially constructed stimuli tells us nothing about processes involved in memory for severely traumatic events. However, recognizing that memory is malleable does not mean recovered memories of childhood abuse are necessarily inaccurate; it simply means they are not necessarily accurate. Whereas there is clinical observation and personal anecdote that individuals may avoid or be unaware of threatening memories (Martinez-Taboas, 1996), such memories can be influenced by various cognitive and social events (Loftus, 1993). In other words, there is no strong reason or evidence why memory for traumatic events should follow entirely different psychological principles from those followed


by memory for nontraumatic events (Kihlstrom, 1994, 1995); equally, memory should follow the same principles whether or not hypnosis is involved (Kihlstrom & Barnhardt, 1993). Notably though, at a biological level, the release of neural hormones during trauma may enhance the consolidation and storage of memory for that event (Cahill, Prins, Weber & McGaugh, 1994; but see Bremner, Krystal, Charney & Southwick, 1996). Also, the experience of trauma may be more likely to lead to the occurrence of recurrent and intrusive memories than to the forgetting of that experience (Frankel, 1994; LeDoux, 1991; LeDoux, Romanski & Zagoraris, 1989).

Discussion about the recovery of memory for traumatic events typically shows various views about repression (McConkey, 1997). In general, repression can be said to involve the motivated forgetting of information that is threatening to the self. Repression and related constructs such as dissociation, however, have been conceptualized in a variety of ways and that variation is one of the problems of the debate on recovered memory (Bowers & Meichenbaum, 1984; Lynn & Rhue, 1994; Singer, 1990; Spiegel, 1994). Notably, analyses of the original concept of repression in the writings of Freud have highlighted its internal inconsistencies and its limited value beyond a very general description of assumed processes (Holmes, 1974, 1990; Macmillan, 1997; for a summary of empirical work, see Pope & Hudson, 1995). The relative impreciseness of the concept of repression and the difficulty of testing it led Holmes (1990) to say that 'despite over sixty years of research ... there is no controlled laboratory evidence supporting the concept of repression' (p. 96). Further, he suggested that those who use the notion should warn that 'the concept of repression has not been validated with experimental research and its use may be hazardous to the accurate interpretation of clinical behavior' (Holmes, 1990, p. 97). Notwithstanding this view, clinical observation suggests that thoughts about and memories of important personal events can be set aside from normal awareness, and concepts such as repression or dissociation may be of heuristic value in helping to understand that process (Bower, 1990; Davis, 1990; Erdelyi, 1993; Nemiah, 1984; Weinberger, 1990). Although such concepts may have some value, this does not mean that if 'repressed' or 'dissociated' thoughts and memories are reported, then they are necessarily accurate representations. That is, accepting a notion of repression does not necessarily mean that recovered memories are historically accurate. Even if a memory has been forgotten for a time, this does not mean that it is not influenced by the constructive and reconstructive features of memories in general (Bowers & Farvolden, 1996).

We should not assume that freshly reported material indicates the lifting of repression that is linked to traumas of childhood. Rather, the fact that people sometimes remember events they had forgotten does not mean those events were traumatic, nor does it mean those particular memories were repressed. In other words, much of the nonreporting of such events may occur because of normal forgetting, embarrassment over reporting the events, the consequences of reporting the events, or various other reasons that relate to factors other than repression. In


this respect, it does not seem to be possible to distinguish between people who do not report abuse and those who do not remember it; among the latter, it does not seem possible to distinguish forgetting that reflects repression, dissociation, other pathological processes, and benign processes (Kihlstrom, 1995). Nevertheless, when clinicians are faced with clients who experience themselves remembering a previously forgotten trauma, they must recognize the clinical relevance of this; equally, however, clinicians need to recognize that memories are affected by factors like suggestion, transference, personal values, social interactions, and fantasies associated with the event and its remembering (Nash, 1994).

Whatever their nature, it is clear that memories and the meaning placed on them change during therapy in various ways. For instance, Foa, Molnar, and Cashman

(1995) examined the memory reports of female rape victims during therapy, and
found that their length increased across treatment, the percentage of reported
actions and dialogue decreased, and the percentage of thoughts and feelings
increased. There was an increase in the number of thoughts that attempted to
structure the memory of rape. Thus, their narratives changed with the imaginal
reliving of the trauma, and the victims tried to restructure their memory to provide
a sense of coherence. That coherence may give a strong feeling of narrative truth
and may feel right for both the client and the clinician, but it may not be an
indication of the historical truth of the event. The fact that narrative and historical
truth (Spence, 1982, 1994) may not coincide is nonproblematic and manageable by
clinicians with relevant knowledge and skill. However, it may be problematic in
nonclinical settings, such as the courtroom, in which the processes, goals, and
demands are very different from the clinical setting. As Spiegel & Scheflin (1994)
noted, it is possible to convince oneself of a false belief, and memory alone cannot
be trusted in the absence of independent corroboration.

Questions about the trust that can be placed in recovered memory and the utility of such memory in clinical and court settings have led to research on whether memories of childhood abuse can be recovered. While recognizing that childhood sexual abuse can cause significant physical and emotional harm (Janoff-Bulman, 1992; Kendall-Tacket, Williams & Finkelhor, 1993; Nash, Hulsey, Sexton, Harral-son & Lambert, 1993; Romans, Martin, Anderson, O'Shea & Mullen, 1995), recovered memories of abuse cannot be seen as self-validating. Rather, the nature and accuracy of memories recovered during therapy need to be determined independently instead of being assumed by the client, the clinician, or others; this is especially the case when dealing with those therapies that may strongly bias the creation of illusory memories (Lindsay & Read, 1994). As Bowers & Farvolden

(1996) noted, however, the situation becomes complicated if clinicians accept abuse
memories at face value; sometimes clinicians do this because they feel they must
serve the client by confirming each of his or her ideas, memories, and beliefs. This
tendency by some clinicians is unfortunate not only because it may lead clients to
assume the validity of memories that may not be accurate, but also because it
conveys that the clinician knows the truth about the client. As Bowers & Farvolden


(1996) argued, however, neither the clinician nor the client has definite knowledge of the reasons for a particular problem. Of course, the clinician can have more or less plausible theories regarding that problem, but these theories should not be confused with absolute truth, however compelling they may seem. In other words, clinicians need to deal with recovered memories in terms of their clinical utility, without focusing on the truth or falsity of those memories (Fowler, 1994).


The use of hypnosis to enhance memory can lead to major changes in recall, as well as in the confidence that people hold in the accuracy of their recall. The influence of hypnosis on memory generally has been the focus of substantial investigation and comment (American Medical Association, 1985, 1994; American Society of Clinical Hypnosis, 1995; Laurence & Perry, 1988; McConkey & Sheehan, 1995; Pettinati, 1988, Scheflin & Shapiro, 1989), and the influence of hypnosis on recovered memory has been the focus of two special issues of the International Journal of Clinical and Experimental Hypnosis (October 1994; April 1995). Overall, it is clear that people can believe strongly in the accuracy of their hypnotically enhanced memories, even when those memories are wrong. In summary of the experimental findings about the effect of hypnosis on memory, McConkey (1992) concluded, 'It should be understood clearly that the experimental findings provide no guarantee that any benefits (e.g., increased accurate recall) will be obtained through its use, and that some costs (e.g., inaccurate recall, inappropriate confidence) may well be incurred through its use' (p. 426). For instance, hypnosis can lead to an apparent increase in memory, because it may lead people to generate and report more material as memory than they would if hypnosis were not involved (McConkey & Kinoshita, 1988). Also, hypnotized individuals can accept subtle changes to their memory, incorporate those changes into their memory, and develop confidence in the accuracy of what they report; one of the most consistent findings from the experimental research is that hypnosis may lead people to be inappropriately confident in the accuracy of their memory (Nogrady, McConkey & Perry, 1985; see also Krass, Kinoshita & McConkey, 1988). Finally, hypnosis can lead to the creation of pseudomemory when a hypnotized person accepts a suggestion for false information and subsequently reports that information as a genuine memory (Barnier & McConkey, 1992).

Although some have debated the interpretation and relevance of experimental research on hypnosis and memory (American Society of Clinical Hypnosis, 1995), in their analysis of recovered memories of abuse Pope & Brown (1996) considered that 'because hypnotic technique can enhance suggestibility and lead to the development of pseudomemories in some individuals, its use as a memory enhancement or memory-retrieval strategy seems questionable at best' (p. 59). The importance of understanding the processes involved, as well as the possible risks


and benefits, when hypnosis is used to recover memory is thrown into bolder relief by a consideration of selected clinical material.

McConkey & Sheehan (1995; see also McConkey, 1995) presented the case of BT, who was 21 years old when she went to a clinician for help in remembering events that her older sister had said BT had witnessed about 10 years earlier. BT's sister had told police that their father had sexually abused her as a young adolescent, and had said that BT witnessed much of that abuse. BT could not remember this, but underwent four hypnosis sessions at the request of her mother and her sister. Early in Session 1, the following interaction occurred:

hypnotist: Are you aware that in the case of your elder sister, in her relationship with her father, that there are various charges being brought about against him?

bt:    Yes.

hypnotist: Right. As her sister, I am asking you now, as to whether you are a witness in the past to any impropriety that your father may or may not have committed towards your sister?

bt:    No.

By the end of Session 1, after using a series of techniques that focused on the father and his assumed acts of abuse, the following interaction occurred:

hypnotist: Are you only aware for the moment at this your first subconscious session, are you only aware of that occasion when you walked into your father's room on a Saturday afternoon and were suddenly aware that [your sister] was in your father's bed with him under the blankets and sheets. Is this the only occasion that you noticed your father was not at all acting out the proper fatherly role?

bt:    Yes.

In Sessions 2 and 3, the hypnotist used various techniques and metaphors to help BT feel secure and confident about whatever events came to mind. By the end of Session 3, BT was answering explicit questions about witnessing multiple sexual interactions between her father and sister. Moreover, she was giving details, such as the precise positioning and movement of the father's hands and genitals, that would have required extraordinary ability not only to witness (since they reportedly occurred under bedclothes), but also to remember so precisely (since they reportedly occurred approximately 10 years previously).

At the end of Session 3, the hypnotist summarized the progress they had made together, and ended treatment with the following interaction:

hypnotist: Your subconscious mind is a memory bank, and you can entrust a third party to help you resolve all that you've seen, all that you've experienced, all that you as a Christian have been coerced to be witness to ... You may feel


some satisfaction as you leave here, that your prayers to resolve issues that you've seen can be answered. You are a Christian, are you not?

bt:    Yes.

hypnotist: Yes. So through Jesus Christ, you can pray for this, that these issues be resolved for yourself, as a previous victim and now a survivor, for your sister, the victim but hopefully a survivor, through the grace of Jesus Christ. And you can say Amen.

bt:    Amen.

hypnotist: I'm going to count up from zero to five. On the count of five you will be wide awake, feeling really good. Really alive on the count of five. Knowing that through courage, through revelation, you can proceed on with your life.

BT subsequently made a detailed statement to police about various sexual assaults on her sister by her father. The prosecution, however, considered that the judge would not allow testimony by BT because of the way in which her memories had been recovered. This case highlighted not only how clinicians can get caught up in events, but also how they can have difficulty looking critically at their own behaviour in the clinical setting. Moreover, it highlighted the creativity, if not the recoverability, of memory; BT constructed a personal meaning around a possibility of unremembered events. When one looked at the processes that were involved in BT moving from reporting no memory to reporting exceptionally detailed events from 10 years hence, substantial doubt could be cast on the accuracy of BT's memory reports. Nevertheless, BT developed a strong belief in the accuracy of her memories, and this changed the way in which she thought about her self and other members of her family (McConkey & Sheehan, 1995).

The impact of hypnosis on memory and on self-representation can be seen clearly in cases involving the intentional hypnotic falsification of memory for therapeutic benefit. For example, Janet (1889/1973) believed that successful treatment was based on not only uncovering a traumatic childhood event, but also reconstructing or replacing the original memory with a false, and more acceptable, memory; that is, changing the way in which the client thought about themselves. Janet's famous case of Marie exemplifies this treatment approach (Janet, 1889/ 1973; see also Ellenberger, 1970). Marie suffered from anaesthesia of the left side of her face and blindness of her left eye, both of which had been present for many years. Janet determined through hypnotic age regression that as a 6 year old, Marie had slept with a child of the same age who had impetigo on the left side of her face. After this, Marie developed an almost identical impetigo as well as blindness. Janet hypnotically age regressed Marie to the time of the incident and reconstructed the memory. This treatment was successful, and five months later there were no signs of hysterical symptoms. As Janet (1889/1973) put it, 'I put her back with the child who had so horrified her; I make her believe that the child is very nice and does not


have impetigo (she is half-convinced. After two re-enactments of this scene I get the best of it); she caresses without fear the imaginary child. The sensitivity of the left eye reappears without difficulty, and when I wake her up, Marie sees clearly with the left eye' (pp. 436-440).

Contemporary examples also demonstrate the intentional hypnotic reconstruction of memory. Baker & Boaz (1983), for instance, reported the hypnotic treatment of a 30-year-old woman's severe dental phobia. During hypnotic regression, she described being taken to the hospital for a tooth extraction at 9 years of age and becoming terror stricken during the procedure; she could not recall being comforted by anyone. The clinician suggested that as the client thought about being taken into the operating room, she would remember the doctor holding her and stroking her forehead and telling her that she would not be afraid. The client said that she could hear the doctor comforting her, and subsequently reported that her fear was diminished as she re-experienced going into the operating room. A second session involved hypnotic age regression, and repetition of the suggestion that the doctor was comforting her; again, the client reported reduction of her anxiety. During follow-up, she recalled the implanted material as original memory, without awareness of either the construction of the suggested pseudomemory or the trauma associated with the original memory. Thus, the use of hypnosis assisted in the creation of a new memory. The client became committed to the accuracy of the memory to the extent that the constructed events were indistinguishable from the original event and integrated into the understanding and knowledge that the client developed about herself.

Returning to the issue of recovered memory of childhood abuse, Smith (1996) presented the case of 'Cindy' whom he successfully treated by helping her to recover and deal with an apparent memory of being abused by neighbours during childhood. Cindy presented with serious depression, suicidal ideation, and obsessional behaviour; even after admission to a psychiatric hospital, her treatment progressed with no apparent improvement. Although Cindy could recall a college rape incident and an abortion two years later, she had no memories of childhood abuse. However, the referring psychiatrist suspected that some traumatic sexual event may have occurred in childhood. To explore this, and to help Cindy access and master her emotions about present and past experiences, Smith introduced hypnosis into the treatment programme. Across a number of sessions, Cindy was hypnotically age regressed to childhood; during a regression to 8 years of age, she recalled being invited to a neighbour's house, told to undress, encouraged to touch herself and another girl, being fondled by a male neighbour, and having photos taken. She also recalled similar events from 12 or 13 years of age that involved being threatened with a knife. The recall of these events helped her to make sense of the emotions associated with those events, and in her view helped her to understand some of her current problems. By the end of treatment, Cindy's overall functioning had improved substantially and these treatment gains were maintained at a 5-year follow-up.


From this client's point of view, hypnosis was a key factor in her improvement, because it allowed her to 'remember and share intimate details very quickly' (Smith, 1996, p. 124). Notably, however, Cindy made no effort to corroborate her hypnotically retrieved memories of the events at the neighbour's house. Indeed, Smith (1996) acknowledged that 'in the absence of external verification, there is no way to know whether Cindy's memories are authentic or not. They seemed compellingly real to her and to me, but from a scientific standpoint, "seeming" real is not confirmation' (p. 124). Nevertheless, these memories, whether accurate or inaccurate, appeared to offer a plausible explanation for Cindy's symptoms, and served as a useful and ultimately successful 'therapeutic leverage for recovery' (Smith, 1996, p. 124).

In commenting on this case, Lynn, Kirsch & Rhue (1996) argued that such memory recovery work can be a gamble, and that clinicians must consider both the risks and benefits of using hypnosis to recover memories; indeed, the emotional, societal, legal, and financial stakes can be very high in such cases. Further, Lynn, Kirsch & Rhue (1996) offered a number of recommendations to help clinicians decide whether the 'benefits of attempting to access potentially forgotten life experiences outweigh the potential risk of distorted memories' (p. 404). These include warning the client about the risk of memory distortion, exercising caution regarding the wording and implications of therapeutic suggestions, and evaluating the credibility of memories recovered during therapy. Such recommendations underscore the need for appropriate guidelines to assist in ensuring clinical practice is based on reasonable evidence and is consistent with acceptable standards.


Across a range of theoretical and therapeutic orientations, there is agreement about the need for evidence-based practice in the treatment of individuals who have or may recover memories of childhood abuse (Beutler & Hill, 1992; Bowers & Farvolden, 1996; Courtois, 1995; Enns, McNeilly, Corkery & Gilbert, 1995; Fowler, 1994; Lindsay & Read, 1994; Knapp & VandeCreek, 1996; Lynn & Nash, 1994; McConkey, 1997; Pope, 1996; Pope & Brown, 1996). To help in this regard, various statements and guidelines are available from professional bodies (American Medical Association, 1994; American Psychiatric Association, 1993; American Psychological Association, 1994; Australian Psychological Society, 1994; British Psychological Society, 1995) as well as from individuals (Bloom, 1994; Bowers & Farvolden, 1996; Lynn, Kirsch & Rhue, 1996; McConkey & Sheehan, 1995; Pope & Brown, 1996; Knapp & VandeCreek, 1996; Yapko, 1994). At a general level, Bowers & Farvolden (1996) highlighted two essential points, no matter what problem is being treated or what technique is being used. They argued that clinicians should not define healing in terms that require themselves


and their clients to understand the latter's problems in the same way; also, clinicians should always consider alternative hypotheses to account for clients' problems, and should be especially careful not to fixate on one of those hypotheses. McConkey's (1997) consideration of the available statements and guidelines underscored general agreement that: (a) childhood abuse is a reality that may have devastating consequences; (b) the existence of particular problems in adulthood is not a reliable indicator of the occurrence of abuse in childhood;

memories may be unreliable, and inaccurate memories can be held strongly;

the existence of repression should not be rejected, but it cannot be accepted
without question; (e) recovered memories of childhood abuse may or may not be
accurate, and independent corroboration is the only way of determining this; (f)
clinicians'  responsibilities  to  their  clients  are  best met through  a cautious
approach to the assumptions they make and the techniques they use; and (g)
clinicians' professional and ethical responsibilities are best met by avoiding an
excessive encouragement or discouragement of reports of childhood sexual abuse.
In a more concrete way, Knapp & VandeCreek (1996) commented on risk
management procedures for psychologists treating individuals who recover mem
ories of childhood abuse. They argued that 'effective treatment included maintain
ing appropriate boundaries, developing an accurate diagnosis that is based on a
collaborative relationship with the patient, using intervention techniques that have
been empirically derived or in other ways have received the profession's endorse
ment, obtaining informed consent from patients when using experimental techni
ques, and showing concern for the patients' long-term relationship with their
families of origin. Consultation in difficult cases and careful documentation are
also essential' (Knapp & VandeCreek, 1996, p. 455).

