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Table of contents :
I Special Addresses.- Scottish Contributions to the Development of Hypnosis and Psychosomatic Medicine.- Hypnosis - Both Poetry and Science.- Conscious and Unconscious Processes in Hypnosis.- The Clinical Relevance of Hypnotizability in Psychosis: With Reference to Thinking Processes and Sample Variances.- II Behavior in Hypnosis.- In Search of Hypnosis.- The Relevance of Hypnotizability in Clinical Behavior.- Interaction Between Hypnotist and Subject: A Social Psychophysiological Approach.- Non-Volition and Hypnosis.- Visual Memory Processing During Hypnosis: Does it Differ From Waking?.- A Study on the Hypnotic Susceptibility of Persons Attempting Suicide: Some Therapeutic Considerations.- III Electrophysiological Studies.- EEG Evoked Potential, Hypnotic Anosmia, and Transient Olfactory Stimulation in High and Low Susceptible Subjects.- Depth EEG Recordings in Epileptic Patients During Hypnotic and Non-Hypnotic States.- Evoked Potential Correlates of Verbal Versus Imagery Coding in Hypnosis.- Hemispheric Specificity and Hypnotizability: An Overview of Ongoing EEG Research in South Australia.- Some Neuromuscular Phenomena in Hypnosis.- IV Self Hypnosis.- The Essential Aspects of Self-Hypnosis.- Representations of Self-Hypnosis in Personal Narratives.- An Investigation into Audiotaped Self-Hypnosis Training in Pregnancy and Labor.- Change in Subjective Experiences During Therapeutic Self-Hypnosis.- V Hypnosis and the Alleviation of Pain.- Why is Hypnosis Effective in Pain Control?.- Hypnosis and Plasmatic Beta-Endorphins.- VI Hypnosis and Addictive Behavior.- Hypnosis in the Alleviation of the Smoking Habit.- The Treatment of Alcohol and Drug Addiction: An Overview.- VII Hypnosis and Psychosexual Problems.- Hypnosis and Sexual Disorders.- Hypnotherapy in Male Impotence.- VIII The Use of Hypnosis in Criminology.- Hypnosis, Coercive Persuasion and the Law: A Historical Perspective.- Hypnosis in Criminal Investigation - Ethical and Practical Implications.- An Examination of the Effects of Forensic Hypnosis.- Hypnosis and the Law: The Role of Induction in Witness Recall.- IX Hypnosis and Anxiety.- Effects of Hypnosis on State Anxiety and Stress in Male and Female Intercollegiate Athletes.- Results of Anxiety Control Training in the Treatment of Compulsive Disorders.- X Case Histories.- On a Case of Urinary Retention Treated by Means of Hypnosis.- Hypnosis in the Treatment of a Case of Guillain-Barre's Disease.- Hypnoanalytic Treatment of Severe Borderline Neurosis by Means of Spontaneous Multiple Personalities: A Case Report.- XI Some Uses of Hypnosis in Dentistry.- The Treatment of Dental Phobia with a Meditational and Behavioral Reorientation Self-Hypnosis.- The Difficult Dental Patient.
MODERN TRENDS IN HYPNOSIS
MODERN TRENDS IN HYPNOSIS Edited by DAVID WAXMAN Chairman of the Scientific Program International Society of Hypnosis London, England
Gartloch Hospital Glasgow, Scotland
MICHAEL GIBSON Child Guidance Centre Edinburgh, Scotland and
M. ANTHONY BASKER British Society of Medical and Dental Hypnosis Westcliff-on-Sea, England
PLENUM PRESS • NEW YORK AND LONDON
Library of Congress Cataloging in Publication Data Main entry under title: Modern trends in hypnosis. "Proceedings of the Ninth International Congress of Hypnosis and Psychosomatic Medicine, held August 22-27, 1982, in Glasgow, Scotland" - T.p. verso. Includes bibliographies and index. 1. Hypnotism- Therapeutic use-Congresses. 2. Hypnotism-Congresses. I. Waxman, David. II. International Congress of Hypnosis and Psychosomatic Medicine (9th: 1982: Glasgow, Strathclyde) [DNLM: 1. Hypnosis-congresses. W3 IN415 9th 19821 WM 4151612 1982n] 616.89'162 84-26432 RC490.5.M6 1985
ISBN-13: 978-1-4684-4915-0 DOl: 10.1007/978-1-4684-4913-6
Proceedings of the Ninth International Congress of Hypnosis and Psychosomatic Medicine, held August 22-27, 1982, in Glasgow, Scotland 1985 Plenum Press. New York Softcover reprint of the hardcover 1st edition 1985 A Division of Plenum Publishing Corporation 233 Spring Street, New York, N.Y. 10013
All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher
To Eric Wookey, MC, LDS, Honorary Consultant Dental Surgeon of the Royal Free Hospital, First President of the London Dental and Medical Society for the Study of Hypnosis. He imparted his enthusiasm and knowledge of hypnosis widely, and thus played a prominent part in securing the acceptance of hypnosis by professional colleagues throughout the United Kingdom.
The 9th International Congress of Hypnosis and Psychosomatic Medicine expresses the continuity in the effort to gain scientific knowledge of hypnosis and scientific status for it, ever since the 1st International Congress for Experimental and Therapeutic Hypnotism was held in Paris in 1889, attended by many of the best-remembered psychiatrists and psychologists of the day - men such as Babinski, Bernheim, Binet, Delboeuf, Freud, James, Lombroso, F.W.H. Myers, Ribot, and many others. The continuity was broken by the period of reduced interest in hypnosis between the time of the 2nd International Congress for Hypnotism in Paris in 1900, and the revival of interest shown by the 3rd International Congress for Hypnosis and Psychosomatic Medicine in Paris in 1965. Since then, the Congresses have met more regularly, making the one of which this is the report, the 9th. The programs of these Congresses have become increasingly rich through the years, with many of the older problems still with us but now studied more dispassionately in the light of new knowledge and new scientific methods in the design of investigations and the validation of scientific findings.
An examination of the titles of the papers and the places from which their authors come shows how diverse and widespread the interests in hypnosis have become, both in the effort to define the nature of hypnosis and its boundaries in relation to other categories of behavior and experience, and to explore its potential service in psychotherapy and other social applications, as in forensic medicine. On the side of understanding hypnosis itself, there are the papers on the nature of hypnotic responsiveness and its physiological vii
correlates, on the subjective experiences within whatever the hypnotic condition may be found to be, the nature and consequences of self-hypnosis, and the characteristics of the dissociative phenomena manifested in hypnosis. On the clinical side there are cases and discussions reflecting the use of hypnotic methods in the treatment of disorders of self-control, in obstetrics, in pain and anxiety reduction, in psychosomatic disorders, in symptoms met in dentistry, and with problems met in children and adolescents. Comparative studies relate hypnosis to meditation and behavior therapy. Hypnosis and the law receives attention in several contributions. One cannot help but be impressed by the seriousness with which the direction has been taken to move away from "it has been my experience ••• " as the way of validating hypnotic practices to the interest in comparative and controlled studies which place hypnosis on the same status as other medical or psychiatric practices as they are taught and studied in our medical schools and university departments. The battle to establish hypnosis on a sound scientific basis has not yet been won; even where it is accepted as permissible, there are still too few scientists among those outside its active practitioners who show any enthusiasm for it. The gains that are being made, however, as these Proceedings show, augur well for its future. Ernest R. Hilgard
Practitioners whose interests extend over the entire spectrum of the healing disciplines assembled in Glasgow from August 22nd to the 27th 1982 to attend the 9th International Congress of Hypnosis and Psychosomatic Medicine. They came to listen to learned addresses, to present papers, often the culmination of many years of research and clinical experience, to participate in workshops and generally to mark, learn and teach a subject as old as mankind and yet amongst the most recent and sophisticated of psychotherapies in the multidisciplinary field of the treatment of psychological illness. The excellent of the ambiance, the impressive array of speakers and the high quality of the lectures culminated in a meeting which was without doubt a considerable academic success. As a result the 9th Congress proved an outstanding event, and it is hoped, made a real contribution to the practice of hypnotherapy. The significance of the occasion was additionally marked by the joint sponsorship of the University of Glasgow and the Royal Society of Medicine, as well as the warm support of the City of Glasgow. In these proceedings appear some of the papers which were presented at this meeting. Although there were over 100 speakers, it is regretted that in view of the restrictions of space, only a very carefully selected number of these papers could ultimately be included in the publication. Each paper was rated independently by a panel of referees and the final selection represents a wide cross-section of the subject matter outlined in the program.
In view of the high quality of all the talks given the referees were faced with a formidable task and it is hoped that those speakers whose papers do not appear in this volume will in no way feel that their efforts were in vain. Abstracts of all papers were published in the issue of The International Journal of Clinical and Experimental Hypnosis of April 1982 and the Editor has given his kind permission for this to be used as a citable reference. The principal aim of the Scientific Program was the encouragement of learning and research in hypnosis both in clinical practice and experimental study, with the actual participation of as many as possible in the wide range of subjects which were offered. The general scientific papers consisted of clinical reports and experimental findings covering as extensive an area as time permitted. The subjects included the neuroses, pathological anxiety and the many incapacitating symptoms resulting therefrom. Other papers covered the considerable field of personality problems, the addictions and sexual dysfunctions. Hypnosis for the modification of pain and its use in obstetrics and in pediatrics was discussed and a full session was devoted to hypnosis in dentistry. Dynamic and behavioral techniques were included and the many lectures dealing with selfhypnosis proved very popular. Of particular interest were the' case histories which provided evidence of the practical results of hypnotherapy. One fact that has emerged clearly over the past few years is that clinical hypnosis, however good the results, will never be fully accepted unless validated by experimental studies and scientific evidence. It is essential that the clinician works closely with the experimental psychologist and the research neurophysiologist. With this in mind, theories explaining hypnotizability and suggestibility as well as the neurophysiology of hypnosis were explored and numerous experimental studies were described. The use of hypnosis in criminology occupied several hours of talks as well as the final Plenary Session. In addition to the scientific papers Special Invited Addresses were given by recognized authorities and National Presidents talked on their individual specialities. Other Invited Addresses and Speciality Seminars were designed to complement the workshops. In the concluding paper, the President Elect of the International Society of Hypnosis, Professor Germain Lavoie combining learned experimental studies with clinical findings, chose as his subject The Clinical Relevance of Hypnotizability in Psychosis. This presentation will undoubtedly prove a valuable contribution to future research. Thus after five days of intensive work and study, of scientific lectures and learned discussion, the 9th Congress was bought to a close. Perhaps it was because of the considerable amount of well-
constructed laboratory investigation, coupled with the clinical experiences so ably reported by so many devoted therapists, that the meeting was such a success. Perhaps it was the Scotch mist, the warmth and generosity of the hosting society or some magnetic influence, but somehow the purple cloak of Mesmer which had hung over the city of Glasgow that August week seemed to have been lifted to allow bright sunshine to penetrate a subject that had been shrouded in myth, mystery and misunderstanding for so many years. As a result it is hoped that Modern Trends in Hypnosis will influence many to explore further the psychological and neurophysiological understanding of the hypnotic state and that it will advance the therapeutic skills of all who read it for the ultimate benefit of the suffering. D.W. P.C.M. M.G. M.A.B.
The editors wish to express their thanks to the Principal and Court of the University of Glasgow and to the President and Council of the Royal Society of Medicine for their sponsorship of this Congress. Also to the President. Council and Members of the British Society of Medical and Dental Hypnosis and the British Society of Experimental and Clinical Hypnosis. to Professor M.R. Bond. 9th Congress Chairman. to Professor F.H. Frankel. President of the International Society of Hypnosis. to Professor M.T. Orne and Mrs Emily Carota Orne for their invaluable help in assembling the program as well as to all Members of the Committee of the 9th Congress. Thanks are particularly due to those hundreds of participants who made this meeting such a success.
Scottish Contributions to the Development of Hypnosis and Psychosomatic Medicine M. R. Bond, Chairman, 9th Congress of Hypnosis and Psychosomatic Medicine
Hypnosis - Both Poetry and Science F. H. Frankel, President, International Society of Hypnosis
Conscious and Unconscious Processes in Hypnosis E. R. Hilgard, Founding President, International Society of Hypnosis
The Clinical Relevance of Hypnotizability in Psychosis: With Reference to Thinking Processes and Sample Variances G.F. Lavoie, President Elect, International Society of Hypnosis II
BEHAVIOR IN HYPNOSIS
In Search of Hypnosis A. M. Weitzenhoffer
The Relevance of Hypnotizability in Clinical Behavior F. H. Frankel
Interaction Between Hypnotist and Subject: Social Psychophysiological Approach E. I. Banyai, I. Meszaros and L. Csokay
Non-Volition and Hypnosis S. J. Lynn, M. Nash, J. Rhue, V. Carlson, C. Sweeney, D. Frauman and D. Givens
CONTENTS Visual Memory Processing During Hypnosis: it Differ From Waking? H. J. Crawford and S. N. Allen
A Study on the Hypnotic Susceptibility of Persons Attempting Suicide: Some Therapeutic Considerations I. Boncz, L. P. Pallag and J. Fodor
EEG Evoked Potential, Hypnotic Anosmia, and Transient Olfactory Stimulation in High and Low Susceptible Subjects A. P. Barabasz and C. Lonsdale
Depth EEG Recordings in Epileptic Patients During Hypnotic and Non-Hypnotic States G. De Benedittis and V. Sironi
Evoked Potential Correlates of Verbal Versus Imagery Coding in Hypnosis I. Meszaros, E. I. Banyai and A. C. Greguss
Hemispheric Specificity and Hypnotizability: An Overview of Ongoing EEG Research in South Australia C. MacLeod-Morgan Some Neuromuscular Phenomena in Hypnosis M. Pajntar, E. Roskar and L. Vodovnik IV
The Essential Aspects of Self-Hypnosis E. Fromm
Representations of Self-Hypnosis in Personal Narratives E. Fromm, A. M. Boxer and D. P. Brown
An Investigation into Audiotaped Self-Hypnosis Training in Pregnancy and Labor G. P. Davidson, N. D. Garbett and S. G. Tozer
Change in Subjective Experiences During Therapeutic Self-Hypnosis R. Van Dyck, P. Spinhoven and J. Commandeur
xvii V HYPNOSIS AND THE ALLEVIATION OF PAIN
Why is Hypnosis Effective in Pain Control? P. Sacerdote
Hypnosis and Plasmatic Beta-Endorphins G. Guerra, G. Guantieri and F. Tagliaro
HYPNOSIS AND ADDICTIVE BEHAVIOR
Hypnosis in the Alleviation of the Smoking Habit M. A. Basker The Treatment of Alcohol and Drug Addiction: Overview D. Waxman VII
HYPNOSIS AND PSYCHOSEXUAL PROBLEMS
Hypnosis and Sexual Disorders P. C. Misra
Hypnotherapy in Male Impotence K. Fuchs, I. Zaidise, B. A. Peretz and E. Paldi
THE USE OF HYPNOSIS IN CRIMINOLOGY
Hypnosis, Coercive Persuasion and the Law: A Historical Perspective J.-R. Laurence and C. Perry
Hypnosis in Criminal Investigation - Ethical and Practical Implications M. Kleinhauz and B. Beran
An Examination of the Effects of Forensic Hypnosis H. W. Timm Hypnosis and the Law: Witness Recall G. F. Wagstaff
The Role of Induction in 345
HYPNOSIS AND ANXIETY
Effects of Hypnosis on State Anxiety and Stress in Male and Female Intercollegiate Athletes E. W. Krenz, R. Gordin and S. W. Edwards
xviii Results of Anxiety Control Training in the Treatment of Compulsive Disorders R. P. Snaith
X CASE HISTORIES
On a Case of Urinary Retention Treated by Means of Hypnosis A. Bottoli, G. Guantieri and V. Azzini
Hypnosis in the Treatment of a Case of Guillain-Barre's Disease A. Gambacciani and G. Guantieri
Hypnoanalytic Treatment of Severe Borderline , Neurosis by Means of Spontaneous Multiple Personalities: A Case Report R. Kampman, R. Hirvenoja and H. Karlsson XI
SOME USES OF HYPNOSIS IN DENTISTRY
The Treatment of Dental Phobia with a Meditational and Behavioral Reorientation Self-Hypnosis G. W. F. Smith
The Difficult Dental Patient J. Gall
SCOTTISH CONTRIBUTIONS TO THE DEVELOPMENT OF HYPNOSIS AND PSYCHOSOMATIC MEDICINE M. R. Bond University of Glasgow 6 Whittinghame Gardens Glasgow. Scotland Abstract Scots have made very significant contributions to both the understanding and practice of hypnosis and psychosomatic medicine. Most believe that the development of animal magnetism by the Austrian. Franz Mesmer in the 18th century. represented the beginning of interest in trance states. but his work was influenced by earlier thoughts of a Scot. William Maxwell. author of 'De Medicina Magnetica'. Perhaps the most well known of all Scots involved in the development of hypnosis was James Braid. a Scottish Surgeon working in Manchester. Though a great sceptic of Mesmerism at first. he changed his attitude completely in 1841 after attending a demonstration by 'a magnetiser' Monsieur Lafontaine. It was Braid who concluded that the trance state was not due to magnetic fluids but to heightened suggestibility on the part of the subject and introduced the term 'neurohypnotism' to describe the state or condition of nervous sleep that this represented. A year later he shortened this term to 'hypnotism'. Scots. especially James Esdaile. were involved in the development of clinical uses of hypnosis. especially in surgery. throughout the remainder of the 19th century. The place of hypnosis in medicine in the 20th century has been no less ambiguous than in the previous one. but during the 1914-18 war another Scot. McDougall. demonstrated that it could make a positive contribution in the treatment of 'shell-shock' and began a further revival of the medical use of hypnosis which has persisted since that time. 3
M. R. BOND
Scots have been no less involved in the development of psychosomatic medicine than of hypnosis and perhaps the most well known contribution of all was that made by Dr. John Halliday still living in Glasgow, who, as a Public Health Officer in the city, threw new light on psychosomatic medicine when he published a book entitled 'Psychosocial Medicine' in 1943. In it he drew attention to the role of social factors in the development and maintenance of illness. His work and that of other Scots in particular, Kissen and Aitken, will be discussed in the final section of this paper.* INTRODUCTION - AN HISTORICAL PERSPECTIVE Scots played a major part in the birth of the practice of hypnosis and its therapeutic uses, and also in the development of the modern concept of psychosomatic medicine. In order to understand why this prominence was achieved, particularly with regard to hypnosis, it is necessary to understand something of the growth of medical education in Scotland up to the early years of the 19th century prior to discussing a number of the main characters involved. In his book, 'The Healers, a History of Medicine in Scotland', David Hamilton (1981), a surgeon in Glasgow, commented, "Scotland offers almost unique opportunities for medical historians ••• there is a rich stock of famous doctors and their discoveries, there are also the contributions of the ancient Universities and of three equally old Colleges of Physicians and Surgeons". It might be imagined that having four very ancient Universities - St. Andrews, Glasgow, Edinburgh and Aberdeen, they would have long been involved in the education of Scottish doctors, but that is not the case. A post of 'mediciner' was established at King's College, Aberdeen, in 1497 and for a brief period between 1637 and 1642 there was a Chair of Medicine in Glasgow but this was suppressed by the Church which, at that time, held the reigns of power in the University. University medical degrees were not established until the 18th century and even then most of them were awarded without formal teaching or examination to medical men of good repute who could find others to sponsor them. The degrees were sought to increase the status of doctors and also to give weight to those who wished to practice medicine in England where the earliest degrees obtained by Scots were called 'Scotch Degrees' in a rather derogatory fashion because of the ease with which they could be obtained. In fact, a rather amusing scandal arose in London in which an illiterate London brushmaker obtained an M. D. from Edinburgh and, armed with it, applied for a post at the London Hospital.
*Inaugural address by the Chairman of the 9th International Congress.