These comments highlight that clinicians need to know how to work in a setting of ambiguity, uncertainty, and differential demands. Moreover, to engage in competent practice clinicians must have a knowledge of memory research, an understanding of trauma and memory loss, and must develop specific intervention skills and practices to work with clients who may recover memories. In terms of hypnosis, clinicians need to be alert that its use can be potentially problematic; in particular, hypnosis can offer no guarantee of the veracity of the reports that it may elicit, and the memories that are recovered during hypnosis may be very difficult to corroborate independently. Moreover, Pope & Brown (1996) set out specific questions that should be addressed by clinicians considering the use of hypnosis to recover memories: '(a) Am I competent in the clinical uses of hypnosis as demonstrated by my education, training, and experience? (b) Have I adequately considered alternative approaches that do not involve hypnosis? (c) Have I consulted with a qualified attorney to ensure that I understand the ways that using hypnosis may affect the client's legal rights (e.g., admissibility of claims, testimony, or other evidence based on hypnotically refreshed recollection)? (d) Am I adequately aware of the research and theory about the use of hypnosis for this population in this situation? and (e) Have I accorded the client full informed consent or informed


refusal?' (p. 126). An additional question, of course, is whether the use of hypnosis will add anything to the treatment of the client.


Overall, we need to recognize that work with individuals who report recovered memories of childhood abuse should be undertaken with an open attitude, a commitment to evidence-based therapy, and an acceptance of their experience in a way that conveys the concern and care that is needed when dealing with any possibility of childhood abuse (McConkey, 1997). In doing so, however, we need to maintain appropriate boundaries and use justifiable methods of diagnosis and treatment. If clinicians engage in evidence-based practice, then they will provide better treatment to their clients and will reduce the professional and legal risks to themselves (Knapp & VandeCreek, 1996). Kirsch, Montgomery & Sapirstein (1995) reported that in general hypnosis can enhance the effectiveness of therapy, but we must recognize that hypnosis also has a long history of misuse and a tendency toward controversy. Because of this, clinicians who use hypnosis must be especially careful not to engage in substandard thinking and practice. As Bloom (1994) and London (1997) noted, how a clinician behaves may profoundly shape the nature of any recovered memory as well as how that memory is subsequently used in the clinical setting and beyond. Given the importance of sound professional judgment and practice, the behaviour of the clinician must be consistent with scientifically based and clinically sound therapeutic intervention.

The use of hypnosis can lead to changes in memory, and this can lead to changes in our sense of self and our view of others. In other words, in altering memory, hypnosis can change how people think about themselves and others. This can be positive; it can also be negative. As clinicians, we need to keep in mind that individual memory serves a major role, and that 'lives would be intolerable without some predicate, some ballast of identity, to provide a context for the wisps of thought and action that constitute our instantaneous selves' (Albright, 1994, p. 21). When seeking to recover the past, with hypnosis or without, we need to appreciate that it is not just memory that we are dealing with, but rather the past and the future of a human life. That is the reason we need to know why and what we're doing if we choose to use hypnosis to recover memory.


The preparation of this chapter was supported in part by a grant from the Australian Research Council to the author. I am grateful to Amanda Barnier for assistance in its preparation.



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 International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley, P. B. Bloom

Copyright © 2001 John Wiley & Sons Ltd

ISBNs: 0-471-97009-3 (Hardback); 0-470-84640-2 (Electronic)

Hypnosis in the Management of Stress and Anxiety Disorders


University of Melbourne, Australia

Stress is a ubiquitous phenomenon, with which we are all familiar and yet the term is used in popular and clinical contexts without precision. 'Stress' is the process whereby this distress occurs, rather than the psychological and/or physiological distress response itself. The distress response resulting from the 'stress' process is a variable reaction that involves highly individual combinations of psychological or physiological distress.

Not all 'stress' is negative. As an acute response to the environment (and for some people even the repeated acute response) stress may be a motivating force to action, and may act as a useful stimulant to problem-solving and productivity. The concept of 'eustress' has also been introduced to describe the difference between this positive motivating pressure by which some thrive, and the 'distress' which we are commonly referring to in the clinical situation. While it may be agreed that events such as natural disasters are stressful for almost everyone, the majority of situations become part of a stress process only because of their significance to the individual. What may be simply problematic and challenging for one may be threatening and highly stressful for the next. 'Stress' then is neither a diagnosis nor an adequate description of psychological distress.

The stress process results in subjective distress and/or unpleasant physiological arousal, when the real or perceived demands being made on the person by the situation exceed, or are perceived by that individual as exceeding, their ability to cope. These perceptions of an imbalance between demand and coping result in the psychological or affective state of current or impending threat as well as a disturbance in physiological arousal that if persistent may damage the homeostatic functioning of bodily and psychological processes alike. The pattern of response to the stress process is variable and dependent on both genetic factors and learned response patterns. The personal relevance and availability of coping mechanisms

International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley and P. B. Bloom © 2001 John Wiley & Sons, Ltd


are key factors, making it more logical to define stress by the process resulting in the response, rather than the problematic situation. Thus overall the 'stress' response will depend on individual characteristics, life experiences; other problematic or challenging situations; the availability of suitable coping strategies to resolve problematic situations; the patient's confidence in putting these into effect and their ability to tolerate partial solutions to challenging situations.

Stress is implicated as a factor in precipitating a wide range of psychiatric and psychological disturbances. For some, the repeated or chronic perception of threat or inability to cope leads to anxiety, while for others it leads to a sense of helplessness and depression. It is probable, given the similarities between the anxiety and stress responses, that the same vulnerabilities to stress show up as vulnerabilities to anxiety disorders. Similarly in depression, psychologically confronting demanding and problematic situations repeatedly, or in the perceived absence of coping strategies, may lead to a sense of helplessness and contribute to a depressive response. The same neurotransmitter processes of the hypothalamic-pituitary axis and serotonergic and adrenergic mechanisms are implicated in both depressive disorders and stress vulnerabilities. To deal with chronic or severe acute stress patients self-medicate. The use of alcohol is a common strategy to reduce stress responses. Psychological dependence on this as the solution to chronic stress leads often to alcohol abuse with all its associated problems. The same problem occurs with marijuana and other illicitly obtained drugs that have some sedative effect. Benzodiazepine abuse and dependence in dealing with stress is common. Similarly other drug use such as nicotine can have an element of self-medication to dampen the physiological components of stress.


The treatment of stress is divided into three phases (Stanley, Norman & Burrows, 1999). Firstly, the medical, psychiatric and psychological conditions that are the outcome of the stress experience are treated in their own right. Anxiety, depression or the effects of attempts to manage their psychological distress by alcohol or drug use require appropriate clinical management first. Secondly, the chronic hyperar-ousal is treated, and this 'arousal management' contributes to controlling the secondary psychological distresses. In the third phase, the patient is assisted with stress prevention by developing more effective strategies for dealing with life stressors as well as changing attitudes, habitual thought processes and learned behavioral patterns.

Hypnosis as a therapeutic approach contributes to all three of these components of stress management. The part hypnosis may play in cognitive/attitudinal change, arousal management and in the treatment of the psychological and physical consequences of stress, will be reviewed and the management of anxiety disorders that may result from chronic stress will be outlined.



Medical illnesses contributed to by the stress process require the same medical interventions as those conditions where stress has not contributed. In treating the condition the contribution of stress as a precipitant and exacerbating factor is noted. So cardiovascular disease is treated as cardiovascular disease is usually treated, respiratory disorders as any respiratory disorder.

The same applies to depression or anxiety disorders. With the diagnosis of a psychiatric or psychological disorder the treatment of choice may be either pharmacological or psychological or both. The nature and severity of the presenting condition will be considered in making this decision. Effective antidepressant medication or the judicious use of benzodiazepines may have a part to play in treating the outcome of the stress.

The psychological treatment of stress-related and anxiety disorders may involve a wide variety of techniques based on psychotherapeutic, behavioral and cognitive principles. Cognitive, behavioral and other psycho therapies are applied on the basis of their proven effectiveness in treating the particular presenting condition. If the treatment of choice for the particular condition precipitated by the stress experience is psychotherapy, this may be used with or without drug therapy. Hypnosis may enhance treatment as a result of being a particularly persuasive form of communication. Some of the phenomena of hypnosis may be used directly to enhance the psychological treatment.


This phase focuses on lowering stress-proneness and involves individualized treatment. Cognitive and attitude change takes into account personality characteristics, flexibility, life experiences, ongoing problem situations, the availability of suitable coping strategies to resolve problem situations and the patient's confidence in coping strategies. It may also need to consider the patient's ability to tolerate partial solutions to challenging situations. Stress prevention programmes are also individualized on the basis of the aetiological contributions to the particular stress responses the patient shows, or if carried out in a group setting they need to cover the full range of likely contributors. Patient education, concerning the nature of stress and the variety of stress responses, is an essential part of the programme. The patient is assisted in recognizing what events result in stress, including what is the impact of their lifestyle. Many are unwilling or unable initially to identify the events, interpretations or lifestyle contributions, and require encouragement to do so.

Interpretation of events and situations as threatening, an essential cause of attitudinal and cognitive causes of stress, requires the sufferer to be encouraged to challenge their assumptions about the nature of their current experiences. This is


done using the common cognitive-behavioral therapy approaches (Beck, 1995). Inappropriate interpretations are dealt with by the cognitive-behavioral approach of challenging automatic thoughts. When the process involves problem-solving strategies which are ineffectual, treatments focus on developing effective problem-solving strategies and on making them habitual. These approaches involve appropriate labelling of the problem as a challenge to be overcome, identifying the range of solutions available, choosing the solution that has the potential most likely to minimize discomfort and effect a resolution, and evaluating the outcome if the solution is not as desired. Passivity and problem avoidance must be overcome, and rather than seeing problems as threats, the patient must be encouraged to see them as part of the range of life's challenges.

Because personality characteristics such as perfectionism and obsessiveness get in the way, patients need to be encouraged to be flexible in evaluating the situation. They need to develop the ability to perceive the range of complete or partial solutions. They need to be assisted to choose between the possible solutions, in the knowledge that while they may desire to get it right, if they do not they will simply make another choice or consider it a learning experience. They need to see that their self-esteem or self-worth is not related to finding the perfect solution. Indecision and passivity are presented as being worse than trying an inadequate solution that can be changed later if unsuccessful. The realistic recognition that life is problematic and challenging is encouraged. Some experiences such as the death of a loved one are to be coped with and survived as part of the vicissitudes of life. A willingness to deal with the unsolvable is a necessary part of coping with the inevitable challenges life throws at us all.

Self-esteem and confidence in their ability to find and effect solutions need to be encouraged. Low self-esteem may reflect long-standing personal difficulties that require more extensive interventions. If necessary, psychotherapy may be recommended to free the patient from the 'ghosts' of the past that continue to colour the way they deal with their present life and therefore to sensitize them to exhibit stress responses in the present.


The exaggerated physiological response to the particular difficulties and/or a habitually increased basal level of arousal may be treated in the initial phase with appropriate medication.

Longer term it is desirable that the patient can manage the exaggerated phasic and tonic arousal via other strategies such as relaxation, meditation, self-hypnosis, biofeedback or exercise programmes. Relaxation/meditation techniques if practised regularly have been shown to progressively lower the basal physiological arousal. There are many different approaches to meditation and relaxation (Jacob-son, 1929; Benson, 1975), but they essentially involve similar principles. The patient needs to be motivated to persist as it is the alteration of a habitual basal or


phasic response that is being sought. Practice may be needed daily for 6-12 months and regularly after that time (maybe 2-3 times a week).

The modern use of hypnosis is a very effective technique in reducing inappropriate or prolonged arousal. Self-hypnosis can be used to alter the phasic responses or the habitual elevation in basal arousal levels (Stanley, Norman & Burrows, 1999). If the patient can use hypnosis and the therapist is properly trained in its use, it not only speeds up treatment (perhaps by as much as one-third) but also enhances the sense of self-control and problem resolution in the future, thereby becoming part of stress prevention as well. There are contraindications to the use of hypnosis and its inappropriate use can worsen the patient's condition (Stanley, 1994). Effective training is essential for the use of hypnosis to be safe (Stanley, Rose & Burrows, 1998).

Exercise and the maintenance of physical fitness also reduce the inappropriate arousal responses to stressful life events. The effects are reported immediately after exercise and following a regular exercise programme (Markoff, Ryan & Young, 1982; Ransford, 1982). Both basal and phasic physiological responses are reduced as a result of increased physical fitness. Once more motivation of the patient to maintain this programme is difficult even after the rationale is explained.

Where stress is not the result of challenges being turned into threats, stress management may need to consider lifestyle changes. Constant, ongoing stimulation (even positive stimulation) may accumulate to manifest itself in a hyperarousal stress response. The patient needs to accept the requirement for restoration of biological and psychological homeostasis, or in other words the reduction of basal arousal back into the middle of the range. Lifestyle and behavioral changes of this sort are difficult to achieve and maintain. It is rarely easy for patients to make the connection between constant stimulation of their lifestyle and the stress-related disorders they suffer or may likely suffer. They are often deriving such benefits from their current lifestyle, that they are ambivalent if not downright resistive to change. Even if they do make significant changes, they have difficulty in maintaining them as the pay-off is not clear (and the habitual behaviors that have more evident rewards return). Ongoing tangible or self-administered rewards for suitable lifestyle change may need to be built into the stress management. Effective time management, exercise programmes, relaxation, recreation, changes in diet, alcohol use and other drug use (including smoking) need to be considered. These are difficult to achieve until the patient makes the connection (and not just intellectually) between their lifestyle and their health. Even with this connection being made, motivation to change must be present or be cultivated. Hypnosis may be used to develop the individual motivation.


While anxiety is a normal emotion experienced at some time by virtually all humans, 'pathological' anxiety, excessive or inappropriate to the situation, may


appear in the form of an anxiety disorder. The distinction between normal and 'pathological' anxiety needs to be established for each. Normal anxiety has a protective function in threatening situations and may enhance motivation to resolve the threat. On the other hand, pathological anxiety serves no useful purpose and is associated with an inability to function at a satisfactory level. It has been estimated that perhaps as many as 10% of the population may experience an anxiety disorder.


An association between hypnotic susceptibility and several anxiety disorders has been suggested. Frankel (1976) first presented evidence that phobic patients show greater hypnotic susceptibility than other patient groups and that a disproportionate number of his 24 phobic patients were in the highly hypnotizable range, when assessed using standardized assessments of susceptibility. There is some additional evidence supporting this observation (Frankel & Orne, 1976; Gerschman, Burrows, Reade & Foenander, 1979; Foenander, Burrows, Gerschman & Home, 1980; Frischolz, Spiegel et al. 1982; Robney, Hollander & Campbell, 1983; John, Hollander & Perry, 1983; Kelly, 1984) but two studies, using different assessment techniques, have failed to find greater hypnotic susceptibility in phobic patients (Gerschman, Burrows & Reade, 1987; Owens, Bliss, Koester & Jeppsen, 1989). Frankel (1974) has also speculated that the heightened hypnotic susceptibility may be implicated aetiologically in the development and maintenance of phobic conditions.


Management of the anxiety disorders may include psychotherapy, pharmacotherapy or both. The primary goals of psychological and hypnotically based therapies for the treatment of anxiety disorders are: the exposure of the patient (via imagery or reality) to the situation provoking the anxiety (thereby allowing deconditioning, habituation or desensitization); cognitive re-evaluations of the situation to alter the perception of threat; determining the personal significance (symbolic) of the stress or anxiety provocation; increasing the sense of self-efficacy in the patient's ability to deal with the stress-eliciting situation and the stress or anxiety symptoms; and the rehearsal of coping strategies. Despite the applicability and efficacy of hypnosis-based behavioral, cognitive and other psychotherapy interventions, there is a need to understand patient differences and to individualize treatment interventions (Jackson & Stanley, 1987). There is a need to bear this in mind when deciding on clinical interventions appropriate for individual patients. Insight-oriented psychotherapy attempts to assist the patient in finding, understanding and thereby changing the cause of the anxiety. In this approach anxiety is assumed to be symbolic of some other issue, which the patient is not facing or is not aware of. In contemporary therapy,  insight-oriented therapy approach is  less  common,  as


cognitive-behavioral psychotherapies have demonstrated their effectiveness, particularly in treating anxiety disorders. The principal components of cognitive-behavioral therapy are applied differently in the different anxiety disorders.

Arousal Management

With appropriate training the majority of patients can learn control of their anxiety response. This leaves them free to focus on problem-solving, or unlearning the connection between the anxiety and the anxiety-provoking situation. The anxiety-management techniques can have either or both of two purposes, the lowering of average—that is basal—anxiety levels, or the control of the acute anxiety response in the anxiety-provoking situation. Meditation, yoga and the many other forms of meditation can be of great assistance, particularly in lowering the average or basal levels of anxiety and arousal. These techniques may be of less use in treating situational anxieties.

There are numerous other approaches to training patients in the control of anxiety responses. All require the patient to practise the skill being acquired for a significant time, in order to have the degree of control over the anxiety necessary to deal with the anxiety disorder. The use of relaxation techniques to assist patients in learning to control their anxiety responses has a long history. Jacobson (1929) first introduced Progressive Relaxation which involved the patient learning discrimination of the muscle tension and control over it via a process of systematically tensing and relaxing the muscle groups of the body. An alternative, briefer and effective approach to training patients in anxiety control was introduced by Benson (1975).

Hypnosis, and in particular self-hypnosis, plays a very useful part in the treatment of anxiety disorders. Principally hypnosis is used to train the patient in cued rapid relaxation to be applied in the anxiety-provoking situation, as well as assisting in changes in perception about the nature of the perceived threat and the patient's confidence in their ability to cope with that situation. A detailed review of the various uses of hypnosis appears in Stanley, Judd & Burrows (1990), Stanley (1994), and Stanley, Norman & Burrows (1999).

When patients use self-hypnotic arousal reduction and relaxation it adds to their confidence in coping and their sense of self-control. They are able to influence what they previously thought unalterable. This shifts their locus of control beliefs and increases their sense of self-efficacy.

Cognitive-Behavioral Therapy

Cognitive therapy is based on the belief that it is the interpretation of the situation as threatening that is involved in the maintenance of the anxiety disorder (Beck & Emery, 1985). A three-stage schema-based information-processing model of anxiety has been proposed (Beck & Clark, 1997). Anxiety may result from the symptoms of the anxiety being interpreted as threatening, as in panic disorder.


Threat may be attributed to an animal, germs or blood, as in a specific phobia and some obsessive-compulsive disorders. The perceived threat may result from some aspect of a particular situation, as in social phobia, agoraphobia, or from reminders of past traumatic events, as in post-traumatic stress disorders. The cognitive approach has the patient challenge the beliefs about threat through helping the patient to examine the irrational thought processes and self-statements.

As a form of persuasive communication, hypnotically based treatments offer a powerful addition to the cognitive-behavioral strategies. The suspension of critical thinking in the hypnotic state may make the patient more susceptible to accepting the persuasive communications of cognitive-behavioral therapy.

Clients, who typically make critical and negative comments towards therapeutic communications, are essentially required by the hypnotic context to listen to persuasive messages from the therapist, in a way that they may not ordinarily do so; this process of attending and listening, without commenting, may make the clients more accessible to the content of the therapist's message. (McConkey, 1984, p. 80)

Additionally, alterations in cognitive processes may help patients accept alternative interpretations of events, their significance, their own coping abilities, and the expected outcome.

Exposure Based Unlearning

When anxiety is situation-specific, exposure-based treatments take a prominent role in cognitive-behavioral treatment. While the patient manages the anxiety by techniques detailed above, therapist-guided, or more commonly patient-guided stepwise exposure to the situation, is the basis of unlearning of the anxiety response. While there is no evidence that the exposure-based treatments need to be carried out in stepwise fashion, the gradual exposure of the stepwise approach maintains patients in treatment and prevents the therapy experience itself becoming traumatic.

Many psycho therapies use imagery and fantasy to facilitate the process of change. For some patients hypnotically assisted therapies may result in them being able to respond to imagery and fantasy as reality. Specifically, hypnosis may enhance a variety of interventions applied to the treatment of anxiety.

(i) Systematic desensitization remains one of the most common treatments for specific phobic disorders. Lang (1979) showed that patients who benefit from systematic desensitization have a greater ability to generate emotional responses to the imagined items from a hierarchy. The more realistic the experience of the imagined situation, the more likely are such responses to be generated. Hypnosis offers an adjunct to desensitization that is potentially extremely powerful, since the attribution of realism to imagined events is a characteristic of the hypnotic state.


(ii) The effectiveness of coping rehearsal may similarly be aided by the reality attributions effected through hypnosis. With the increased realism of fantasy rehearsal, and the uncritical acceptance of the implied message that this will occur, patients' expectations and motivations to expose themselves to the anxiety-provoking situation may be heightened. In the absence of self-defeating thoughts that maintain anxiety (Beck & Emery, 1985) successful coping may become a viable outcome.

Dissociation from Anxiety Symptoms and Situations

Patients with anxiety disorders frequently become over-absorbed in their anxiety. Their anxiety responses result in thoughts concerning the danger posed by the symptoms and their inability to cope. Dissociation from the symptoms via hypnosis can provide an adaptive and useful method of reducing this reactivity to the anxiety-producing situation and to the symptoms that may follow.

Treatment Approaches to Anxiety Disorders

The anxiety disorders have been variously subdivided. One widely accepted classification, the Diagnostic and Statistical Manual of Mental Disorders (4th edition) (American Psychiatric Association, 1994), subdivides the anxiety disorders into panic disorders with/without agoraphobia, social phobia, simple phobia, generalized anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder. Management may include pharmacotherapy and/or a wide variety of psychological treatments.

Panic Disorders

The cardinal clinical characteristic of panic disorder is the rapid onset of anxiety symptoms, without apparent or clearly defined precipitating events.

With panic disorder the three priorities are firstly, the teaching of skills to lower average or basic anxiety level and to give specific control of the acute anxiety episodes. Often this may involve the relaxation techniques or self-hypnosis. Additionally, appropriate breathing techniques may be used to control the physiological signs of the panic disorder. The second component of the treatment of panic disorder involves realistic patient education and techniques of patient self-talk about the nature of their symptoms, as signs of the panic disorder rather than signs of threat to the patient's life, survival or well-being. That is, they are something unpleasant to be managed rather than something to be panicked about. Fears of embarrassment are dealt with in the same way that they would be dealt with in social phobia. The third component of treatment involves therapist-guided graded exposure to the situation the patient is most afraid of, be that situations that trigger the panic attacks, social situations where the fear may focus on what others will


think, but more commonly the anxiety symptoms themselves. Exposure to the symptoms may be brought about through the patient hyperventilating on instruction, and then managing the symptoms by means of the relaxation technique or breathing techniques previously taught to them.

Suggested strategies for dealing with the frequently present agoraphobic symptoms are detailed below. With sufficient practice, self-hypnosis techniques may assist in reducing the panic state and gaining control over symptoms. Rapid reduction in anxiety, and dissociation from fears of the panic state, may be used to truncate the secondary anxiety response (anticipatory anxiety) about having a panic attack.

Additionally hypnosis may be used with panic disorder patients to reinforce their belief that they can deal with intense anxiety states. Such improved self-efficacy (Frankel, 1974) and a shift to an internal locus of control may come about via hypnotic demonstrations of control (behavioral control) or through attitudinal shifts toward confidence in coping (cognitive control) encouraged by persuasive communications of exploring the precipitants of panic states, should any exist.


As avoidance and escape from anxiety are the key features of agoraphobia, whether with panic disorder or without, the priority is therapist-guided graded exposure to the situation the patient is anxious about. The patient, in a step-by-step way, approaches the situations that trigger anxiety and which they have been avoiding. Exposure to the anxiety symptoms themselves is also of importance, especially where panic disorder is involved with the agoraphobia. The acquisition of anxiety-management skills, while not essential, is helpful in facilitating the graded exposure and making treatment less threatening, by establishing specific control over acute anxiety. The anxiety-management skills may involve the patient in regular practice of either relaxation techniques or self-hypnosis, with or without imagery-based rehearsal of exposure to the anxiety-producing situations. Alternatively, breathing techniques may be taught to assist in the control of the physiological signs, if the agoraphobia is a secondary development of panic disorder. The third component of the treatment of agoraphobia involves the patient in realistic self-talk about the nature of their anxiety, the absence of real threat, and their acceptance of the anxiety symptoms as unpleasant experiences to be faced and coped with, not run away from.

Hypnotic interventions may assist the treatment of agoraphobia by re-establishing a sense of security and coping through a supportive therapist relationship, enhanced by hypnosis, establishing a sense of 'control' over physical symptoms and cognitive anxiety, thereby permitting exposure and changing self-efficacy perceptions, imaginal rehearsal of coping as a prelude to in vivo exposure, enhancing motivation and determination through the exploration of what freedom from the symptoms means to lifestyle ('Doing what they have always wanted to


do'), changing general self-image, and enhancing dissociation from the anxiety and self- or symptoms focus (a healthy dissociative mechanism).

Social Phobias

Social phobias present in a variety of forms with different aetiological implications: fears of public speaking, fainting, losing control of bladder or bowels, vomiting, or embarrassing oneself by inappropriate action or speech. Jackson & Stanley (1987) noted the variety of aetiological explanations which have been offered to account for social phobias, ranging from inadequately developed social skills to fears of incurring the displeasure or rejection of others and catastrophic assumptions concerning the outcome of such displeasure, and even to a general intolerance of discomfort. In addition, some cases of social phobia may occur as a secondary complication of panic disorder (Liebowitz, 1987).

With social phobias the main feature to be addressed is the patient's fear of the evaluation of others in the social situation. Their cognitive processes result in them turning embarrassments into disasters and their normal preference for the approval of others into almost a requirement for their survival. Cognitive therapy actively encourages them to explore and challenge their beliefs that the situation is any more than embarrassing. The three-stage schema-based cognitive model of anxiety proposed by Beck & Clark (1997) is a useful starting point for conceptualizing social phobias. The cognitive approach has the patient challenge the beliefs about threat through helping the patient to examine the irrational thought processes and self-statements, particularly in the social situation. Homework-based exposure to the feared social situations is mandatory in the treatment of the socially phobic. Exaggerated confronting of social anxiety by 'shame-attacking exercises' may also greatly assist the socially phobic patient if they can be encouraged to do them.

Apart from general anxiety reduction, hypnotic techniques may be applied to establish a sense of self-worth and self-esteem. For example, cognitive restructuring within the hypnotic state may sensitize patients to their positive characteristics and successes, while emphasizing that projected disasters do not occur, and that those problems which do can be coped with. Additionally, through the use of rapidly induced self-hypnosis, patients may develop control over bodily processes where they fear loss of control (Jackson & Stanley, 1987). Dissociation into a tranquil and relaxed state on a cue specific to social situations may be achieved, as may realistic coping through fantasy rehearsal.

Specific Phobias

With specific phobias, systematic desensitization, in vivo or in imagination, remains the mainstay of treatment. Treatment by exposure in reality is more effective than imagery-based treatment, but imagery-based treatments are of considerable importance where the situation of which the patient is fearful cannot


easily be produced (e.g. storms, earthquakes, injury, etc.). The therapist guides and encourages the patient through graded exposure to the phobic stimuli or situation. It is an advantage if the patient understands the ways in which phobias are acquired and the process of deconditioning. Phobic anxiety is learned as a result of one of four processes: traumatic experiences of the phobic situation (classical conditioning); observing role models acting with fear (observational learning); informational learning coming about through either a lack of reality-based information about the situation or being encouraged to believe the situation is threatening (cognitive learning); or the consequences of accidental anxiety reduction on leaving a situation, resulting in threat and anxiety being attributed to the situation (operant learning). This new insight results in the patient recognizing the phobic response as an adaptive anxiety response inappropriately attached to the phobic situation, and assists the patient not only in understanding the process of unlearning, but also in ceasing self-blame or criticism. While the graded exposure is not vital to unlearning phobic responses the approach is more acceptable to the patient and assists in their therapy commitment. Group support and treatment of a variety of phobias with a group of phobic patients also assists in normalizing the process of the acquisition and unlearning of specific phobias. The acquisition of the anxiety-management skills based on either relaxation techniques or self-hypnosis, and with or without imagery-based rehearsal of exposure to the anxiety-producing situations, while not essential, may facilitate the in vivo graded exposure.

Specific phobias, whether single or multiple in nature, may respond well to hypnotic interventions. As observed by Frankel (1974), phobic patients tend to be more hypnotizable than other patients or the general population. As well as facilitating imaginal desensitization via enhancement of the imagined stimuli and coping strategies (covert modelling), hypnotic techniques may be used to produce cognitive changes concerning feared situations. Enhancement of the sense of self-control, increased self-confidence and a reinterpretation of the phobic circumstances may also be achieved (Liebowitz, 1987). In addition, therapeutic dissociation from the fear-inducing situation may be developed via hypnosis to facilitate the exposure component of therapeutic interventions. This approach controls patients' tendency to become absorbed in their symptoms, a tendency which may accelerate their phobia response. The hypnotic technique of age regression may assist in exploring the symbolism of the feared object/situation, or in uncovering trauma where this is aetiologically involved (Clarke & Jackson, 1983).

Post-traumatic Stress Disorder

With post-traumatic stress disorder two issues require resolution. The first issue is dealing with the memories and affect of the traumatic experience. The patient with post-traumatic stress disorder attempts to avoid the memories and affect and may voluntarily or involuntarily use full or partial dissociation, as a coping mechanism. The dissociated affects and/or memories are then responded to as though they are


reoccurring when they intrude into consciousness. As well there is often a continuous level of anxiety associated with the impending intrusion into consciousness of the affects and memories. Hypnotic techniques and eye movement desensitization are used in dealing with this dissociative partial coping, with cognitive restructuring of the thoughts of the trauma being a primary goal (Spiegel, Hunt & Dondershine, 1988; Shapiro, 1989).

Secondly, the avoidance of stimuli associated with the traumatic events needs to be dealt with as a form of phobic avoidance with progressive exposure. Systematic desensitization, in vivo or in imagination, remains an important part of treatment. Treatment by exposure in reality is more effective than imagery-based treatment, but imagery-based treatments are of considerable importance where the traumatic associations cannot easily be produced. The therapist guides and encourages the patient through the graded exposure to the traumatic stimuli or situation. The acquisition of anxiety-management skills based on either relaxation techniques or self-hypnosis, and with or without imagery-based rehearsal of exposure to the anxiety-producing situations, while not essential, may facilitate the in vivo graded exposure.

Brett & Ostroff (1985) have argued that images play a central role in the maintenance of post-traumatic stress disorder. Stutman & Bliss (1985) noted that, amongst Vietnam veterans, victims of this disorder demonstrated higher hypnotic susceptibility and imagery vividness than those without the disorder. Kingsbury (1988) detailed the application of hypnosis to the treatment of post-traumatic stress disorder, including cognitive reframing of events, dissociation to distance the sufferer from the event and alterations of memories of the events. Similar applications of hypnosis to achieve both abreactive reactions and cognitive restructuring are often the treatment of choice (MacHovec, 1985).

The psychoanalytically oriented use of hypnosis in post-traumatic stress disorder has been described (Peebles, 1989). The use of age-regression and abreactive techniques permits therapeutic changes to occur.

Generalized Anxie ty

With generalized anxiety disorder there are two specific goals of treatment; firstly the lowering of the average level of anxiety and secondly the changes in thoughts, perceptions and attitudes that reactivate the anxiety response. With appropriate training the majority of patients can learn to control their basal level of anxiety. There are numerous approaches to training patients in the control of anxiety responses. All require the patient to practise the skill being acquired for a significant time in order to have sufficient control over the anxiety necessary to deal with the anxiety disorder. The use of relaxation techniques to assist patients in learning to control their anxiety responses has a long history. Apart from the relaxation techniques commonly used (Jacobson,  1929; Benson,  1975), hypnosis and in


particular self-hypnosis, play a useful part in the treatment of generalized anxiety disorder (Stanley & Burrows, 1998).

Generalized anxiety may be reduced through the use of frequent brief self-hypnosis to decrease physiological arousal and to alter the absorption in anxiety symptoms. Through enhancement of a sense of self-control with hypnosis and cognitive restructuring, those with generalized anxiety can be assisted. Combined with age regression, cognitive restructuring may be useful in re-establishing a sense of 'safety in one's own company'.


Hypnosis offers an adjunct to the variety of strategies that are applied to the treatment of stress and anxiety disorders. The rationale for its role is supported by the observation that increased hypnotic susceptibility is present in phobic and post-traumatic stress disorders. The use of dissociation, altered perceptions, cognitions and memories, the enhanced control over anxiety symptoms, cued self-hypnosis, and hypnotic uncovering for psychodynamic psychotherapy may all be facilitated by this ancient and often neglected therapeutic modality.


American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental

Disorders 4th Edn. Washington, DC: American Psychiatric Association. Beck, A. T. & Emery, G. (1985). Anxiety Disorders and Phobias: A Cognitive Perspective.

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and strategic processes. Behav. Res. Ther., 35, 49-58.

Beck, J. S. (1995). Cognitive Therapy: Basics and Beyond. New York: Guilford Press. Benson, H. (1975). The Relaxation Response. New York: William Morrow. Brett, E. A. & Ostroff, R. (1985). Imagery and post-traumatic stress disorder: An overview.

Am. J. Psychiat., 142, 415. Clarke, J. C. & Jackson, J. A. (1983). Hypnosis and Behaviour Therapy: The Treatment of

Anxiety and Phobias. New York: Springer. Foenander, G., Burrows, G. D., Gerschman, J. & Home, D. J. (1980). Phobic behavior and

hypnotic susceptibility. Aust. J. Clin. Exp. Hypn., 8, 41. Frankel, F. H. (1974). Trance capacity and the genesis of phobic behavior. Arch. Gen.

Psychiat., 31, 261.

Frankel, F. H. (1976). Hypnosis. Trance as a Coping Mechanism. New York: Plenum. Frankel, F. H. & Orne, M. T. (1976). Hypnotizability and phobic behavior. Arch. Gen.

Psychiat., 33, 1259. Frischolz, E. J., Spiegel, D., Spiegel, H., Balma, D. L., & Markell, C. S. (1982). Differential

hypnotic responsivity of smokers, phobics and chronic-pain control patients: a failure to

confirm. J. Abnorm. Psychol., 91, 269.


Gerschman, J. A., Burrows, G. D. & Reade, P. C. (1987). Hypnotizability and dental phobic disorders. Int. J. Psychosom., 33, 42.

Gerschman, J. A., Burrows, G. D., Reade, P. C. & Foenander, G. (1979). Hypnotizability and the treatment of dental phobic illness. In: G. D. Burrows & D. R. Collison (Eds), Hypnosis 1979, pp. 33-39 Amsterdam: Elsevier.

Jackson, H. J. & Stanley, R. O. (1987). The missing factors: Influences in choice of treatment strategies. Aust. J. Clin. Exp. Hypn., 15, 83.

Jacobson, E. (1929). Progressive Relaxation. Chicago: University of Chicago Press.

John, R., Hollander, B. & Perry, C. (1983). Hypnotizability and phobic behavior: Further supporting data. J. Abnorm. Psychol., 92, 390.

Kelly, S. F. (1984). Measured hypnotic response and phobic behavior: A brief communication. Int. J. Clin. Exp. Hypn., 32, 1.

Kingsbury, S. J. (1988). Hypnosis in the treatment of post-traumatic stress disorder: An isomorphic intervention. Am. J. Clin. Hypn., 31, 81.

Lang, P. J. (1979). A bio-informational theory of emotional imagery. Psychophysiol., 16, 495.

Liebowitz, M. R. (1987). Social phobia. Mod. Probl. Psychopharmacol., 22, 141.

MacHovec, F. J. (1985). Treatment variables and the use of hypnosis in the brief therapy of post-traumatic stress disorders. Int. J. Clin. Exp. Hypn., 33, 6.

Markoff, R. A., Ryan, P. & Young, T. (1982). Endorphins and mood changes in long distance running. Med. Sci. Sport and Exercise, 14, 11-15.

McConkey, K. M. (1984). Clinical hypnosis: Differential impact on volitional and non-volitional disorders. Can. J. Psychol., 25, 79.