Returning to the 17th century, there were four groups of men involved in the care of the sick. First, and most prestigious of all, were the physicians. Although the smallest group they were distinguished by their wealthy backgrounds, continental University training, and the large fees they demanded. Astrology, which had been central to the practice of their work for a long time, faded from use at this period, but in its place they substituted uroscopy diagnosis by examination of the urine. This method of diagnosis eased their professional life considerably as they did not need to examine the patient. In fact, they were prepared to treat by post! Their remedies were complex, often involving the use of animal and plant extracts and some chemicals. However, they did not administer or deliver these personally but left matters to more lowly beings the apothecaries and surgeons. One point of interest and significance to those interested in hypnosis and psychosomatic medicine was their interest in, and search for, a single powder or agent to cure disease, wherein lies the germ of the later development of mesmerism and then hypnosis. The second group of healers were the apothecaries and it only remains to say that they made considerable incomes but, when they began to challenge physicians for patients they were, with some difficulty, excluded from the training of doctors and the full practice of medicine by laws which were promoted by the physicians. Surgeons were regarded as lesser men than physicians, though not to such a great extent in Scotland as in England. They were seen as craftsmen and learned their trade by apprenticeship, a method of education which lasted until the first half of the 19th century when University degrees and the Medical Act of 1858 regularised all medical training. Barbers were also involved in surgery, but regarded as inferior to surgeons. Nevertheless, at the inception of certain Colleges they were admitted and their activities were controlled. For example, Robert Haries was admitted to the Faculty, later the Royal College of Physicians and Surgeons of Glasgow, in 1645 with the strict ruling that he should be allowed "only to meddle with simple wounds and not to meddle with physic, tumors, ulcers, dislocations and fractures", (Hamilton 1981). Eventually the barbers were forbidden to enter the Colleges and to take up any form of medical or surgical practice. This bar took place in Edinburgh in 1648, but not until 1722 in Glasgow. The dreadful standards of care given to the sick in the 16th century by all manner of people, including physicians, led eventually to the formation of bodies or corporations which were established to maintain standards of skill and patient care and, of course, the financial interest of those who had medical training. Three Colleges were formed and, in order of foundation, they were the Royal College
M. R. BOND
of Surgeons of Edinburgh in 1505, the Royal College of Physicians and Surgeons of Glasgow in 1599, and the Royal College of Physicians of Edinburgh in 1681. This order is rather curious bearing in mind that physicians had the highest status, and that Glasgow in the 16th century was a much smaller town than Edinburgh. The origins of the corporations were very different and worth mentioning. The incorporation of surgeons and barbers in Edinburgh took place in 1505 and the terms under which the craft was founded was similar to that of others, in other words a body for the protection of its members and regulation of their training and conduct. Hamilton tells us that after apprenticeship the potential surgeon was examined in anatomy, had to prove he was able to read and write, and that he understood the signs of the zodiac necessary for the prognosis of disease by astrology. Entry was limited to the sons and sons-in-law of craftsmen, sons of the nobility, or those marrying the daughter of a surgeon - provided she was a clean virgin! The Edinburgh surgeons were given a monopoly to sell aqua vitae, an early form of whisky, a drink which had not become popular and which was only considered to be a medicine at that time. In 1599 Glasgow was not a major town. Nevertheless an important medical corporation was established at that date, even though there was only one physician, six surgeons, one apothecary, and two midwives, in Glasgow. The corporation's jurisdiction, unlike that of the Surgeons' College in Edinburgh, covered a wide geographical area, including much of West and Central Scotland. In addition to powers to regulate medical training and practice it was also empowered to inspect the sellers of drugs. The reason for the establishment of the College in Glasgow at all lies in the stature of the person who was the driving force behind its birth. He was Master Peter Lowe, a Scot, medically trained in France and almost certainly connected with the political activities of James I in that country. Why he chose to live in Glasgow is not known but his early awareness of the medical problems of the area, and his close relationship with the king, led to his gaining a charter for the establishment of the College. The king was interested in medical matters, apart from his well known dislike of smoking, which be banned at Court. It is interesting to note that the College was prepared to admit physicians without examination, but not surgeons! The College of Physicians in Edinburgh was the last corporation to be established, and then only with considerable difficulty. Undoubtedly the physicians sought to control their own numbers, which were increasing quite rapidly, and.if possible to gain power over the surgeons and apothecaries., as had happened in London. The surgeons were outraged, the Faculty in Glasgow felt threatened, and King's
College in Aberdeen stated that the restrictions proposed would apply to their trainees who wished to practice in Edinburgh and thus contravened their charter. Even the Town COuncil of Edinburgh were opposed, no doubt because of the number of surgeons who were members of it, but perhaps their real fear was that the training of physicians would move away from Edinburgh University, which they controlled. Eventually, having made several attempts to found the College from 1621 onwards, a charter was granted in 1681, probably because one of the backers had close connections with the Royal Court and also because the apothecaries were engaged in a dispute with the surgeons and thus supported the proposals for the first time. Hamilton makes the interesting and rather amusing point that, at the time of the first application of the physicians, which was to Oliver Cromwell, there was a certain lack of subtlety on their part in the framing of their request. Thus, a College was needed because of "the frequent murders committed universally, and in all parts, by quacks, women, gardeners, and others grossly ignorant ••• and the unlimited and unaccountable practice of surgeons, apothecaries and empirics pretending to medicine •••• all these undertaking the cure of all diseases without the advice and assistance of physicians". By the 18th century Scotland had a wide reputation for the training of doctors and was especially famous for surgery. The influence of Scottish Colleges and Universities was such that at the beginning of the 19th century 95% of doctors in Britain with a medical degree trained in Scotland, which had a virtual monopoly in medical education. For example, in 1815 there were more than a thousand doctors in training in Scotland. It is not surprising therefore that much of English medical practice was in the hands of Scotsmen or men trained in Scotland and, therefore, that these men were at the center of events surrounding the birth of hypnosis. However, the general public was not over impressed with medical care and at the end of the 18th century doctors were, with good reason, regarded with fear and suspicion. They were still making great use of the practices of bleeding and purging and surgery was barbaric. In addition there was evidence of the practice of the new mysterious cults of phrenology (Millingen 1837) mesmerism and homeopathy. Little wonder that home remedies abounded and that a self-help movement centered on the use of 'spa' therapy developed. Thus, at the turn of the 19th century the practice of medicine left much to be desired and, apart from external criticisms, there were many internal controversies and rivals, not least in relation to mesmerism, and it was here that Scots were at the center of the debate and the vitriolic exchanges that abounded. THE RISE OF MESMERISM For centuries there was a belief that certain substances and man-made objects like amulets possessed curative powers, especially
M. R. BOND
when made under the influence of magic. The mysterious attractive powers of magnets led to the belief that they could affect the body by virtue of imperceptible emanations and. in fact. a Scot. William Maxwell. author of De Medicina Magnetica. was hounded by academic. religious and medical men for his theories in this area. In a similar way electricity. which could actually be seen passing from a generator to the human body. was also held to have curative properties. However. in the late 18th century these matters were of relatively little interest until the dramatic appearance on the medical scene of Franz Anton Mesmer. It was Mesmer who was at the center of heated disputes that raged over his theory of animal magnetism which stimulated James Braid. a Scot. to examine its various aspects. to define hypnotism and to establish the practice of medical hypnosis on an acceptable basis. Mesmer was a Swiss, born in 1734. He took a medical training in Vienna and in 1766 wrote a treatise based on his interest in astrology entitled 'The Influence of The Planets on the Human Body'. This was far from being a new topic and the work was greeted with amusement. Mesmer was heartily ridiculed and. as a result. became much more secretive and mystical in his interests and works thereafter - a fact which probably contributed further to his condemnation. His theory was founded upon the assumption of the existence of a subtle element or essence prevading all nature. or what Newton called 'the ether'. At first Mesmer thought this might be electricity but later rejected the idea in favor of magnetic emanations. This idea he may have taken from the Jesuit Professor of Astronomy in Vienna. Maximilian Hell. Using magnetised rods Mesmer put theory into practice. travelling widely in Europe and effecting a number of miraculous cures. Later he gave up the use of rods believing that the fluid they conducted from his body to the patient could be transferred equally well by repeatedly passing his hands from the patient's head to his legs just in front of the body. Believing his power to be due to transmission of a magnetic fluid he coined the term 'animal magnetism' to differentiate it from mineral magnetism. In medical circles Mesmer was regarded as an imposter and continued criticism was heaped upon him. At last he reached Paris where he generated great emotions. large numbers of patients. a great deal of money. and the wrath of the scientific and medical establishment. The latter eventually set up a commission. the first of three. to investigate Mesmer's work. It was headed by Benjamin Franklin and included Lavoisier and Dr. Guillotin. Its report of 1784 made two important points. First. that imagination played an important part in the cures achieved. and second that evidence for a magnetic fluid was lacking. It did not damn Mesmer's work out of hand but the comments were loudly acclaimed as a rejection of all that Mesmer stood for. Although increasing
pressure forced Mesmer to leave Paris his work was carried on by numerous pupils, including D'Eslon, who was the first of many mesmerists to visit Britain in the late 18th, and early 19th century. However, mesmerism was overshadowed for several years at the beginning of the 19th century by interest in phrenology - them method of relating mental and moral attributes to the shape and contours of the heat and proposed by the German, Franz Gall, and his pupil and disciple, Johann Spurzheim (Critchley 1979). Apparently Dr. Gall was a brilliant anatomist and dissector who, despite the failure of his system of phrenology, contributed very significantly to understanding of the anatomy of the brain and cranial nerves and who was a forerunner of those who have since sought to localise brain functions in what might be termed, a new sort of phrenology. In its heyday the cult of phrenology was represented by no fewer than 29 societies in Britain. One of those who was an avowed phrenologist was the Scot, Dr. John Elliotson of University College, London. He was editor of the Zoist, a periodical which commented upon phrenology and which will be mentioned later. He was also first President of the London Phrenological Society and a number of other famous people were also supporters of the cult, including Thomas Wakely, Editor of the Lancet. Elliotson, also interested in mesmerism, was regarded as an overactive eccentric. In fact, one of his eccentricities was the use of the stethoscope which he introduced into British medical practice! Nevertheless, he held the Chair of Practical Medicine at University College, London, and was President of the Royal Medical and Chirurgical Society there. In 1837 his interest in mesmerism was raised to fever pitch by the visit of a famous French mesmerist, Baron du Potete, and, as in everything else he did, Elliotson plunged into experiments and treatments with a certain lack of caution, characteristic of him. Wakely, Editor of the Lancet, was violently opposed to mesmerism and in an effort to convince him of its worth Elliotson made the fatal mistake of attempting early experiments at Wakely's house using two girls, the Okey sisters, who were unstable, highly suggestible young women, prone to petty fraud and considerably exhibitionism. The experiments failed miserably and the full venom of Wakely fell upon Elliotson who later, because of his many unorthodoxies, became discredited and was removed from his professorial post. However, he remained in private practice, continued his interest in mesmerism and remained an active editor of the quarterly magazine, The Zoist, from its first publication in 1843 until he died in 1856. This journal served to collect and diffuse an enormous volume of information about mesmerism and cerebral physiology and was very influential, especially amongst lay people. A second Scot, not a doctor but a lawyer, J. C. Colquhoun (1836). made a more reasoned approach to the nature of mesmerism in his two volume work 'Isis Revelata - An Inquiry into the Origins, Progress and Present State of Animal Magnetism.' With a clarity of
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mind possessed by the best legal brains he constructed a positive case for the reality of the phenomena associated with animal magnetism. He criticised sceptics for ignoring the huge mass of facts available to them and commended the subject for scientific investigation. He was unconvinced by the arguments for a magnetic process or fluid but much impressed by the powerful effects the mind could have on the body and vice versa. The practical value of mesmerism was clearly demonstrated by a pragmatic Scot in the Indian part of the Colonial Service. Dr. James Esdaile (1846) appalled by the pain and suffering of his patients and impressed by the powers of mesmerism to induce trance, used it in many successful surgical operations, mostly of a minor nature. It should be borne in mind that the sentiments of the day regarding pain differed from our own. They were summed up in Esdaile's quote from a Dr. Copland who stated that, "pain is a wise provision of nature, and patients ought to suffer pain while their surgeon is operating; they are all the better for it and recover better". In one period of eight months Esdaile operated upon 73 patients and in the same period treated 18 medical cases, most having neurological or what we would call psychiatric disorders. Pragmatism, a strong feature of the Scottish personality even today, led him to several basic conclusions which were, first, the operator should not put too much emphasis on careful selection of subjects; second, failure to respond to mesmerism in healthy people did not mean that when possessed by the desire to overcome an illness they would remain resistant to it and, last, that the effects of mesmerism were similar to certain native mystical treatments for illness, an effect commented upon by others, notably Colquhoun and Braid. The Scot who made the greatest and most lasting contribution to the debate on mesmerism was James Braid (Dingwall 1968). He was born in 1795, son of a landowner in Fife, and was educated at Edinburgh University. He reconciled many of the conflicts surrounding mesmerism by careful experimentation and thoughtful literary contributions, of which the best known is 'Neurypnology or the Rationale of Nervous Sleep considered in relation with Animal Magnetism' (Waite 1899). The work, hypnotism, is his own shortened form of the term, neurophypnotism which he derived from neurypnology. Braid regarded mesmerism, or hypnotism, as a serious subject and believed that its use in the treatment of illness should be confined to doctors. He proved to his own satisfaction and that of others that magnetic fluid was non-existent and emphasized that hypnotism involved the use of considerable powers of suggestion by the hypnotist, together with a need for suggestibility on the part of the patient. He concluded, in his own words, that "all I claim for hypnotism is now willingly admitted by the great majority of scientific men who have investigated the subject without previous prejudice in favor of mesmerism". In addition to his work on hypnosis
Braid also dealt firmly with a number of other issues, for example he disproved the existence of many of the phenomena associated with clairvoyance, proved that the cult of electrobiology was essentially the process of hypnotism induced by the use of zinc and copper discs, and showed that several phenomena associated with mesmerism were subjective, that is of the mind's invention and not a result of magnetic forces or fluid. Interestingly, at an earlier stage Bertrand, in France, had come to a similar conclusion. Despite Braid's work the practice of mesmerism continued (Townsend 1844) and indeed Elliotson, through the medium of the Zoist attempted to discredit him on several occasions. A Mr. William Davey (1862), actually established a Scottish Curative Mesmeric Association in 1853 well after the publication of Braid's book, and he was joined in this venture by Gregory, the Professor of Chemistry at the University of Edinburgh, who became President of the Society. It was supported by a number of eminent Scots in the city, including the President of the Royal Society of Edinburgh, Sir Thomas Brisbane. As far as Scotland was concerned the interest shown in mesmerism and hypnotism faded and the dominant features of the medical scene in the latter half of the 19th century were related to the discovery of anaesthesia and the control of surgical sepsis, together with the rapid development of the specialities of surgery and pathology in both Glasgow and Edinburgh. The line of hypnosis was not dead. Braid's work was quickly taken up in France where the Nancy and Parisian Schools of Hypnosis were established and it was to Paris that Sigmund Freud went to learn more of hypnosis from the French neurologist, Charcot, who believed that hypnosis could be induced in neurotic patients and that the susceptibility to hypnosis was a sign of hysteria. Freud is the link between the 19th century and between hypnosis and psychosomatic medicine, because it was in the early years of the 20th century that his pupils established the formal study of psychosomatic disorders. HYPNOSIS AND PSYCHOSOMATICS IN THE 20TH CENTURY Interest in hypnosis for the first 50 years of the century was almost non-existent in Scotland and prior to the 1950s its use was seldom mentioned except in relation to treatment of shell shock in the 1914/18 War by a Scot, Dr. John McDougall. In the 1950s fresh interest was generated in hypnosis and was reflected in the fact that Professor Ferguson Rodger, then the Professor of Psychological Medicine in Glasgow, headed a group which on behalf of the British Medical Association investigated the claims of
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the practitioners of hypnosis. The Commission concluded that it had a useful role in pain control and psychotherapy and that it should be taught to medical and dental students. At the same time Dr. David Fisher. both a doctor and dentist. established several hypnotherapy clinics in Glasgow and was also the moving force behind the foundation of the Scottish Division of the British Medical and Dental Hypnosis Society - the parent body of which had been founded by the fusion of the Medical and Dental Societies in 1952. Much more recently the British Society of Experimental and Clinical Hypnosis was founded and has two branches in Scotland. Thus. in the last 30 years there has been increasing interest in hypnosis in Scotland and. at present. its practice is both flourishing and expanding. Psychosomatics is a term covering interest in the relation between physical and emotional aspects of disease. This has a long history and the term. psychosomatic, appears to have been used first at the beginning of the 19th century in Germany by Heinroth. However, formal study of diseases, regarded as specifically psychosomatic, did not begin until the early part of the 20th century when pupils of Freud firmly established the study of psychosomatic disorders linking certain conditions of the mind with particular physical symptoms or diseases. The most outstanding contribution in Scotland to this field of medicine was made by Dr. John Halliday, an epidemiologist and Medical Officer of Health in Glasgow. In the 1930s and 40s Dr. Halliday became impressed by, and studied the effects of, social factors upon illness. In his book. 'Psychosocial Medicine', published in 1948 he refined the concept of a psychosomatic disorder as follows: "A psychosomatic affection is a disease which complies with the psychosomatic formula and whose prevalence rises or falls in accordance with the rise or fall of communal upsetting events, that is, in accordance with the pressure of environment in its psychological aspects". This seems to have been a forerunner of later interest in the subject of life events and their relation to emotional distress and mental illness. Dr. Halliday's investigations revealed that disorders fitting this pattern. included peptic ulceration and gastritis. exopthalmic goitre, hypertensive disorders including hypertension, coronary thrombosis. angina and cerebrovascular disorders. and psychoneuroses. including anxiety states and hysteria. There are many others detailed in his book and his work was warmly received. especially in the United States where one of the founders of the psychosomatic school in that country. Dr. Flanders Dunbar (1946) acknowledged his contribution at length in her book. 'Emotions and Bodily Change. a literature survey of 1910-1945'. Dr. Halliday was the first President of the Glasgow Psychosomatic Society. which remains one of only two in Britain and which was founded in 1959 at the instigation of the late Drs. David Kissen and Astor Sclare. This Society continues to flourish.
Another Scot who made a significant contribution to psychosomatic medicine was the late Dr. David Kissen who, prior to his untimely death in 1968, carried out a series of studies, some with Professor Hans Eysenck of London University, upon the relation of psychological and physiological aspects of personality and proneness to malignant lung disease. Professor Cairns Aitken of the University of Edinburgh, currently editor of the Journal of Psychosomatic Research and Professor of Rehabilitation Medicine at Edinburgh University, has made significant contributions to our understanding of anxiety, as an aspect of psychosomatic medicine, and one of his close associates, Dr. Lorna Cay, has provided much information about emotional aspects of heart disease and the rehabilitation of victims of myocardial infarction. To conclude, the psychosomatic approach to medicine flourishes and continues to grow in Scotland. It is appropriate to conclude this paper with the hope that the present trend towards a wider use of the psychosomatic approach and integration of hypnosis and allied techniques into the treatment programmes for those with a combination of psychological and physiological symptoms will continue. REFERENCES Colquhoun, J. C., 1836, Animal magnetism, in: Isis Revelata - "An Inquiry into the Origins, Progress and Present State of Animal Magnetism," (Vol I), Isis Revelata, ed.,Maclachlan Stewart, Edinburgh. Critchley, M., 1979, "The Divine Banquet of the Brain," Raven Press, New York. Davey, W., 1862, "The Illustrated Practical Mesmerist," (6th ed.), J. Burns, London. Dingwall, E. J., 1968, "Abnormal Hypnotic Phenomena - a Survey of 19th Century Cases," (Vol.IV), United States of America and Great Britain, J. & A. Churchill Ltd., London. Dunbar, F., 1946, "Emotions and Bodily Change," (3rd ed.), Columbia University Press, New York. Esdaile, J., "Mesmerism in India and its Practical Application in Surgery and Medicine," 1846, Longman, Brown, Green & Longman, London. Halliday, J. L., The incidence of psychosomatic affections in Britain," 1945, Psychosom.Med., 7:135-146. Halliday, J. L., 1948, "Psychosocial Medicine: A Study of the Sick Society," Heinemann Medical Books, London. Hamilton, D., 1981, "The Healers, A History of Medicine in Scotland," Canongate, Edinburgh. Millingen, J. G., 1837, "Curiosities of Medical Experience," (Vols. 1 and 2), Richard Bently, London. Townsend, C. H., 1844, "Facts in Mesmerism," (2nd. ed.) Bailliere, London.
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Waite, A. E., 1899, Braid on hypnotism, in: "Neurypnology or the Rationale of Nervous Sleep etc.,"Redway, London.
HYPNOSIS - BOTH POETRY AND SCIENCE*
Fred H. Frankel Beth Israel Hospital and Harvard Medical School 330 Brookline Avenue Boston, MA, 02215, USA Abstract The or1g1ns of hypnosis are indisputably clinical, but its current acceptability and recognition stem largely from the high calibre of academic investment and the findings in experimental laboratories in recent years. What we know has been accumulated in the context of a rigorous adherence to finely developed research methods, constructive scepticism, and cold facts. Clinical results, on the other hand, demand flexibility, imaginative phrases, deep feelings, and even lofty thoughts. The poetry and the science are both essential for survival. INTRODUCTION I have wondered in common with many of you I am sure, about the appropriate nature of a presidential address. It certainly is poorly timed for a political statement because it comes toward the end of the term of office, and the line of succession has already been established for the coming six years. If I were fortunate enough to be able to make some extraordinarily valuable pronouncements today in the hope of returning to office in 1989, you will surely all have forgotten them by then. On the other hand, the address might be considered to be something akin to a State of the Nation Address - a review of where the Society has been, where we are at, and where we are headed.
* Presidential Address by the President of the International Society of Hypnosis. 15
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If it were to follow the theme currently predominant in most institutions in the United States including hospitals and academic centers, it would be like an address to the shareholders - a business report that would be filled with fiscally relevant statements and an eloquent bottom line. I mean no disrespect to politics, to the presidency of my adopted country, or to big business. I believe I recognize the importance of all three. However, in the hope that there are other prerogatives open to the president of a society such as ours, I will choose yet another format. With your indulgence I will use the occasion, unashamedly, to elaborate on a personal perspective on hypnosis that is admittedly neither wholly original nor unique. I wish at the outset to acknowledge the many contributions of my colleagues, some of whom are in this audience or on this podium. I will, I fear, have to depend, in my presentation, on those contributions, and will try to avoid shaping their findings to my own ends. I come not as a theorist, grappling with formulae to relate the psychological to the physiological, although I might wish that I were. I come not as an experimentalist with a keen insight into methodology and that enviable ease with statistics that resembles the skills of the trapeze artist grabbing supports out of nowhere, although I might wish that I did. I come rather as a clinician and clinical teacher who has travelled the highways and byways of clinical and academic psychiatry on two continents for more than three decades. It seemed to me that if I did not use this opportunity to confront some of what I have gathered along the way, I probably never would lay claim openly to my own ambivalence. Having spent most a of my time as a clinician, and some as an investigator, I believe I am generally regarded as a clinical investigator. On the other hand, I might also qualify as an investigative clinician, or even as a curious one. Which all somewhat resembles the conflict that many of us seem to have as we grow older. Initially having preferred to see ourselves as liberals with a conservative leaning, we now find that we are really conservatives with, perhaps, a liberal bent. I believe the essence of what I wish to address is the unavoidable complexity, uncertainty, and ambiguity in our field as I see it, and the need for us to tolerate the situation while we still struggle to understand what it is that we accomplish with the use of hypnosis. As we well know, close vision while vital to the pursuit of any details, tends to blind us to the view of the whole. In our impatience to foster ideas that we personally cherish, our nemesis lurks in a tendency to be cavalier about what others do. As a clinical psychiatrist I am no stranger to complexity and ambiguity. Doubts, uncertain meanings, and the need to live with a combination of interpretations are a way of life in the field that has nurtured me for most of my professional life. How else can one
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be of help, for example, to a patient torn by angry feelings toward an elderly parent, or a dying spouse? Moral and psychodynamic absolutes are of little value. Directed by the moral imperative, I could say to him, "How can you be so vicious or unkind toward someone who is dying?" Or will I help him psychodynamically, do you think, i f I tell him that he has every right to be angered by the fact that his life is being eroded by the demands and the needs of his suffering relative? Should I say then, "You go ahead, and let them know?" Perhaps what I might ultimately do that might be more useful, is to sit sympathetically, saying little, but making it clear that I, too, know the human condition to be a tough one, and that I will try to help him cope with whatever irreconcilable and irrational feelings arise in him. How should I best respond to the needs of a patient who recites a list of physical complaints for which her physicians can uncover no physiological cause. As she recounts them, I detect a hint of sadness in her voice. On an invitation to her to share her feelings with me, she describes a series of deep personal losses, the deaths of close family members that immediately preceded the onset of her symptoms. Should I treat her be encouraging her to talk about the hurt of her grief, or should I prescribe medication that is aimed at helping to lift her depression? Will I be wiser yet to use a combination of both methods; have her first recall her feelings and then wait for an opportune time to introduce medication in addition. Perhaps I will select that path. but it should be noted that there is a literature and a body of professional opinion in favor of each position. preferring either one approach or the other, rather than a combination. How should I regard physical symptoms that respond to biological remedies, but that nevertheless originate in the emotions - in the anguish of that curious mixture of physical and psychological discomforts that Lindemann (1945) described as the "grief reaction". Although on more solid ground in some areas than we were twentyfive years ago. psychiatry still has more questions than answers but we offer no apologies. We have a growing body of knowledge derived from our clinical experience and our laboratory studies; some of our dearest concepts have stood the test of time. In moments of crisis our colleagues, even those who are critical, know that they must calIon us because. limited though we might be, we still know more about the management and treatment of distressed and psychotic behavior and suicidal depressions than they do. When their patients on the medical and surgical floors and in the emergency wards behave irrationally they calIon us. Both burdened and armed with knowing how ambiguous is our trade, we go forth. Because our data are for the most part soft. not hard. and because we cannot rely on an impressive battery of unequivocal laboratory tests, we have to rely on a modicum of good sense and a demonstration of good manners. We aim to be receptive but not passive. cautious but not cowered, and
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realistic but not cavalier. We know that the final solution to disturbed behavior has yet to be written. But we have learned that we are more likely to be successful if we remain flexible, nonjudgmental, and open to suggestion as we proceed with our interviews and our treatment plans. Subsequent events are often open to various interpretations as we struggle to balance the demands of the psychological and the physical, of the rational and the emotional. We learn when to prescribe a pill, when to explore feelings, and when to offer reassurance. Sometimes we prudently wait to discover the course of action that is best. I have said we go forth both burdened and armed with the knowledge of the ambiguities inherent in our calling. Burdened, because it is bothersome not to know many of the answers, but armed because without being aware of the uncertainties in our work we might well do more harm than good. Unexpected though it might seem, tolerating uncertainty is not peculiar to only those of us who toil in the behavioral sciences. Closer examination of the hard sciences impresses us with the fact that even there, beyond a certain point, assertions are less finite. The Albert Einsteins and the Niels Bohrs provide us with notable examples. What should be clearcut is frequently not so. Those illustrious individuals had the ability to acknowledge the value of more than one theory of light. Theirs is a sober reminder of how the great learn to live with ambiguity. Einstein (1924) wrote, "We now have two theories of light, both indispensable, but, it must be admitted, without any logical connection between them, despite twenty years of colossal effort by theoretical physicists." Bohr (1934) in his evaluation of the apparently contradictory wave and particle theories to explain the propagation of light, suggested more directly that opposite viewpoints under the circumstances are not only indispensable, they are complementary. In other words, rather than being mutually exclusive, they can be mutually enhancing. Hypnosis in Mesmer's Time Moving now closer to home, to our own field of endeavor, we might ponder how Franz Anton Mesmer. the acknowledged father of hypnosis. might have felt had he sensed the potential and the complexity of what he bequeathed to us. To what extent could he have appreciated that his practices would. on the one hand. contribute to the development of an important religious institution (Podmore. 1963) and on the other lead to some of the most sophisticated methodology in the study of the behavioral sciences? To what extent could he have been aware that his work heralded a new perspective - that it lay on the threshold of a dialogue between the psyche and the soma and that it would pave the way to sweeping psychological theories (Ellenberger. 1910) that would initially reveal more questions than answers. Could he have even vaguely recognized that among those who showed an interest in his work would be some dedicated to the accumu-
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lation of facts, and yet others whose primary commitment was to the exercise of fantasy. It seems that in whichever direction one follows hypnosis, one encounters this juxtaposition of two seemingly contradictory perspectives - a kind of dualism that seeks to explain the phenomenon in the irreducible terms of one or another system. Is it physical, or all psychological? Is it rational, or all emotional? Is it fact, or all fantasy? There is little to suggest that either Mesmer or the spirit of his time could have appreciated the pervasiveness of the purely psychological, the impact of the emotions, or the influence of fantasy. Mesmer wrote that the explanation of what he accomplished resided in his Fluid Theory (Mesmer, 1774) in the physical reality of a magnetic fluid that could pass through the body of the magnetizer to the patient. As the world was being opened up at that stage in history by the dramatic discoveries of modern physics, it comes as no surprise that the important answers were assumed to lie in that realm. It is interesting to note however, that despite Mesmer's written commitment to a physical explanation that he hoped would be acceptable to science, he was not above performing an elaborate and theatrical ritual in his clinical practice, obviously aimed at what we today would regard as the psychological sensibilities of his patients. His method of magnetizing, we are told, was choreographed with color and sound. Looking into the rear mirror of history we must wonder whether he really did settle for an amalgam of poetry and science - or whether, despite the scientific pretensions of his Fluid Theory, he was not essentially a poet - a committed 18th century prototype of the modern science fiction writer, perhaps with less personal insight. It is useful to note that in our time, in the field of hypnosis, the contest is lined up in a way that bears the mark of two centuries of clinical work, and a half century of modern laboratory investigation. We are confronted by the fact that unbridled clinical experience with hypnosis is now being pitted against the logical findings of sophisticated methodology. Perhaps the greatest challenge to the field of hypnosis at this time lies in how we resolve the differences between a richly imaginative clinical focus and the facts that emanate from the laboratory, between the poetry on the one hand and the science on the other. Are they irreducibly different, or are they interdependent? Are they mutually exclusive, or in the words of the physicists, are they complemetary? Modern Hypnosis It might be useful to take stock again of the artistry that has been an integral part of the practice of clinical hypnosis since its
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inception. Mesmer's purple cape, the music, and the general milieu surrounding the event in his time had a distinctly theatrical quality. To this day. many clinicians in the induction procedures assume the studied pose or the voice inflection of the "hypnotizer." Their behavior is distinctly manipulative. Whether overtly controling or permissive. the tempo of the directions is slow. and the speech monotonous. quieting. and reassuring. Patients are offered a "very enjoyable" or even "momentous" experience; they are perhaps encouraged to believe they are "entitled" to the reward of a deep sense of relaxation. They are persuaded to disconnect or disengage from the workaday world, and to soar with the images that are suggested directly. or encouraged. Existence becomes purple prose or sheer poetry. It is onto this substrate that the selected therapeutic strategy is grafted - the numb feeling to displace the pain. the image of the blood vessels expanding to allow a greater degree of body heat to reach the fingers or the toes afflicted by arterial spasm, or the wondrous sense of a great confidence like a pillar of light growing within oneself. Colorful language. vivid imagery, and a voyage to a make-believe world are closely woven into the whole experience. Some clinicians prefer to strip the event of these embellishments; however, even when the induction procedures are pedestrian. such as "close your eyes. count to ten and relax". the strategy must still depend on imagination for its energy. This can be fostered by allowing a spontaneous unfolding of fantasy; it might be brought on by asking the patient to use whatever images he chooses to create the numb feelings. or the warm feelings. or the sense of increasing self confidence. This latter approach is generally favored by those who graduate to clinical work through a previous involvement in investigative studies in the laboratory. Many clinicians seem to show little preference for this paler version of hypnosis, while still others assume a style of practice that lies somewhere in between. There are few if any dependable studies reporting on the incidence of the different styles or on their comparable efficacy. My own inclination has been to deemphasize the theatrical in hypnosis, and to come down on the somewhat conservative side of my ambivalence. Both my practice and my teaching reflect this. My patients are often invited to participate in the event. motivated not only by the wish to get well. but also by a spirit of adventure and curiosity. I believe I chose to follow this line because of my respect and continued admiration for the investigative studies that have emerged in recent decades. By casting hypnosis in a casual mould. stripped of its magic and mystique, investigators have made it real; their work with standardized procedures has led to major developments. With the refinement of the hypnotizability scales and an increasingly impressive methodology. they have uncovered several parameters of hypnosis - some of which might have been suspected while others came as a surprise. Working largely with volunteers from the college
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student population in a friendly but very prosaic manner compared with that in the clinical situations, investigators have shown that hypnotizability is not universally distributed, that women are not on average more hypnotizable than men, and that the level of general education has no effect on the degree of responsiveness. They have demonstrated these facts, and many more (Hilgard, 1965). A major consequence of this intellectual and determined pursuit of the phenomenon of hypnosis has been the distillation of what is believed to be its essence - the alteration of perception. This might be associated with altered cognition and even altered memory, but within this conceptual framework the altered state of awareness measured primarily in terms of the subjective experience of the hypnotized individual is the hallmark of hypnosis. For some clinicians deeply invested in the use of hypnosis, immersed in the rich metaphors in frequent use, and involved in the intense relationships that mark the therapeutic encounter, this simple explanation is somewhat dull and not altogether relevant. It is seen at best as a disappointment, and at worst as a betrayal. They regard it as leaving little justification for the imaginative practices and intense relationships that surround their use of hypnosis. Although the relationship between the hypnotizer and the subject, and the subject's consenting participation are seen as necessary for the development in the laboratory of the altered perception or altered awareness, the phrase itself "altered perception" by its very nature diminishes the importance of the overtones so dear to the hearts of clinicians who prefer more colorful practice and phraseology. The creative style and the imaginative terms they use add to the psychological impact of the procedure. Perhaps because the words are often purposefully obscure and the content rich in metaphor, the whole lends stature to the clinician and enhances his procedures. He says: "I am about to make contact with your deeply unconscious mind, to help you communicate with a part of you that has been hidden from you until now. Deeply unconscious pathways will lead you to the psychological forces within you that will enable you to resist the urge to reach for a cigarette." Despite the reservations of these who criticize the laboratory definition, this ornate phraseology leads precisely to the experience of an altered perception. The hypnotizer, with the aid of importantsounding language, encourages the patient to experience what he, the patient, perceives to be deeply hidden strengths. Even though they might not be so deeply hidden that only the therapist can provide access to them, they can be made to seem so inaccessible in order to have them be that much more influential when they emerge. What is not immediately conveyed by the brief phrase, "altered perception", perhaps, is the artistry, the poetry. and the tendency clinically to encourage the impression that things in hypnosis are
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larger than life. This latter aspect seems to belong more to the hypnotic situation, than to hypnosis. It is carried in the style, in the language, and in the ambience. Let me try to explain as I proceed. In a great spirit of compromise, or possibly complementarity, the late Ronald Shor described hypnosis as possessing three dimensions (Shor, 1962). The experience of the altered perception or trance is but one. The other two include the important and special relationship between the subject and the individual carrying out the procedure, and the subject's interest in and motivation to participate in hypnosis. This interpersonal interaction, and the inner preparedness to respond to the hypnosis exert considerable influence on the way in which the hypnosis proceeds. In the clinical setting these dimensions are particularly complex, involving many other psychodynamic forces, the attitude of the patient to his illness, his expectations of hypnosis, the environmental factors - all of which influence the patient's ultimate response to hypnosis and his symptomatic response to the therapy. It should be remembered that these two factors, namely the relationship and the motivation, are equally relevant to the progress of any other form of psychotherapy. We who use hypnosis are not alone. All who practice psychotherapy depend, for the effectiveness of their methods, on the strength of the relationship and the patient's deep interest in improving. It is unfortunate that the theoretical and investigative concept of the altered perception, useful as it is, when examined out of context conveys a predominantly intellectual interpretation of the event of hypnosis. While this does an injustice to the idea as it was originally formulated (Orne, 1959) there is no escaping the inhospitable reaction to it among many clinicians. Perhaps it is because the other factors contributing to the hypnotic situation appear to receive short shift in comparison. Perception is discussed, described, and measured. Even though subjective it qualifies as science. On the other hand the importance of the interpersonal relationship involved in hypnosis, the rapport, or the transference, and the sum total of the psychodynamic forces which influence motivation, acknowledged though they be, still appear to be relegated to a minor role. They are essentially the derivatives of feelings, ubiquitous, and challenging to any would-be scientist. They promote the illusions and give life to the metaphors; and as such they are the poetry. Few clinicians will deny the importance of the therapeutic relationship, whether they regard 'it merely as rapport, or whether they invest it with the complexities that make up the psycho-analytic transference. The psychiatric literature is replete with references to the phenomenon. We know it has much to do with the emotional
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lives of the two people involved. Something ineffable, it is yet crucial to, the calibre of the therapy and of the hypnotic experience. The relatively lacklustre outcome with self hypnosis learned from books confirms this view. The phenomenon has, however, thus far defied measurement, and in the laboratory publications is given little attention. It will come as no surprise to you now to hear that the scientist in me often succumbs to this other'very clinical side of the ambivalence. I am, however, reassured in my surrender by the fact that the role of imagination in hypnosis was dealt with only cursorily in investigative work until the importance of imaginative involvement emerged from clinical observation (Hi1gard, 1970). I submit that the affect in hypnosis is also an idea whose time in the laboratory has come. Although the less fastidious have regarded every aspect of the hypnotic interaction as hypnosis, others among us have differentiated between the essence of hypnosis - the altered perception - and the other forces in the hypnotic situation. It is time now to turn our attention to the latter, to examine them, to try to measure them if we dare, and to learn to live with them. Even though this serious dialogue between the poetry and the science is only now about to dawn, a glimmer has been seen for some time. We might fashion discussions in the future on the format of those currently in vogue. Two examples immediately come to mind: hypnotizability in both the laboratory and clinical contexts, and the value of memories recalled in hypnosis. Perhaps a brief review of these two areas and of how the varying viewpoints can be and have been thus far reconciled, will remind us that contradictory viewpoints are not necessarily mutually exclusive; they can in fact complement each other. Hypnotizability Measure As already indicated by me, clinicians have often been inclined to disregard the laboratory measurements as inapplicable to the clinical scene. Contrasting the populations, one young and healthy, the other suffering and representing several age groups, they conclude that laboratory hypnosis and clinical hypnosis are not comparable entities. When requested to apply to measures developed in the laboratory to patients, these critics demur on the grounds that the tests are lengthy and intrusive (Sacerdote, 1982), or that they would interfere with the course of treatment were they to be introduced into the clinical situation. There is evidence to the contrary (Frankel et al., 1979), indicating that the laboratory scales can indeed be applied to patients without creating the havoc that has been prophesied by the critics; furthermore studies reveal interesting correlations between high scores and specific types of psychiatric disorders (Frankel and Orne, 1976). But that is not the focus of this presentation.