Owens, M. E., Bliss, E. L., Koester, P. & Jeppsen, E. A. (1989). Phobias and hypnotizability. Are-examination. Int. J. Clin. Exp. Hypn., 37, 207.

Peebles, M. J. (1989). Through a glass darkly: The psychoanalytic use of hypnosis with post-traumatic stress disorder. Int. J. Clin. Exp. Hypn., 37, 192.

Ransford, C. P. (1982). A role for amines in the antidepressant effect of exercise: A review. Med. Sci. Sport and Exercise, 14, 1-10.

Robney, J., Hollander, B. & Campbell, P. (1983). Hypnotizability and phobic behavior: Further supporting data. J. Abnorm. Psychol., 92, 390.

Shapiro, F. (1989). Eye movement desensitization: A new treatment for post-traumatic stress disorder. JBehav. Ther. Exp. Psychiat. 20, 211-217.

Spiegel, D., Hunt, T. & Dondershine, H. E. (1988). Dissociation and hypnotizability in post-traumatic stress disorder. Am J Psychiat. 145, 301-305.

Stanley, R. O. (1994). The use of hypnosis in the treatment of anxiety disorders—general considerations. In B. Evans (Ed.), Hypnosis in the Management of Anxiety Disorders. Melbourne: Monash University Press.

Stanley, R. O., Judd, F. J. & Burrows, G. D. (1990). Hypnosis in the management of anxiety disorders. In M. Roth, R. Noyes & G. D. Burrows. (Eds), Handbook of Anxiety, Vol. 4. Amsterdam: Elsevier Science Publishers.

Stanley, R. O., Norman, T. & Burrows, G. D. (1999). Stress, Anxiety and Depression. Melbourne: Adis.

Stanley, R. O., Rose, L. & Burrows, G. D (1998). Professional training in the practice of hypnosis—The Australian experience, Am. J. Clin. Hypn., 41, 29-37.

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International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley, P. B. Bloom

Copyright © 2001 John Wiley & Sons Ltd

ISBNs: 0-471-97009-3 (Hardback); 0-470-84640-2 (Electronic)

Hypnosis and Depression


University of Melbourne, Australia; University of Western Australia, Australia

Depression is a frequently occurring disorder with estimates of the lifetime risk for Major Depressive Disorder varying from 10 to 25% for women and from 5 to 12% for men. Significant levels of depression are also associated with many other major disorders, such as chronic pain. There appears to be a widespread assumption that hypnosis has no role, indeed is inappropriate, in the management of depression. In Australia, over the past 10 years, material presented for examination by the Australian Hypnosis Society or for publication in the Australian and New Zealand Journal of Hypnosis has not included any detailed description of clinical or experimental work on the use of hypnosis in the treatment of depression. The understanding has been that expert opinion regards hypnosis as contraindicated for the management of individuals presenting with depression. It would seem that the situation has not significantly changed since Burrows (1980) concluded that

It would seem nevertheless that most experienced clinicians teach that severe depressive illness is a definite contraindication to hypnosis. Although they teach this, depressive illness appears to have received, for such an exceedingly common medical problem, minimal attention in most modern reference books on hypnosis. A possible interpretation is that the authors concerned may believe hypnosis has little place in the therapy of depression, (p. 167)


A review of the literature indicates that the consensus of opinion is not, in fact, strongly opposed to the use of hypnosis in the treatment of depression. Commentators vary, however, in their readiness to accept the use of hypnosis unconditionally . Yapko (1992) advocates a broad-based acceptance: 'As for the specific contraindications to the use of hypnosis, it may seem a bold statement to make, but I am aware of no such contraindications' (p.   186). Clarke &

International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley and P. B. Bloom © 2001 John Wiley & Sons, Ltd


Jackson (1983) adopt a similar viewpoint, suggesting that the notion that hypnosis has no place in the treatment of depression is a 'bit of clinical folklore'. Miller (1984) produces a chapter on the application of hypnosis to the treatment of depression without questioning the appropriateness of this approach. Crasilneck & Hall (1985) advocate a more conservative view, listing some contraindications but concluding that 'while hypnosis can be used in treating depression, we strongly advise that such use be only by therapists adequately grounded in psychodynamics; even then it should be used with caution and care' (p. 324).

Given that significant differences exist between respected authors in the area, what accounts for this variation?


In terms of DSM-IV criteria, a diagnosis of Major Depression requires evidence of at least one primary symptom and at least four associated symptoms lasting nearly every day for at least two weeks. Depressed mood and a distinct loss of interest or pleasure in most or all activities (anhedonia) count as primary symptoms. The secondary symptoms are: (a) appetite disturbance or weight change; (b) sleep disturbance; (c) psychomotor agitation or retardation; (d) fatigue or loss of energy; (e) feelings of worthlessness or guilt; (f) diminished concentration or decision-making ability, (g) thoughts of death or suicide.

DSM-IV distinguishes between Major Depression and a range of other mood disorders including Dysthymic Disorder and Bipolar I Disorder. This range of classifications attempts to encompass the variety of presentations of significant depressive mood. Current thinking (e.g. Parker, 1996) emphasizes that the notion of depression includes a range of disorders: 'As "depression" encompasses heterogeneous conditions, single answers should not be sought'. Parker (1996) distinguishes between melancholic and non-melancholic depression in his challenge to current thinking about responsiveness to antidepres-sant medication and other treatments for depression. He argues that: 'Any study which amalgamates separate depressive subgroups, rapid and slow remitters, will give limited information as the "group" trajectory subsumes a set of potentially distinctly different trajectories'. Such thinking warns us against responding to depression as if it were a unitary construct and against too readily attempting to make generalizations about individuals struggling with depression.

Very little useful comparison can be made between treatment accounts unless some objective measure of depression has been utilized. Whilst the Hamilton Depression Rating Scale (HDRS) and the Beck Depression Inventory (BDI) are extensively used in research studies, they are only rarely utilized in the body of case accounts that form the data base in this area.



Yapko (1992) argues that the discrepancy in opinion about the value of hypnosis in the treatment of depression can, in part, be understood by variations in the model of hypnosis being utilized. He describes three general models: traditional, standardized, and utilization. Other workers distinguish between directive and non-directive or Ericksonian techniques. The opposition to the use of hypnosis in depression is primarily associated with the traditional, standardized or directive approaches and hence Yapko (1992) argues that the association is a function of the model of hypnosis used rather than of hypnosis per se. This point of view suggests the empirical question of whether one approach to working with depressed individuals is more useful than another.


Examination of published accounts suggests that, in addition to differences in hypnotic techniques, there is a great deal of variation in what therapists actually do with hypnosis in the management of depression. A review of the available documented case material indicates that there are a range of therapeutic goals either specifically stated or implied by the model of therapy associated with the use of hypnosis. Hypnosis is a tool, not a therapeutic model, and has been used to facilitate a range of different therapeutic approaches. The bulk of the published literature consists of case reports, often providing minimal detail of actual therapeutic practice and no objective documentation of outcome.


Very few clinicians describe a direct, symptom removal approach to the management of depression. Crasilneck & Hall (1985) state that 'we are careful to avoid a symptom removal approach' (p. 323). Yapko (1992) considers that suggesting a symptom away is valid as it serves as 'pattern interruption' but is inappropriate therapy unless it is also accompanied by 'pattern building', the establishment of new choices and behaviours (p. 52).

Milton Erickson's (described by Alexander, 1982) approach to the management of suicidal depression in a young woman is an elegant, indirect approach allowing a suggestion about the relief of pain to generalize to 'the much more profound and deeply disturbing depression' (p. 219).


One of the most comprehensively described treatment strategies which includes these aspects is Alladin's (1994) Cognitive Dissociative Model of non-endogenous


unipolar depression (CDMD). Whilst primarily utilizing cognitive strategies, Alladin (1994) describes a multifactorial approach, including the use of posture modification, attention switching, social skills training and goal setting with rehearsal using hypnotic induction techniques.


Alladin's (1994) Cognitive Dissociative Model utilizes the hypnotic process to facilitate cognitive restructuring. He describes a theoretical model linking hypnosis with depression and reports preliminary data finding no difference in outcome between this treatment methodology and Beck et al.'s (1979, 1985) cognitive therapy approach . However, subjects in the cognitive hypnotherapy group showed more rapid improvement, greater reduction in anxiety scores, and a significant increase in self-confidence.

Hypnosis has also been used to facilitate imagery techniques, from either a cognitive-behavioural or a psychodynamic theoretical framework. Fromm (1976) successfully used a metaphor of nature and new growth in her therapy with a woman following the deaths of her parents.


The majority of the earlier case reports describing the clinical use of hypnosis with depressed individuals have utilized a psychodynamic framework. Rosen (1955) describes the use of hypnotically induced regression, Abrams (1964) discusses the uncovering of repressed material and Chambers (1968) describes a woman's compulsion to eat raw potatoes in psychoanalytic terms. Haley (1967) details a case report of Milton Erickson's use of hypnosis with automatic drawing in a case of obsessional depression.

A significant amount of more recent case material also utilizes hypnotic techniques within a psychodynamic framework. Alden (1995) reports the case of a 35-year-old man with long-standing symptoms of anxiety, depression and multiple traumas, involving the use of hypnosis to provide a 'safe, relaxing framework for the client's therapy and regression to traumatic events'. Gravitz (1994) describes a treatment method illustrated by three cases involving the retrieval and restructuring of past memories of traumatic experiences using hypnotic regression and revivification. Leistikow (1990) details the case of a male patient undergoing hypnoanalysis for depression using techniques such as word association, dream suggestion and age regression in conjunction with hypnosis. Griggs (1989) also describes the process of medical hypnoanalysis, using hypnosis in conjunction with dream analysis and age regression. Mendelberg (1990) used an uncovering technique in


association with corrective imagery and relaxation with a 12-year-old depressed, asthmatic girl referred after her second suicide attempt.


Whilst a reduction in anxiety has been proposed as contributing to an increased suicide risk for the severely depressed (Crasilneck & Hall, 1985; Burrows, 1980), the use of hypnosis has been advocated for anxiety management for milder forms of depression. Burrows (1980) suggests that the relief of the patient's anxiety is a common approach. 'Direct suggestions of being able to feel less tense, relaxed, and ability to cope more realistically are useful' (p. 169).


In discussing their clinical use of hypnosis for depression, Crasilneck & Hall (1985) state that 'our approach is to increase the patient's ego strength and to enhance his ability to deal with the problems leading to depression' (p. 324). Sachs (1992) describes the use of ego-strengthening achieved by hypnotically enhanced mental imagery, in conjunction with progressive relaxation in the management of cancer patients. McBrien's (1990) depression prevention programme utilizes self-hypnosis to produce an increased confidence in managing and reducing depressed feelings. Hypnosis is also used to increase the ability to experience positive thoughts and feelings that lead to an increase in pleasant events.


The postulated relationship between depression, loss and internalized anger has informed a number of case reports. Abrams (1964), for example, describes the use of hypnosis to create situations in which the individual could learn to express unacceptable angry feelings.


Despite the concern expressed by some therapists that the use of hypnosis may increase suicide risk, other workers have attempted to use the technique to modify suicidal impulses. Hodge (1972, in Hammond, 1990) describes suggestions to deter suicide. These involve the use of direct suggestions to enter a trance and contact the therapist in response to suicidal ideation. 'In the trance you will be unable to commit suicide unless I give you permission; the trance itself may be just the factor you need to break up your suicidal thoughts and to help you to relax and find better ways to handle your problems' (p. 332). Wright & Wright (1987) describe the use of hypnotic techniques to develop a 'suicide fantasy' in which the suicidal images


and affect of the client were elicited and processed, enabling him to put these impulses aside to consider more adaptive life alternatives.


The process of hypnosis, in practice, is extremely variable. With a few exceptions (e.g. Yapko, 1992; Alladin, 1994) therapists rarely specify in any detail what they do in practice. It is clear that the comparison of treatment techniques and outcomes is extremely difficult when clinicians who describe their work broadly in terms of similar models are in practice doing very different things.


The reluctance to utilize hypnotic techniques in the management of depression is associated with a range of concerns or factors which are seen as contraindications. These include the following.


It has been argued that the risk of suicide makes the use of hypnosis dangerous in the management of depression. Crasilneck & Hall (1985) argue that hypnosis is inappropriately used in an outpatient setting for this reason. The potential for increased suicide risk has been explained in a number of ways. Burrows (1980) argues that hypnosis may inappropriately relieve anxiety before depressive affect has significantly lifted, allowing the depressed individual sufficient energy and anxiety reduction to act on suicidal impulses. Crasilneck & Hall (1985) observe that this phenomenon is not confined to hypnosis but has also been described for the range of treatment methods including psychotherapy, antidepressant medication and electroconvulsive therapy (p. 323). The evidence to support this proposal is primarily in the form of clinical case material, making it difficult to counter the criticism that, given the significant rate of suicide in patients with major depression, such case material represents a chance correlation.

Spiegel & Spiegel (1978) suggest that the potential for suicide lies in the possibility that the depressed individual will place unrealistic hopes in the trance experience as a way of ending their depression. These unmet expectations may result in a suicide attempt. Meares (1979) argues a similar viewpoint when he expresses his concern that: 'A trial of hypnotherapy usually leads to disappointment and may involve the patient in an unnecessary risk of suicide' (p. 293) Yapko (1992) is critical of the Spiegels and other workers in the field who emphasize the formal assessment of suggestibility, arguing that this promotes a sense of success or failure which may enhance suicide potential. He argues that negative expecta-


tions are a core component of depression and rather than being seen as a risk factor, they need to be addressed in treatment using hypnosis.

The conclusion from this literature is that relief of anxiety without associated improvement in depression and unmet treatment expectations are potential predictors of suicide risk. In fact, prediction of suicide risk has been well researched and there appears to be good agreement about the primary factors involved. Beck and coworkers (Beck, Rush et al., 1979; Beck, Brown et al., 1990), reporting two large-scale prospective studies of suicide, found that hopelessness, as measured by the Beck Hopelessness Scale (1988), was a powerful predictor of eventual suicide. Fawcett, Schefter, Clark et al. (1987), again utilizing a predictive design, also found that hopelessness was a significant predictor, as was loss of pleasure or interest and 'mood cycling during the index episode'. Fawcett et al. (1987) also refer to the predictive value of a variable they describe as 'depressive turmoil'. It is not clear whether this is related to anxiety but certainly the findings are in the opposite direction to that suggested in the clinical literature, that is, increased turmoil was associated with increased suicidal risk while the clinical hypothesis predicts that decreased anxiety is associated with increased risk.

Given our understanding that hopelessness is the best predictor of suicide risk, the decision for the clinician becomes whether to avoid the use of hypnosis with patients high on this variable, or to utilize hypnosis as a tool for the modification of hopelessness. The cognitive-behavioural literature provides some data relevant to the field of hypnosis. For example, a study by Rush, Beck, Kovacs et al. (1982), showed that depressed patients treated with cognitive therapy showed a more rapid reduction in hopelessness scores than a comparison group of depressed patients treated with an antidepressant drug.


There is a range of variations to this hypothesis that either individuals with depression are less able to attend or are less hypnotizable.

Spiegel & Spiegel (1978) suggest that: 'Those with serious depressions may be so narcissistically withdrawn and devoid of energy that they cannot attend to the input signals' (pp. 148-149). Others point to the difficulties in concentration and attention associated with severe depression, suggesting that these individuals are unable to focus on the induction process. Yapko (1992) talks about the way in which depression impairs the client's ability to focus. Rather than seeing this phenomenon as a contraindication for therapy, Yapko (1992) spends some sessions 'providing some general relaxation and focusing techniques to help build an attention span adequate to utilize in therapy'. He advocates the repeated use of session tapes as ongoing practice increases ability to focus meaningfully (p. 47).

Studies which compare various clinical populations in terms of level of hypnotiz-ability provide evidence on the question of whether depressed individuals are less


hypnotizable. Pettinati, Kogan, Evans et al. (1990) compared hypnotizability on two measures, the Hypnotic Induction Profile (HIP) and the Stanford Hypnotic Suggestibility Scale: C (SHSS: C) for five clinical and one normal college populations. The group with a diagnosis of major depression scored higher on the SHSS: C than the normal population and only marginally lower, although higher than the anorexia nervosa and schizophrenia groups, on the HIP.


This notion exists in a number of forms. Several commentators have suggested (e.g., Miller, 1979; Terman, 1980) that by focusing hypnotically on emotionally laden aspects of the individual's life, further disintegration of the ego may occur. Hypnosis has also been described as precipitating a more rapid development of 'transference' distortions which may result in the patient being over-reactive to specific therapy issues (Burrows, 1980). These issues appear to be related to the psychodynamic model of therapy which defines them rather than to hypnosis as a technique and there is no objective evidence to suggest that these are significant issues when the therapist is an experienced clinician.


Hammond (1990) discusses the use of age projection techniques with significantly depressed patients. He refers to Erika Fromm's belief that age regression procedures are contraindicated with seriously depressed and suicidal patients, despite Erickson's utilization of this method. Hammond urges 'great caution' in utilizing this technique with seriously depressed patients 'who may project themselves negatively into the future, stimulating further feelings of hopelessness' (p. 543).


Michael Yapko (1989, 1992, 1994) is the most prolific current therapist to enthusiastically embrace the application of hypnotic techniques to the management of depression. Unfortunately, it is necessary to agree with recent reviewers of his work (Stanley, 1994; Council, 1993) that what is undoubtedly a 'flexible and creative approach to patient management' (Stanley, 1994) is accompanied by a relative disregard for empirical data. Others have levelled this criticism at the Ericksonian/ brief therapy literature in general (Bloom, 1991). The criticism of a general lack of attention to theory, research and to standardize assessment, however, can validly be directed towards the body of published material in the area of hypnosis as a whole, which remains dominated by descriptive case material.

To make any useful statement about the value of hypnosis in the management of


depression, it is necessary to look more broadly at the wider research on depression and consider the ways in which hypnotic techniques may augment clinical approaches to the management of depression. The National Institute of Mental Health Treatment of Depression Collaborative Research Programme (TDCRP: Elkin, Parloff, Hadley & Autry, 1985) with its analysis and follow-up of 250 unipolar depressed outpatients at three different sites, randomly assigned to one of four treatment conditions (cognitive-behaviour therapy, imipramine plus clinical management, interpersonal psychotherapy and a pill-placebo control), contributes significantly to the current body of knowledge. The findings of this research and the ongoing debate (see, for example, Jacobson & Hollon, 1996) raise numerous significant issues for the area. As Shea, Elkin, Imber et al. (1992) point out, none of the treatments perform well in their capacity to promote lasting recovery. Major depression remains a challenge for all treatment approaches, including pharma-cotherapy. Jacobson & Hollon (1996) also raise the important issue of therapeutic allegiance in this context, suggesting that therapists who have a commitment to a specific treatment modality are likely to more effectively implement that treatment and less effectively implement others. Such considerations represent both a challenge and a potential source of increased power.