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What is at stake here is the apparent contradiction between the extent of the hypnotic response on the hypnotizability scales and the degree to which patients respond symptomatically to therapy involving hypnotic procedures. While these individual reactions are related in several ways, they are not identical. The response to a hypnotic induction procedure is not equivalent to the response to a therapeutic procedure. In fact, patients who are highly hypnotizable might show no therapeutic response to a treatment involving hypnosis if the secondary gain from their symptoms is such that they are loath to give them up. Secondary gain is a vital force in the perpetuation of symptoms. We know well the extent to which attentive and sympathetic relatives can unwittingly prolong the behavior of illness. Pain clinics have a remarkable accumulation of data to support that. Furthermore, and in contrast, patients who respond poorly to tests of hypnotizability might yet show a positive therapeutic response to procedures involving hypnosis, for the simple reason that they respond to the setting in which hypnosis takes place even though they might not be hypnotizable. They respond to the therapeutic influence of the ambience, the encouragement, and the relaxation that contribute to the situation in which the hypnosis is encouraged to take place, even when the hypnosis per se fails to occur. We are here again talking about the hypnotic situation. It is, in truth, inescapable, and we come full circle. The poor hypnotic subjects gain relief from their symptoms very often from the reassurance, the trust, and the expectations that are inherent in all acknowledged clinical procedures. The mystique surrounding hypnosis, unreliable though it be, might well add to the effects. The benefits thus stem from the poetry which lies here appropriately juxtaposed to the measurements of science. Memory Yet another conspicuous example in which science and poetry, measurement and metaphor have intersected recently, is that of memory. To what extent is it enhanced by hypnosis? How many in this audience have encouraged patients to turn their attention to the deep levels of the unconscious mind, to orientate themselves to events in the past, and to allow themselves to remember, in detail, hidden past experiences. At times the affect-laden response is dramatic. It affects the quality of a patient's feelings and contributes in a major way to the development of his insight. What we sometimes lose sight of, however, is that what is recalled might well be the feelings of the past, but not necessarily the facts. Clinically whether they are facts, or feelings, or pure fantasy, is not relevant. For instance, it matters little clinically whether one's father was a stern man, or whether one imagines him to have been such. What is of importance is that one should be able to
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sense, examine, and discuss such feelings in the light of increased experience and maturity. Whereas an individual might start out in hypnosis being unsure of the details he recalls, he can be encouraged to believe that the procedure itself is capable of producing accurate memories from the far distant past - even from the moment of his birth and before. Such claims are not unknown, and taken to the absurdly logical conclusion he might, if prepared for it by his beliefs and attitudes; be encouraged to recall in detail a former life or incarnation. He might even project himself into the future, and depending on his familiarity with science-fiction provide a view of the world in the twenty-first century that can be as vivid and convincing as his account of the past. The results of his recall if interpreted psychodynamically are useful in the course of psychotherapy, the procedure thus being regarded as a projective technique. Much like dreams, such fantasies have value in leading to an uncovering of the unconscious. In this way the poetry is persuasive. It moves to another realm, however, when the product of the process is presented as proof of the nature of the birth experience or as verification of a previous incarnation. Careful studies of recall in hypnosis have revealed the importance of suggestibility. They have demonstrated that a hypnotized subject will create memories that mesh with the expectations of the examiner. It has been shown (O'Connell et al., 1970), that if a hypnotized individual cannot recall, on request, the name of his teacher in a specific grade, he will in all probability, convinced and convincingly, offer you the name of a teacher in another grade if that is the one teacher's name that comes to mind. Similarly, he will confabulate in other ways in order to meet what he sees as the expectations of the individual who asks for the information. The distinction between fact and fiction is perhaps academic in the clinical context. In the forensic use of hypnosis, however, it is crucial, and is at the heart of the controversy that currently predominates the admissibility of evidence from witnesses or victims who have been questioned in hypnosis about specific events in the past. Furthermore, we have learned from careful studies of recall that while the presence of hypnosis leads to a greater number of items, it also leads to a greater number of inaccuracies among those items (Stalnaker and Riddle, 1932). These stem from the circumstances of the interview, the nature of the questions, the relationship between the interviewer and the subject, and what the subject believes hypnosis will enable him to do. Are we not here again in the embrace, or the grip, of the hypnotic situation, caught up in the magic and imagination of the moment? While careful studies illustrate the limitations of recall in hypnosis, enthusiastic clinical use encourages quite the opposite viewpoint. One is science, the other poetry - but both are in the practice of hypnosis.
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Conclusion I propose that we have, in a sense, been dealing with the ageold contest between the head and the heart. History amply chronicles the shifts from romance to reason, and then back again. In the search for truth our reach seems always to exceed our grasp; functioning in the one mode seems to interfere with our effectiveness in the other. We fail to acknowledge the romance when we plod the heavy path of logic; and we repudiate the rational when caught up in the exuberance of the spirit. Clearly, neither reason nor romance alone can lead us to the answers. In hypnosis, one is the life blood of the other. If the field is to survive as an academically and clinically acceptable entity, it must remain poised between an imaginative blend of illusion and affect on the one hand, and cold objectivity on the other. A seasoned perspective demands that we encompass and pay homage to both viewpoints. I submit, however, that one crucially important caveat must be added. Above all, the seasoned perspective demands that we know how to tell them apart. While paying homage to both we need to learn how to recognize that which is the voice of poetry, and how to differentiate it from the substance of science. REFERENCES Bohr, N., 1934, The quantum postulate and the recent development of atomic theory, in: "Atomic Theory and the Description of Nature", Cambridge, University Press, New York, Macmillan Co. Einstein, A., 1924, Das Comptonsche Experiment, Berliner Tageblatt, Suppl. p. 1. Ellenberger, H. F., 1970, "The Discovery of the Unconscious," Basic Books Inc., New York. Frankel, F. H., Apfel, R. J., Kelly, S. F., Benson, H., Quinn, T., Newmark, J., and Malmaud, R., 1979, The use of hypnotizability scales in the clinic: A review after six years, Int.J.clin. exp.Hypnosis, 27:63-73. Frankel, F. H., and Orne, M. T., 1976, Hypnotizability and phobic behavior, Archs.gen.Psychiat., 33:1259-1261. Hilgard, E. R., 1965, "Hypnotic Susceptibility," Harcourt, Brace and World, Inc., New York. Hilgard, J. R., 1970, "Personality and Hypnosis: A Study of Imaginative Involvement," University of Chicago Press, Chicago. Lindemann, E., 1945, Symptomatology and management of acute grief, . Am.J.Psychiat., 101:141. Mesmer, F. A., 1948, Memoire sur la decouverte du magnetisme animal, Geneva, 1774, With the Precis historique ecrite par M. Paradise en mars 1777, Paris, Didot, 1779, English version: Mesmerism by Doctor Mesmer Dissertation on the discovery of
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animal magnetism, 1779. Translated by V.R. Myers, Published with G. Frankau, Introductory Monograph, London, MacDonald. O'Connell, D. N., Shor, R. E., and Orne, M. T., 1970, Hypnotic age regression: An empirical and methodological analysis, J.abnorm.Psychol., 76:(Monogr.Suppl. No.3) 1-32. Orne, M. T., 1959, The nature of hypnosis: Artifact and essence, J.abnorm.soc.Psychol., 58:277-299. Podmore, F., 1963, "From Mesmer to Christian Science: A Short History of Mental Healing," University Books, New Hyde Park, New York. Sacerdote, P., 1932, A non-statistical dissertation about hypnotizability scales and clinical goals: Comparison with individualized induction and deepening procedures, Int.J.clin.exp. Hypnosis., 30:354-376. Shor, R. E., 1962, Three dimensions of hypnotic depth, Int.J.clin. exp.Hypnosis., 10:23-38. Stalnaker, J. M., and Riddle, E. E., 1932, The effect of hypnosis on long-delayed recall, J.gen.Psychol., 6:429-440.
CONSCIOUS AND UNCONSCIOUS PROCESS IN HYPNOSIS*
Ernest R. Hilgard Department of Psychology Stanford University, Jordan Hall, Building 420 Stanford, C A 94305, USA
Abstract The distinction between what is conscious and what is unconscious in human mentation is by no means clear and obvious. The problem arises because unconscious processes which are of interest are those which closely resemble conscious ones. Completely "unconscious" processes such as homeostatic mechanisms and habits that have become automatized are not relevant in this connection. The frequent assertion that one can "talk directly to the unconscious" in hypnosis is not a precise statement. The "hidden observer" approach provides a method for examining the basis for such claims.
For an American psychologist whose primary identification has been with experimental psychology to speak on conscious processes a few years ago would have seemed somewhat surprising in view of the commitment of American psychologists to beh~viorism or related forms of operationism or positivism. However, the fact that I am speaking on consciousness results from no conversion experience of my own, for I was one of the many American psychologists who never were committed to behaviorism. and I am pleased to report that the hold of behaviorism has been so weakened in America. now that cognitive psychology has been embraced. that I no longer felt that I am rowing upstream against the current. This is important for hypnosis. because its *Invited Address by the Founding President of the International Society of Hypnosis. 29
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essence lies in modification of consciousness, and hypnosis finds a more central place in psychological science now that serious discussions of consciousness have again become respectable. I should offer a caveat. When old views are overthrown, and there is a new freedom, that freedom is readily abused. We learned a good deal through the discipline of behaviorism, and ·the return of consciousness does not mean that just anything is acceptable. The problems of understanding conscious processes were always difficult, and they still are. Furthermore, the cognitive psychology that has replaced behaviorism is not ipso facto a consciousness psychology. Ulric Neisser, for example, whose book by that title (Neisser, 1967) helped recognize the maturing of cognitive psychology, still feels that we are not quite ready to bring back consciousness, particularly states of consciousness as explanatory concepts. Still, the opening up of psychology has made it much easier for the phenomena of hypnosis to be integrated into general psychology, and, indeed to contribute to general psychological theory. A dynamic unconscious has had greater difficulty in gaining acceptance among American psychologists than the facts of consciousness. The currently popular cognitive psychology turned away from Freud as it turned away from affective and motivational influences upon thought. This was represented in developmental psychology by moving from Freud toward Piaget. As I have noted elsewhere, one finds no reference to sibling rivalry in Piaget's conception of the cognitive growth of children. Correctives are being offered within cognitive psychology itself to bring back more emphasis on the other parts of the old trilogy of cognition, affection, and conation, once so popular in Great Britain under the influence of Stout and McDougall. Because hypnosis gets at many central problems of the personality if well researched it may contribute substantially to keeping psychologists aware of these problems in all their richness, and help to avoid a certain faddishness with which psychology is plagued. Turning now more specifically to hypnotic theorizing, I wish first to mention briefly the residues from the earlier period in which subjective states were to be avoided and then go on to consider two positions with respect to conscious and unconscious processes.
Heightened Suggestibility The interpretation of hypnosis that for many years was most popular in America was that hypnosis was the study of suggestibility. This was noted in the title of Clark Hull's book, Hypnosis and suggestibility: an experimental approach, published in 1933. Hull was an out-and-out behaviorist, who preferred to measure movements and time-relations in as physical a manner as possible. His book was a model of good experimentation and the statistical tests of differ-
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ences, but weak on some of the basic characteristics of hypnosis such as the production of hallucinations. Hallucinations were not congenial to an objectivist. Twenty years later, in the spirit of the time, Weitzenhoffer, to whom I owe my introduction to hypnosis, summarized the literature in his book entitled, "Hypnotism: an objective study in suggestibility" (1953). Again the emphasis on suggestibility. T. X. Barber's first scale was called the Barber Suggestibility Scale (Barber, 1969). Of course, the suggestibility doctrine was already familiar. It was the doctrine of the Nancy School in France in the late 19th century, with Bernheim as its distinguished spokesman, as he countered the neurological disease theory of the Salpetriere School of Charcot. The suggestibility theory naturally appealed to American experimenters who like to think in terms of stimulus and response, for the suggestion was a stimulus and what the hypnotized person did was a response. This tradition has been carried on, despite the weakening of stimulus-response theory in psychology in the meantime, by Barber, who at first developed what was clearly an input-output theory of hypnosis, with a trenchant attack on anything resembling a state of hypnosis, dramatized by always writing hypnosis in quotation marks. Lately he has modified his position somewhat through the recognition of some familiar characteristics of the highly hypnotizable person, including imagery and fantasy. But imagery as he conceives it is carefully guided so that there is little room for creativity in ordinary hypnotic practice as his subjects think along with the hypnotist in a newer scale, developed with Sheryl Wilson, and rather inappropriately named by them the Creative Imagination Scale (Barber and Wilson, 1979). Any major alteration in Barber's position is quite recent because he repeated the chapter which appeared in the earlier Fromm-Shor volume in essentially the same form in the revision of 1979 (Barber, 1979). Barber's most faithful and highly productive disciple is now Nicholas Spanos. Not to be confused in its details with Barber's position is the role-enactment theory of Sarbin and Coe, enlarged upon in their book of 1972 entitled, "Hypnosis: a social-psychological analysis of influence communication," and reiterated frequently since. The social psychological implications of their approach came by way of their espousal of the role theory developed by sociologists such as George Herbert Mead; the influence communication part is merely a new name for suggestion. When one gets a little distance from the two positions - that of Barber and that of Sarbin and Coe, they appear very similar in their impact, despite their differences in vocabulary and orientation. At least they attack the same people who seem to find more psychological reality than they do in the familiar phenomena of hypnosis.
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Heightened suggestibility or social response to influence by another person is present in hypnosis, but as the sole criterion of hypnosis, it is not entirely satisfactory. The suggestibility that is relevant is of a restricted kind, working within certain boundaries, as shown by the work of Rosemarie Moore (1964), in which many forms of responses to suggestion, defined by social persuasibility or acquiescence showed very low correlations with measured hypnotizability. A distinction between primary and secondary suggestibility has also been recognized for a long time, with only primary suggestibility closely related to hypnosis (Eysenck and Furneaux, 1945; StukAt, 1958). I wish to turn now to two conceptions that relate more directly to the conscious-unconscious distinction: one deriving from psychoanalysis and one deriving from Janet's theory of dissociation. I shall start first with psychoanalysis, because it has been better represented in the hypnosis literature since mid-century. Psychoanalysis and Hypnosis There are two main aspects to the Freudian theory of the unconscious and the dynamics of hypnosis, the first the principle of repression, the second, the principle of regression. Limiting discussion to these two concepts is to simplify greatly. The origin of the unconscious is said to be by way of the repression of socially unacceptable impulses, sexual and aggressive, into an unconscious reservoir, where they remain active but express themselves only indirectly. Psychoanalytic theory is designed to derive a useful picture of the unconscious through free associations and their interpretations. In addition to free associations, the unconscious may find expression through slips of speech, mannerisms, dreams, or symptoms of illness, such as the conversion symptoms of hysteria. I am here disregarding the Jungian interpretations, which allow for a racial unconscious, but I wish to note one aspect in common: The unconscious to both Freud and Jung is never directly accessibl;:-but is known only by inference from symbolic manifestations in one form or another. We shall return to this aspect later. The concept of regression has been brought most clearly from psychoanalysis into the interpretation of hypnosis. In this context we are not talking about age-regression as familiarly studied in hypnosis, but rather regression as an alteration in thought processes within hypnosis in the direction of a more infantile or primitive mode of thought. The conception of hypnosis as a regressed state was implied in some earlier writings, but came to prominence as the psychoanalytic ego-psychology was developed under the influence of Anna Freud (1936) and Heinz Hartmann (1958), as later interpreted by David Rapaport
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(see Gill, 1967). Ernst Kris (1952) had proposed the concept of regression in the service of the ego - a partial regression that could be halted and reversed, particularly in the support of the creative thinking of the artist. This idea then became the basis for the interpretation of hypnosis by Gill and Brenman (1959), two American psychoanalysts who made extensive use of hypnosis in their practice. According to their view, hypnotic induction disrupts the ordinary ego structure, and the fractions that remain are then reassembled at a more primitive level as the hypnotic condition is established. The thought processes that persist at a partially regressed level give evidence of what is called primary-process thinking, to distinguish between it and ordinary rational thinking and problem-solving known as secondary process thought. Primaryprocess thought is more primitive, illogical and impulsive. By definition, fantasy and hallucination are taken as signs of primaryprocess thinking. This assignment of hallucination to primaryprocess is based on selecting the dream as the model of primaryprocess thinking, because the dream goes on primarily in the form of visual hallucinations rather than in words. The presence of fantasied and hallucinated experiences in hypnosis makes it clear that, by these definitions, the hypnotic consciousness gives signs of primaryprocess thinking and therefore illustrates regression. In their effort to make an experimental approach to this problem, Fromm et al., (1970) studied the presence of primary-process thinking in a group of moderate to high hypnotizable subjects by administering the Rorschach inkblot test in both the waking and the hypnotic condition. They found, not unexpectedly, that there was more primary-process thinking evidenced in hypnosis than in waking, as judged according to scoring system of Robert Holt (1963). However, they did not find convincing evidence for an adaptive regression, that is, regression in the service of the ego, as posited by Gill and Brenman. I find some limitations to an experiment of this kind. In the first place, the assumption is made that after hypnosis the subject is in an altered state of consciousness that has its own defining characteristics. The conception of a characteristic hypnotic state may lead to the faulty conception of a 'neutral' state of hypnosis, that is, the state while the hypnotized person just sits or lies there, doing nothing. If a relaxation hypnosis has been undertaken, then this may well be a state of relaxation, as described by Edmonston (1981), who equates hypnosis with relaxation. However, hypnosis may also be an aroused state, as Banyai and I (Banyai and Hilgard, 1976) showed by inducing hypnosis while the subject rode a laboratory bicycle ergometer. The conscious condition and the physiological condition, under hypnosis, depend on what the patient is doing while hypnotized. Consequently, physiological processes while
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hypnotized may be at any point on the spectrum from quiescence to high activation. To be sure, when presented with Rorschach cards to interpret, the patient is doing something, but how typical is that something? Why not study what he or she was ~ while being tested for hypnosis: experiencing age regression, having a dream, hallucinating an odour or hallucinating a voice? There is little justification for making inferences about the adaptive responses from a limited set of demands when a richer set of demands can be studied through the hypnotic behaviors and experiences themselves. I made a small excursion into this area twenty years ago in a paper on the primary-secondary type of thinking, and noted, with examples from hypnosis, that the ideas could not be applied very simply to the phenomena of hypnosis (Hilgard, 1962). For example, sometimes the two types of thinking went on quite independently, while sometimes they were fused in a single experience. Let me illustrate by a pair of responses to a hypnotic test item with which we had had a good deal of experience. The hypnotized subject is told that he or she is soon to be told a joke, and will find it amusing. Then the hypnotist says, "The whale is undoubtedly one of the largest mammals alive today." Two subjects who responded characteristically to the suggestion each laughed uproariously. Asked why the joke was funny, the first subject said it wasn't funny at all. "I just had a laughing fit." Here there was no integration between the response to the affective suggestion, illustrating the involuntariness of hypnotic responses, while the ordinary meaning of the statement about the whale as a large mammal was interpreted in secondary-process thinking as a simple proposition about a whale. The second subject said, however, "You should have seen the funny whale I pictured, with a long snout and tiny legs. It sure was funny I " Here the primary process affect was integrated with the cognitive process of hallucinatory transformation. I suppose that there would be a higher primary process score here than in the first case, but note that, while hypnotized, even this subject could communicate in a discriminating way how the humor was created by the distortion. The mixture between primary process and secondary process is evident throughout hypnosis. This has been described for many years as a preservation of the normal observing ego, while part of the ego has been transformed. For example, when an arm has been paralyzed as the result of suggestion, the subject perceives the arm in the same way as an arm paralyzed by a stroke would be perceived. "When I try to bend it, I am unable to bend it no matter how hard I try." The contracture was produced involuntarily, but the voluntary trying may be perfectly normal and genuine, often accompanied by a normal surprise that the arm does not bend. This is one reason that I am troubled by the concept that hypnosis can be described simply as a particular altered state of consciousness.