As summarized earlier, numerous case studies have suggested ways in which hypnotic methods can be utilized in psychodynamic therapy. Yapko (1989, 1992, 1994) has described a variety of indirect and metaphoric techniques in a cognitive-behavioural framework. However, as Stanley (1994) has commented, he has made little use of the wide variety of well-documented, more directive cognitive-behavioural techniques. The Cognitive Dissociative Model of nonendogenous unipolar depression (Alladin, 1994) attempts to utilize hypnosis and cognitive-behavioural techniques in a multifactorial treatment approach. The way in which hypnotic techniques may augment a cognitive-behavioural management programme for depression represents a challenge for future research.


A range of possibilities exists for the integration of hypnosis with cognitive-behavioural techniques. These include

1    A thorough assessment of depression, including records of activities, cognitions


and formal rating scales (such as the Hamilton Depression Rating Scale, the Beck Depression Inventory and the Beck Hopelessness Scale), is required so that an individualized treatment approach can be developed. It is highly likely that the severity of depression will be a significant factor in deciding the focus of treatment.

Hopelessness may need to be addressed before an individual experiencing
major depression is able to engage in any other aspect of therapy. An under
standing of hopelessness is a significant feature of cognitive-behavioural ap
proaches   to   depression.   The   learned  helplessness   model   of depression
(Abramson, Seligman & Teasdale, 1978) emphasizes 'depressive' attributional
style whilst Beck's (1979) theory of depression included a negative view of the
future as one aspect of his depressive triad. Yapko (1992) describes several
strategies to address hopelessness. Appendix A contains a description of a
possible approach to the modification of hopelessness using a hypnotic process.

Ego strengthening techniques hold considerable promise for the modification of
depression on theoretical grounds. A negative view of the self is one of the
primary components of Beck's (1979) cognitive triad. Hartland (1971) popular
ized the concept of 'ego-strengthening' and utilized it in much of his therapy to
reinforce self-reliance and a positive self-image, (see Hammond, 1990, for a
useful discussion and a range of hypnotic approaches to ego-strengthening).

The process of cognitive restructuring may be facilitated by the use of hypnotic
techniques. Alladin (1994) describes a process of cognitive restructuring under
hypnosis. Trance is established and the client imagines a situation that normally
causes distress. The client is then instructed to

focus on the dysfunctional cognitions and associated emotions, physiological, and behavioural responses. Encouragement is given to identify or 'freeze' (frame by frame, like a movie) the faulty cognitions in terms of thoughts, beliefs, images, fantasies, and daydreams. Once a particular set of faulty cognitions is frozen, the patient is helped to replace it by more appropriate thinking or imagination and then to attend to the resulting (desirable) 'syncretic' responses. This process is repeated until the patient can confidently restructure a set of faulty cognitions related to a specific situation, (p.283).

5 Hypnosis may be used to facilitate imagery and cognitive rehearsal strategies to
deal with depressive thoughts and behaviours. Clarke & Jackson's (1983)
method for the use of visualization and rehearsal strategies with hypnosis for
assertive problems (p. 256) may serve as a useful starting point for the use of
similar strategies for depression.


Hypnosis and depression have traditionally been regarded as 'forbidden friends' (Yapko, 1992). This taboo has prevented a serious assessment of whether hypnosis


has anything significant to contribute to the very common, challenging and disabling problem of depression. Closer examination suggests that there is little basis behind this lengthy separation, in fact there is considerable evidence of furtive meetings out of sight of mainstream books, journals and training courses. Both hypnosis and depression are heterogeneous constructs and a more useful association can be established by looking at questions related to the conditions under which various hypnotic approaches can be helpful for which aspects of what type of depression. The time for an open assessment of the strengths and weaknesses of this relationship is long overdue.


Abrams, S. (1964). Implications of learning therapy in treatment of depression by employing

hypnosis as an adjunctive technique. Am. J. Clirt. Hypn., 6, 313. Abramson, L. Y., Seligman, M. E. P. & Teasdale, J. D. (1978). Learned helplessness in

humans: Critique and reformulation. J. Abn. Psychol., 87, 49-74.

Alden, P. (1995). Back to the past: Introducing the 'bubble'. Contemp. Hypn., 12, 59-68. Alexander, L. (1982). Erickson's approach to hypnotic psychotherapy of depression. In J. K.

Zeig (Ed.), Ericksonian Approaches to Hypnosis and Psychotherapy. New York: Brunner/

Mazel. Alladin, A. (1994). Cognitive hypnotherapy with depression. J.  Cogn. Psychother: Int.

Quart., 8, 275-288. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental

Disorders 4th edn. Washington, DC: American Psychiatric Association. Beck, A., Brown, G., Berchick, R., Stewart, B. & Steer, R. (1990). Relationship between

hopelessness and ultimate suicide: A replication with psychiatric outpatients. Am. J.

Psychiat., 147, 190-195. Beck, A., Rush, J., Shaw, B. & Emery, G. (1979). Cognitive Therapy of Depression. New

York: Guilford Press. Beck, A., Steer, R., Kovacs, M. & Garrison, B. (1985). Hopelessness and eventual suicide: A

10 year prospective study of patients hospitalised with suicidal ideation. Am. J. Psychiat.,

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measuring depression. Arch. Gen. Psychiat., 4, 561-571. Bloom, P. B. (1991). Some general comments about Ericksonian hypnotherapy. Am. J. Clin.

Hypn., 33, 221-224. Burrows, G. D. (1980). Affective disorders and hypnosis. In G. D. Burrows & L. Dennerstein

(Eds), Handbook of Hypnosis and Psychosomatic Medicine (pp. 149-168). Amsterdam:

Elsevier. Chambers, H. (1968). Oral erotism revealed by hypnosis. Int. J.  Clin. Exp. Hypn., 16,

151-157. Clarke, J. C. & Jackson, J. A. (1983). Hypnosis and Behaviour Therapy. The Treatment of

Anxiety and Phobias. New York: Springer. Council, J. R. (1993). Book Review: Yapko, M. D. (Ed.), Brief Therapy Approaches to

Treating Anxiety and Depression. Int. J. Clin. Exp. Hypn., 41, 153 — 154. Crasilneck, H. R. & Hall, J. A. (1985). Clinical Hypnosis: Principles and Applications. New

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Elkin, I., Parloff, M. B., Hadley, S. W. & Autry, J. H. (1985). NIMH Treatment of Depression

Collaborative Research Programme: Background and research plan. Arch. Gen. Psychiatry, 42,305-316. Fawcett, J., Schefter, W., Clark, D., Hedeker, D., Gibbons, R. & Coryell, W. (1987). Clinical

predictors of suicide in patients with major affective disorder: A controlled prospective

study. Am. J. Psychiat., 144, 35-40. Fromm, E. (1976). Altered states of consciousness and ego psychology. Social Service Rev.,

50, 557-569. Fromm, E. & Nash, M. R. (Eds) (1992). Contemporary Hypnosis Research. New York:

Guilford Press. Gould, R. C. & Krynicki, V E. Comparative effectiveness of hypnotherapy on different

psychological symptoms. Am. J. Clin. Exp. Hypn., 32, 110-117. Gravitz, M. A. (1994). Memory reconstructed by hypnosis as a therapeutic technique.

Psychother, 31, 687-691. Griggs, N. (1989). The successful treatment of psychoneurosis and depression with medical

hypnosis. Med. Hypnoanal. J., 4, 41-44. Haley, J. (Ed.) (1967). Advanced Techniques of Hypnosis and Therapy. Selected Papers of

Milton H. Erickson. New York: Grune & Stratton. Hamilton, M. (1967). Development of a rating scale for primary depressive illness. Br. J.

Soc. Clin. Psychol, 6, 278-296. Hammond, D. C. (1990). Handbook of Hypnotic Suggestions and Metaphors. New York:

W. W. Norton. Hartland, J. (1971). Medical and Dental Hypnosis and its Clinical Applications, 2nd edn.

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Hypnotic Suggestions and Metaphors. New York: W. W. Norton. Jacobson, N. S. & Hollon, S. D. (1996) Cognitive-behaviour therapy versus pharmacother-

apy: Now that the Jury's returned its verdict, it's time to present the rest of the evidence. J.

Consult. Clin. Psychol, 64, 74-80.

Leistikow, D. (1990). Rapid therapy. Med. Psychoanal. J., 5, 163-167. McBrien, R. J. (1990). A self-hypnosis programme for depression management. Special

issue: Hypnosis. Individ. Psychol. J. Adlerian Theory, Res. Pract., 46, 481-489. Meares, A. (1979). A System of Medical Hypnosis. New York: Julian Press. Mendelberg, H. E. (1990). Hypnosis with a depressed, suicidal, asthmatic girl. Psychother.

Private Pract., 8, 41-48. Miller, H. R. (1984). Depression—A specific cognitive pattern. In W. C. Wester II & A. H.

Smith  (Eds),   Clinical Hypnosis.  A  Multidisciplinary Approach.  Philadelphia:   J.  B.


Miller, M. (1979). Therapeutic Hypnosis. New York: Julian Human Sciences Press. Parker, G. (1996). On brightening up. Triggers and trajectories to recovery from depression.

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Hypnotizability  of psychiatric  inpatients  according to  two  different  scales.  Am.  J.

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depressed patient. Int. J. Clin. Exp. Hypn., 3, 58-70. Rush, A. J., Beck, A. T., Kovacs, M., Weissenburger, J. & Hollon, S. D. (1982). Comparison

of the effects of cognitive therapy and pharmacotherapy on hopelessness and self-concept.

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Sachs, B. C. (1992). Coping with cancer. Stress Med., 8, 167-170. Shea, M. T., Elkin, I., Imber, S. D., Sotsky, S. M., Watkins, J. T., Collins, J. F., Pilkonis, P. A.,


Beckham, E., Glass, D. R., Dolan, R. T. & Parloff, M. B. (1992). Course of depressive symptoms over follow-up: Findings from the National Institute of Mental Health Treatment of Depression Collaborative Research Programme. Arch. Gen. Psychiat., 49, 782-787.

Spiegel, H. & Spiegel, D. (1978). Trance and Treatment. New York: Basic Books.

Stanley, R. (1994). Book Review: Yapko, M. D., Hypnosis in the Treatment of Depressions: Strategies for Change. Int. J. Clin. Exp. Hypn., 42, 94—96.

Terman, S. (1980). Hypnosis and depression. In H. Wain (Ed.), Clinical Hypnosis in Medicine. Chicago: Year Book Medical Publishers.

Wright, M. & Wright, B. (1987). Clinical Practice of Hypnotherapy. New York: Guilford Press.

Yapko, M. D. (Ed.) (1989). Brief Therapy Approaches to Treating Anxiety and Depression. New York: Brunner/Mazel.

Yapko, M. D. (1992). Hypnosis in the Treatment of Depressions. Strategies for Change. New York: Brunner/Mazel.

Yapko, M. D. (1994). When Living Hurts: Directives for Treating Depression. New York: Brunner/Mazel.



Individuals experiencing depression express a pervasive sense of hopelessness. The present is seen as negative and joyless and the future is just more of the same. It is important, in order to do any useful work, to attempt to modify this stable negative attribution that characterizes depressed thinking. Ideally the clinician will utilize material from the client to facilitate a trance induction aimed at the modification of hopelessness. Sometimes, in order to access a client's involvement in the process of change, it will be necessary to begin by working with little information other than the client's sense of hopelessness. The following script is one possible approach.

I wonder ... whether you can allow yourself to notice ... the heaviness of the depression ... like a heavy blanket of dark smoke ... Allow yourself... to let go, not struggle ... to simply experience the weight of the depression that ties you down ... And as you look around in your mind's eye, it is as if a fire has been through the landscape and left nothing untouched ... it seems as if the blackness, the barrenness, reaches all the way to the end of your vision ... without change ... and there is no way ... to be less tired ... weighed down ... by the heavy dark cloud of depression ... There is such stillness that... it seems as if... no change is possible ... that there will always be ... the endless wait ... to be ... always tied. And you know ... that this heaviness has been with you for some time ... and you have come to believe ... that this is the pattern of your life ... that the future will be ... more of the same ... and there will be no way out.

And perhaps ... as you notice the heaviness of your body ... I wonder if you can discover ... that some of that heaviness that weighs you down ... is a sense of increasing relaxation ... and your wait ... can feel like an untying. Let yourself ... become aware ... of the point where the wait becomes ... the burden of curiosity ...


to know ... what awaits you. As you allow yourself ... to continue to experience ... the comfortable weight... of a deep, relaxed tiredness. And perhaps now, perhaps in a short time ... it becomes possible ... to discover a part of you that begins to see another way ... to be less tied ... to discover ... that tomorrow is not tied to today. That it is possible ... to allow yourself to discover ... that something else awaits you ... and you can begin to untie this waiting and ... find a way forward.

As you look around ... in what seems like endless blackness ... I wonder if you can look closely enough to see ... the beginnings of new growth ... Because you know ... that Nature will always find a way ... to renew. Even when the landscape ... seems overwhelmingly barren ... it is always possible ... to find signs of change ... Because change can move so gradually ... perhaps you can begin to let yourself notice ... how much the comfortable weight of relaxation can seem lighter ... And the heavy darkness of night... becomes the lightness of day ... because you know ... that there will always be ... a moving forward ... And you can discover yourself less tied to the darkness ... and increasingly aware of signs of the lightness ahead ... More and more, it will be possible to be aware of renewal ... of the growth of new beginnings ... of patterns of light and shade ... and the greater lightness that awaits.


 International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley, P. B. Bloom

Copyright © 2001 John Wiley & Sons Ltd

ISBNs: 0-471-97009-3 (Hardback); 0-470-84640-2 (Electronic)

Hypnosis, Dissociation and Trauma


Stanford University School of Medicine, USA

This chapter was initially prepared as part of a visit to the Oklahoma Psychiatric Association five months after the bombing of the Alfred P. Murrah Federal Office Building on 19 April 1995. A powerful bomb was exploded in front of the building that morning, killing almost 200 people, destroying the Federal Building, and damaging buildings within a 12-block radius. I will delineate the nature and prevalence of post-traumatic stress disorder symptoms in the aftermath of such trauma, the role of dissociative features in such symptoms, and treatment approaches, including the use of hypnosis.


The DSM-IV (APA, 1994) diagnostic criteria for acute and post-traumatic stress disorder (PTSD) involve intrusion, dissociative, avoidance, and hyperarousal symptoms in the aftermath of a traumatic stressor. A taxi driver in Oklahoma City said: 'Oklahoma lost its innocence in this attack, the sense of being the heartland, of being safe.' He added: 'I used to like driving downtown, but I don't work downtown much any more. It just doesn't have the same feeling that it used to.' A psychiatrist who was head of the disaster committee commented that things seemed so unreal to him that he had trouble recounting the details of what had happened that day afterwards: 'Although I was feeling like a fraud because the event and job seemed unreal, I was amazed at the universally receptive response to my calls. There was a feeling of relief, as though each contact was a symbolic bridge between islands' (Poarch, 1995, p. 9).

Post-traumatic stress disorder is a disturbingly common problem. For example, in the United States a study by Naomi Breslau and colleagues (Breslau, Davis et al., 1991; Breslau & Davis, 1992) demonstrated that 9% of the population of Detroit had post-traumatic stress disorder. The leading cause of deaths of young adults is automobile accidents and there is much associated physical and psycholo-

International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley and P. B. Bloom © 2001 John Wiley & Sons, Ltd


gical trauma in relation to that. Firearms are the leading cause of death for young people in Texas. Physical trauma is a major cause of mortality and morbidity in the United States and that means that psychological syndromes which accompany trauma are a very prevalent part of our collective psychological experience. There are estimates that 12 million adult women have been raped in the United States and another 10 million have been victims of aggravated assault. (Bowners, O' Gorman et al., 1991; Browne, 1993; Koss, 1993a, b; Koss, Heise et al., 1994). Edna Foa's work (Foa & Riggs, 1993), and that of others, suggests that some two-thirds of women who have been raped develop post-traumatic stress disorder, 45% have the disorder 3 months later, and among all rape victims regardless of time since the trauma, 15% suffer PTSD. It can be, it isn' t always, but it can be a lifelong disorder. Similarly studies of Vietnam era veterans indicate that somewhere between 15 and 25% of veterans suffer from post-traumatic stress disorder (Keane & Fairbank, 1983). This is a huge proportion of the population. While the majority of people who have been through terrible trauma do not get post-traumatic stress disorder, a substantial minority do. This compels us to understand the phenomenology as a first step to diagnosis and treatment.


There has been a tendency to slip into one of two mistaken extremes in regard to PTSD. One is a cynical attitude which implies that most patients are making up their symptoms for secondary gain. An example is a case in which an armored car driver was shot in the chest three times during a robbery. His two colleagues were killed as they were walking out of an elevator. The company he worked for objected to providing treatment for post-traumatic stress disorder. This was not some fantasy of childhood sexual abuse: he took three bullets in the chest and saw two of his friends die and yet there was doubt that he had genuine psychiatric symptoms afterwards. One of our professional responsibilities is to have the kind of educated empathy to understand what it is like to go through this and be able to articulate that. Post-traumatic symptoms often involve considerable (and frequently inappropriate) guilt about imagined or real lapses during the traumatic event. This can generalize into a sense of shame, reducing the willingness of patients with PTSD to talk about their symptoms.

On the other hand, there is a victimology approach that can allow people to evade responsibility for all aspects of their lives because they have been victimized. For example, some patients with an axis II antisocial personality disorder may be looking for an excuse to blame everybody else for their problems in living.

The concept of post-traumatic stress disorder has had a rather checkered history. It has tended to emerge largely in the aftermath of war. During and after World War I there was discussion of 'shell shock'. The treatment then infantilized patients by removing those who could not function in combat as far from it as possible. They


usually remained emotional cripples much of their life because the premise was they had been so neurologically damaged that there was no repairing them. This turned out to be a mistake. So in World War II the term was changed to traumatic neurosis, and the idea there was to treat people 'within the sound of the guns' (Kardiner & Spiegel, 1947). This was a much better idea because it acknowledged the reality of intense reaction but did not presume that you had to consolidate it by pulling the soldiers away from their combat duties. Most were able to respond, which was a major advance. However, with the development of the psychoanalytic model there was more emphasis placed on early childhood development and less of the effect of proximate trauma. Indeed much has been made of Freud's abandonment of the trauma theory in the etiology of neuroses and the subsequent development of a metapsychology which emphasized the role of unconscious fears and wishes in developing symptoms rather than traumatic experiences. It came to be believed that the reason people got PTSD was because of developmental difficulties. This point of view can be seen as a denial of the reality of trauma. Indeed the idea that traumatic experience is less important than developmental history in the etiology of PTSD is problematic because it fits into a common fantasy that we control and therefore deserve whatever happens to us, thereby creating inappropriate guilt for events over which we have no control. Such thinking allows one to distance oneself from being in the category of potential victim. But this denies the existential reality that we are all in the category of potential victim.

However, the psychoanalytic domination of traumatology was ended in 1944 when Eric Lindemann wrote his classic paper on the symptomatology and management of acute grief (Lindemann, 1944[94]). He described the now-familiar symptoms of PTSD in his study of the aftermath of the Coconut Grove Night Club fire, in which hundreds of people were killed or badly wounded. He saw people who were agitated, restless, pacing, experiencing a sense of unreality, somatic discomfort, and intrusive recollections of the fire. He classified them into three groups: (a) people who had extreme symptoms: hyperactive, restless, unable to sleep, some became psychotic; (b) people who were acutely agitated and went through a very difficult period of adjustment but then recovered; (c) those who acted as through nothing had happened. An example of this last group is a man whose wife had been killed and the next day he went to work and said 'well she would want me to go on with things and I should just go on'. Lindemann found that people at either extreme did the worst. The ones who were the most severely agitated did very badly. But the ones on the other end of the symptom continuum, who pretended nothing had happened, also did very badly. A number had committed suicide within several years. Lindemann then describes how the principles of grief work as a means of working through and beyond trauma, which means mourning what was lost. He noted that it was necessary to decathect a loved one who had died before it was possible to recathect to someone new. Grief work may also involve the loss of a sense of personal invulnerability, or the loss of somatic function due to injury. This conceptualization makes it understandable why some people who appear to be


getting through a traumatic experience with little or no disturbance may be at elevated risk for subsequent psychiatric difficulties. Dissociative symptoms during and in the aftermath of trauma may interfere with this process of working through traumatic experiences (Spiegel & Cardena, 1991). Thus depersonalization, dereali-zation, dissociative amnesia, or numbing may interfere with necessary emotional and cognitive processing in the aftermath of trauma. Thus the ones who look the best may actually be doing the worst. These people often don't ask for help, but need it.

With the Vietnam era there was renewed interest in post-traumatic stress disorder. PTSD was a special problem in Vietnam because of the lack of community support for the war, and the rotation system which meant that soldiers came and went alone for a fixed period of time, rather than with their units (Spiegel, 1981). Soldiers could be in the jungles dying with their comrades one day and 72 hours later they were back on the streets of their home town, alone, with no one to talk to. The fact that we lost the war complicated reintegration of combat experiences as well. Many Vietnam era veterans reported outright hostility from veterans of other wars. Thus PTSD was found to be relatively common and persistent long after the end of the Vietnam War (Keane & Fairbank, 1983).



Trauma can be understood as the experience of being made into an object, a thing, the victim of nature's indifference, of somebody else's rage. The key issue in trauma is neither fear nor pain, but rather helplessness. For a period of time one has no control over what is happening to their body. It is not uncommon for trauma victims to detach themselves emotionally and cognitively mentally from traumatic experience as it is occurring, as a means of protecting oneself from the reality of threat.

A young woman who was quite hypnotizable and was using self-hypnosis quite effectively to control anxiety related to her Hodgkin's Disease, described a prior hospitalization during a routine psychiatric interview: 'Well yes, I once fell off a third story balcony and fractured my pelvis.' I inquired whether she had been suicidal: 'Did you jump?' She said 'No, I was pushed.' I became concerned that she was paranoid. She then said, 'I was at this party and a big huge guy, twice my size, turned around suddenly with a beer in his hand and just knocked me over the railing. It was just a stupid accident.' When I said 'That must have been horrifying,' she said 'No, actually it was quite pleasant.' At this point I became even more concerned. I said 'What do you mean?' She said, 'I imaged it as if I was on another balcony watching a pink cloud float down to the ground. I felt no pain at all, and in fact I tried to walk back upstairs.'


More examples of this kind of extreme dissociative response to trauma emerged, leading to more systematic examination of the connection between trauma and dissociation. The phenomenology of post-traumatic stress disorder involves, first of all, a traumatically stressful event (APA, 1994). In the DSM-IV there are two components. The first is the actual experience: The person experienced, witnessed, or was confronted with an event or events that involved an actual or threatened death or serious injury, or a threat to the physical integrity of self or others (p. 209). The second requirement is 'the person's response involved intense fear, helplessness, or horror' (p. 209). The idea was to make it a stringent requirement. There are problems, however, with this definition in that some peoples' reaction to fear, helplessness or horror may come a long time after the trauma itself.


Then there are three classes of symptoms. First are the intrusive symptoms. The persistent and unbidden reexperiencing of the traumatic event, which includes distressing recurrent images, recollections, flashbacks, dreams, nightmares, delusions or hallucinations. In the example given earlier of the armored car driver who was shot, he said: 'I don't just think about this guy. When an elevator door opens in front of me, I see that guy' This kind of intense reliving of the event, as though it were happening, is typical of people with post-traumatic stress disorder, including 'intense distress at internal or external cues that symbolize or resemble an aspect of the traumatic event' (p. 210). Only one such intrusive symptom is required for the diagnosis.


The second class of symptoms are the avoidance symptoms, like the Oklahoma City taxi driver who would not drive downtown much anymore: 'Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness' (p. 210). Examples include efforts to avoid thoughts or feelings about the event, efforts to avoid activities that arouse recollections, inability to recall important aspects of the trauma, feeling detached or estranged from others, diminished interest in usually pleasurable activities, restricted range of affect, and a sense of a foreshortened future (p. 21). Three such symptoms are required for the diagnosis ofPTSD.


The fourth criterion involves hyperarousal symptoms: trouble falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and an exaggerated startled response. Two such symptoms are required. The reader may notice that in many ways these symptoms seem inconsistent. How can one be


numb, detached and avoidant and at the same time have intrusive flashbacks and nightmares? The crucial issue is that the cluster of PTSD symptoms is a combination of intrusion and avoidance. These sometimes come in sequence, sometimes with more intrusion, sometimes more avoidance. But the normal homeostatic equilibrium, the control of one's inner life, is very much disrupted by traumatic stressors. The worse the intrusions are, the more desperate are the efforts to avoid them. Indeed, the flashbacks and hyperarousal come to symbolically represent the traumatic circumstance itself, repetitively imposing distress just as the assailant, accident, or natural disaster did.


There is growing interest in the overlap between hypnotic and dissociative states and post-traumatic stress disorder. Hypnosis has three main components: absorption, dissociation, and suggestibility (Spiegel, 1994). There is a clear analogy between these components of hypnosis and the above described categories of symptoms of PTSD.


Absorption involves an intense focus, like looking through a telephoto lens in a camera (Tellegen & Atkinson, 1974). When people are having flashbacks, that is all they are aware of. Elizabeth Loftus has written about what she calls the weapon focus in crime victims (Loftus, 1979). The police are frustrated when someone who has just been mugged gives them a brilliant description of the gun, but has no recollection of the face of the assailant. They were so focused on the thing that was threatening them that the ordinary peripheral awareness is something they don't have. There are studies that show that literally when people are aroused and stressed the things that are at the periphery of awareness just are not registered in the same way because they are so focused (Loftus & Burns, 1982), One part of the transformation and experience that occurs during trauma is this narrowing of the focus of attention.


The second is detachment or dissociation. People tend to compartmentalize aspects of experience. Trauma can be thought of as a sudden discontinuity in experience. In traumatic circumstances, what is normally a smooth continuum of experience suddenly becomes a discontinuity. This can be reflected by a discontinuity in mental function. Often one's self-image is radically altered by the traumatic experience—the loss of control, sense of vulnerability, indignity, and fear can suddenly create a radically different view of self. This can lead to a compartmenta-lization of these different aspects of experience.


If the state of mind occurring at the time of the trauma is altered or hypnotic-like, the way memories are stored may be influenced by this narrowness of attentional focus. The range of associations may be more limited and therefore those that exist more intense. Strong emotion, for example, which is usually associated with traumatic memories, may influence both storage and retrieval (Cahill, Prins et al., 1994). There is evidence that congruence in mood between the state in which memories were stored and that in which they are retrieved improves recall (Bower, 1981). Similarly, another form of state dependency involves the dissociative state itself. To the extent that individuals do enter a spontaneous dissociative state during trauma, the memories may be stored in a manner that reflects this state (e.g. narrower range of associations to context). There may be fewer cross-connections to other related memories (Evans, 1988; Evans & Kihl-strom, 1973; Hilgard, 1986). Furthermore, retrieval should be facilitated by being in a similar dissociated state, for example hypnosis. Trauma can be conceptualized as a sudden discontinuity in experience. This may explain the reversibility of dissociative amnesia with techniques such as hypnosis (Spiegel & Spiegel, 1978; Loewenstein, 1991).

That such amnesia for traumatic events does occur is most convincingly demonstrated by Williams. She obtained hospital records of 129 women indicating emergency room contact for sexual or physical abuse, and interviewed them an average of 17 years later. The results were striking: 38% of the subjects did not report the abuse that had been recorded, nor did they report any sexual abuse by the same perpetrator. Indeed, 12% reported no abuse at all (Williams, 1994). An additional 16% (10% of the whole sample) of the women who did remember the abuse, reported that there was a period in their lives when they could not remember it (Williams, 1995). In fact, if the analysis was conservatively restricted to only those with recorded medical evidence of genital trauma and whose accounts were rated as most credible (in the 1970s), 52% did not remember the sexual abuse. It should be noted that this lack of memory was not diagnosed as a dissociative disorder, but the interviews were not designed to establish the presence or absence of any psychiatric disorder, merely the presence or absence of traumatic memories. It makes sense that mental processes which segregate one set of associations from another might well impair memory storage or retrieval (Kihlstrom, 1987).


The third component of hypnosis is suggestibility, a tendency to respond readily and uncritically to social cues. The hyperarousal states in PTSD are analogous to that. On the other hand, during trauma many people find themselves in a 'state of shock', responding in an automaton-like fashion. In a traumatic situation, as people narrow the focus of attention they tend to act without thinking about consequences. The police, for example, frequently do not believe a rape victim's story because she doesn't fit their image of what rape victims should look like. A supposedly classic


rape victim is bruised, with torn clothing and a tearful, hysterical demeanor. Most rape victims don't look like that. They are desperately trying to maintain some semblance of their dignity, emotional control, and their prior ordinary life. They wish it were a bad dream and it would all go away, and often overcontrol their affect rather than expressing it. At the same time, they are exquisitely sensitive to cues that may trigger recollection of the trauma—this hypersensitivity is a kind of suggestibility.


There is growing clinical and some empirical evidence that dissociation may occur especially as a defense during trauma, an attempt to maintain mental control just as physical control is lost (Spiegel, 1984; Kluft, 1985; Putnam, 1985; Spiegel, 1988; Bremner, Southwick et al., 1992; Cardena & Spiegel, 1993; Koopman, Classen et al., 1994; Mannar, Weiss et al.,1994; Butler & Spiegel, 1997; Butler, Jasiukaitis, Koopman & Spiegel, 1997). Fifteen studies of immediate psychological reactions within the first month following a major disaster provide evidence of a high prevalence of dissociative symptoms, and some show that such symptoms are strong predictors of the development of post-traumatic stress disorder. These studies examined the experiences of survivors, victims and their families, and rescue workers in a variety of disasters: the Coconut Grove fire mentioned earlier (Linde-mann, 1944[94]), the 1972 Buffalo Creek flood disaster caused by the collapse of a dam (Titchener & Kapp, 1976); automobile and other accidents and serious illnesses (Noyes, Hoenk et al., 1977; Noyes & Kletti, 1977; Noyes & Slyman, 1978); correctional officers' experience as hostages in a New Mexico penitentiary (Hillman, 1981); the collapse of the Hyatt Regency Hotel skywalk in Kansas City (Wilkinson, 1983); a lightning strike disaster that killed one child with others present (Dollinger, 1985) a 1984 tornado that devastated a North Carolina community (Madakasira, 1987); an airplane crash-landing (Sloan, 1988); an ambush in a war zone in Namibia (Feinstein, 1989); the 1989 Loma Prieta earthquake in the San Francisco Bay Area (Cardena & Spiegel, 1993); the Oakland-Berkeley firestorm (Koopman, 1994); witnessing an execution (Freinkel, Koopman et al., 1994); and shootings in a highrise office building (Classen, Abramson et al., 1997).

Survivors of these traumatic situations reported a variety of dissociative symptoms. Stupor, a dulling of the senses and decreased behavioral responsiveness have been described in survivors of automobile accidents (Noyes et al., 1977). Amnesia or memory impairment was reported by 29% of the Bay Area earthquake victims (Cardena & Spiegel, 1993) and by 8 out of 14 of the soldiers directly involved in the Namibia ambush (Feinstein, 1989). Impairment of memory or concentration was reported by 79% of the airplane crash-landing survivors (Sloan, 1988). One boy in the lightning strike disaster had total amnesia for the event (Dollinger, 1985).

Numbing, loss of interest, and an inability to feel deeply about anything, were


reported in about a third of the survivors of the Hyatt Regency skywalk collapse (Wilkinson, 1983), and in a similar proportion of survivors of the North Sea oil rig collapse (Holen, 1993). This is consistent with our findings among survivors of the Loma Prieta earthquake (Cardena & Spiegel 1993). A quarter of a sample of normal students reported marked depersonalization during and immediately after the earthquake, and 40% described derealization, the surroundings seeming unreal or dreamlike. While the most common reported memory problem was intrusive recollection, 29% of the sample reported difficulties with everyday memory.

Dissociative symptoms have also been retrospectively reported to occur during combat. Bremner et al. (1992) administered the Dissociative Experiences Scale (DES) to 85 Vietnam veterans, 53 with PTSD and 32 with medical problems. They found that the DES scores of 53 Vietnam veterans with PTSD were twice as high as those obtained among a comparison sample of 32 other veterans. Veterans with PTSD have been found to obtain higher scores on measures of hypnotizability as well (Stutman & Bliss, 1985; Spiegel, 1988).


Dissociative symptoms, especially numbing, have been found to be rather strong predictors of later post-traumatic stress disorder (McFarlane, 1986; Solomon, Mikulincer et al. 1989; Koopman et al., 1994, 1996; Classen et al., 1997). McFarlane found that the time course of dissociative symptoms is critical in the prediction of subsequent PTSD (McFarlane, 1997). Automobile accident victims' dissociation scores on the day of the trauma did not predict subsequent PTSD symptoms, their dissociation scores at 10 days did. Thus a failure to readjust quickly after trauma seems to place people at higher risk for later PTSD. Thus, physical trauma seems to elicit dissociation or compartmentalization of experience, and may often become the matrix for later post-traumatic symptomatology, such as dissociative amnesia for the traumatic episode. Indeed, more extreme dissociative disorders, such as Dissociative Identity Disorder, have been conceptualized as chronic Post-traumatic Stress Disorders (Spiegel, 1984, 1986; Kluft,1985). Children exposed to multiple trauma are more likely to use dissociative mechanisms which include spontaneous trance episodes (Terr, 1991). Recollection of trauma tends to have an off-on quality involving either intrusion or avoidance (Horowitz, 1976) in which victims either intensively relive the trauma as though it were recurring, or have difficulty remembering it. Thus, physical trauma seems to elicit dissociative responses.


This evidence reviewed above regarding the prevalence of dissociative and other symptoms in the immediate aftermath of trauma formed the basis for including


Acute Stress Disorder (ASD) as a new diagnosis in the DSM-IV (Spiegel & Cardena, 1991; Liebowitz, Barlow et al., 1994). It is diagnosed when high levels of dissociative, anxiety and other symptoms occur within one month of trauma, and persist for at least 2 days, causing distress and dysfunction. Such individuals must have experienced or witnessed physical trauma, and responded with intense fear, helplessness, or horror. This 'A' criterion of the DSM-IV requirements for ASD is identical to that of PTSD. The individual must have at least three of the following five dissociative symptoms: depersonalization, derealization, amnesia, numbing, or stupor. In addition, the trauma victim must have one symptom from each of the three classic PTSD categories: intrusion of traumatic memories, including nightmares and flashbacks; avoidance; and anxiety or hyperarousal. If the symptoms persist beyond a month, the person receives another diagnosis based on symptom patterns. Likely candidates are dissociative, anxiety or post-traumatic stress disorders.


Three types of psychotherapy have been applied to PTSD: psychodynamic, cognitive-behavioral (CBT), and hypnotic-re structuring. In each of these approaches, telling and retelling the story of the trauma is an essential element, albeit with different methods and goals: clarification of unconscious themes and transference distortions in psychodynamic treatment, correction of cognitive distortions in CBT, and abreaction and the restructuring of traumatic memories with the help of hypnosis.

Psychodynamic treatment is rooted in the exploration of unconscious implications of traumatic loss, with the premise that the disorder is complicated by unconscious implications of the trauma (Horowitz, 1976; Horowitz, Wilner et al., 1980). At the same time it can help to strengthen ego function by bringing unconscious determinants of symptomatology into conscious awareness, thereby rendering the symptoms less overwhelming and facilitating coping (Marmar, Weiss & Pynoos, 1995; Menninger & Wilkinson, 1988).

The helplessness imposed at the time of trauma is seen as generalizing to encompass the self as helpless in other domains of life, a fate experienced as deserved. Ironically, fantasies of omnipotence reinforce rather than contradict this self-schema. Attempts to compensate for the lack of control imposed by traumatic stress often lead to guilt-inducing fantasies of unrealistic control: the accident or assault should have been foreseen and therefore avoided. Therefore it happened because of a lapse of judgment or personality defect rather than the randomness of life. Fantasized guilt at 'causing' trauma is for some more bearable than enduring the helplessness engendered by it.