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Is the Relationship Between the Hypnotist and the Patient a Regressive Transference? There is another aspect of the concept of regression as related to the hypnotic state that is emphasized by Gill and Brenman, referred to by them as a regressive transference. What this means is that the hypnotic setting stirs up the early emotional attachments to a parent-like figure, and therefore shares, as psychoanalysis does, in a regressive transference which also affects the thought processes within the hypnotic session. The late Ronald Shor in his characterization of hypnosis referred to archaic involvement, and felt it to be an important aspect of the phenomena (Shor, 1962). He noted, however, that it had to be encouraged by the hypnotist, so that it might be a product of the hypnotist's manipulations instead of something essential to the hypnotic condition. Many conjectures about hypnosis are contaminated by the uses to which hypnosis is being put. If hypnotic treatment of a neurotic condition is long-continued and repeated, as in a hypno-analysis, it may be expected that a transference relationship will develop. Such transference may belong to the therapeutic relationship rather than to hypnosis itself. My wife, Josephine Hilgard, a trained psychoanalyst and member of the Freudian American Psychoanalytic Association, conducted a large number of depth interviews with our laboratory subjects who had shown high involvement in their hypnotic experiences (J. Hilgard, 1965; 1979). They all demonstrated success in experiencing a variety of responses to suggestion indicative of hypnosis as conventionally conceived. The characteristic response to the hypnotist did not reflect regressive transference or archaic involvement. The role of the hypnotist was more frequently that of a guide, described in the subjects' words as a tour guide, leading the subject but he or she did not have to go where the hypnotist directed if they didn't wish to; or the hypnotist was a catalyst ••• a facilitator helping the person to experience hypnosis, an aide rather than a director or manager. Even subjects who had experienced hypnosis for ten or more times did not alter their picture of the hypnotist. The personality of the hypnotist seemed to have very little to do with it; in fact, one common assertion was that the hypnotist was mostly a voice that could guide the person's own experiences. If this interpretation is correct, transference is not an essential feature of hypnosis itself, though it may develop in longer continued therapy using hypnosis. The Preconscious and the Unconscious.
An older psychoanalytic position is commonly reflected in the hypnotic conception of layers of consciousness and unconsciousness. For Freud there were in the topographic view of the conscious, the preconscious and the unconscious.
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The preconscious is usually conceived as the residue of available memories, not conscious only because they are not attended to. Unlike the unconscious, they are not the result of repression. If one uses a familiar conception of hypnosis on the basis of concentrated attention to one source of information with neglect of other information, one can easily think that the neglected information belongs to the preconscious. I find this congenial because the preconscious can be used as equivalent of divided consciousness, for when the preconscious is made conscious there are no unusual surprises in it, the material that emerges was once conscious, and emerges as such. But what about the deeper unconscious? In psychoanalysis, this is inferred from its derivatives. Yet some of our colleagues like to speak as if, through hypnosis, they can talk to the unconscious. Let us be a little clearer about this. A favorite technique has been to use finger signalling while hypnotized (Cheek and LeCron, 1968). An open discussion has been carried on between the hypnotized person and the hypnotist. The hypnotist may suspect, on psychodynamic grounds, that there is a hint of unconscious material that may contradict the open conscious report. Suppose, for example, that the inference is that a male patient hated his mother, but he insists that he loves her wholeheartedly and nothing untoward ever went on between them. Anyone familiar with dynamic interpretations will know about the ubiquity of ambivalence, so that it is a fairly safe inference that all was not so uniformly loving and congenial. Hence the finger technique can be used to expose a deeper level. I have seen this done and carried on to still deeper levels. It was concluded that at last the hypnotist was talking to the unconscious. I am not questioning the fact that this procedure may have turned out to be therapeutic, but I doubt that the hypnotist was talking to the unconscious. The unconscious is not a directly accessible repository of memories or wishes or warded-off affects. It is a metaphorical concept that has to be used cautiously in relation to broader aspects of a theory of motivation and personality, and is not to be used glibly, no matter how serviceable the metaphor may be in some instances. It can lead to such abuses as uncovering birth experiences and prior lives, such extensions will make it more difficult for hypnosis to find its rightful place in psychological and medical science. Dissociation Theory as an Alternative A rather different view of the relationship between the conscious and the subconscious was proposed by Pierre Janet. I use the word subconscious rather than unconscious because that was the term that Janet introduced, even though he spoke more frequently of dissociation. Janet viewed dissociation as pathological, related to
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hysteria or other forms of psychic weakness. Hence in offering a modern form of his theory, that rejects the pathological roots, I have used the expression neodissociation theory (Hilgard, 1977). I am also sidestepping some of the negatives created by those such as Hull (1933) and White and Shevach (1942) who dismissed dissociation because it could be shown to be incomplete. The very advantage of dissociation as related to hypnotic phenomena is that it can be partial of incomplete, and hence account for the degrees of responsiveness to hypnosis, manifested in the differences in hypnotic talent by the less and more hypnotizable, and by the differences in response in waking hypnosis and following a hypnotic induction. Dissociation has the advantage that the early writers such as Morton Prince, Hart and McDougall saw in it, that the dissociated experiences are there to be examined for what they are, not (as in psychoanalytic theory) for what they may be inferred to be. I find amnesia to be one of the clearest features of hypnosis. Amnesia is a model for dissociation as the dream is a model for primary-process thinking. In amnesia a once-conscious set of memories is temporarily forgotten as a consequence of suggestion, overt or covert, within hypnosis, and the fact that the memory was not destroyed is evident because it can be recovered. There are gradations to this: not everything that the subject is told to forget is forgotten, and not everything is always recovered when the signal is given for its return. These are experimentable problems, and much attention is being devoted to them. Amnesia, not only posthypnotic amnesia, but amnesia suggested within hypnosis, is genuine, and it well illustrates what is meant by dissociation, including partial dissociation. A few years ago I chanced upon a phenomenon within hypnosis that I described according to the metaphor of a hidden observer. I wish to say a few words about this, so that my findings are not generalized too far from the context in which they were studied. I found that failure under hypnotic suggestion to hear sounds usually heard or to feel pain normally felt, could be reversed later on, even though the subject while hypnotized was not aware of them. In this the parallel with amnesia is evident: something known is now no longer known, until the release signal is given. In the hearing and pain experiments, something that registered unknowingly is later found to have been registered and stored in memory. The difference from posthypnotic amnesia is that the registration itself under hypnosis, took place without awareness. That is what made the recovery more puzzling. I therefore called attention to this registration without awareness as a cognitive process that could be conceptualized metaphorically as a hidden observer. I might have been wiser to refer to it as a cognitive substructure that did the registration, for the information in this neutral statement would have corresponded to speaking of a hidden observer without calling up the picture of a homunculus within the head, watching what is going on. At the level of experimentation, the phenomenon was limited to a very highly hypnotizable subjects, and not all of them yielded what I
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called hidden observers. Therefore it was a finding of more theoretical than practical interest because it was rare, and the conditions for its appearance were not clearly known. It turned out to have been discovered by others in the past, such as Alfred Binet and William James, but was relatively unfamiliar in contemporary experimental hypnosis. I am aware of the criticisms offered against the hidden observer concept, but I cannot take time to examine the debate at this point except to note that most of those who object are also critical of the reality of psothypnotic amnesia and of pain reduction through hypnosis. Offhand, this looked a little like unconscious processing. I prefer, however, to relate it to the literature on subliminal registration, and, in terms of the models about which I have been speaking, to attribute it to the preconscious rather than to the unconscious. When the concealed material is brought to consciousness through automatic writing or through a related technique that I have called automatic talking, the language is that of secondary process, and there is no welling up of deep thoughts or feelings associated with the unconscious. These experiments were quite limited and others are carrying them on. I hope that some experimenters will use more affect-loaded or guilt-arousing episodes than laboratory experiences of pure tones, or the pain of circulating ice water or of a tourniquet on the arm, which express little personal meaning. Possibly such experiences would dredge up more deeply repressed material through the hidden observer inquiry. The advantages of the dissociation position, as I use it, is that it permits recognition of the partial dissociations that occur in response to simple suggestions, when the only modification of consciousness is in the automatization of a simple act that is otherwise performed voluntarily. The executive control systems are the first to respond to suggestions, as they are the first responses to occur in imitation. other kinds of dissociation, such as multiple personalities, are most difficult, and appear less frequently in a population of patients. One can study these matters, and attempt to theorize about them, without adopting a fixed position about hypnosis as an altered state of consciousness, or as a derivative of the deep unconscious. REFERENCES Banyai, E. I., and Hilgard, E. R., 1976, A comparison of activealert hypnotic induction with traditional relaxation, J.abnorm.Psychol., 85:218-224. Barber, T. X., 1969, Hypnosis: A scientific approach, Van Nostrand, New York. Barber, T. X., 1979, Suggested ("hypnotic") behavior: The trance paradigm versus an alternative paradigm, in: "Hypnosis: Devel-
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opments in research and new perspectives, E. Fromm and R. E. Shor (eds.), Aldine-Atherton, Chicago. Barber, T. X., and Wilson, S. C., 1979, The Barber suggestibility scale and the creative imagination scale: Experimental and clinical application, Am.J.clin.Hypnosis, 21:84-108. Cheek, D. B., and LeCron, L. M., 1968, Clinical hypnotherapy, Grune and Stratton, New York. Edmonston, W. E., Jr., 1981, Hypnosis and relaxation: Verification of an old equation, Wiley, New York. Eysenck, H. J., and Furneaux, W. D., 1945 Primary and secondary suggestibility: An experimental and statistical study, J.exp. Psychol., 35:485-503. Freud, A., 1946, The ego and the mechanisms of defense, International Universities Press, New York. Fromm, E., Oberlander, M. I., and Gruenewald, D., 1970, Perceptual and cognitive processes in different states of consciousness: The waking state and hypnosis, J.Proj.Tech.Pers.Assess., 34:375-387. Gill, M., (ed.) 1967, The collected papers of David Rapaport, Basic Books, New York. Gill, M., and Brenman, M., 1959, Hypnosis and related states: Psychoanalytic studies in regression, International Universities Press, New York. Hartmann, H., 1958, Ego psychology and the problem of adaptation, International Universities Press, New York. Hilgard, E. R., 1962, Impulsive vs. realistic thinking: An examination of the distinction between primary and secondary processes in thought, Psychol.Bull., 59:447-448. Hilgard, E. R., 1977, Divided consciousness: Multiple controls in human thought and action, Wiley, New York. Hilgard, J. R., 1965, Personality and hypnotizability: Inferences from case studies, in: "E. R. Hilgard, Hypnotic Susceptibility," Harcourt,Brace and World, New York. Hilgard, J. R. 1979 Personality and hypnosis: A study of imaginative involvement (2nd ed.), University of Chicago Press, Chicago and London. Hold, R. R., 1963 Manual for the scoring of primary process manifestations in Rorschach responses (9th ed.). Research Center for Mental Health, New York University (Mimeographed), New York. Hull, C. L., 1933, Hypnosis and suggestibility: An experimental approach, Appleton-Century, New York. Kris, E., 1952, Psychoanalytic explorations in art, International Universities Press, New York. Moore, R. K., 1964, Susceptibility to hypnosis and susceptibility to social influence, J.abnorm.Soc.Psychol., 68:282-294. Neisser, U., 1967, Cognitive psychology, Appleton-Century-Crofts, New York. . Sarbin, T. R., and Coe, W. C., 1972, Hypnosis: A social-psychological analysis of influence communication, Hold, Rhinehart, and Winston, New York.
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Shor, R. E., 1962. Three dimensions of hypnotic depth. Int.J.clin. exp.Hypnosis. 10:183-202. StukAt. K.-G •• 1958. Suggestibility: A factorial and experimental analysis. Almqvist and Wiksell. Stockholm. Weitzenhoffer. A. M•• 1953. Hypnotism: An objective study in suggestibility. John Wiley and Sons. New York. White. R. W•• and Shevach. B. J •• 1942. Hypnosis and the concept of dissociation. J.abnorm.Psychol •• 37:309-328.
THE CLINICAL RELEVANCE OF HYPNOTIZABILITY IN PSYCHOSIS: WITH REFERENCE TO THINKING PROCESSES AND SAMPLE VARIANCES* Germain Lavoie and Robert Elie Hopital Louis-H. Lafontaine & Universite de Montreal 7401, rue Hochelaga Montreal, H1N 3M5, Canada Abstract This paper reviews the relationships between hypnosis and psychosis from the point of view of psychoanalytic theory, cognitive psychology and neodissociation theory, and the implications of these in the diagnosis, prognosis and therapy of psychotic patients. Psychoanalytic concepts of thing and word presentations, of primary and secondary processes, and ego psychology concepts, are examined in relation to both hypnosis and psychosis. The contribution of Piaget's theory in understanding the nature of cognitive deficits is discussed. Neodissociation concept of the hidden observer in hypnosis is compared with Freud's concept of the hidden observer in psychosis. The hypnotic assessment situation is viewed as a focalized encounter providing many cues regarding cognitive fluency, attentional flexibility, interpersonal involvement, imaginative potentials, motivation which are all of importance in establishing a prognosis and a treatment plan with or without hypnosis. Major psychoses such as schizophrenia and manic-depressive disorders are considered. The history and stage of the psychoses are examined as major variables impinging on the course of hypnotic investigation and treatment. Some data and experiments are reported and the implications of these for theories of hypnosis and of psychosis are discussed.
*Invited Address presented by the President-Elect of the International Society of Hypnosis. 41
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In this paper on "the clinical relevance of hypnosis in psychosis". we will examine two basic questions. The first question deals with the nature of hypnosis and psychosis: why can we reasonably expect psychotic patients. especially the schizophrenic ones. to be able of experiencing hypnosis. in spite of their often severe and bizarre thinking disorders? In trying to answer that question. we will contend that as long as metaphoric and metonymic thinking and communication is present in the schizophrenic experience. hypnosis is a potentiality. And we will report some data in support of this point of view. The second question deals with the distribution of hypnotic responsivity in schizophrenic samples. and some of the parameters of hypnotizability in schizophrenia. Here we will attempt to demonstrate that the mean susceptibility score of available schizophrenic samples cannot be said to differ from the mean susceptibility scores of comparable normal samples. The dispersion of individual scores around the samples' means. however. is typically smaller with schizophrenic samples than with normal comparable samples. a fact that still awaits proper explanation.* METAPHORIC LANGUAGE. PRIMARY PROCESS AND HYPNOSIS A striking characteristic of the literature on hypnotic techniques lies in the fact that the hypnotist typically appears to act upon the meaning of the words he uses. At this end. he largely relies on the use of two widespread figures of speech: metaphor and metonymy. and upon the primary process "techniques" underlying these, i.e. chiefly. condensation and displacement (Jakobson. 1956). Metonymy consists of the use of the name of one thing for that of another. of which it is an attribute. or with which it is associated. Examples of this are: "lands belonging to the crown" or "smoke a havana". If we refer to the "first violin of the Glasgow orchestra". we are not speaking of the concrete musical instrument, but of this specific musician as a person. The first meaning of "violin". however. is not abolished. but only temporarily put aside. Metaphor is defined as a figure of speech in which a word or phrase literally denoting one kind of object or idea is used in place of another to suggest a likeness or analogy between them. As examples: "the ship plows the sea". or. in Erickson's words: "My English is rusty". or "in my voice, you can hear the whispering wind. the rustle of leaves". Similarly. when Erickson was treating an impotent patient by speaking extensively about cigarette smoking and *The authors wishe to thank Professors R. R. Holt. M. T. Orne and C. Perry for their helpful comments.
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the attractive ashtray offered by his girlfriend, he was employing metaphorical thinking. The hypnotist might say you will sleep - but hypnosis is not sleep; that you will sleep deeply - but nobody knows what depth is, and nonetheless the subject goes deeper; that you will have a dream but it is not like a nocturnal dream; that you will be unable to open your eyes, or move a hand, a foot, a finger, or say your name - but somehow, you could if you wished; that there are two experimenters when there is only one - but you can distinguish who the real one is, even when you see two of them that you can transport yourself anywhere you wish - but you know that this can be only metaphoric. Somehow, the hypnotic subject is a party of these inexactitudes which actually introduce him into the field of imagination, hypnosis, and meaning. Consider the "trance-logic" concept introduced by M. T. Orne (1959). THe S sees two Dr. X when there can be only one. Three elements of condensation are present: (1) vivid hallucination of a second Dr. X; (2) multiple use of the same material (Dr. X) and (3) double meaning. Displacement also occurs in the sense that the Scan be said to have displaced his belief in the reality of the percept to the hallucinated image. WHile the highly hypnotizable can experience this as if it were for real in a very convincing way, he is also able to demonstrate upon explicit or cued request, his access to the other side of the coin: that is, not only to the figurative meaning of Dr. X, but to the unique aspect of Dr. X as well. He testifies that while he is actually hallucinating, he is also able to discriminate the realms of imagination and of reality. Another example could be taken from Hilgard's "hidden observer" experiment: the subject is told that there is a hidden part of himself that knows about what really happened during hypnosis, while the hypnotized part of the subject does not know. The evidence of dissociation revealed with this procedure is convincing (Hebb, 1975). However, as Hilgard (1977) clearly stated, the hidden observer is a structuralized methaphor, that has the power to produce, in half of th highly hypnotizable subjects and in standard conditions, a distinctive dissociation of consciousness. Here again, the S testifies, through his very adoption of the metaphor, that he has full mastery of the borderlines of reality and imagination. Finally, the work of Erickson (Erickson et al., 1976; Rossi, 1980; Zeig, 1980) provides the largest available sample of clinical uses of condensation and displacement in hypnosis: analogies, puns, metaphor, jokes, folk language, apposition of opposites, idiosyncratic signalling, displacement of resistance, confusion, converting a response into another, reverse set, non sequitur, double dissociation, time distortion, a whole catalogue of anecdotes, etc. These techniques clearly illustrate a deliberate triggering of the many
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form-varieties of primary process as described by Gill (1967) and Holt (1970).* Among the specific manifestations of primary process, Gill (1967) reported the following: formation of composite words, multiple use of the same material, double meaning, collective figure, composite figures, "intermediate" cOllDDOn entity acting as bridge between thoughts, "unification" (where new and unexpected unities are set up), linking thoughts by similarity, consonance, the possession of cOllDDOn attributes, allusion (real or apparent), faulty reasoning and absurdity, indirect representation, symbolization, plus some more manifestations of a list initially proposed by Fliess (1959): picturization, representation of a whole through a part, concretization (when the word is treated like the object), representations through opposites, displacement and manifest content against affect, transformation of one affect into another, and suppression of affect. In this paper, Gill followed closely Freud's writings in an attempt to demonstrate that all the specific primary-process phenomena described in dream work, joke work, and symptom formation were reductible as phenotypes of the more basic processes of condensation and displacement, regarded as the economic genotypes (Gill, 1967). Similar account of Freud's concepts of condensation and displacement could be found in the French Vocabulaire de la psychanalyse (Laplanche et Pontalis, 1967, 1973), where displacement was seen as being at work in "every" unconscious formation, condensation was seen as "one of the essential modes of the functioning of the unconscious processes", especially responsible for the exceptional intensity of certain images. Primary process was then characterized not so much by an absence of meaning, but by a "constant sliding of meaning" through the mechanisms of displacement and condensation. According to this view, displacement was present "whenever one psychical element is linked with another by an objectionable or superficial association" (Freud, 1953). Condensation generally *The puzzling problem is how so much deliberate inexactness can lead to secure knowledge, a question of prime importance for the semeiotician: "There are metaphors and metonymies in which the multiple meanings, inherent in the displacements, do result from a calculated inexactness and ambiguity •••• This fact leads to a better understanding of the nature of a speaker's competence in matters of semantic traits •••• It is a certain tact, an adroitness •••• that enables him to decide which train he will emphasize whether he intends, at this moment and in this circumstance, to be exact but hardly heard, or easily heard though little exact, or fairly exact and fairly heard •••• It is this permanent approximation which constitutes the strength and paradoxically, the exactness of human signification." (Van Lier, 1980).
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implied: (1) formation of composite words or images; (2) multiple use of the same material, and (3) double meaning (Freud, 1960). Primary process along with exemption from mutual contradiction, timelessness, and replacement of external by psychical reality, were seen as the characteristics of the Unconscious (Freud, 1957). This conception led the linguist Roman Jakobson (1956) to relate condensation and displacement with the rhetorical processes of metaphor and metonymy, which he himself considered as the basic polarities of language. This view was further developed by Jacques Lacan (1957). Displacement and replacement at distance have also been presented by Van Lier (1980), as the defining characteristics of human signification: "Signification is ceaseless displacement and replacement, always involving flexibility and approximation." Such manipulation and displacement of meanings presumably involve, on the part of the S, and possibly of the hypnotist, both a lifting of censorship and an imposition of censorship (Gill, 1967, Lap1anche and Ponta1is, 1973,) and not only, as is sometimes asserted, a lifting of censorship or critical thinking. Orne's (1959) "trance-logic" concept, and Hilgard's analysis of the monitoring function in hypnosis (Hilgard, 1977) do imply such an interplay of selected inhibition and release mediated by words. Psychosis During active phases of psychosis, there are delusions and hallucinations, and metaphoric and figurative thinking is often greatly impaired. This is well illustrated in the autobiography of the Schreber case who, at some point, believed he was entering into sexual relationships with God, and in the following contemporary example of schizophrenia, quoted from Neal and Oltmanns (1980). D. P. D. P. D. P.
Have you been nervous or tense lately? No, I got a head of lettuce. You got a head of lettuce? I don't understand. Well, it's just a head of lettuce. Tell me about lettuce. What do you mean? Well ••• lettuce is a transformation of a dead cougar that suffered a relapse on the lion's toe. And he swallowed the lion and something happened. The •••• see, the ••• Gloria and Tomy, they're two head and they're not whales. But they escaped with herds of vomit and things like that. (passage omitted) D. - What does all that mean? P. - Well, you see, I have to leave the hospital. I'm supposed to have an operation on my legs, you know. And it comes to me pretty sickly that I don't want to keep my legs ••• D. - You want to have your legs taken off?
G. LAVOIE AND R. ELIE P. - It's possible, you know. D. - Why would you want to do that? P. - I didn't have any legs to begin with. So I would imagine that if I was a fast runner, I'd be scared to be a wife, because I had a plinter inside of my head of lettuce.
It has been said that schizophrenic language is metaphoric. Actually the sample just reported rather indicates, at this stage, a failure of metaphoric thinking. The full range of meanings of the "head of lettuce" does not seem to be available to the patient. In schizophrenic delusions and hallucinations, some meanings are abol ished and the patient is imprisoned into a closed network of associations classically diagnosed as autistic thinking. In contrast, if a hypnotized S happens to have the experience that "he has a head of lettuce", the other meanings of "head of lettuce" would not be abolished or repudiated as in actual psychosis (Lacan, 1981) but only temporarily put aside or suspended, as is the case with metaphor. There is another stage or type of schizophrenia when the patient, though he is still hallucinating and deluded at times, is also able to challenge the "reality" of these hallucinations and delusions. The most hypnotizable schizophrenic the senior author (G.L.) ever met was at such a stage when he experienced hypnosis for the first time. He suggested with a smile that he was feeling better now because "he had finally met his father" (that is G.L.). This in his mind was a metaphor, and was intended to mean, as revealed in the transcript of the interview, that he was experiencing with G. L., at that time, some of the characteristics of the ideal father: trustful, permissive, caring, interested in his difficulties, holding position in the hospital, and above all, having as family name "Lavoie" (from the Latin "via"), literally in English "the route", "the way", "the path", which he was kind enough to express in the following image: "Germain the Path, the right path, the path leading to the right harbor" • Yet, in this same interview, the patient reported having hallucinated G.L. in the Chapel, after the Holy Communion, in the form of an air pilot. He and the air pilot "looked at each other", and from then on, he "knew" it was G.L. In this case, we have an instance where two levels of handling images and symbols appear in communication. The hallucination indicates that the autistic forms of thinking are still active, though they appear in a more sporadic fashion. The same interview also provided some gems of a more socialized deliberate use of images and symbols. Certainly, the "father" metaphor and the sliding of meaning from "Lavoie" to "the path" and finally, "the path leading to the right harbor" indicate in that man a capacity to handle signification in a rich way, a capacity to convey deep meanings. Even if you find here and there some autistic processes whose concealed meaning can be elucidated, however, in the therapeutic relationship.