Psychodynamic psychotherapy is aimed at unearthing and working through such unconscious determinants of symptoms, through retellings of the story of the


trauma, analysis of dreams and intrusive recollections, and exploration of transference issues. The 'traumatic transference' is important, since many trauma victims displace onto the therapist feelings they have about the trauma or traumatizer. They are also quite sensitive to apparent rejection by the therapist, feeling ashamed by their traumatic experience. Clarifying transference distortions can help patients accept and integrate traumatic experiences and repair damage to the self-concept.

Cognitive-behavioral approaches are based in part on the concept of systematic desensitization (Foa & Rothbaum, 1989; Foa, Davidson et al., 1995). Repeated reaccessing of traumatic memories in a more benign therapeutic context gradually deprives them of their affect-arousing qualities. Furthermore, distorting effects of the traumatically induced self-assessment are challenged: the fact that it happened does not imply that the victim deserved it, or that the victim deserves mistreatment in other situations. The retelling is intended to diffuse emotion and provide an opportunity for clarifying and correcting trauma-contaminated cognitions (Keane, Fairbank et al., 1989; Cooper & Clum, 1989).

Since the hypnotizability of Vietnam veterans with PTSD has been found to be higher than that of other populations (Stutman & Bliss, 1985; Spiegel, Hunt et al., 1988), it makes sense that techniques employing hypnosis should be useful. Especially if traumatized individuals with PTSD are in a spontaneous dissociative state during and immediately after the trauma, hypnosis is likely to be helpful in tapping traumatic memories by recreating a similar type of mental state. The literature on state-dependent memory (Bower, 1981) indicates that the content of memory is better retrieved when the individual is in the same mental state at the time of retrieval that he or she was in when the information was acquired. Therefore the ability to tolerate congruent (and painful) affect would seem to be a prerequisite for retrieval of traumatic memories. Similar to predominant affect, the structure of consciousness itself, such as being in a dissociative or hypnotic state, constitutes another mental state which can facilitate recollection.

Treatment employing hypnosis is now seen as involving not merely abreaction of traumatic memories, but working through them by assisting with the management of uncomfortable affect, enhancing the patient's control over them, and enabling him to cognitively restructure their meaning (Spiegel & Spiegel, 1978; Spiegel, 1981, 1992, 1997). Catharsis is a beginning, but it is not an end in itself, and can lead to retraumatization if the catharsis is not accompanied by support in managing affective response, control over the accessing of memories, and working them through. A grief work model (Lindemann 1944[94]) is useful. Observations of normal grief after trauma have led to a recognition that a certain amount of emotional discomfort and physical restlessness and hyperarousal is a natural, and indeed necessary, part of acknowledging, bearing, and putting into perspective traumatic memories (Spiegel, 1986; Spiegel & Cardena, 1990). This is often facilitated by using a hypnotic imaging technique, the 'split screen', in which the patient is asked to picture some aspect of the trauma on one side of the screen,


bearing the associated uncomfortable affect, and then to picture on the other side of the screen something he or she did for self-protection or to aid others. In this way the traumatic memory is acknowledged but restructured to encompass efforts at mastery as well as helplessness.


The principles of this kind of psychotherapy can be summarized with the following eight Cs:

Confrontation. It is important to confront the traumatic events directly rather than attribute the symptoms to some long-standing family or personality problem. Confession. It is often necessary to help trauma survivors to confess deeds or emotions that are embarrassing to them and at times repugnant to the therapist. It is important to help these patients distinguish between misplaced guilt and real remorse. They may well be telling the therapist aspects of the traumatic event that they have discussed with no one else.

Consolation. The intensity of traumatic experiences requires an actively consoling approach from the therapist, lest he or she be perceived as being judgmental or as inflicting rather than treating trauma-induced pain. Appropriate expressions of sympathy and concern can be helpful in acknowledging and diffusing this common reaction.

Condensation. Find an image that condenses a crucial aspect of the traumatic experience. This representation can make the overwhelming aspects of the trauma more manageable by putting it in concrete, symbolic form. Furthermore, this approach can be used to facilitate restructuring of the experience by joining previously disparate images, for example, linking the pain associated with the death of a friend in combat with the happiness experienced during some earlier shared time. This allows patients to alter the pain of the loss by attending to positive aspects of the lost relationship that remain in memory.

Consciousness. Make conscious previously dissociated traumatic memories in a gradual manner that does not overwhelm the patient.

Concentration. Use the intense and focused concentration characteristic of the hypnotic state to reinforce the boundaries of the traumatic experience and the painful affect associated with it. Directing sharply defined attention on the loss also implies that when the hypnotic state is ended, attention can be shifted away from the traumatic experience.

Control. Because the most painful aspect of severe trauma is the absolute sense of helplessness, the loss of control over one's body and the course of events, it is especially important that the process by which the therapeutic intervention is conducted enhance the patient's sense of control over the traumatic memories. Structure the experience so that patients are given the opportunity to terminate the working through when they feel they have had enough, can remember as much


from the hypnosis as they care to, and feel they are in charge of the self-hypnosis experience. They should learn to use it on their own as a self-hypnosis exercise as well as with the therapist. Such procedures help patients to deal with traumatic memories with a greater sense of control and mastery.

Congruence. The goal is to help patients integrate dissociated or repressed traumatic material into conscious awareness in such a way that they can tolerate experiencing the memories as part of themselves. In this way the traumatic past is not incompatible with their present experience. Patients should emerge from therapy having reviewed not only what was done to them but what they did to protect themselves, not only what they lost but what they had valued and why.


Post-traumatic stress disorder is a challenge in many ways. It challenges patients' defenses, interferes with working through of traumatic experiences, and impairs function. It poses special problems for families as well as therapists who treat it. Working with survivors of trauma forces therapists to confront their own vulnerabilities as well. Maintaining an empathic connection with such patients is crucial to the treatment of people who feel ashamed and degraded, and yet it stimulates difficult emotions in those who do this work. When the traumatic stressor is a collective one, as in the Oklahoma City bombing, symptoms of intrusion, avoidance, and hyperarousal may affect the community as a whole. At the same time, community action and support can help to heal the wounds inflicted by the violence. People gathered and left mementos by the hundreds on the fence surrounding the damaged building: flowers, poems, stuffed teddy bears. One group showed photographs of the blasted shell of the building with cloudy 'figures' which they claimed represented the spirits of those who had died watching after injured children in the rubble. There is a strong human need to make some kind of sense out of tragedy. While some trauma defies meaning, psychotherapeutic techniques, including the use of hypnosis, can help in finding meaning and managing emotion in the aftermath of traumatic stress.


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 International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley, P. B. Bloom

Copyright © 2001 John Wiley & Sons Ltd

ISBNs: 0-471-97009-3 (Hardback); 0-470-84640-2 (Electronic)

Conversion Disorders


University of Nijmegen, The Netherlands


Trillat (1986) concluded his Histoire de I'hysterie with the words, 'Hysteria is dead, that is clear. She has taken her riddles with her to the grave.' We must agree with Mace (1992a,b), however, that this is not entirely true. Patients still suffer from the often strange motor symptoms of conversion hysteria. Over recent years, patients have presented for treatment at our psychiatric outpatient unit specializing in such complaints with the following symptoms: attack-like swinging and swaying of arms and legs, shaking attacks of the head in which nodding and a side-to-side movement alternate, paralysis of one side of the body, paralysis of both legs, blindness, the loss of the sense of smell or taste, total loss of coordination of the muscles, pseudo fits, cramps in the hand or foot, the inability to open the eyes, numbness in both legs, inability to speak, the inability to speak above a whisper, pseudo spastic speech, the inability to swallow, tremors of the arms, legs or head, and assorted disorders relating to the senses and pain. What is remarkable is that these patients have often already been treated for many years outside the areas of psychiatry and psychology by a neurologist or rehabilitation specialist.

The terms 'hysteria' and 'conversion' have often been used interchangeably. 'Hysteria' comes from the Greek for womb. The ancient Greeks thought that the many starkly changing complaints were caused by the womb moving about within the body (Abse, 1974). Abse refers to Plato (c.360 bc) on the subject: 'and the same is the case with the so-called womb or matrix of women; the animal within them is desirous of procreating children, and when remaining unfruitful long beyond its proper time, gets discontented and angry, and wandering in every direction through the body, closes up the passages of the breath, and, by obstructing respiration, drives them to extremity, causing all varieties of disease.' The term 'conversion' was already in use as far back as the Middle Ages. There are descriptions from that period of women suffering from what was called 'suffocation of the womb' (Mace, 1992a) a syndrome which, following an emotional crisis, tended to develop into various other syndromes; that is, the one syndrome as it were

International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley and P. B. Bloom © 2001 John Wiley & Sons, Ltd


'converted itself into another. It is not difficult to recognize in this echoes of hysteria.

In DSM-IV (APA, 1994), conversion disorder is defined as follows: the diagnosis 'conversion disorder' is applicable when the complaints consist of unexplainable disorders of the voluntary muscular tissue or of the sensory functions. The symptoms suggest a neurological or other physical disorder. However, no physical explanation for the complaints is discovered, so they are referred to as pseudoneur-ological. Moreover, psychological factors (e.g. stress) should be associated with the onset or an exacerbation of the complaints.

The theories which attempt to explain the onset of a conversion disorder are speculative in nature. Good empirical research is lacking, but theories that have stood the test of time have one important aspect in common—the underlying notion that conversion symptoms are brought on by particular events that are experienced as threatening or catastrophic. These can be either one-off calamities or threatening circumstances that persist over many years.

Support for this supposition has come from, for example, studies of incest victims and the incidence of conversion symptoms in men during wartime. Albach (1993) studied the incidence of conversion symptoms in victims of incest (n = 97) and in a control group (n = 65). The finding was that the women in the incest group exhibited these phenomena significantly more often. Paralysis, blindness, deafness and similar afflictions were shown by 26%, as against 0% in the control group. For fainting, the percentages were respectively 28 and 0%. For 'hysterical attacks'—the term used to cover episodes of kicking and screaming followed by imperfect memory of the event—the percentages were respectively 28 and 3%. These are impressive differences, though it must be noted that much could be said about the methodology employed in this study.

Farley, Woodruff & Guze (1968) also found a high incidence of conversion symptoms in 100 otherwise healthy mothers of new-born children. The percentages here were: paralyses, 22%; fainting, 5%; hysterical attacks, 4%. It should be noted, however, that the authors did not check for a history of incest.

The disorder is rare in men, except in wartime. 'We've never seen so much male hysteria,' commented Binswanger in his book on war hysteria, recounting his experiences of treating First World War soldiers (Binswanger, 1922). Carden & Schramel (1966) studied 12 Vietnam soldiers with conversion disorders. In each case, the conversion symptoms had come on quite soon (within hours or days) following a traumatic event (e.g. a bomb attack).

Recent research has pointed to a relationship between trauma and dissociation (Boon & Draijer, 1993; Chu & Dill, 1990; Vanderlinden, van Dyck, Vandereycken & Vertommen, 1993; for an overview, see Spiegel, 1993). Cognitive theorists such as Kihlstrom see conversion disorder as a dissociative disorder (Kihlstrom, 1992a) and indeed it is classified as such in ICD-10 (World Health Organization, 1992). There are indications that the way in which the memory of traumatic events is stored differs from the norm (Alpert, 1995; Christianson, 1992; Le Doux, 1993; van derKolk, 1994;


van der Kolk & Fisler, 1995). Van der Kolk suggests that dissociation is a characteristic feature of traumatic memory (van der Kolk & Fisler, 1995). In extreme stress the 'memory categorization system'—in which the hippocampus plays a central role— may break down and, as a result, memories are stored as fragmented affective and perceptual states with little verbal representation (van der Kolk, 1994). When these individual sensory and affective imprints are incorporated into a coherent account, the result is a semantic and therefore explicit memory. The processing of perceptual features is more rapid than semantic processing. The former can take place on an implicit, unconscious level, whilst the latter, precisely because it is concerned with supplying meaning, is associated with consciousness (Kihlstrom, 1992b).

It may be concluded from the above that traumas play a significant role in the development of dissociative disorders. The same cannot be said with any certainty about the development of conversion disorders since, though they are frequently regarded as dissociative disorders, there is a lack of systematic research into the occurrence of traumas in their etiology.

Inconsistencies in the symptom pattern can be seen both in patients with a conversion disorder and in those with a dissociative disorder. An example of the former is that of a patient at our clinic who could not see, but was perfectly able to walk across a room full of furniture without bumping into any of it. She was also able to 'guess' how many fingers were being held up in front of her. She was asked to look in the direction of the fingers and call out the first figure between one and ten that came into her head. She never failed to give the correct answer. When asked, 'But how did you know that?', she replied, 'You'll have to explain it to me. I can't see anything and yet you tell me I keep getting the answer right.' There clearly is perception, however much the patient might not realize it (Kihlstrom, 1992b).

Various reports on these inconsistencies in dissociative disorders are reviewed by Kihlstrom, Tataryn and Hoyt (1990) and Schacter and Kihlstrom (1989). For example, Lyon (1985) describes a patient suffering from amnesia who was asked to dial a telephone number at random. The number she dialed turned out to be her mother's. In the same way, we asked a patient with total amnesia to give us her date of birth. She did not know the answer. Then we asked her to say the first date that came into her head, and it was her birthday.

It would seem from the above that, despite the patients' protestations that they cannot remember or have not seen things, these 'not remembered' or 'not seen' facts or events still influence their experiences, thoughts and behaviour (see Kihlstrom, 1992b).


The so-called dissociative phenomena are explained by Kihlstrom as follows. The information is not processed explicitly; the patient does not consciously perceive


an object or remember a happening. Implicitly, however, the stimuli do influence the patient's behaviour. These observations support the view that there are two memory systems: the explicit memory system and the implicit memory system (Schacter, 1987) or memory with and without awareness (Jacoby & Dallas, 1981). A similar distinction is suggested for perception (Kihlstrom 1992b). Alongside implicit memory and perception, Kihlstrom (1992b) talks of unconscious emotion and cognition as information processes that can influence ongoing experience, thought and action, outside of the phenomenal awareness.

Dissociation and the hypnotic trance are closely related. Hypnosis can be seen as an altered state of consciousness in which it is possible to focus the attention in a particular direction and thus easily achieve a state of muscle relaxation. During this procedure it is possible to change a subject's experience of pain, cold, heat and other sensory perceptions (Frankel, 1978). This kind of altered perception could also occur in patients with conversion symptoms. Patients feel their legs are paralysed and behave like someone whose paralysis has a physical cause. They see that they are paralysed and feel paralysed. Under hypnosis, disorders such those seen in conversion patients can be evoked and made to disappear again in very suggestible subjects.

Research carried out by Bliss (1984) revealed that patients who suffer from a conversion disorder are exceptionally suggestible. The Stanford Hypnotic Susceptibility Scale (Form C, range 0-12) was used to measure the suggestibility of 18 patients. Their average score was 9.7 ± 0.48, significantly higher than that of a control group of cigarette smokers (6.6 ± 0.37). The conversion patients' average places them in the top 10% of the population with regard to suggestibility. This is the level of suggestibility required for a subject under hypnosis to have auditory hallucinations or negative visual hallucinations (not seeing things which are actually there). Bliss (1984) suggests that the ability to put oneself very rapidly into a state of trance (the hypnoid state) can be regarded as a primitive defense mechanism. The conversion symptoms might therefore be brought on by self-hypnosis.

A reflection of this can be found in the animal kingdom. When danger threatens animals might flee or, if they are suitably equipped, fight. There are times, however, when the enemy is too powerful, too strong or too fast. For these situations some animals have a third possibility, the 'Totstellreflex', or 'playing possum' as it is more commonly known in English. A good example of this is the mouse that appears to be dead when carried into the house by the cat, but who later runs away. The reaction can also be seen in insects such as the dung beetle, in spiders and in fish. Anglers are very familiar with the sight of a large bream floating on its side for a while without moving after having been caught and thrown back in the water. Similar behaviour can be found in birds, crocodiles, snakes, chickens and guinea pigs.

A reaction similar to the 'Totstellreflex' is the way some animals suddenly feign disability. Taylor (1986) describes, for example, how a curlew with young chicks


imitates the behaviour of a bird with a broken wing to distract a bird of prey away from the nest. Similar violent, almost uncoordinated motor reactions are also seen in various other animals exposed to extreme threat. When captured, a bee will buzz around as though demented; a bird caught in a room will flutter desperately, flying against walls and windows in its panic.

In animals these phenomena are survival mechanisms triggered by danger (cf. Hoogduin, 1988). In people, too, the dissociative reaction seems to be a way of coping with extreme circumstances.

The following points can be made in summary of the foregoing:

Patients with conversion symptoms develop the disorder when they have been,
either long term or momentarily, in severely threatening situations.

There are indications that a similar mechanism lies at the root of both
conversion disorder and dissociation

Conversion symptoms resemble states or conditions that can be induced
through hypnosis.

Conversion symptoms resemble behaviours sometimes observed in animals at
moments of extreme threat.

THE HYPNOTHERAPEUTIC STRATEGY (Hoogduin & van Dyck, 1990,1992)

Van Dyck and Hoogduin (1989) divided hypnotic intervention into two broad categories: symptom directed and exploratory. The former is the older of the two and consists of the creation of a state of heightened suggestibility in order to influence symptoms in a favourable way. In the exploratory approach, techniques such as revivification or age regression are used in order to discover the possible cause of the symptoms. This may be followed by symptom-directed suggestions.

The procedures described here are a combination—where possible—of both these strategies. Firstly, investigations were carried out to discover whether the onset of the conversion symptoms had been preceded by some traumatic experience. If so, revivification was used, followed by an attempt to influence the symptoms both directly and indirectly. Where no psychological trauma was discovered, the approach was limited to direct and indirect influence of the symptoms.

The treatment strategy suggested here is therefore the following:

A rationale, explaining that the symptoms are the result of strong emotions
which the patient has been unable to deal with and that, by reliving the event
which gave rise to the emotions, these will be re-experienced and dealt with,
causing a reduction of the symptoms.

Formal trance-induction with revivification during which the patient is encour
aged to give free rein to any emotions.


Post-hypnotic suggestions: at the end of the session, the post-hypnotic sugges
tion is made that the patient will be able to continue dealing with the emotions,
e.g., at night during sleep in the form of dreams.

The use of direct and indirect suggestions to reduce the symptoms.

Training in autohypnosis using audio-cassettes.

Face saving: this can be ensured by emphasizing the importance and gravity of
revivification, preferably in the presence of the partner or parents of the patient.
Giving the treatment an aura of importance and gravity ties in with the rationale
of the patient's being unable to deal with such intense emotions earlier.