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In a third type or stage of schizophrenia, you find patients who don't present autistic thinking and language for long periods of time. These are active, quite flexible in their use of images and symbols, sometimes creative people. They might be depressed at times, but still, there is a meaning to it, that can be worked through in metaphoric terms. A fourth type of patients would rather appear rigid, stereotyped, little talkative, matter-or-fact, isolated, with a certain flatness of affect. These patients are difficult to interview, and do not manifest much of the liberate and socially shared manipulations of images and symbols which characterize metaphoric thinking. A Measure of Socialized versus Autistic Use of Primary Process From these sets of clinical examples, three relevant measures of form-varieties of primary process can be developed: a measure of autistic use of images and symbols, to be represented here by AF; a measure of socialized and readily meaningful use of images and symbols, to be represented here by SF; a measure of the rapport between these two scores, represented here by SF ratio, that is the proportion of socialized use of images and symbols, on the total observed production of such formal mechanisms, whether autistic or socialized. These scores were derived from Holt's (1963, 1970) system for gauging primary and secondary processes manifestations in the Rorschach test. Holt (1963, 1970) suggested, for each of 40 categories of formvarieties of primary process, a weighed score ("Defense demand") on a 5 point-scale. The more socialized and readily meaningful formal mechanisms would receive a lower score (e.g. 1, 2 or 3) and the more autistic ones, a higher score (e.g. 4 or 5). Our SF (socialized form-varieties) score is the sum of all the weighedlformal scores ranging from 1 to 3, divided by a number of responses (R). Our AF (autistic form-varieties) score is the sum of all the weighed formal scores ranging from 4 to 5, divided by the number of responses (R). Our SF ratio is defined as SF/(SF + AF). These scores are somewhat different from Holt's "level 1" and "level 2" formal scores. For instance, all the explicit instances of symbolism would fall in the SF ("socialized") score, while the AF ("autistic") score constains only the most extreme formal deviations of thinking. The SF ratio does include such figure of speech as metaphor and metonymy, as well as many other indicators of socialized formvarieties of primary process. In fact, although metaphor was taken here as the most readily available example of the type of figurative process involved in hypnosis, the other related form-varieties of such process are relevant as well. In psychoanalytic thinking, metaphor belongs with a group of "techniques" representing the more socialized part of the form-varieties of primary process. Among these processes listed in Holt's system (1963, 1970) from which our
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indexes are derived. one can find the formation of composite images. arbitrary combination of separate percepts. arbitrary use of color. puns and ma10propisms. hyperbole and inappropriate simile. displacement in time. explicit use of symbolism. impressionistic language. peculiar verbalizations and some types of contradiction of reality. Altogether. it is the amount of such occurrences that constitute the numerator of our index for socialized forms of primary process (SF ratio). Many of these form-varieties of primary process were found to be significantly increased under hypnosis (p ,
4 3 2
Mean SHSS:A score, with one SD below and beyond the mean, for 7 samples of schizophrenics and 8 samples of normal Ss from Morgan and Hilgard (1973).
and the Stanford scales measure somewhat different things (Hilgard, 1982).* *Pettinati (1982) reported, for 25 schizophrenics tested with SHSS: C, a mean of 5.76 which was comparable to normal mean. She found, however. that patients obtained a lower mean score on the HIP when compared to normals, and suggested that the HIP may have different properties from the HGSHS:A and SHSS:C. Horne, Pettinati and Orne (1981) also found that young acute hospitalized schizophrenics (mean age 29) scored as high as the normative samples on HGSH:A and SHSS:C. As far as variance is concerned, an examination of Pettinati (1982) tables reveals a striking agreement with the data presented here, which shows the very high consistancy of this "effect" across available schizophrenic samples. Among her clinical groups, schizophrenics presented the lowest variance (SD 2 = 3.6). compared to variances of 9.6 and 10.9 for two normal samples. With the HIP, on the contrary, the variance for schizophrenics (SD 2 8.4) was higher than the variances for the normal samples (SD 2 = 4.8 and 6.3, respectively).
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Mean susceptibility scores (SHSS:A) for 7 samples of schizophrenics and for 8 samples of normal Ss from Morgan and Hilgard (1973) Schizophrenics(l)
Nonna1s (Morgan & Hi1gard, 1973)
(Age:x ! 42.0;SO!10.22)
Age 29-36 114
Age 1 37-73 03
(1) M=ma1e; F= female; V. volunteer; cv="coerced volunteer".
(2) Comparison of the variances: F = 2.1977. p < .001 . (3) See Figure 3 for identification of schizophrenic samples. Greene (1969) sample has not been included in this table. since only 10 of the 12 SHSS:A items were used in that study.
The striking characteristic of schizophrenic response to SHSS:A is that, as a group, they tend to cluster around the mean, in the middle range of susceptibility, while scores of normal Ss are more evenly distributed over the whole range of susceptibility. This confirms on a much wider scale our 1973 observation (Lavoie et al., 1973) stating that two characteristics distinguished schizophrenic scores from normals: (a) a lower variance and consequently (b) a difference in the shape of the hypnotic scores distribution. The left part of Figure 4 shows the means of the seven (7) samples of patients, totaling 306 psychotics, mainly schizophrenics. The middle part shows the means of four (4) groups of normal Ss in
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the 29 to 36 age range, totaling 114 Ss, and the right part, the means of four (4) groups of normal Ss: 37 years and older, totaling 103 SSe Each mean is accompanied by a line representing 1 SD beyond and 1 SD below the mean. Figure 4 illustrates the data presented in Table ~ The variance is smaller in all the schizophrenic groups than in any of the normal groups. The variation of the distribution of the means in schizophrenics is similar to the variation of the distribution of the means in normals. The overall mean of the 306 schizophrenics (M = 5.32, SD 2 = 5.26) falls between the mean of normals in the 29-36 range-of age (M = 6.45, SD 2 = 11.39, N = 114) and the mean of normals, 37 years of age and older (M = 5.05, SD 2 = 11.75, N = 103). Further inspection of the distribution of the schizophrenics' means in Table 1 and Figure 3 reveals that the highest means were obtained in three (3) samples, where ~s were female, volunteering for experiment, and where on the whole, 38.4% of the initially identified sample were ruled out of the experiment. The highest mean of 7.64 (SD 2 = 5.24) (Kramer and Brennan, 1964), from 25 female patients, 28 years of age (X) does not differ significantly from Morgan and Hilgard's (1973) reported mean of 7.34 (SD 2 = 9.1) for 172 normal female Ss, aged 21 to 36. Therefore, Kramer and Brennan's mean is not especially "high", as has been reported by numerous authors including ourselves, but is in line with comparable normal means. The lowest means were obtained with male schizophrenics, defined as coerced volunteers, and where very few patients from initial samples were excluded. Given a standard measure of hypnotic responsivity, high-and-low scoring schizophrenic samples differ significantly among themselves essentially because of a conjunction of 4 main factors: age, sex, type of volunteering, and - as we have seen (Figures 1 and 2) - the capacity of the patient for a shared, socialized use of signs, images and symbols. DISCUSSION It should be clearly understood that results presented here in Figures 1 and 2 are not tantamount to a demonstration that hypnotizability is linked with "mental health" per see Such a view would rapidly lead to a dead-end. There is enough evidence (see Figure 4) that you can be very sick and hypnotizable, and that you can be in good mental health and barely hypnotizable. What our results do suggest is that across the whole spectrum of normality and psychopathology, one of the conditions of hypnotizability is a certain inclination to metaphoric thinking, and a capacity to establish a communication along this pathway, with minimal disruption from either the censorship or critical thinking (that would indicate full restoration or ordinary waking life controls and/or failure of the selective controls of hypnosis) and with minimal instrustion of autistic material (that would indicate failure of ordinary waking life controls and/or failure ·of the selective controls of hypnosis).
G. LAVOIE AND R. ELIE
This post hoc analysis of our 1976 data (Lavoie et al., 1976) seems to have more heuristic value than our previous report on adaptive regression. The study of form-varieties of primary process such as condensation, displacement, symbolization, metaphor and metonymy is of interest to all specialities of clinicians and researchers in the clinical field. It is further at the core of differential diagnosis, psychotherapy, and cover the whole range of normality, creativity and psychopathology. It is amenable to experimentation, with or without hypnosis, and can be readily scored from projective techniques or from free interview transcripts. In contrast, the adaptive regression theory of hypnosis, such as proposed by Gill and Brenman (1959) is, from a conceptual point of view, very difficult to apply in groups of patients precisely characterized by severe pathological regression. This was, according to Gill and Brenman (1959) a "crucial" problem for their theory. Whatever the inner connection between the many interrelated form-varieties of primary process (see Footnote 3), we could demonstrate, in this sample, that they lead to hypnosis to the extent where they convey a shared meaning. And they prevent the development of hypnosis to the extent that they appear queer, incoherent, or autistic. It is therefore a certain agreement of the sender and of the receiver concerning the signification of a given message, even if far-fetched, that support the hypnotic relationship. As long as this agreement persists, the considerations of representability are expended: the thoughts that can, through-displacement, be meaningfully replaced by substitutive images and symbols is astonishingly high, and monitored imaginative processes are permitted (J. R. Hilgard, 1979). Concerning the hypnotizability of schizophrenic patients, evidence presented here in Table 1 and Figures 3 and 4 compelling: schizophrenic patients do present mean susceptibility scores essentially similar to the ones obtained by normal Ss of comparable age. Their scores cover the whole range of susceptibility (0-12) although the standard deviation is significantly lower than with available samples of normal ~s. In the total sample, the scores of psychotics tend to cluster around the mean, in the middle range of susceptibility, and suggest that there is likely to be a lower occurrence of very high and/or very low scores. However, both the available experimental and clinical evidence do indicate that high hypnotic responsivity is not incompatible with a diagnosis of psychosis and/or schizophrenia (Lavoie and Sabourin, 1980; Baker, 1981; Podvoll, 1979). The belief in lower hypnotizability for psychotic and schizophrenic patients generally seems to result from 7 main sources of bias (1) the failure of most studies (except Gordon, 1973; Horne et al., 1981; Pettinati, 1982) to compare the mean of patients with that of normal Ss of the same age; age does appear to be the single most
HYPNOTIZABILITY IN PSYCHOSIS
important source of bias; (2) the confounding, in the typical "status questionis", of means obtained with scales having fewer items than the Stanford Scales, such as the BSS; (3) the prejudice we entertain towards psychotic and schizophrenics which consists in believing that they should not be able to obtain normal scores on hypnotic scales; (4) volunteering bias (Boucher and Hilgard, 1962), illustrated by the fact that means were lower in coerced volunteer samples and higher in true volunteer samples, as the selection ratio increases; (5) failure to recognize, in samples of younger psychotic patients, the interaction of sex and age, as shown in the normative data reported by Morgan and Hilgard (1973); so-called "high" psychotic means are in line with the means of normal Ss of the same age and sex; (6) failure to distinguish clearly what belongs to the means and what belongs to the variance of susceptibility scores; (7) failure to control for the patient ability to relate meaningfully with other persons. Also, it is important to note that the smallness of the hypnotic variances in schizophrenic samples is independent of the size of the mean. That is, with less hypnotizable samples (e.g. Lavoie et al., 1973), the clustering around the mean will result in a greater scarcity of high hypnotic scores, and to a lesser extent, of low hypnotic scores. With more hypnotizable samples (e.g. Kramer and Brennan, 1964), the clustering around the mean will result in a great scarcity of low hypnotic scores. This very constant variance factor across schizophrenic samples tested with SHSS: A still awaits proper explanation. I shall however indicate several areas of research where controlled studies are needed to deepen our understanding of these data.* *There is some indication that this variance factor is not specific to schizophrenia, but does characterize hypnotic scores with other clinical groups as well. Frankel and Orne (1976) observed a variance of 4.49 for 24 phobic patients, and a variance of 8.88 for a matched sample of Ss who applied for help in quitting smoking. All Ss were tested on either the Stanford Scale Form C (SHSS:C; Weitzenhoffer and Hilgard, 1962) or the Havard Group Scale (HGS; Shor and E. Orne, 1962) administered individually. Baker and Copeland (1978) reported SHSS:A variance of 4.75 for 45 depressed patients. Pettinati (1982) reported SHSS:C variances of 5.76 for 18 depressed patients, 5.76 for 60 anorexic patients, and 4.0 for 12 alcoholic patients, compared to variances of 10.89 for 87 Pennsylvania students and 9.61 for 58 Stanford students. Such a constant lowering of SHSS:A and C variance as soon as one deals with clinical samples from so different sources could possibly find some element of answer from social and cognitive psychology. Perhaps the treatment of information and the exploration of meaning is limited as psychopathology develops, with a resulting conformity and stereotype of the person's behavior on SHSS:A and SHSS:C. The reasons why the reverse occurs with the HIP are not clear and reveal, from a new angle, the important differences in the psychometric properties of the HIP and the Stanford Scales.
G. LAVOIE AND R. ELIE
One way of approaching the problem would be the study of schizophrenic' hypnotizability as a function of demand characteristics (Orne. 1962. 1969. 1972). In effect. this concept does remind us that there can be no univocal correspondence between a given clinical or experimental observation and its meaning or interpretation. One has to keep into account the six corners of signification. as defined by Van Lier (1980): (1) the sender. (2) the receiver. (3) the signifier. (4) the signified (the concept or mental scheme). (5) the interpreters ("interpr~tants"). or alternative signifiers. and (6) the referent in reality. Distinguishing genuine hypnotic experience from compliance would be a first target for research. It may be that the scarcity of very low scores on SHSS:A reflects the tendency of the patient to comply with the various requests by doctors. and the fear of disappointing the experimenter or the clinician. This could readily be illustrated in several individual protocols. To what extent this model could partly account for the scarcity of high hypnotic scores is more problematic. But as long as there is a widespread unfounded belief that "schizophrenics are not hypnotizable". the ones who will get a 12 on SHSS: A will be regarded with suspicion. And schizophrenics do know as well as anyone else what doctors expect from them. From a clinical point of view. feigning (Lacan. 1981) or simulation (Orne. 1962). if present, could be as instructive, in view of the theory presented here. as hypnotizability itself.* *The complexity of meaning is best examplified in two critical instances of human communication: simulation. and testimony. Orne (e.g. 1982) studied both with experimental or quasi-experimental methods. The French structuralist Jacques Lacan put both at the root of inter-subjective relationship: "Feigning is the hallmark of the relationship between two subjects. by which it can be distinguished from the rapport from a subject to an object ••• You know you are in presence of a subject to the'extent that what he says and does •••• can be supposed to have been said or done in order to feint you. with all the dialectic so implied. up to and including the possibility that he tells the truth in order to make you believe he is lying •••• What the subject says is always in a fundamental relationship with potential feigning. where he sends and where I receive the message in an inverse form •••• It is essentially this unknown in the otherness of the other. which is characteristic of the spoken word as spoken to another subject •••• This structural description •••• is the only appropriate basis for stating the problems." (Lacan. 1981). And about testimony: "It is clear that everything that has some value as a communication. is in connection with testimony •••• The whole thinking of scientists is based on the possibility of a communication whose terms could be settled once and for all in an ex-
HYPNOTIZABILITY IN PSYCHOSIS
Other factors. however, are undoubtedly at work, such as the item structure of the hypnotic scale. It is now clear that success on some hypnotic items such as reversible posthypnotic amnesia rests partly on sophisticated cognitive operations where schizophrenics. as a group, have been shown less effective than normal controls (Lavoie and Sabourin, 1980; Lavoie. 1980). In some schizophrenic samples, other items may generate atypical responses as well. For instance, in the Lavoie et al., (1973) sample, eye closure, eye catalepsy and hand movement presented significant difficulty for the patients. Nobody would interpret the blind's inability to fixate a point, or the deaf's inability to listen to instructions as indicating low hypnotizability. These examples suggest that it is risky to test for hypnotizability with a small number of items whose psychometric properties, with schizophrenics, are unknown. There is an increased risk then that specific deficits or behaviors unrelated to hypnotizability will be mistaken as indicating low hypnotizability. A failure of careful examination for response genuineness could lead to erroneous conclusions. Another area of investigation would lead to controlled studies of the relationship between the dissociative processes in psychosis and in the hypnotic experience, in line with Hilgard's (1977) neodissociation model. Although Freud (1964) contended that a "hidden" normal appraisal of reality persisted in numerous psychoses (Lavoie and Sabourin, 1980) and although clinicians consider such an occurrence as extremely significant and useful from a therapeutic point of view, controlled research in that area is virtually absent.
conti •• periment about which everybody could agree. The founding of the experiment itself is a function of testimony." (Lacan. 1981). It is out of the scope of this paper to develop Lacan's thinking about feigning, testimony and acknowledgement of the unknown in otherness. For him. these issues are at the root of any possible distinction of the three essential orders of the psycho-analytic field. namely the Real, the Symbolic and the Imaginary (Lacan 1981) and they are basic to his theory of psychosis. Lacan introduced the term "Foreclosure" (Repudiation) denoting a specific mechanism held to lie at the origin of the psychotic phenomenon and to consist in a primordial expulsion of a fundamental "signifier" from the subject's symbolic universe" (Laplanche and Pontalis, 1973). "Foreclosure consists in not symbolizing what ought to be symbolized (e.g. castration): it is a "symbolic abolition," One might say that the lifting of this "abolition" is correlative of the re-establishment of the primacy of the symbolic order in inter-subjective relationships, and is at the basis of a reasonable discrimination between reality and imagination.
G. LAVOIE AND R. ELIE
Finally, a genuine semeiotic theory of hypnosis is a task for the future. The human being is basically characterized by his mastery of signs, images and symbols, whether one uses analogical or digital languages (Van Lier, 1980). The hypnotist has always been placed by his subject in a position where he had just a sign or a few signs to make in order to throw both parties into the gear of the hypnotic realm of meaning. James Braid (1846) had discovered just that, when he demonstrated to his fellow physicians that passes and magnets were no more than signs, and that the most simple signs and figures of speech, when shared, could have a tremendous symbolic power. Meanwhile, the clinician of whatever allegiance should be alert to variables that are in the core of his practice: highly susceptible schizophrenics are mainly recruited among those patients who are able to use form-varieties of primary process, including condensation and displacement - and hence metaphors, images and symbols - in a meaningful way, and whose process of metaphoric and symbolic thinking is minimally disturbed by impenetrable autistic deviations in the formal aspects of thinking and language. And he is likely to find more among younger patients, especially women, than among older patients, and more if he respects the genuine volunteering, choice and interest of his patients than if he tends to be coercive. Under these conditions, many schizophrenic patients can reveal, in the hypnotic relationship, their ability for exploration of meaning and human relationships. REFERENCES Baker, E. L., 1981, An hypnotherapeutic approach to enhance object relatedness in psychotic patients, Int.J.clin.exp.Hypnosis, 24: 136-147. Baker, E. L., and Copeland, D. R., 1978, Hypnotic susceptibility of psychotic patients: a comparison of schizophrenics and psychotic depressives. Unpublished manuscript. Research Institute of Mental Sciences, Houston, Texas. Barber, T. X., Karacan, 1., and .Calverley, D. S., 1964, "Hypnotizability" and suggestibility in chronic schizophrenics, Archs.gen.Psychiat., 11:439-451. Barber, T. X., 1969, Hypnosis: A scientific approach, Van Nostrand, New York. Boucher, R. G., and Hilgard, E. R., 1962, Volunteer bias in hypnotic experimentation, Am.J.clin.Hypnosis, 5:49-51. Braid, J., 1846. The power of the mind over the body: An experimental inquiry into the nature and cause of the phenomena attributed by Reichenbach and others to a "new imponderable". John Churchill, London. Adam and Charles Black, Edinburgh. This phamphlet is a slightly revised reproduction of three papers published in the Medical Times, June 13, 20 and 23,
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1846. This abridged account is found in A. E. Waite. Synopsis of counter-experiments undertaken by James Briad to illustrate his criticism of Reichenbach. Appendix III, 352-361, in J. Braid, 1889. Another abridged version, 3-19, 31-36, is reprinted in: "Readings in the history of psychology", W. Dennis, (ed-:), Appleton-Century-Crofts, New York, 178-193. Erickson, M. H., Rossi, E. L., and Rossi, S. I., 1976, Hypnotic realities: The induction of clinical hypnosis and forms of indirect suggestion, Irvington, New York. Fliess, R., 1959, On the nature of human thought: The primary and the secondary processes as examplified by the dream and other psychic productions, in: "Readings in psychoanalytic psychology," M. Levitt (ed.)-,-Appleton Century Crofts, New York, 213-220. Frankel, F. H., and Orne, M. T., 1976, Hypnotizability and phobic behavior, Archs.gen.Psychiat., 33:1259-1262. Freud, S., 1953, The interpretation of dreams, Standard Edition, 4 and 5. Hogarth Press, London, 530. Freud, S., 1957, The unconscious, Standard Edition, 14. Hogarth Press, London, 166-215, 187. Freud, S., 1960, Jokes and their relation to the unconscious, Standard Edition, 8. Hogarth Press, London. Freud, S., 1964, Splitting of the ego in the process of defence, Standard Edition, 23, Hogarth Press, London. Gill, M. M., 1967, The primary process, in: "Psychological Issues," 18, 19. International UniversitieS-Press, New York. 276. 286. Gill. M. M•• and Brenman. M•• 1959. Hypnosis and related states: Psychoanalytic studies in regression, International Universities Press, New York. 217. Gordon. M. C., 1973. Suggestibility of chronic szhizophrenic and normal males matched for age. Int.J.clin.exp.Hypnosis. 21:284-288. Greene. J. T. 1969. Hypnotizability of hospitalized psychotics, Int.J.clin.exp.Hypnosis, 17:103-108. Gruenewald, D., Fromm, E., and Oberlander, M. I., 1972, Hypnosis and adaptive regression: An ego-psychological inquiry, in: "Hypnosis: Research Developments and Perspectives,"E. Fromm and R. E. Shor, (eds.), Chicago, Aldine-Atherton, Chicago, pp.495-509. Ham, W. M., Spanos, N. P., and Barber, T. X., 1976, Suggestibility in hospitalized schizophrenics, J.abnorm.Psychol., 85:550-557. Hebb, D.O., 1975, Science and the world of imagination, Canad.Psychol.Dev., 16:4-11. Hilgard, E. R., 1977, Divided consciousness, multiple controls in human thought and action, Wiley, New York, 195, 188, 204, 221, 230-236. Hilgard, E. R., 1982, Hypnotic susceptibility and implications for measurement, Int.J.clin.exp.Hypnosis, 30:4, 394-403.
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Hilgard, J. R., 1979, Personality and hypnosis: a study of imaginative involvement, (2nd. ed.)., University of Chicago Press, Chicago. Holt, R. R., 1963, Manual for scoring of primary process manifestation in Rorschach responses, (9th ed.)., Research Center for Mental Health, New York University, New York. Holt, R. R., Manual for scoring of primary process manifestations in Rorschach responses, (Rev. 10th ed.)., Research Center for Mental Health, New York University, New York. Horne, R. L., Pettinati, H. M., and Orne, M. T., Hypnotizability of schizophrenic patients. Paper presented at the meeting of the Society for Clinical and Experimental Hypnosis, Portland, Oregon, October, 1981. Jakob son , R., 1956, Two aspects of language and two types of aphasic disturbances, In the fundamentals of language, Mouton, The Hague, p.81. Kramer, E., and Brennan, E. P., 1964, Hypnotic susceptibility of schizophrenic patients, J.abnorm.soc.Psychol., 69:657-659. Lacan, J., 1957, L'instance de la lettre dans l'inconscient ou la raison depuis Freud, in: "La psychanalyse," 3:47-81. (Reprinted in Lacan, J. Ecrits, Editions du Seuil, Paris, 1966. English translation, The insistence of the letter, Yale French Studies, 1966, 36-37, 112-147. Reprinted in Ehrmann, J. (ed.): Structuralism, Doubleday Anchor Books, New York, 1970. Lacan, J., 1981, Le seminaire, livre III: Les psychoses, Jacques-Alain Miller, (ed.)., Editions du Seuil, Paris, 47-50. Laplanche, J., and Pontalis, J. B., 1967, Vocabulaire de la psychanalyse, Presses Universitaires de France, Paris. Laplanche, J., and Pontalis, J. B., 1973, The language of psychoanalysis (D. Nicholson-Smith, trans.)., Hogarth Press, London, 121,82,83 and 339, 123, 166, 168. Lavoie, G., 1980, Posthypnotic amnesia and retrieval in schizophrenia, Paper presented at, Annual Convention of the American Psychological Association, Montreal. Lavoie, G., and Sabourin, M., 1980, Hypnosis and schizophrenia: a review of experimental and clinical studies, in: "Handbook of Hypnosis and Psychosomatic Medicine," G. D. Burrows and L. Dennerstein (eds.), North Holland Biomedical Press, Elsevier, pp.377-420. Lavoie, G., Sabourin, M., and Langlois, J., 1973, Hypnotic susceptibility, amnesia and I.Q. in chronic schizophrenia, Int.J.clin.exp.Hypnosis, 21:157-168. Lavoie, G., Sabourin, M., Ally, G., and Langlois, J., 1976, Hypnotizability as a function of adaptive regression among chronic psychotic patients, Int.J.clin.exp.Hypnosis, 24:3, 238-257. Lavoie, G., Lieberman, J., Sabourin, M., and Brisson, A., 1978, Individual and group assessment of hypnotic responsivity in coerced volunteer chronic schizophrenics, in: "Hypnosis at its Bicentennial: Selected papers," F. H. Frankel and H. S. Zamansky (eds.), Plenum, New York, pp. 109-124.
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Lieberman, J., 1975, Suggested posthypnotic amnesia under active and passive learning conditions in chronic schizophrenia: A quantitative and qualitative analysis, Unpublished master's thesis, Universite de Montreal. Lieberman, J., Lavoie, G., and Brisson, A., 1978, Suggested amnesia and order of recall as a function of hypnotic susceptibility and learning conditions in chronic schizophrenic patients, Int.J.clin.exp.Hypnosis, 26:4, 268-280. Morgan, A. H., and Hilgard, E. R., 1973, Age differences in susceptibility to hypnosis, Int.J.clin.exp.Hypnosis, 21:78-85. Neal, J. N., and Oltmanns, T. F., 1980, Schizophrenia, Wiley, New York, 102. Obstoj, I., and Sheehan, P., 1982, Posthypnotic amnesia and the cognitive efficiency of schizophrenics, Unpublished manuscript, University of Queensland, Australia. Orne, M. T., 1959, The nature of hypnosis, Artifact and essence, J.abnorm.Soc.Psychol., 58:277-299. Orne, M. T., 1962, On the social psychology of the psychological experiment: With particular reference to demand characteristics and their implications, Am.Psychol., 17:776-783. Orne, M. T., 1969, Demand characteristics and the concept of quasi-controls, in: "Artifact in Behavioral Research," R. Rosenthal and R.~. Rosnow, (eds.), Academic Press, New York. Orne, M. T., On the simulating subject as a quasi-control group in hypnosis research: What, why and how, in: "Hypnosis: Research Development and Perspectives," E. FromDland R. E. Shor (eds.), Aldine-Atherton, Chicago, 399-443. Orne, M. T., 1982, Affidavit (April 28) in the People vs Donald Lee Shirley Hearing, Supreme Court of the State of California. Pettinati, H. M., 1982, The capacity of hypnosis in clinical populations. Paper presented at 9th International congress of hypnosis and psychosomatic medicine, Glasgow, Scotland, August. Podvoll. E. M•• 1979. Psychosis and the mystic path. Psychoanl.Rev •• 66:4,571-590. Rossi, E., (ed.). 1980, The collected papers of Milton H. Erickson. (4 volumes). Irvington, New York. Schreber. D. P., 1847. Memoirs of my nervous illness, Dawson, London. 1955. Short R. E., and Orne. E. C•• 1962. Harvard Group Scale of Hypnotic Susceptibility. Form A., Consulting Psychologists Press. Palo Alto, Calif. Speigel. H•• 1974. Manual for the hypnotic induction profile, Soni Medica. New York. Spiegel, H., Detrick. D•• and Frischholz, E•• 1982, Hypnotizability and psychopathology. Am.J.Psychiat •• 139:4.431-437. Van Lier. H•• 1980, L'animal signe, Belgique. Rhode St. Genese. Visscher. 25. 64. Vingoe, F. J •• and Kramer. E•• 1966. Hypnotic susceptibility of hospitalized psychotic patients: a pilot study. Int.J.clin.exp.Hypnosis. 14:47-54.
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Weitzenhoffer, A. M., and Hilgard, E. R., 1959, Stanford hypnotic susceptibility scale, Forms A and B, Consulting Psychologists Press, Palo Alto, Calif. Weitzenhoffer, A. M., and Hilgard, E. R., 1962, Stanford hypnotic susceptibility scale, Form C., Consulting Psychologists Press, Palo Alto, Calif. Zeig, J., 1980, Erickson's use of anecdotes, in: "Teaching Seminar with Milton H. Erickson, M.D.," J. Zeig-(ed.), Brunner/Mazel. New York, pp. 3-29.
IN SEARCH OF HYPNOSIS
Andre M. Weitzenhoffer Veterans Administration Hospital 921 N. E. 13th Street Oklahoma City, Oklahoma, USA
Abstract Starting out as de Puysegur's "magnetic somnambulism," hypnosis has gone through a number of transformations over the last 140 years, culminating in today's "Ericksonian hypnosis." Factors leading to the changes are discussed. There have been many, clinicians rather than researchers having the main influence upon this transformation. In contrast to earlier research, carried out prior to 1920, modern research has contributed very little new to our understanding or utilization of hypnosis. Some of the reasons for this are also examined. Today we are faced with no certainty that what passes as hypnosis is the same as what passed for it 140 years, or even 50 years, ago. Nevertheless, when we speak of hypnotism most of us have in mind the phenomenology that essentially characterized hypnotism prior to 1910. These are the phenomena also ascribed to de Puysegurian somnambulism. It needs to be recognized that the latter condition probably occurs in less than 1% of individuals; thus it is rarely encountered in the laboratory and office. The proper study of hypnosis, nevertheless, should focus on this group rather than on the much larger group of suggestible but nonsomnambulistic subjects, as has been the case in recent times. Implications of these considerations and speculations regarding traditional hypnosis conclude the presentation.
A. M. WEITZENHOFFER
In 1841 James Braid witnessed two demonstrations of mesmerism. More specifically, he saw demonstrations of so-called magnetic or artificial somnambulism, a condition discovered by de Puysegur in 1782. Shortly thereafter, Braid renamed the condition hypnotism or nervous sleep. He also showed it could be brought about in some individuals by merely asking them to focus their eyes and attention on a small, bright object held in front of them. Braid researched and utilized hypnotism therapeutically for some twenty years, until his death in 1861. Braid's (1841) view of hypnotism can be summed up as follows: (1) It is a state of monoideism, i.e., of concentrated attention to an idea. (2) It can be brought about in five minutes or less in the fashion already described. (3) It is an all-or-none condition, i.e., without degrees. (4) It is usually associated with the outward appearance of sleep. (5) It is a condition in which a person is frequently found to be most readily influenced by verbal communications. (6) Although initially appearing asleep, such a person is capable of being active in this state. Most important, (7) it is always accompanied by a spontaneous amnesia for all events transpiring during its presence. Braid viewed this last feature as a sine qua non for its presence. Regardless of whatever else unusual or different might be observed, he held there is no hypnosis without amnesia. Also to be noted is that the deliberate, direct, use of what was later to be called suggestion appears to have been minimally used by Braid. My own first experience with hypnotism was as an observer some 50 years ago. I then witnessed a demonstration of the postural sway test as prescribed by mesmerists and an induction of hypnosis by means of mesmeric passes. This was the start of my interest in hypnotic phenomena. I was then about 12 years old and it was quite a while before I became actively involved as a hypnotist. By the time I did, around 1947, the practice and subject matter of hypnotism had suffered some changes since Braid's time. The term "hypnosis" had replaced the term "hypnotism" to denote the state in question. "Hypnotism" was now used to denote the use of the hypnotic state and all of its attendant phenomenology. Authoritarian overt suggestion now played a dominant part in the production of all hypnotic phenomena, including the hypnotic state •• Very much in contrast to Braid's view, hypnosis was now seen as being on a continuum; i.e., as having degree or depth. Much of the time, too, post-hypnotic amnesia was routinely suggested and was no longer considered a necessary sign of hypnosis. Also, considerable emphasis was placed on the use of multiple tests of sugg~stibility (or of hypnotizability) prior to formal inductions of hypnosis. Inductions were usually a combination of visual or auditory fixation with suggestions of the precursor signs of sleep. For the most part, hypnotism centered around the use of suggestion, and hypnosis came into the picture mainly as a way to enhance suggestibility. Indeed, hypnosis was frequently defined as a state of enhanced suggestibility (Weitzenhoffer, 1953, 1957).
IN SEARCH OF HYPNOSIS
Whence came the authoritarian element in this phase of hypnotism? I could only speculate. Since I do not see it as representing a significant conceptual change or leading to one, I will limit myself to saying there are several possible origins for it and leave it at that. On the other hand, the shift from hypnosis as an all-ornone state to a graded one, does represent a major conceptual change which bears further discussion. This becomes more evident when one considers that, whereas for de Puysegur and Braid artificial somnambulism was the whole, entire state, by 1947 artificial somnambulism was merely viewed as the upper range or segment of a scale. In this transformation, the hypnotism of Braid had lost its unique identity to become a part or aspect of a wider condition now given the label "hypnosis." Hypnotism had thus been redefined. Put another way (using Braid's criteria for hypnotism), the hypnosis of 1947 included behavior he would not have agreed to call hypnotic! As many of you know, this state of affairs came about mainly as the result of the work of Liebeault, and especially of Bernheim. Influenced in this by Faria, Liebeault introduced suggestion as a major tool in the production of hypnotic phenomena. It was left for Bernheim to elaborate this use and to point out in 1886 that: (1) suggestibility is to be found in non-hypnotized as well as hypnotized individuals; (2) in either case, it is found present in different degrees; (3) hypnosis is a state of enhanced suggestibility par excellence; (4) hypnosis is a physiological state which can be brought about by appropriate suggestions alone. Bernheim reached these conclusions strictly on the basis of informal observations made in the course of working with hypnotism. While he did perform some elegant formal experiments to test various issues, there is no evidence that he ever formally tested any of these points. However, if by hypnotized and non-hypnotized we understand a formal induction of hypnosis has been or has not been performed, then all but the last of these propositions are demonstrable. Bernheim made an important BRA 10' S HYPN OTiSM
~ .......... \
oI REFRACTORY THROUGH DEEP
"--------------~-------------~ MODERN CONCEPTION OF HYPNOSIS
A. M. WEITZENHOFFER
fifth proposition: (5) hypnosis has depth or degree, and the latter is measured by the suggestibility of the hypnotized subject. Although this last proposition appears most reasonable, it cannot logically be deduced from the other four propositions, nor is it demonstrable. This fifth proposition holds a further gratuitous assumption: that individuals are hypnotized if they show any degree of suggestibility following the use of a formal induction. In the light of these observations, there is little scientific validity in the position that the study of hypnotism from Bernheim on has been entirely the study of Braid's hypnotism. Although he failed to do so, Bernheim had the possibility of insuring some sort of continuity with Braid's concept of hypnosis. For Bernheim also ascribed to the notion that a spontaneous, i.e., a non-suggested, post-hypnotic amnesia, occurred with some subjects. And even though he seems to have felt obligated to place these subjects on his continuum of hypnotic depth, he also appears to have had some difficulty doing so. He compromised by distinguishing a range of hypnotic sleep and a range of hypnotic somnambulism on his scale of hypnotic degree. However, by 1947 post-hypnotic amnesia was routinely suggested. And while persons scoring high on suggestibility were frequently referred to as "somnambulistic" subjects, relatively few thus labelled could have been identified as being so in the de Puysegurian sense. Unfortunately, investigators did not realize this or chose to ignore it, and the scientific study of hypnotism has proceeded without taking this possibility into account. Without going so far as to state categorically that there is an artificial somnambulism in the de Puysegurian sense, or hypnotism in Braid's sense, to be distinguished from other conditions of high suggestibility, I will state that there is a good chance that there is. This matter of the changing concept of hypnosis does not, however, stop here. Until the middle 1950's, training in hypnotic techniques had been largely a matter of self-training and training at the hands of stage hypnotists. Around 1955, a small group of professionals banded together in the United States to teach and promote the use of hypnotism by physicians, dentists, and psychologists. At their head was Milton H. Erickson. They set out with a certain evangelical zeal to sell hypnotism to as many professionals as they could. And sell it they did, frequently in an atmosphere reminiscent of religious revivals and seances. However, at first this was not an easy task. In the early days, many interested or potentially interested professionals were nevertheless wary of the subject matter. They feared adverse reactions from their peers and'patients and real and imaginary dangers inherent in hypnotism. The reputed relatively low hypnotizability of the average individual was a further deterrent. To many, the use of hypnotism appeared fairly complex and often time-consuming. Many felt foolish when performing inductions or testing procedures. Failures were a great concern to many.
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Others were greatly perturbed by the seeming lack of clear cut criteria for ascertaining when a person is hypnotized. In those early days, the only available techniques were highly authoritarian, and many clinicians did not take too well to these. Finally, for some, whose perception of the hypnotized person was that of a mindless robot, this feature was repellent, and for others the thought of so much power and responsibility was frightening. All these features made hypnotism less than attractive to many. Strategies were developed to deal with these issues and others. One was to present hypnosis to students and patients as being an everyday experience. Thus people were told that when they were engrossed in an experience, enraptured by a musical composition, daydreaming, or in a so-called brown study, they were actually hypnotized. The word "trance" was increasingly substituted for "hypnosis." Accordingly, it was stated that people went into all kinds of "trances" all of the time. Life was essentially a succession of trances. The issue of who is in control was handled by telling everyone that all hypnosis really is self-hypnosis. Incidentally, this last was not altogether a new idea. It had the further advantage of placing the onus of failure on the subject. The success rate was very much increased by the simple subterfuge of accepting indiscriminately any evidence of suggestibility as a sign of hypnosis. In the course of time, any response, any spontaneous act (whether relevant or not to such suggestions as might have been given) was turned, at appropriate moments, into evidence of hypnosis. This particular gambit had the additional advantage of giving the whole affair a very permissive character. Another highly favored subterfuge was the substitution of the term "relaxation" for "hypnosis." This was recommended to those professionals who wanted to hypnotise their patients but were afraid of the latter's reaction to the idea. In time, attaining an obvious condition of muscular relaxation became a widely accepted single index of a successful induction. Finally, the term "resistant" was substituted for "insusceptible" and "low susceptibility" to hypnosis, thus again placing the onus of failure on the patient or subject. Perhaps more than in any other period in the past, a great deal was made at this time by clinicians, of the idea that hypnosis was the royal road to the "unconscious" - that when a person is hypnotized, the hypnotist is then in communication primarily and even only with that person's unconscious. The idea that so-called unconscious processes are accessed when hypnotic behavior is brought about goes back at least to Bernheim and his contemporaries. Bernheim, in particular, considered ideo-dynamic action, an unconscious process par excellence, as central to all suggested behavior and hence, to hypnotism. But with Bernheim, it was merely a matter of suggestion initiating unconscious activities in a pure stimulus-response fashion, whereas in the middle 1950's suggestion became increasingly a matter of intelligent communication with the subject's so-called
A. M. WEITZENHOFFER
"unconscious." With some authorities it became even a matter of communicating with not one but many 'unconsciouses' each being "deeper" or less "deep" than the others. The use of finger movements, so-called ideo-motor signalling, was developed for communicating with the unconscious. This was basically a modification of traditional automatic writing and the planchette of spiritists. A whole new and very popular form of hypnotherapy was to grow out of this. This also gave rise to a popular method for obtaining subjective estimates of hypnotic depth from the subjects themselves. On the other hand, except for one test, objective tests for suggestibility and depth of hypnosis were largely eschewed by practitioners. The one exception, popularized by Erickson, was the so-called arm or hand catalepsy test for hypnosis. This is not the well-known suggested effect frequently called the arm rigidity test, but a much more subtle test which actually had first been described by Braid. Like Braid, Erickson believed it reflected a non-suggested characteristic tonic change in the musculature of subjects when they became hypnotized. For both, this tonic change was an intrinsic physiological characteristic of hypnosis. The possibility that it might be a non-verbally suggested effect was not considered by Erickson. Be that as it may, Erickson did eventually combine this test with a very impressive and effective non-verbal modification of his original hand levitation induction, a combination he made much use of in demonstrations after the mid-1950's. The net effect of all this is that, by 1960, not only were many practitioners of hypnotism holding to the position that all sorts of everyday changes in awareness were trance or hypnosis, but they were reducing yoga, meditation, various drug-induced states, brainwashing, religious healing, voodoo, and even the whole process of formal education, all to being hypnotism. There was actually nothing new in this development. The same sort of thing had taken place earlier, around the last quarter of the 19th Century (Barrucand 1967). In view of the current interest in so-called "Ericksonian hyp~ notism," let me say a little more about Erickson. His work with hypnotism seems to me to fall into three phases. Until the middle 1940's he seems to have functioned largely in the framework of traditional hypnotism, working with traditional somnambulists and other highly suggestible subjects in a very creative and productive manner. The second phase is the one I have just described at length, and which I see as a transition to the final phase of Erickson as primarily the clinician and teacher. It is evident that many of the elements of his so-called "indirect" method of producing hypnotic phenomena were being used by him as early as 1944, but always in a framework where there was a clear-cut, formal, induction of hypnosis. In the third phase of his work, it became frequently difficult to determine when or where hypnosis had been induced by him, how deep it had been, the extent to which it had been used, and even whether there had been any hypnosis present. It became equally difficult at times
IN SEARCH OF HYPNOSIS
to ascertain when a suggestion had been given. as well as what consitituted a suggestion. More than once those of us who watched him work. and had sufficient temerity. were led to ask him point blank questions relevant to these issues. We rarely received straight answers. In any event. from 1960 onwards. Erickson increasingly took the position that the elicitation of any suggested effect was tantamount to entering or being in a trance. and eventually extended this to the elicitation of any "unconscious" response. Erickson also developed great faith in the ability of a person's unconscious to tap a bountiful reserve of human potentials and to utilize the latter for good without being told how to proceed. He held to this as early as the middle 1950's. and not only did he teach this. but so did many of his students. in turn. teach this to others. In still later years. Erickson made the accessing of the unconscious of a subject synonymous with the evocation of a trance and hence. of hypnosis. since he used both terms interchangeably. Erickson increasingly centered the production of hypnotic phenomena around communication techniques. presumably aimed at bypassing conscious processes and reaching unconscious ones. NLP. short for Neuro Linguistic Programming. the latest potential American fad. has been a natural outgrowth of this approach. I do not plan to deal with NLP further except to remark the following. Although NLP ostensibly deals with Ericksonian hypnotism separately from NLP proper. it should be noted that according to its originators. Bandler and Grinder (1979). "All communication is hypnosis." and throughout the practice of NLP proper one encounters elements reminiscent of Ericksonian techniques. Thus. the distinction between NLP proper and Ericksonian hypnotism NLP style may be more academic than real. This brief history of hypnotism reveals certain rather clear and perturbing facts. Namely. under the impact of increased clinical interest in them. the concepts of hypnotism and hypnosis have suffered an ever increasing dilution from 1900 on. Today these concepts have become so diffused as to have ceased to be meaningful. Indeed. as Bandler and Grinder (1979) have also recently stated in a different context. "Hypnosis is everything." If so. it is. therefore. also nothing. The reasons for this evolution are probably not something we can all agree on. There is. however. one fact we may be able to agree on since it is easily verifiable. This is that the literature provides no scientific foundation for this evolution. Not only does the scientific literature provide no solid support for these conceptual changes but, as a matter of fact. research since Bernheim's time has done little to clarify the picture. By 1900. and really earlier, all of the essential phenomenology of hypnotism had been described. Nothing new has been added, and much of the research since 1900 (and especially since 1920) has been characterized by re-discovery rather than discovery. In fact, if
A. M. WEITZENHOFFER
anything, modern and especially contemporary research have only further abetted the situation created by the clinicians. Today, some 200 years after the discovery of artificial somnambulism, researchers are divided on even such basic issues as the veridicality of hypnotic phenomena and whether or not hypnosis exists as a state. There are some who even insist it is all a matter of role playing brought about by appropriately chosen motivating techniques. About the only point on which there seems to be a general consensus is that, if it exists, hypnosis is not sleep. I could go on at this point and share with you my thoughts as to the reasons why modern research has failed to be more effective. To do so, however, would take us into methodological questions of rather a technical nature and into such issues as the nature of science, the character of American psychology, the personality of American psychologists and health professionals, and the quality of higher education in America. I think I can more valuably use the space in a more directly relevant and productive way. One thing I have tried to do is to bring into focus the fact that the concept of hypnosis has evolved more as a function of speculations than as a function of scientifically well-established facts. There is nothing wrong about speculations provided they are recognized to be just that and are not confused with facts. Additionally, to be productive, speculations should be based on the proper use of logic and should at least be consistent with such facts as are available. It is in this context that I have already discussed the validity of certain early speculations such as the relation of suggestibility to hypnotic depth. There are a number of other speculations I have touched upon which have played and continue to play an important part in hypnotism and which bear further scrutiny. For a start, there is the question of whether or not the state of hypnosis exists. Let me first say that it is not possible to disprove its existence, as Barber and Sarbin have tried, by showing that something labelled otherwise can be associated with the same kinds of behaviors. From the proposition that A and B are each associated with, or even cause, C," it does not follow that A is B, or that only one can exist. Heat causes blisters, so does cold, but heat and cold are not the same. Indeed, they are the opposite. Quite apart from this issue, there are other fundamental weaknesses, such as those created in this context by the substitution of motivation and role-playing for hypnosis and hypnotic behavior. The existence and presence of these substitutes are no more objectively demonstrable than is that of hypnosis. To state that procedure A has motivated John to behave in a certain way implies a change in his state of being. I defy any of you to show me how I can detect this motivation by any means other than the kinds I use to detect hypnosis. How, then, is the one better than the other? As for roleplaying, how do you tell when a person is role-playing? As I have
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pointed out elsewhere (Weitzenhoffer 1973), the Barber and Sarbin theses are generally quite weak. Furthermore, it needs to be pointed out that in essence what the Barber-Sarbin school of thinking really maintains, is that hypnotic behavior is all conscious, voluntary behavior, whereas the "hypnosis-as-a-state" adherents hold to the opposite view. That seems to be the real issue, not what might or should be substituted for hypnosis. To date, this first issue remains an unsettled one, largely because both 'sides have concentrated on the second one. Perhaps, indeed, as Barber and Sarbin have maintained, hypnosis is a chimera, a mere metaphor. Past efforts to detect its physiological counterparts have failed miserably. Some years ago, I spoke in Malmo (Weitzenhoffer 1978a) at another Congress about this and other failures to substantiate hypnotic phenomena at a physiological level. This has been a personal failure of mine, one extending over a period of ten years. Possibly, this failure is indeed a reflection that there is no hypnosis, or, and I still maintain this to be a very strong probability, it reflects that to date, we have gone about the task in the wrong way. I proposed in Malmo that properly placed deep electrode implants in the cortex of selected patients undergoing brain surgery was as yet an untried by highly logical approach. Although my efforts to find collaborators to do this in the last few years have been unsuccessful, I still believe it to be a desirable step. Short of this approach or of some new, revolutionary, alternative technique for studying brain activity becoming available, we may have to resign ourselves to dealing with the state of hypnosis at a speculative and inferential level. This is by no means an ideal situation. Whether or not there is a state of hypnosis, if not many hypnoses, whether or not we can satisfactorily document its existence, and whatever we may otherwise call it, there is another side of the coin we cannot ignore - namely, suggestion. Until Bernheim, the state of hypnosis was the dominant feature of hypnotism. From Bernheim on, it has been suggestion. So much so that Bernheim himself proposed that one speaks of suggestion states in lieu of hypnosis. Others, such as Gill and Brennan (1959), and Erickson (1976) in his latter years, have tended to view hypnosis and suggestion as synonymous. Indeed, if evoking a suggested response is accessing unconscious processes and hypnosis is the attendant condition when evoked unconscious processes dominate, then there is some merit to this view. For my part, as many of you are aware, I have always held suggestion to be central to traditional hypnotism. How else could it be - being the entire modus operandi? By far and large, the study of hypnotic phenomena has been the study of suggested phenomena, and to that extent the issue of whether there is or is not a state of hypnosis has been an unfortunate distraction. If we hypnotise, it is only because we believe, first, that it enhances suggestibility. Additionally, there are some who believe certain processes and func-
A. M. WEITZENHOFFER
tions become more accessible because of the presumed change in state, i.e., quite apart from increased suggestibility. In any event, the bulk of the research that has gone on since Bernheim has centered on the effects of suggestions. This is not to minimize hypnosis. As an enhancer of suggestibility, it is obviously important for both the study of suggested effects and the applications of suggestion. Furthermore, a better understanding of hypnosis may also mean a better understanding of suggestion. I am inclined to believe that there are a number of enhancing processes, possibly states, both from theory as well as practice. Around 1954, when I was exploring topics for my doctoral dissertation, I collected certain preliminary data which when plotted appeared as in Figure 2a. There are several ways of looking at these points. One can assume that a curvilinear relationship, reflecting a single process at work, is the best fit. One can also assume that a polygonal line with two discontinuities at A and B is the best fit. Such a fit is consistent with the presence of three processes activated at different times being associated with the enhancement. (See Figure 2c). At the time, I opted for this alternative. Unfortunately, the necessary statistical tests for the existence of such discontinuities were not available then. Therefore, I abandoned this line of investigation and never returned to it. As it happened, I did not encounter any somnambulists in the de Puysegurian sense in my pilot study. I am inclined to believe that a different kind of discontinuity must be considered for such cases possibly leading to the results seen in Figure 2d. Thus, the discontinuity at C is somewhat like a quantum jump. Be that as it may, let me now add that if hypnosis exists as a state, it is unlikely it can be viewed merely or purely as a "state of concentration" or a "state of relaxation," these being two rather popular views of hypnosis. If it is a state of concentration, what is the nature of this concentration? Presumably, it is one of attention. This notion goes back to Braid and perhaps was fairly appropriate to the condition he provoked. Its appropriateness to the condition induced from Bernheim onwards is another matter. For modern inductions of hypnosis more often than not require the subject to shift his attention from one point of his body to another and from one experience to another. Furthermore, once hypnosis is presumably induced, the subject can be asked to expand and shift his attention in a variety of ways in order to carry out various activities, with hypnosis presumably still continuing to be present. None of this seems consistent with a strict monoideism. At best, we can describe hypnosis as involving selective control of the span and focus of attention.
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The growth of suggestibility.
A. M. WEITZENHOFFER
Similarly. I must seriously question the description and definition of hypnosis as a state of relaxation. Again. we need to ask: Relaxation of what? Presumably. of muscles. Or are we using it to mean a reduction of. say. vigilance. ego control. or still something else? Insofar as muscular action is concerned. a moment's thought will clearly show how inappropriate this view is. To begin with. it is well established that not all accepted induction techniques have required or called for either physical or mental relaxation. Furthermore. even when an induction calls for intense physical or mental relaxation. it is always an agreed-upon fact that the relaxed condition can give place to a very active mental or muscular state. the subject being no less hypnotized. The human plank demonstration fully attests to this! In brief. the traditional phenomenology of hypnotism as it was generally described at least until 1950 is not compatible with the notions of hypnosis as being purely a state of concentration or of relaxation. On the other hand. I would agree that these may be compatible notions when applied to certain approaches to hypnosis. for instance. when the subject is asked to close his eyes and do nothing more than relax his body and mind in a recliner chair while the hypnotist talks on and on. But are we now dealing with the same condition as traditional hypnosis or a different one? I certainly do not know which for a fact. nor does anyone else. But I do know that. in the absence of any other objective sign than that a profound physical relaxation has occurred. there is very little scientific validity in asserting that this is a case of traditional hypnosis. The most prevalent definition of hypnosis by state adherents is that it is an altered state of consciousness. Without specification of just how consciousness is altered. this is a really meaningless definition. It is the more so because "consciousness" itself is not much more tangible than hypnosis. As I pointed out several years agot (Weitzenhoffer. 1978b). in the final analysis. whatever we can say about consciousness is ultimately derived from subjective reports - even whether or not is is present on any occasion. As for what we mean by an altered state of consciousness. it would appear that we invariably are referring to alteration of its contents. In any case. this is the only way I find I can talk intelligently about altered states of consciousness. and the remainder of my discussion will be in this context. Strictly speaking. anytime a process is set into motion in us or ceases. there is a state change. It does not follow that there is also a change in consciousness. In particular. a personality or an attitude change, even a change in response to a stimulus. may not necessarily be associated with an altered consciousness. And most important. the initiation of a non-conscious or of a non-voluntary
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act need not involve such an alteration. Think of the multitude of reflexes and other automatic learned responses that are constantly taking place within you during your normal waking condition. Is there any evidence that you are undergoing alterations in consciousness at such times? I mean solid, objective evidence? Of course not. I am not against speculating that with hypnosis we are dealing with some kind of alteration of one or more parameters of consciousness, but speculating is all we can do and we need to recognize this. Furthermore, if such speculation is to be useful or even meaningful, it needs to be done more carefully. While I am on this subject of altered state of awareness, let me speak briefly of the use of the term "trance" in relationship to hypnotic phenomena. Except for the fact that it gets away from any associations with the idea of sleep, I see no other advantages in using this term as a substitute. Certainly not as long as various authorities go on making such assertions as "almost everyone goes into a trance in an elevator," or state that one automatically induces " a series of trances" when getting a personal history from a patient; or, to top this, assert "one person's normal state may be another person's. trance!" Not only is there no factual basis for any of these statements, but they take away all meaning from the term, hence, its usefulness. "Trance" was once a perfectly good term which, like "hypnosis," evolved for the purpose of distinguishing certain behaviors from others. While I will concede that there are similarities between traditional trances and traditional hypnosis, I believe that there also are sufficient differences to support a continued distinction of sorts. A more scientifically tenable position than making the two one and the same would be to view hypnosis as a potential element of a class of trances, itself to be viewed as a sub-class of a broader class of so-called altered states of awareness. This is explicated further in Figures 3 and 4. 1 In this context, one might then specifically speak of a hypnotic trance in distinction to, say, a "yoga trance." If by nothing else, hypnosis can be distinguished from other trances on the basis of its dyadic interactional character. The next issue I wish to examine with you is that of the socalled "unconscious" in relation to hypnotic phenomena. In 1947, when I began working actively with hypnotism, it was generally believed that somehow or other hypnosis freed unconscious material or processes from some of the restraints that kept them in the unconscious. There was little question that we were then speaking of the Freudian unconscious (or system USC). Hypnotic techniques used to facilitate the outflow of unconscious material tended to make use of non-hypnotic conditions known to facilitate unconscious manifestations. Hypnotic techniques were also used to implant behavior segments which were to function outside of the subject's awareness.