Rehabilitation: when improvement occurs in symptoms which have existed for
years, good physiotherapeutic rehabilitation and guidance are essential.

Influencing stress factors which have contributed to the onset of the disorder.

Influencing any possible reinforcement of the disorder by those close to the
patient. This often involves correcting the attitude of the partner or parents who
often play a significant role in sustaining the notion that the disorder is physical
(Taylor, 1986).

When no indication is found that revivification is necessary, this element is left
out of the procedure. The rest of the treatment strategy remains the same, i.e.,
direct and indirect influence of the symptoms, a plausible rationale, formal
trance-induction and post-hypnotic suggestions. Face saving, rehabilitation and
influencing any possible antecedent or consequential factors also remain part of
the treatment strategy.


Treatment, by Revivification, of a Woman Suffering from Flaccid Paralysis of Both Legs

Mrs A is a 40-year-old teacher who feels that her life has not been easy. She sees her marriage and family as a heavy burden. Her relationship with her partner had been bad for about ten years. During this time, Mrs A had had back trouble and had undergone an operation for a slipped disc, but even after the operation, she had continued to feel pain in her back.

After a fearful argument one day, her husband decided to leave her. In desperation she went to run after him, whereupon she became paralysed in both legs and fell. Her husband came back to her that evening and there was no more talk of separation. The paralysis nevertheless persisted.

Various admissions to hospital and inpatient treatment for a year in a rehabilitation centre were of no avail; the patient was confined to a wheelchair and eventually moved into a house specially designed for people in this condition.

The years rolled by. Then, almost 9 years after the onset of the paralysis, a social worker who had heard that the condition of such patients can often be improved by the use of hypnosis, registered Mrs A for treatment.


On examination, it was found that the legs were completely paralysed from the knee down and that there was only minimal strength from the knee up. Various neurological tests provided no explanation. Conversion syndrome seemed to be a reasonable diagnosis. It was explained to the patient that sometimes when a person is subjected to extreme stress, the tensions and emotions experienced can manifest themselves by affecting a particular part of the body. It was then suggested that if such emotions are re-experienced and dealt with, normal function could possibly be restored to the part of the body affected.

In the second session, during an extremely emotional re-experience of the events of 9 years previously, the patient moved her foot a few centimeters. This happened again in the following session. She managed to move her foot intentionally by thinking back. Subsequently, with the help of post-hypnotic suggestion, the patient managed to move her foot when she was not in a state of trance.

Gradually she overcame the disability and, after about 6 months, was practically cured. On follow-up examination 6 months later, it was found that her condition had in no way deteriorated and she is now able to go for walks of about an hour's duration.

Treatment by Direct and Indirect Suggestions

Mrs B was 42 years old when she was referred for treatment for a clenched fist. She had had the condition for 11 months without intermission. It had first occurred 16 years previously. She had been riding her bike when suddenly, and possibly as a joke, a truck driver had sounded his horn very loudly. Her reaction had been to grip the handlebars very tightly and, as a result, both her hands had cramped up. She had managed to release the handlebars, but thereafter her left hand had remained cramped for some months. She had subsequently suffered from periods of cramping of shorter and longer duration. The last, which had occurred 4 years previously, had lasted for 8 months. Between these periods her hand was completely normal. Sometimes the clenched fist relaxed spontaneously, at other times it had to be treated by a hypnotherapist. However, for the 11 months prior to her referral to our outpatient clinic, treatment had been entirely unsuccessful.

The patient was married and had four healthy children. She said that she was not subject to stress or tension, and had no particular problems. She had never been, nor was she overburdened in any way.

The fist looked strange, quite unlike the sort of fist a person would normally make. The knuckles were sunken rather than protruding. The muscle tone in the arm was normal, even though it was impossible for the therapist attempting to open the fist, to move the fingers even by a millimeter. There was some movement, but only at the knuckle joints. The complaint was limited to the fingers (i.e. not the thumb) of her dominant left hand.

The only change in her life due to the handicap was that she could no longer peel potatoes. She was well able to carry out all her other household chores. Repeated


neurological examinations had revealed no abnormalities. Thorough investigation did reveal, however, that there had been many physical complaints in the past which conformed to the DSM-III-R diagnostic criteria for somatization disorder.

At the fifth session it was suggested to the patient that the object she was holding—a big plastic foam egg—was growing alternately bigger and smaller, so that the hand opened and closed a little. After an hour and a half, her fingertips were pink and the hand was relaxed and able to open. The patient was then told to come out of the trance with her arm still in a relaxed state. She did so and the symptoms had disappeared.

The session ended with a discussion of the possibility that the hand might close up again. The patient was told that if that happened, she must above all remain calm and that she would have to learn, through hypnosis, to gain control over the condition.

At the sixth session it was possible to evoke the condition and then make it go away again. The patient was then taught how to do this. She was asked first of all, while in a deep trance, to close her right hand and then to open it slowly, so as to teach her left hand to open. This suggestion appeared to work well. The depth of trance was then lessened during the exercises. Finally she managed to open the hand using the procedure outlined here and without formal hypnosis.

On follow-up a year later, the cramping was still causing her some problems, but she was managing to open the fist without help. At that time she was complaining of a burning sensation in the eye. She was seen by an ophthalmologist, who could not find a somatic cause for her complaint (Hoogduin, Akkermans, Oudshoorn & Reinders, 1993).

Reversed Hand Levitation in a Case of Pseudo-ataxia

Mrs C is a 40-year-old hairdresser who had been suffering from ataxia for about 7 years. She could not carry out coordinated, goal-directed movements of her hands. When she tried to bring her hands together, for example, they missed each other by several centimeters. Sometimes the action was so uncontrolled that she hit her hands against a wall or cupboard. She could barely eat or drink without help. She only managed to do the former by holding her face very close to the plate.

A second major complaint was a coordination disorder of the torso muscles. When Mrs C tried to stand up, for example, her torso swayed in all directions and she could not walk unaided. She managed to move about with the help of a walking-stick, but still with a swaying motion. This did not, however, cause her to fall. The complaints had come on suddenly. Some 7 years previously she had had to have an operation. She had been frightened by the idea of anaesthetization because a friend had previously spent a long time in a coma after having been anaesthetized. On the morning of the operation Mrs C had woken up completely paralysed and the operation had had to be cancelled. Muscle power had returned after a few days, but the patient had been left with the ataxic complaints, which had remained unex-


plained despite exhaustive and repeated neurological investigations. In the end the patient had been declared unfit for work. The complaints had remained unchanged for about 6 years. In addition to the complaints already described, she had arthritis of the right knee, as a result of which she was becoming less and less able to walk. The combination of the ataxia and the pain ended in the patient being confined to a wheelchair and this increasing invalidity prompted the treating neurologist to suggest referral.

During the intake procedure (at which her husband was present) the patient appeared to have little faith in the possibility that a psychiatrist could help her achieve an improvement in her condition. She had just undergone 2 years of treatment by hypnosis and had unsuccessfully tried many different medicines. She had in fact resigned herself to her invalidity and had only kept the appointment on the urgent entreaty of the neurologist who had referred her.

In her treatment use was made of catalepsy induction as described by Sacerdote. As an explanation for the complaints, the patient was told that it was evidently an obscure condition that probably had its origins in neuropsychological, psychological, neurophysiological and neurobiochemical processes—too subtle, therefore, to be detected via crude neurological diagnostic procedures. The treatment could simply consist of an investigation into the possibilities of regaining some control over the complaints, with the help of hypnosis; not the sort of hypnosis she had already had, which had been a kind of discovery hypnotherapy, but with a technique that worked directly on the muscles. Sacerdote's technique was then applied to the right hand. Within a few minutes the hand was cataleptic and the patient experienced the hand as dissociated. A demonstration of the resultant analgesia of the hand was used to emphasize how remarkable a state this was.

The next phase of the treatment was given over to teaching the patient to move the dissociated hand very carefully. In the first instance the suggestion was given that the hand could move its position a little by itself. Once this had been achieved and the hand was still, the patient could eventually move her right hand, albeit very slowly and stiffly.

Her husband was then taught how to help his wife achieve the feeling of dissociation of the hand and an exercise programme was devised in which the patient would gradually learn how to use the hand again to do some of the tasks about the house. This was a great success. After four sessions the patient was able once again to use both arms somewhat robotically but without ataxia.

The coordination disorders in the patient's torso were the second target for treatment. Here too, use was made of the Sacerdote technique. First, with the patient standing, a state of catalepsy was evoked in both arms. One of the patient's hands was then placed on the front of her hipbone. The therapist then put one hand on the patient's back and the other hand over the hand on her hip. By pushing the patient slowly backwards and forwards, applying pressure first to one hand and then to the other, it was possible to extend the cataleptic state to the whole body. In the end it was barely possible to push the patient off balance. She was then asked to


'spontaneously' slide her foot forward a little. She managed this, albeit rather sluggishly and woodenly. Finally, the patient was given a programme of exercises that she could do with her husband's help, so that she could progress from these stiff, robot-like first steps to once again being able to carry out normal movements. Six treatment sessions later, Mrs C was able to walk for 15 minutes without ataxia. She still complained of tiredness, but the wheelchair was once and for all relegated to the attic. On follow-up 3 years later, she was still without complaints (Hoogduin & van de Kraan, 1987).


Although clinical treatment involving hypnosis appears to offer the possibility of a favourable result for patients with a motor conversion disorder, it is as well here to finish on a note of caution. It is important to remember that there is a very real chance that a patient who appears to have conversion symptoms could actually be suffering from a severe physical condition. The diagnosis 'conversion disorder' should only be considered when thorough somatic and neurological investigation has produced no explanation for the complaints and, even when this is the case, the therapist must remain alert to adverse changes. If there is any doubt, one should always seek further neurological examination. The patient will only appreciate such caution.

No less than 26-60% of patients diagnosed as having a conversion disorder later turn out to have a severe (neurological) disorder (Weintraub, 1983). Two patients provide sad illustration of this. The first was a 40-year-old woman who declared in a very theatrical manner that she had a bloated feeling in her abdomen. She also said she was experiencing some pain in her back and rather unpleasant sensations in her legs. Repeated (and also clinical) neurological investigations offered no explanation for the complaints. A few months later, after having been discharged from the neurological clinic, the patient was readmitted to hospital with a tumour on the spinal cord membrane.

A second patient who, also in a very theatrical manner, said that she could not talk properly and clearly tried to demonstrate this, was convinced that her symptoms were physical and refused to follow the directions given her by the psychotherapist. Indeed, she wanted nothing to do with him. She died a year later as a result of a tumour of the cerebellum.

A further note for caution is that it is not known for certain that hypnosis is an essential element in all the cases where treatment involving it leads to a favourable result. There is a great need for controlled research in this area. It is possible to be equally brief, however, in one's conclusions relating to other treatment strategies: there has been no controlled research. There are, however, some well-documented case descriptions from which it can reasonably be supposed that behaviour therapy


and physiotherapy achieve very positive results (Kop, van der Heijden, Hoogduin & Schaap, 1995; Hoogduin et al., 1993).


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 International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley, P. B. Bloom

Copyright © 2001 John Wiley & Sons Ltd

ISBNs: 0-471-97009-3 (Hardback); 0-470-84640-2 (Electronic)

Personality and Psychotic Disorders*


Human Resource Consultants, Chapel Hill, NC, USA



The current status of clinical hypnosis in the treatment of Personality and Psychotic Disorders has been evolving since the mid-1800s. The earliest notation of successful hypnosis with a psychotic patient was reported by Esquirol in 1838. In this report, Esquirol described experiments done by Abbe Faria and himself in 1813 and 1816 on the effects of magnetism in mental disease. Esquirol reported that he and Faria experimented on eleven women, either insane or monomanic. He stated that only one of these eleven women responded to the magnetic influence (Lavoie & Sabourin, 1980).

Later, in 1868, Dr Andries Hoek, a practicing physician in The Hague, reported on his successful treatment of a psychotic patient with hypnosis in 1851 (van der Hart & van der Velden, 1987). Following this report by Hoek, the French psychiatrist Auguste Voisin also reported positive clinical work with psychotic patients (1884, 1887, 1897a,b). Voisin described work with patients with delusional psychotic conditions and was enthusiastic about the therapeutic results of the use of hypnosis with these conditions. Voisin estimated that 10% of the psychotic population was hypnotizable.

However, following these moderately encouraging reports of Esquirol, Hoek and Voisin, several subsequent clinical reports indicated varying and conflicting results with hypnosis and severe mental illness. Pitres (1891), reporting on his clinical studies with psychotics, concluded that persons suffering from nonhysterical delusions did not usually profit from 'suggestive therapy'. Terrien (1902) concluded from his studies that hypnotism was not useful in the treatment of severe mental

* See the Editor's Note on page 186.

International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley and P. B. Bloom © 2001 John Wiley & Sons, Ltd


illness in general. Tuckey (1902) also concluded that the possibility of hypnotism being successful in the treatment of severe mental illness was very poor. Gilles de la Tourette (1889) reported, in partial agreement with Pitres, that hypnosis was successful only with delusional hysterics or manic patients. Grasset (1916) concluded that hypnosis did some good for hysterical psychotics (if they were hypnotizable), but he did not feel that hypnosis was useful for psychotic disorders of attention, or 'true psychosis'. In general, many clinicians in the late 1800s and early 1900s held a rather pessimistic attitude toward the hypnotizability and use of hypnosis with psychotics, but nevertheless reported on some successful and useful individual cases (Lavoie & Sabourin, 1980).

However, an exception to this pessimistic attitude was presented by Wetterstrand (1902). With unusual perceptiveness and foresight for his time, Wetterstrand stated that the main difficulties in utilizing hypnosis with severely disturbed mental patients were the difficulty in obtaining consent of the subjects and the difficulty in maintaining their attention and cooperation over a sufficient time period. Wetterstrand concluded that hypnosis could be possible and useful in certain stages of psychosis depending on these factors of attention and cooperation. He further proposed that, in order to work successfully with psychotic patients with hypnosis, it was essential to reach the subjective world of the patient. Wetterstrand also reported some success in clinical hypnosis with psychotics in influencing various symptoms, including hallucinations and persecutory ideation.

Again sounding a more pessimistic note, Copeland & Kitching (1937) reported on a study utilizing hypnosis in the diagnosis and treatment of severely mentally ill hospitalized patients. They concluded, with somewhat circular reasoning, that 'true psychotics' could not be hypnotized. They stated that, 'If susceptibility to hypnosis developed, we were compelled to reverse the diagnosis'.1

As recently as the mid-1900s, clinical reports continued to note the difficulty of utilizing hypnosis with psychotic patients (Schilder & Kauders, 1926 [1956]; Kraines, 1941; London, 1947). However, they also began more frequently to note limited, specific areas of successful hypnotic work with psychotic patients. Schilder and Kauders noted that cases of schizophrenia that initially presented the clinical picture of neurosis were frequently amenable to hypnotic intervention. London reported the uncovering of important clinical material in the hypnotic treatment of a paranoid condition.


A significant breakthrough in understanding the potential use of hypnosis with psychotic patients came in 1945 with the publication of Lewis Wolberg's book on the hypnoanalysis of Johan R. Johan R. had been confined on the chronic ward of a hospital with a diagnosis of hebephrenic schizophrenia when Wolberg first attempted to work with him. It took Wolberg more than a year to establish a


beginning therapy relationship with the patient. Beginning with traditional psychoanalytic techniques, Wolberg decided to experiment with hypnosis when the patient experienced difficulty with traditional free association. Initial attempts at hypnosis were unsuccessful. However, eventually dream interpretation allowed the patient to utilize hypnosis and ultimately to conclude a positive hypnoanalytic treatment. Johan R. was eventually discharged with no outward trace of mental disorder. A post-treatment Rorschach test revealed no evidence of anxiety and no neurotic or psychotic tendencies. A follow-up by Wolberg 16 years later indicated that Johan was continuing to live a productive, independent life.

Following Wolberg's landmark book, the work of Margaretta Bowers provided another major advance in our understanding of the clinical potential of hypnosis with psychotic patients. Bowers (Bowers, Berkowitz & Brecher, 1954) expanded the concept of the use of hypnosis for the severely disturbed patient from the unique individual case to the general class of severe mental illness. In 1954, Bowers reported on positive hypnotherapy work she had done with a series of 10 psychotic and other severely disordered patients. In later publications, she summarized hypnotic work with a series of 30 chronic, ambulatory schizophrenics and addressed the issues of the use of hypnosis with schizophrenic patients as a general group (Bowers, Berkowitz & Brecher, 1954; Bowers, 1961; Bowers, Brecher-Marer & Polatin, 1961; Bowers, 1964). Bowers also reported on her early use of hypnosis with positive clinical results with Multiple Personality Disorders (Bowers & Brecher, 1955; Bowers, Brecher-Marer et al., 1971). Bowers concluded that psychosis was a defense and that it was the task of the therapist to assist the healthy self to regain its lost dominance over the defensive facade presented by the psychotic patient. Bowers felt that hypnosis was a powerful tool to assist the therapist in this task of connecting with and reestablishing the dominance of the 'healthy self.

Following the pivotal and pioneering work of Wolberg and of Bowers in the mid-1900s, a continual flow of clinical work utilizing hypnosis with severely disturbed patients was reported in the literature. Schmidhofer (1952) reported symptom relief in groups of psychotic war veterans through relaxation and suggestion. Danis (1961) reported that some of his schizophrenic patients were able to utilize hypnosis to help them to sustain and continue their ongoing therapy work. Stauffacher (1958) described the successful treatment with hypnosis of a paranoid schizophrenic male patient. Hypnosis was utilized to help the patient uncover repressed material. The patient was able to utilize the insight from these recovered memories and to achieve a complete remission of his illness.

Then in 1959, Gill and Brenman reported that while most schizophrenics in their studies were apparently not amenable to hypnosis, nevertheless some schizophrenics were paradoxically highly responsive to hypnosis. Gill and Brenman reported specifically on successful hypnotic therapy intervention with a 'severely disturbed schizophrenic girl, regarded by most of the staff as hopelessly psychotic'. The positive response and clinical improvement in this severely disturbed psychotic patient, as reported by Gill and Brenman, was unmistakable and impressive.


Abrams (1963) also described hypnotherapy work with a female inpatient diagnosed as 'schizophrenic reaction, chronic undifferentiated type'. Her symptoms included hallucinations and delusions. During previous treatment, she had not responded to psychotherapy, electroconvulsive therapy, or to drug therapy. With the introduction of hypnosis into her therapy treatment the patient exhibited a reduction of resistance which enabled her to discuss previously unapproachable/inaccessib