A. M. WEITZENHOFFER
This process was generally viewed along the lines of setting up a complex conditioned-reflex-like response. Attempts at an interactive communication with the unconscious, in which the latter was treated like a personality, was not the usual approach. Although earlier investigators of hypnotic phenomena such as Janet and Grasset had seen similarities between hypnotism and spontaneously occurring multiple personalities, I believe the general view in 1947 had moved away from this position. In fact, multiple personalities had been artificially produced by hypnotic techniques, and the resulting entities were not generally viewed as being identifiable with the system USC of Freud. As pointed out earlier in this presentation, hypnotism today is being increasingly viewed and utilized in the context of an interactional communication with an unconscious. For some practitioners, such as Erickson, getting responses from this kind of mental apparatus is the essence of hypnosis. But what kind of sense is one to make out of a hypnotist saying to the hypnotized subject, "I want your unconscious to show ~ which finger it will move to answer 'yes' to my questions"? To whom is this statement being directed? It would seem it is to the subject's conscious. However, if we accept the Ericksonian model much in vogue today, hypnosis, in its most complete form, is nothing more than full, direct communication with the subject's unconscious. If so, we are then faced with the hypnotist presumably telling the subject's unconscious to allow its unconscious to do something! But even if we ignore this implication, we still have to contend with another practice, with its own implications. These same hypnotists will usually go on to ask the subject's unconscious to enter into a dialogue with, say, "that part of you which is responsible for your overeating." Later, a dialogue may be set up between the unconscious and the patient's "creative part," and even between the two parts just referred to, not to mention other "parts" that may be brought into the picture. Presumably, these so-called parts function outside the patient's normal awareness and hence meet one condition for being considered to belong to the domain of the unconscious. Does this mean the unconscious is fractionated? Or are there a number of unconsciouses? If so, is there a hierarchy, as it seems there might be? If so, how does it all fit into the concept of hypnosis merely being a condition where the unconscious takes precedence over the conscious? There are a number of variations of this theme, each confusing more, rather than clearing up the situation. It seems clear that we are no longer speaking here of the unconscious in the Freudian sense. I am not sure that we are speaking of any kind of unconscious. A more appropriate label would seem to be "co-conscious" or "alternate'conscious" for whatever it is with which it is being intet'acted. As I have pointed out elsewhere (Weitzenhoffer, 1960), the behavior of the so-called unconscious (and now of these various parts) is essentially that of a conscious
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ANIMAL HYPNOSIS SAMADHI
BALINESE DANCE TRANCE
STATES OF NON-CONSCIOUSNESS
PSYCHOSES + LIKE-STATES NAT URA L --+--t-.-, S LEE P
-===:at----Il..-. LS D- S TATE
SLE E P
Altered states of consciousness.
Altered states of consciousness (alternative view).
A. M. WEITZENHOFFER
person. All of which would seem to bring us right back to Janet and Grasset. So much for progress! Worse, there is no solid foundation for any of this modern development. If anything, one needs strongly to suspect that hypnotists holding dialogues with unconsciouses, various and sundry "parts," and Hidden Observers in hypnotized subjects may most likely have created them by the very procedures they use. That is, they are very likely to be artifacts. As Berillon, the editor of the Revue de l'Hypnotisme, used to point out, hypnotized individuals are extremely malleable. To tell a subject. for instance, that he will feel no pain but that there is a Hidden Observer within him who can report on the pain which nevertheless is there, can be tantamount to telling him that he will be two persons, one who fe~ls no pain and one who does. A good hypnotic subject can be expected to comply quite literally. Indeed, the kind of contradiction introduced by telling the subject there is and there is not any pain might well be expected alone to promote a spontaneous response not unlike a dissociation of this kind in some subjects. Whether or not "Hidden Observers" and the likes are used metaphorically, the end result may be anything but a metaphor. I grant there is some speculation on my part here, but no more than on, say Hilgard's part. If there is one fact to be observed here, it is that there is nothing clearcut anymore in this area - not even who it is we are interacting with when a person is hypnotized. --The speculations I have taken up thus far are all concerned with explaining hypnosis in terms of other concepts. The view of hypnosis as self-hypnosis does not aim to do so. In fact. being circular, it can not explain anything. On the other hand. the concept of selfhypnosis is of some theoretical and, especially, practical interest. Because of this I will make a few more remarks regarding it. There are two distinct issues involved here. The first is the production of a state of hypnosis in oneself using methods believed to produce it in others. The second issue is utilizing this state in a way comparable with heterohypnotism. I do not know of many recorded and, especially, well-documented cases of self-inductions not preceded by a first exposure to hypnosis in a heterohypnotic setting. Braid reports a case with himself as the subject. I believe I have experienced two occurrences of Braid-type hypnosis, one induced by accident and one deliberately. Erickson has also reported spontaneous occurrences in himself of a like state. Although I feel reasonably sure that my accidental production of hypnosis was a true case of Braidtype hypnosis, I believe one needs to be very cautious in labelling accidental and spontaneous occurrences of presumed hypnosis as such. In any case, most cases of so-called self-hypnosis are clearly responses to heteropost-hypnotic signals and suggestions and are, therefore, "self-hypnosis" only as a result of a play on words
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(Weitzenhoffer, 1957). A more accurate labelling might be selfinduced heterogenic hypnosis. The big stumbling block that the concept of self-hypnosis faces is in the utilization phase of heterohypnosis. In my opinion, the very nature of heterohypnotic behavior rules out the possibility of a truly comparable autohypnotic behavior. Let me explicate. There is no problem regarding the production of limited non-hypnotic selfsuggested action. This possibility is well documented. The problem centers around the fact that the traditional heterohypnotic state calls for and seems to elicit what I have referred to as an abdication of volitional control (Weitzenhoffer, 1963). At best, the subject's volitional participation seems highly circumscribed. Put another way, if traditional heterohypnotism is viewed as a situation in which there is a separate director and a separate directee, then a comparable autohypnosis calls for one person being both a director and directee, being both active and passive. Any theoretical resolution of this paradox that I can come up with leads to a situation which cannot be said to be fully comparable with heterohypnosis. As for the practical end, I do not know of anyone who has successfully duplicated heterohypnosis at its best with autohypnosis. Lastly, let me return to the topic of suggestion. Even this term, so central to hypnotism, has been greatly misused and abused. It, too, has been used with great linguistic carelessness. So much so that Grasset (1904) was complaining of its having become essentially meaningless. What, indeed, is a suggestion? Whether verbal or non-verbal, it can be agreed it is a communication made by one party to another. But what distinguishes it qua communication as being a suggestion rather than being, say, a request, a transmission of information, or even a command? Is it just anything the hypnotist says to the subject? Hypnotists, even those engaged in research, seem rarely to have taken time out to consider this question. ,Yet, obviously it is a very important crucial question for modern hypnotism. The answer ought to make some differences for research as well as practice. I think Bernheim made it pretty clear that for him suggestion was any communication which elicited an automatism, i.e., nonvolitional activity. In my opinion, this view agreed well with that of his contemporaries, as well as with many of his successors. In more recent times, this view has again been made more or less explicit by Erickson and some of his students under the guise of suggestion being communications eliciting responses from the subject's unconscious. Erickson's view, however, does appear to differ from Bernheim's in an important aspect; namely, the Ericksonian unconscious seems frequently to exhibit a volitional apparatus of its own. Thus, while the subject's usual volitional apparatus may not be
A. M. WEITZENHOFFER
involved, one cannot say the Ericksonian suggestion involves acts fully devoid of volitional activity. Therefore, they. are not automatisms in quite the sense Bernheim used this term. Be that as it may, as I have pointed out previously (Weitzenhoffer 1974), either position implies that a communication cannot be stated to be a suggestion de facto, but to have been one only post facto, i.e., after the response has resulted and shown itself to be non-voluntary. It is, of course, permissible to speak of a communication as being a suggestion by intent prior to the occurrence of a response. But this must be clearly understood. Failure to do so can obviously readily lead to improperly crediting a subject's suggestibility and hypnotizability. There is more than this to a proper definition of suggestion. For instance, suggestions always evoke responses which are an actualization or realization of their main ideational content. But we need not get into this aspect at this time. I hope this discussion had made it clear that much of the speculation behind past conceptual changes relating to hypnosis and hypnotic phenomena does not meet the criteria for being considered scientifically acceptable. Where does this leave us? Where do we go from here? I believe the time has come to take serious stock of the situation and to realize that we have strayed far and wide in our search for hypnosis and its magic. We ought to discard all these wild speculations. As least we ought to stop acting as if they were facts. If we are able to speculate, we ought to be more-moderate. We should be especially careful not to build speculations upon ot ..e.:poorly founded speculations such as psychology offers us in abundance. Undoubtedly hypnotism belongs to the domain of psychology. It might be better, however, if one were to make less effort to fit hypnotism into the existing body of psychology. In this connection, we ought to be more careful with regard to the use of vague, poorly defined psychological concepts and constructs to describe, define, or explain hypnotism. Above all, I think we need to get back to basics. Get back to and start allover from certain basic observations. There is the facts of suggestibility. That is, some individuals respond to communications in such a way as to allow us to differentiate the latter specifically as suggestions. There is the fact of a Braid-type or de Puys~gurian-type of hypnosis. That is, certain well-defined procedures are associated with behavior satisfying criteria for being labelled hypnotic in that sense. I believe we would do well to go back to these facts and re-examine them with the following additionally in mind:
IN SEARCH OF HYPNOSIS 1) 2) 3) 4)
Clearly distinguish between communications that are effective suggestions and those which are intended to be so but are not. Cease the unfounded practice of assuming that suggestibility is a measure of a presumed hypnotic depth. Consider se~iously that hypnosis may be an all-or-none condition. Stop the unfounded practice of assuming hypnosis is present whenever an appropriate response to an intended suggestion is obtained after an induction of hypnosis procedure has been completed. Consider that "hypnotic suggestibility" may appreciably differ processwise from "non-hypnotic suggestibility." For instance, the former may be a combination of the latter with added, new elements promoting a broader kind of influencability. Be more stringent with regard to what we accept as being necessary and sufficient behavior to be labelled "hypnotic." Consider that there is a strong possibility that everyone cannot be hypnotized in the traditional sense, maybe only a handful. If so, more often than not we see only evidence of varying degrees of suggestibility when we think we see varying depths of hypnosis. Consider that there is a possibility that not everyone who is hypnotized knows he is; hence, can give an accurate self-report of depth, if hypnosis has depth (Weitzenhoffer, 1963). There may be more to some of the traditional signs of hypnosis than they have been credited with. These signs include decreased occulomotor activity and blinking (so-called "trance stare"), lack of spontaneity and initiative, tonic immobility (disinclination to move), psychomotor retardation, decreased reactivity, demonstrated hypersuggestibility, and rapport (selective responsiveness). The process of inducing and utilizing hypnosis can shape it in ways which mask some to all of its essential, i.e., intrinsic characteristic features. Hypnosis is basically a human experience centered around communication. It does not follow, however, that there are special "magic" forms or ways of using communication which promote hypnotic behavior. Hypnotic behavior is always induced in the context of a dyadic relationship which is anything but trivial. Stated another way, hypnotic phenomena are always defined within a tran~actional or interpersonal context. Hypnotic behavior appears to have affective and regressive elements, as well as elements of compulsivity, or acquiescence (or compliance), of a childlike belief, which Bernheim (Weitzenhoffer 1980) called "credivite". These have too often been ignored.
A. M. WEITZENHOFFER Hypnotized subjects always try (often compulsively) to give a response. More often than not they will produce the best approximation they can of what is asked of them rather than give no response. This may lead to apparent confabulation and role playing. Prior to entering on a career of research or therapy with hypnotism, it is essential to become thoroughly familiar with as many aspects of hypnotism as possible in a naturalistic setting, one free of the restrictions imposed by experimental design or therapeutic goals. Too many would-be hypnotists read one book, attend one weekend workshop, and assume they now know all there is to be known about hypnotism.
Maybe if we do these things, 200 years from now there will no longer be authorities in this field still admitting as they do today that "We do not know what hypnosis is", or that "The domain of hypnosis is obscure." Maybe our successors will at last be able truly to speak of scientific hypnotism. REFERENCES Bandler, R., and Grinder, J, 1979, Frogs into Princes. Moab, Utah, Real People Press. Barrucand, D, 1967, Histoire de l'Hypnose en France, Presses Universitaires de France, Paris. Braid, J, 1841, Neurypnology, John Churchill, London. Erickson, M. H., Rossi, E. L., and Rossi, S. I., 1976, Hypnotic realities, in: "The Induction of Clinical Hypnosis and Forms of IndirectSuggestion," Irvington Publishers, Inc., New York. Gill, M. M., and Brennan, M., 1959, Hypnosis and Related States, International University Press, New York. Grasset, P., 1904, L'hypnotisme et la suggestion, O. Doin, Paris. Weitzenhoffer, A. M., 1953, Hypnotism: an objective study in suggestibility, John Wiley & Sons, Inc., New York. Weitzenhoffer, A. M., 1957, General Techniques of Hypnotism, Grune and Stratton, Inc, New York. Weitzenhoffer, A. M., 1960, Unconscious or Co-conscious? Am.J.clin. Hypnosis, 2:177-196. Weitzenhoffer, A. M., 1963, The nature of hypnosis, part III, Am.J. clin. Hypnosis , 6:40-72. ---Weitzenhoffer, A. M., 1973, Hypnosis and hypnotherapy, six lectures on cassettes, Fort Lee, New Jersey, Behavioral Science Tape Library. Weitzenhoffer, A. M., 1974, When is an instruction an "instruction?", . Int.J.clin.exp.Hypnosis, 22:258-269. Weitzenhoffer, A. M., 1978a, The physiology of hypnotism. Methodological and conceptual aspects, Svensk Tidskrift for Hypnos, 5:15-20.
IN SEARCH OF HYPNOSIS
Weitzenhoffer, A. M., 1978b, Hypnosis and altered states of consciousness, in: "Expanding Dimensions of Consciousness," A. A. Sugarman andlR. E. Tarter, eds., Springer Publications, New York. Weitzenhoffer, A. M., 1980, What did he (Bernheim) say? An addendum and a postscript, Int.J.clin.exp.Hypnosis, 28:252-260.
THE RELEVANCE OF HYPNOTIZABILITY IN CLINICAL BEHAVIOR
Fred H. Frankel Beth Israel Hospital and Harvard Medical School 330 Brookline Avenue Boston, MA, 02215, USA Abstract Scepticism regarding hypnosis and its clinical value can be countered by the accumulation of knowledge. Separating the effects of hypnosis from the influence of other factors common to several treatment methods contributes importantly to this. Hypnotizability ratings in the experimental context set the stage, initially, for the growth of information. Clinical studies using the rating scales developed in the laboratory continue to reveal that the incidence of specific clinical behaviors correlates well· with hypnotizability. This contributes to our understanding of diagnosis and treatment in both psychiatric and psychosomatic problems. INTRODUCTION Clinicians have tended to look askance at the investigative studies involving the use of the hypnotizability scales with the same impatience and intolerance, unfortunately, as the experimentalists have at times shown to single clinical case reports - even good ones. A not uncommon clinical view denounces the laboratory scales, essentially the group of Stanford susceptibility scales (Weitzenhoffer and Hilgard, 1959; Weitzenhoffer and Hilgard, 1962) as too lengthy, as intrusive, and as not entirely relevant to the demands and patterns that prevail in clinical work (Sacerdote, 1982). Even the Hypnotic Induction Profile (Spiegel, 1978) and the Stanford Hypnotic Clinical Scale (Morgan and Hilgard, 1975) both developed in the clinical sphere, have met with limited enthusiasm among clinicians.
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This attitude prevails despite the fact that the formal testing of hypnotic responsiveness has achieved considerable recognition in scientific circles in recent years. largely. I believe. as a consequence of the compelling data that have been accumulated. The measuring instruments are clearly not beyond improvement. However. it is primarily to the standardized rating of hypnotizability that we owe the growing body of knowledge and the evolving basic science related to hypnosis. It is from the analyses of the laboratory data that we can confidently declare. for example. that hypnotizability is not universally distributed. that it is not related to sex or to educational level. and that it is unlikely to alter much on a permanent basis. regardless of what the individual is subjected to (Hilgard. 1965). In essence. the development of the scales. and the concomitant growth of a highly sophisticated investigative methodology have enabled the study of hypnosis to emerge from the shadowy world of assumptions. to take its place among the academically acceptable behavioral sciences. In keeping with my purpose in addressing this subject at this time. I will choose this opportunity: 1. 2. 3. 4.
to draw attention to the clinical methods in use. some for more than a century. to test the hypnotic responsiveness of patients; to describe the importance of the hypnotic situation and to emphasize the value of hypnotic techniques even in the absence of recognizable hypnotizability; to stress the importance of the investigative use of the laboratory scales in the clinical context. in order to examine clinical experience in the light of the laboratory findings; and to indicate the relevance of the laboratory scales to clinical events.
CLINICAL ASSESSMENT OF HYPNOTIZABILITY From the earliest clinical records of the use of hypnosis it is apparent that experienced clinicians have recognized the difference in the extent to which individual patients seemed able to respond to hypnosis. While using the concept of "depth". doctors in the nineteenth century literature did indeed refer to criteria whereby they believed they could determine whether their patients were in a light trance. a medium trance. or in an even deeper state of hypnosis. Inability to open the eyes. catalepsy. degree of response to suggestions. negative hallucinations. and posthypnotic amnesia were some of the behaviors used to determine the depth of trance. For thirty years. from the early 1930's to the early 1960's. these criteria were studied and refined and then incorporated in the laboratory scales already referred to.
HYPNOTIZABILITY IN CLINICAL BEHAVIOR
Contemporary clinicians in the western world use criteria in their measurement of hypnosis that are not dissimilar. However, encouraged by the prevailing social customs, the permissive nature of the therapeutic relationship, and the modern tendency to demystify hypnosis, they do so in a less structured and more flexible manner. Sensitive to the need to protect the illusion in hypnosis, they map out the strategy as they proceed, careful not to present demands or suggestions that are beyond the capacity of the patient. They usually avoid creating a sense of failure by conducting their suggestions in terms such as "You will probably feel" or "You might experience", or "I do not know exactly when or how, but you will begin to notice ••• ". They then wait for signals, verbal or otherwise, that some change is taking place, or they specifically request the patients to communicate whether or not they are experiencing the suggested events, and in what way. "The muscles in your eyelids are relaxed beyond the point where they will be able to work - you might test their strength when you are ready, but be sure they are too relaxed to work before you test them." This statement is followed by close observation of the eyelids to determine the extent of the response. Suggestions for anesthesia or analgesia are offered in a similar vein, if the purpose of the hypnosis is to relieve pain or discomfort. If the purpose is to aid in the recall of events from a meaningful period in his past as vividly as he can, the patient is encouraged to turn his mind toward the past to make contact with any events that have to do with the situation under examination. His response under such circumstances is likely to be a valid indicator of his ability in hypnosis to recall past events. It is probably more dependable than his response to the request to regress to an unrelated and emotionally neutral event as part of a standardized rating scale. The open-ended suggestion, so often in use in the current clinical context, encourages responses which reflect the individual's capacity. There can be little question that such responses are entirely adequate for the purposes of therapy for that particular patient. Because, however, neither the suggestions nor the responses are standardized, they can add little to any generalizations that the therapist might wish to make about the patient population, the symptoms, or the use of hypnosis. THE ROLE OF HYPNOTIZABILITY VERSUS THE HYPNOTIC SITUATION, IN CLINICAL PRACTICE Clinicians by and large have been challenged by the concept of hypnotizability as it has emerged from the experimental studies and have tended to turn away from it. This could have been a mixed blessing, with both benefits and disadvantages. Of benefit because
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the customary clinical practice is to proceed with hypnotic techniques (modified of course by the kinds of clinical responses elicited) regardless of the limited hypnotizability. Disadvantageous because it impedes any growing understanding of what takes place in the therapy. Let me elaborate on these two aspects. Any benefits to the patient from the use of hypnotic techniques in the absence of moderate hypnotizability must be a consequence of other factors in the hypnotic encounter. What can we assume takes place in such an encounter? Generally the procedure is initiated by encouraging a strong relationship, and involves suggestions for relaxation, for optimism, for a lessening of discomfort, and for increased confidence. None of these are essentially hypnotic events nor are they dependent on the hypnotic capacity to dissociate or to alter perception (Orne, 1959). They can be achieved equally well with the administration of a placebo, with techniques aimed at reassurance, or by some event which distracts attention. The experienced clinician knows, of course, that he is likely to shatter the gains of his therapy if he then directs his relaxed patient to respond with more dramatic hypnotic behavior than he, the patient, is capable of. However, the hypnotic situation or total clinical context in which the hypnotic suggestions are given is of particular importance. If it is appropriate, patients can benefit to some extent from suggestions to relax and gain confidence even in the absence of what I would call a central hypnotic event. Even though I hope to demonstrate that the concept of hypnotizability is both relevant and important clinically, I personally will use hypnotic procedures that are shaped by the patient's responses, in the absence of even moderate hypnotizability. Now for the disadvantages of disregarding the concept of hypnotizability, which though relatively stable for a particular individual, varies from person to person. It is generally the busy pragmatist who belittles the notion. Keen on impringing therapeutically as expeditiously as he can, he usually has little time to pursue an understanding of his practices. While one can respect him for clinical achievements under conditions that are not always convenient for academic inquiry, we must grieve over the lost potential. Great opportunities for increasing our knowledge of the event slip away under such circumstances. For example, the clinical literature abounds in case examples describing how a hypnotic induction procedure was followed by a series of therapeutic suggestions which were followed by a satisfactory outcome. The reasoning in the paper not infrequently assumes that because the outcome was successful the patient must have been hypnotized. Even a brief inspection of the logic will expose the fallacy of that conclusion of one acknowledges that therapeutic forces in the hypnotic situation can stem almost entirely from the transference, from the sense of relaxation, or from
HYPNOTIZABILITY IN CLINICAL BEHAVIOR
the placebo effect. By our having no standardized rating of the hypnotizability of most of those patients, we are denied a full understanding of the role of hypnosis when compared with the other therapeutic factors in those cases. Were even the most unsophisticated literature not constantly reminding us of the fact that some patients are better at hypnosis than others, we might wonder whether this idea of different capacities for hypnosis was not just a figment of laboratory investigations. We need, however, to remind ourselves of the fact that hypnosis originated and developed in the clinical context. Experimentalists who explored the aspect of differing hypnotizabilities took their cue from conventional clinical wisdom.
EXAMINING CLINICAL EXPERIENCE IN THE LIGHT OF THE LABORATORY FINDINGS The most compelling evidence for acknowledging the study of hypnosis as a serious academic pursuit has accumulated in the reports of experimental studies. These could not have been conducted had the hypnotizability scales not been invented. Repeated comparisons between the behavior of highly hypnotizable subjects has led to a substantial body of information on the events of hypnosis. For example, studies like those of imaginative capacity (Hi1gard, 1970) and personal experiences (Shor et a1., 1962) and how these differ among individuals of varying hypnotic abilities, have added not only to our knowledge of hypnosis, but also to our understanding of human behavior. Furthermore the ways in which highly hypnotizable individuals pay attention in hypnosis or remember nonsense syllables in hypnosis tells us about hypnosis, about memory, and about paying attention. The knowledge about hypnosis in the healthy population studied in the laboratory is considerable. There are those who argue that you cannot extrapolate from one context to another - you cannot conclude that what occurs in the laboratory will necessarily apply in the clinic. I believe we do not yet have a definite answer to that challenge and any judgments about the likely correlations are premature and arbitrary. We do, however, have the opportunity to test hypotheses and to find out what the correlations are. We need to examine the clinical population in the light of the knowledge already accumulated in the laboratory, and in order to do this effectively we should stay with the same y~rdstick. In this way we can determine to what extent, if any, the findings in the one correlate with those in the other. There is clearly a host of clinical events that awaits further study. For example:
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1. Common sense seems to dictate that if the majority of patients suffering from a particular syndrome respond to treatment with hypnosis, they might, as a group, be more hypnotizable than others. Patients suffering from asthma and migraine have been treated successfully with hypnotic procedures. We know from one study of asthmatic patients (Collison, 1978) that those who were responsive to hypnosis did better than those who were not. To date, however, we have no systematic study of the range of hypnotizability among asthmatics generally or among patients subject to migraine headaches, or how their ratings compare with those of other patients. I am referring here to the need for simply studying the hypnotic responsiveness of a group of asthmatic patients, or a group of migraine patients and comparing the results with those of a control group. 2. Reports on the hypnotizability of schizophrenic and depressed patients tend to disagree with one another. Here again, is an opportunity for the further administration of the hypnotizability scales in order to determine to what extent hypnosis is facilitated or suppressed by, or has anything to do with, the nature of the disorders. 3. Highly hypnotizable healthy subjects responding to a questionnaire regarding personal experiences reported the occurrence of spontaneous trance-like phenomena considerably more often than healthy subjects who are poor hypnotic subjects (Shor et al., 1962). We have no equivalent study among a patient population, neurotic or psychotic. If healthy, highly hypnotizable subjects report more trance-like events than others, is it not possible that highly hypnotizable psychiatric patients will also report more trance-like events? If that is the case, to what extent do those trance-like events color the clinical picture? 4. One area that pleads for attention is the impact of hypnotizability on the outcome of psychotherapy that does not include hypnosis. Apart from one recent study (Nace et al.,-r982) reporting a positive relationship between clinical improvement and hypnotizability, few data have been accumulated that address the influence of high hypnotizability on therapeutic outcome. To describe such clinical investigations as complicated and difficult to mount is a masterpiece of understatement. That, however, is no reason for us to avoid them or to draw premature conclusions. THE RELEVANCE OF LABORATORY SCALES TO CLINICAL EVENTS We have already completed two studies (Frankel and Orne, 1976; Apfel et al., in preparation) which point to the relevance of the laboratory scales to clinical events. In the first, we tested the
HYPNOTIZABILITY IN CLINICAL BEHAVIOR
hypnotizability of a series of phobic patients by means of the Stanford Scales and their derivatives. We then compared the results with the hypnotizability ratings of other patients, namely smokers. The mean rating among the phobic patients was significantly higher than the mean among the smokers. Although phobic behavior is an essentially clinical phenomenon, patients displaying such behavior achieve scores on the laboratory scales that were significantly higher than the scores achieved by patients who have other problems. Gerschman et al. (1979) in a study of patients with dental phobic illness, reported a significantly higher mean hypnotizability rating in their group than in the normal population, thus supporting our findings. Frischholz et al. (1982) failed to confirm a correlation between phobic behavior and high hypnotizability. This might be explained by their use of an entirely different technique to measure hypnotizability. In our second study (Apfel et al., in preparation) women with hyperemesis gravidarum tested on the Stanford Scales have shown a higher mean hypnotizability score than women who do not have this pathological degree of nausea and vomiting during pregnancy. Here again the scales have demonstrated their relevance to clinical events. I believe this all confirms the potential value of the measurement of hypnotizability in clinical practice. If offers exciting possibilities. Some believe that measurement of hypnotizability can help in planning treatment strategy. Others see the rating scales as providing a useful rehearsal or preparation for patients who then become familiar with hypnosis before their exposure to the clinical application. While not in disagreement with wither of these views, I personally see the major value of such measurement in the information it will yield. It can enrich not only our knowledge of hypnosis, but also our understanding of the clinical events we try to treat. Acknowledgement Aspects of this paper were addressed in a Symposium on "Clinical Implications of Assessed Hypnotizability" presented at the American Psychiatric Association Annual Meeting in Toronto, Canada, in May, 1982. REFERENCES Apfel, R. J., Kelly, S. F., and Frankel, F. H., (in preparation). Collison, D. R., 1978, Hypnotherapy in asthmatic patients and the importance of trance depth, in: "Hypnosis at its
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Bicentennial," F.H. Frankel and H.S. Zamansky, eds •• Plenum Press, New York, 261-273. Frankel, F. H., and Orne, M. T., 1976, Hypnotizability and phobic behavior, Arch.gen.Psychiat •• 33:1259-1261. Frischholz, E. J., Spiegel, D., Spiegel, H., Balma, D. L., and Markell, C. S., 1982, Differential hypnotic responsivity of smokers, phobics, and chronic-pain control patients: A failure to confirm, J.abnorm.Psychol., 91:269-272. Gerschman, J., Burrows, G. D., Reade, P., and Foenander, G., 1979, Hypnotizability and the treatment of dental phobic illness, in: "Hypnosis 1979," G.D. Burrows, D.R. Collison and L. Dennerstein, eds., Elsevier/North Holland Biomedical Press, Amsterdam, 33-39. Hilgard, E. R., 1965, "Hypnotic Susceptibility," Harcourt, Brace and World, New York. Hilgard, J. R., 1970, "Personality and Hypnosis: A Study of Imaginative Involvement," Univer. of Chicago Press, Chicago. Morgan, A. H., and Hilgard, J. R., 1975, Stanford Hypnotic Scale (SHCS). in: "Hypnosis in the Relief of Pain," E.R. Hilgard and J.R. Hilgard, eds., Kaufman, Los Altos, Calif •• 209-221,· Appendix A. Nace, E. P., Warwick, A. M., Kelley, R. L •• and Evans, F. J., 1982, Hypnotizability and outcome in brief psychotherapy, J.Clin. Psychiatry, 43:129-133. Orne, M. T., 1959, The nature of hypnosis: Artifact and essence, J.abnorm.soc.Psychol., 58:277-299. Sacerdote. P •• 1982, A non-statistical dissertation about hypnotizability scales and clinical goals: Comparison with individualized induction and deepening procedures, Int.J.clin.exp. Hypnosis, 30:354-376. Shor, R. E•• Orne. M. T•• and O'Connell, D. N., 1962, Validation and cross-validation of a scale of self-reported personal experiences which predicts hypnotizability, J.Psychol •• 53:55-75. Spiegel. H., 1978, "Manual for the Hypnotic Induction Profile, (IV Rev.)," Basic Books, New York. Weitzenhoffer. A. M., and Hilgard, E. R., 1959, "Stanford Hypnotic Susceptibility Scale, Forms A and B," Consulting Psychologists Press, Palo Alto. Calif. Weitzenhher. A. M., and Hilgard, E. R•• 1962, Stanford Hypnotic Susceptibility Scale, Form C," Consulting Psychologists Press, Palo Alto. Calif.
INTERACTION BETWEEN HYPNOTIST AND SUBJECT:
PSYCHOPHYSIOLOGICAL APPROACH (PRELIMINARY REPORT) Eva I. Banyai. Istvan Meszaros. Laszl6 Cs6kay Department of Comparative Physiology Eotvos Lorand University Muzeum Krt 4/A Budapest. Hungary Abstract There is a vast amount of literature demonstrating that hypnotic susceptibility is a stable personality trait. In the course of our practice of teaching beginners to hypnotize. however. it occurred to us that hypnotists without sufficient previous training frequently measured a lower level of hypnotic susceptibility than the true score. It has to be emphasized that hypnosis is a special altered state of consciousness which develops as a result of an interaction between a hypnotist and a subject. The failure of beginners to induce hypnosis could be explained by considering an insufficient participation of the hypnotist in this interaction. The purpose of the present study was to analyze the necessary and sufficient subjective. behavioral and physiological alterations in both participants of the hypnotic interaction. During successful and unsuccessful hypnotic inductions the subjective experiences. behavioral manifestations and physiological indicators including respiration. ECG. EMG. EOG. GSR and bilateral fronto-occipital EEG leads. were recorded simultaneously in the hypnotists and the hypnotized subjects. The results indicate that hypnotic induction is successful if a mutual "tuning in" of the other person occurs not only on the subjective and behavioral levels. but first of all on the psychophysiological level.
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INTRODUCTION In hypnosis-research attention is generally focussed on the alterations occurring only within the hypnotized person. As a result of this approach standardized tests have been elaborated to study the characteristic differences between persons entering hypnosis. This way the "talent" of a person to respond to standardized hypnotic suggestions has come to be considered to be a stable personality trait (Hilgard, 1965, 1975, 1977, 1981). It must be emphasized, however, that no other altered state of consciousness exists that would be so closely related to an interaction between two persons as hypnosis. The importance of the rerelationship between a hypnotist and subject was brought to the attention of some authors as early as in the late 1950's (Gill and Brenman, 1959; Haley, 1958, 1961, 1963). While Gill and Brenman focussed mostly upon the motives of the hypnotist, Haley, on the basis of Milton H. Erickson's approach, analyzed the manoeuvres of the hypnotist, reflected mainly in sequences of verbal communication between hypnotist and subject. It is striking, however, that in similarly hypnotizable subjects different subjective and behavioral depths of hypnosis can be reached even through completely identical verbal communication, i.e. through the use of standardized texts (the widespread scales of hypnotic susceptibility). These differences can be explained only if we suppose that non-verbal elements of communication also play an important role in the interaction between hypnotist and subject. As a first step towards the goal of determining methods which help to detect the relevant metacommunicative elements within the hypnotic interaction, in the present experiment an attempt was made to study the characteristic psychophysiological alterations accompanying hypnosis both in the hypnotized person and in the hypnotist.
METHOD Subjects Six young persons (3 males, 3 females) served as subjects for the experiment. Moderately susceptible subjects were chosen, as highly hypnotizable persons can enter hypnosis too easily for the purpose of the present experiment, while low susceptibles are unable to reach a sufficient depth of hypnosis. All of the subjects scored 7 on the Hungarian version of the Stanford Scale of Hypnotic Susceptibility, Form A (Greguss et al., 1975).
INTERACTION BETWEEN HYPNOTIST AND SUBJECT
Hypnotists Six hypnotists (3 males. 3 females) using hypnosis for at least one and a half years for therapeutic or research purposes took part in the experiment. None of them had ever hypnotized the experimental subject before. Hypnosis Hypnosis was induced by the standard induction method of SHSS. Form B (Weitzenhoffer and Hilgard 1959). The following standardized test suggestions were administered: 1) 2) 3) 4) 5) 6) 7) 8)
eye closure (as part of induction). hand lowering. left hand (SHSS:A). arm rigidity. left arm (SHSS:A). dream: topic unspecified (Revised Stanford Profile Scale of Hypnotic Susceptibility. Form I; Weitzenhoffer and Hilgard. 1967) • arm immobilization. right arm (SHSS:A). eye catalepsy (SHSS:A). dehypnosis and suggestion of posthypnotic amnesia (SHSS:B) and. posthypnotic suggestion (Harvard Group Scale of Hypnotic Susceptibility Form A; Shor and Orne. 1962).
Recording Subjective experiences. behavioral manifestations and electrophysiological indices were recorded and subsequently analyzed in a complex way. Each session was followed by a detailed tape-recorded interview in which the subjects and the hypnotists were questioned separately about their subjective experiences. They were asked to judge: 1. the depth of hypnosis reached during the actual session on a 10 point scale with 0 as the waking state and 10 as the deepest achievable hypnosis for the subject; 2. the degree of "tuning in" to each other. i.e •• the degree of focussing their attention on the other person. A 10 point scale was used for this purpose as well. where 0 meant lack of paying attention to the other and 10 meant maximal attention. The behavioral manifestations of both participants of the hypnotic interaction were recorded on video-tape. In order to include details of the interaction unobservable on video-tape a trained observer was also present in the experimental chamber. taking detailed notes. Both of these records were analyzed by three trained experimenters who also scored the performances of the test suggestions.
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Electrophysiological indicators of the hypnotists and subjects were recorded simultaneously. An 8-channel Beckman Dynograph type R411 was used for recording vegetative indices: tonic and phasic changes of skin conductance (recorded from the thenar area vs. the back of the right hand by chlorided silver cup electrodes), respiration and heart rate. An 8-channel Medicor EEG was used for recording F -0 1 and F 2-02 EEGs according to the international 10-20 system, and for electromyograms (EMG) from the chin of both participants and horizontal eye movements and left biceps-triceps EMG activity of the subject. EEGs and heart rates were simultaneously recorded on a Philips Ana-Log 7 tape recorder for further computer analysis. The left and right fronto-occipital EEGs were analyzed by Berg's method in the range of 0-16 Hertz using an OTE Biomedical Firenzeltype Fourier-Bert analyzer. A signal marking time facilitated the later identification of the sequences of the experiment. Procedure A total of 12 hypnotic sessions were conducted: each subject was hypnotized twice, once by a male, once by a female hypnotist. Each experimental session began with the fixing of the silver cup electrodes to the appropriate recording places with the use of collodium. This was followed by a check of the different leads, by the establishment of a rapport between hypnotist and subject, by hypnosis itself and finally by the interviews. The entire procedure took approximately 3 hours. RESULTS Considering the preliminary character of this report, only those results are mentioned which, shoWing characteristic differences as a function of hypnotic depth, seem relevant to our goal of determining methods which help to detect the important metacommunicative elements within the hypnotic interaction. In spite of the identical hypnotizability of the subjects and the fully standardized verbal communication, the hypnotic interactions showed marked differences from one session to the other (Figure 1). On the basis of the number of test suggestions performed positively, the hypnotic sessions could be divided into 3 groups: - in 4 sessions a mean score of 6 was achieved and cognitive distortions, changes in body scheme also occurred; i.e. a deep hypnosis was induced;
INTERACTION BETWEEN HYPNOTIST AND SUBJECT
Differences in hypnotic depth according to objective and subjective criteria. A: means and SD values of objective scores. B: means and SD values of subjective depth of hypnosis. C: means and SD values of the degree of "tuning in" to each other. D: means and SD values of the differences in positive and negative comments of the subjects regarding the hypnotist. Vertically striped columns: deep hypnosis; Diagonally striped columns: moderate hypnosis; Empty columns: light hypnosis. Grouping is based on objective behavioral scores.
- in 3 cases only the 2 easiest test suggestions were carried out positively, thus the hypnotic depth was moderate. The subjective depth of hypnosis and the degree of "tuning in" to each other (i.e. the degree of focussing their attention on the other person) also showed marked differences correlating with the objective scores. Spontaneous comments, concerning the hypnotist, made by the subjects also reflected these differences in the depth of hypnosis. While after deep hypnosis the positive comments dominated, after moderate and light hypnosis the subjects mainly criticized the technique of the hypnotist. A part of the differences of scores in hypnotic depth and in "tuning in" to each other can be explained by overt behavioral differences. One of the most important factors seemed to be the hypnotist's turning toward the subject, while maintaining a total visual focus with the situation, even during the 2-minute silent period of the dream suggestion. The amount of the loss of eye contact proved
E. 1. BANYAI ET AL.
102 DEEP HYPNOSIS
LI GHT HYPNOS I S
•• ... 4"'. . .
.... _ FIST' I
• • tn
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-IT IS IE(OIII"; STIFF'
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Electromyographic activity during arm rigidity suggestion. 1. Biceps-triceps electromyographic (EMG) activity of a subject in deep (left side) and in light (right side) hypnosis. 2. Chin EMB-activity of two different hypnotists inducing deep (left side) or light (right side) hypnosis. Texts under the EMG pairs: cue words of test suggestion. Note that the muscular activity of the subject is higher in deep hypnosis according to the more intensive chin EMG of the hypnotist.
to be a valuable index of concentration on the subject necessary to detect subtle reactions such as closing or opening of the eyes, horizontal eye movements in the dream situation, changes in relaxation, etc. These overt behavioral changes were transmitted to the subjects by covert signs. The subjects emphasized that their hypnotic state was deepened if they sensed from his voice that the hypnotist perceived their actual state. This change of voice was a powerful feedback to the subjects. The muscular tension of both the hypnotist and the subject played an important role in the iateraction. When the subject relaxed during the eye closure period of the induction a marked de-
INTERACTION BETWEEN HYPNOTIST AND SUBJECT HYPNOTIST Left Fronto ·Occipit..
Right Fr.a. Occipita'
Left Fronto· Occlplhll
Right Fronto· Occipital
Power spectra of the left and right hemispheres of hypnotist and subject when deep hypnosis was induced. Berg's analysis of fronto-occipital leads in the range of 0-16 Hertz. One curve: average power of 30 sec's activity. Time of experiment in minutes: scale going from the bottom to the top.
crease of the initial tension of the hypnotist was observed, as reflected in the EMG of the chin and in the muscular artifacts of the occipital EEG leads. As a result of this the subject had the feeling that the hypnotist was closely following the changes in his internal events, even if the hypnotist delayed in giving any verbal feedback about noticing eye closure. The increase in muscular tension of the hypnotist's chin - seen at the administration of the challenge suggestions (Figure 2) which required an intensive muscular activity from the subject - proved to be effective in increasing the amount of muscular contractions reflected in the appropriate EMGs of the subject. In cases of seemingly identical positive performances to the challenge suggestions on the behavioral level, the above-mentioned increased contractions made the subjects feel different subjective depths of hypnosis. Characteristic differences were found in the EEG activity reflecting the differences of the hypnotic depth. As is illustrated in Figure 3 by a typical record, when deep hypnosis was achieved, a marked dominance of the left hemisphere's activity could be observed in the power spectra of the right handed hypnotists, while in the hypnotized persons a right hemispheric dominance appeared.
E. 1. BANYAI ET AL. Q
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.. , \
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•• • • I
Relation between lateral difference in total power and hypnotic depth. (Two sessions of the same subject). Solid line: deep hypnosis; Broken line: light hypnosis; Lx: mean total power of left fronto-occipital EEG; RX: mean total power of right fronto-occipital EEG.
The power spectra of the hypnotized subjects, however, showed a significantly different pattern, if only light hypnosis could be induced. As is seen in Figure 4, although a quotient of the total power of the left and right hemispheric activity demonstrated a right hemispheric dominance if the subject entered deep hypnosis, it showed a marked left hemispheric dominance when only a light hypnotic state could be reached. The group-averaged changes of alpha and beta powers (see Figure 5) indicate that the lateral difference in hemispheric activation might be a reliable indicator of the achieved hypnotic depth. While in deep hypnosis the increment of the alpha power is generally more pronounced in the right cerebral hemisphere than in the left, in light hypnosis the change shows an inverse lateralization. The same lateral difference appears in the changes of beta power: in deep hypnosis the decrease in the power is less expressed in the right hemisphere while in light hypnosis the left hemisphere shows practically no change.
INTERACTION BETWEEN HYPNOTIST AND SUBJECT
Change of power spectra in alpha and beta bands. 100%: Group-averaged powers in the initial waking period of the experiment. Dark columns: deep hypnosis; Empty columns: light hypnosis: R: right side change; L: left side change.
As a result of these changes. as is demonstrated in Figure 6. the EEG activity of the subjects achieving deep hypnosis is generally characterized by a right hemispheric dominance. while the activity of the left hemisphere is more dominant in light hypnosis.
DISCUSSION Under sufficiently controlled experimental conditions it could be demonstrated that· changes in the non-verbal elements of communication themselves exert an influence on the effectiveness of hypnotic induction.
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106 Lll-Rll Lx"Rx -2-
Relation between lateral difference of powers (alpha, beta) and hypnotic depth. 1: initial waking period; 2: under hypnosis; 3: after dehypnosis; Dark columns: deep hypnosis; Empty columns: light hypnosis; LX: group-averaged power of left fronto-occipital EEG; aX: group-averaged power of right fronto-occipital EEG.
In the recorded overt and covert processes, relevant communicative functions were demonstrated in changes in the amount of loss of visual contact with the situation, in the tone of voice of the hypnotist and in the muscular tension of both the hypnotists and the subjects. It should be noted that these processes play an active role in the hypnotic interaction in spite of the fact that the participants were usually unaware of them. Although the EEG activity is probably not communicated in the course of the hypnotic interaction the lateral differences found in the power spectra seem to be relevant, suggesting that the dominance of right hemisphere EEG activity can facilitate the marked changes of consciousness characterizing deep hypnosis, while a left hemisphere
INTERACTION BETWEEN HYPNOTIST AND SUBJECT
dominance is more favorable for keeping the control. Since the right cerebral hemisphere is generally characterized as an imagery, automatic, analogous, emotional and holistic processor, these results seem to be in accordance with our data showing an improved capacity for imagery coding in hypnosis (Meszaros et al., 1982). The results on the interaction between hypnotist and subject suggest that a greater understanding of the hypnotic phenomenon can be achieved if it is studied not only from the aspect of the hypnotized person, but also using the methods of the now developing social psychophysiology.
REFERENCES Gill, M. M., and Brenman, M., 1959, Hypnosis and related states: Psychoanalytic studies in regression, International Universities, Press, New York. Greguss, A. C., Banyai E., Meszaros, I., Cs6kay, L., es and Gerber, A., 1975, A hipn6zis iranti erzekenyseg standard vizsgalata magyar nyelven, in: "A Magyar Pszich. Tars. IV. Tud. Jub. Nagygyulese. nov.--17-18. L. Benedek es T.-ne Szekely eds., Budapest, 61-62. Haley, J., 1958, An interactional explanation of hypnosis, Am.J.clin. Hypnosis, 1:41-57. Haley, J, 1961, Control in brief psychotherapy, Archs.gen.Psychiat., 4: 139-153. Haley, J., 1963, How hypnotist and subject maneuve~ each other, in: "Strategies of Psychotherapy," J. Haley, ed., Grune and Stratton, New York. Hilgard, E. R., 1965, Hypnotic susceptibility, Harcourt Brace Jovanovich, New York. Hilgard, E. R., 1975, Hypnosis, Ann.Rev.Psychol., 26:19-44. Hilgard, E. R., 1977, Divided consciousness: Multiple controls in human thought and action, John Wiley and Sons, New York, London, Sydney, Toronto. Hilgard, E. R., 1981, Hypnotic susceptibility scales under attack: an examination of Weitzenhoffer's criticisms, Int.J.clin.exp. Hypnosis, 29:24-41. Meszaros, I., Banyai, E. I., and Greguss, A. C., 1982, Evoked potential correlates of verbal versus imagery coding in hypnosis, Paper presented at the 9th International Congress of Hypnosis and Psychosomatic Medicine, Glasgow, Scotland, August. Shor, R. E., and Orne, E. C., 1962, Harvard group scale of hypnotic susceptibility form A. Consulting Psychologists Press, Palo Alto, Calif.
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Weitzenhoffer, A. M., and Hilgard, E. R., 1959, Stanford hypnotic susceptibility scale, Forms A and B, Consulting Psychologists Press, Palo Alto, Calif. Weitzenhoffer, A. M., and Hilgard, E. R., 1967, Revised Stanford profile scales of hypnotic susceptibility, Forms I and II., Consulting Psychologists Press, Palo Alto, Calif.
NON-VOLITION AND HYPNOSIS. REALS vs. SIMULATORS: EXPERIENTIAL AND BEHAVIORAL DIFFERENCES IN RESPONSE TO CONFLICTING SUGGESTIONS DURING HYPNOSIS S. J. Lynn. M. R. Nash. J. W. Rhue. V. Carlson. C. Sweeney. D. Frauman and D. Givens Psychology Department. Ohio University Athens. Ohio. 45701. USA Abstract Susceptible real and low susceptible simulating subjects were instructed to attend to. imagine. and think about described actions. but not to engage in movements while hypnotized. Susceptible imagination subjects received identical instructions but no prior induction. Testing occurred in small groups where observers rated movement responses to five motoric suggestions. As predicted. reals responded behaviorally following their experiential involvement in suggestions more than did simulators. Simulators moved more at one extreme or the other (movement or no movement) than reals. as predicted. Reals coded testimony reflected more conflict. sensations. imaginative involvement, and lack of volition than simulators. Although the imagination group behaved like simulators. their testimony paralleled the reals. with the exception that more volitional control was reported. In a second replication of real-simulator movement differences with a separate group of subjects. even when simulators were not released from their role plays when subjective reports were collected, they continued to differ on all subjective scales with the exception that they appreciated the conflict inherent in the situation. as did the reals. This second study demonstrated that real-simulator differences are still evident when simulators role play. INTRODUCTION Hypnosis theorists are in sharp disagreement about the inferences that can be made from subjects' reports that their responses to suggestions are often experienced as involuntary. Magda Arnold 109
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(1946), for example, has emphasized the importance of imaginative processes in determining the subject's experience of nonvolition. Sustained uncontradicted imagining of a suggested behavior is posited to lead automatically to the occurrence of that behavior. Subjects' reports of nonvolition are viewed as accurate reflections of the supposed automatic nature of ideomotor action. Hence, only if subjects interrupt their imaginings are they able easily to resist suggested behavior. Spanos and his colleagues (e.g., Spanos et al., 1977: Spanos, 1981) have consistently argued that hypnotizable subjects, despite their reports of nonvolition, retain control over their suggested responses. Subjects come to interpret their imaginings as happenings which are a function of such variables as preconceptions concerning hypnosis and expectations of effortless responding elicited by the wording of hypnotic inductions and test suggestions. While imaginings may legitimate and reinforce the interpretation of effortless responding, they are not a direct cause of actions during hypnosis. Finally, Hilgard (1977) and Kihlstrom et al., (1980) have advocated the position that hypnotizable subjects actually do lose conscious control over their behavior because control over movements may be dissociated from normal consciousness during hypnosis. Reports of nonvolition, then, accurately reflect the fact that behavior normally under conscious control is no longer under such control. The research that I shall describe today summarizes two studies that were conducted as part of a research programme designed to generate findings relevant to the major theories of nonvolition. In the first study, hypnotic, simulating, and imagination control subjects were instructed to attend to, imagine and think about described actions, but resist engaging in movements. We hypnothesized that hypnotic subjects will continue to respond to suggestions when faced with a conflict between resisting suggestions and fully experiencing the suggestions. This prediction is consistent with each of the theories of nonvolition. Subjects' responses were categorized on the basis of the degree of compliance with suggestions. Further, subjects' reports were analyzed to determine whether differences among groups were evident in the number of sensations experienced (Spanos et al., 1977) conflict about responding, experienced nonvolition and imaginative involvement. In the first study, simulators were released from their role-plays prior to completing their subjective reports. In the second study, the hypnotic-simulating conditions were repeated, but simulators continued to role-play while they reported their experiences. In the second study subjects were asked not only about how much they moved in response to the suggestions, but also about how other "good" subjects respond in the experimental context. In addition, during the susceptibility screening phase of the second study, subjects completed questionnaires regarding their experience of hypnosis. This permitted an evaluation of the relationship between subjects' movements in response to countersuggestion and their prior experience of hypnosis.
NON-VOLITION AND HYPNOSIS
Support for Arnold's (1946) position would be secured if hypnotic and imagination subjects, both instructed to sustain suggestion-related imaginings, respond to suggestions and report involuntariness. In contrast, imaginative processes would likely be of secondary importance if imagining subjects, in contrast to hypnotic subjects, resisted suggestions while they continued to imagine and be absorbed in suggestions. Findings which indicated that hypnotic subjects respond to suggestions and report involuntariness to a greated degree than imagining subjects would be entirely compatible with the dissociation position (Hilgard, 1977; 1979; Kihlstrom et al., 1980) as well as the view that emphasized the importance of the experimental context (Spanos et al., 1977; Spanos, 1981). Further support for the latter position would be secured if, in the second study, simulating and hypnotic subjects' responses were found to trace closely their perceptions of appropriate hypnotic behavior. METHOD Study I included hypnotic (N=14), imagination (N=9), and simulation (N=12) conditions. In Study 2, hypnotic (N=12) and simulation (N=ll) conditions were contrasted. In both studies susceptible subjects scored 9 and above on the Harvard Group Scale (HGSHS:A; Shor and Orne, 1962); unhypnotizable simulators scored 3 and below. Studies 1 and 2 differed in two significant respects. In Study 1, simulators were instructed to abandon their role playing before completing subjective reports which described their experiences and responses. In Study 2, simulators role-played throughout the entire procedure. Subjects also completed measures of involvement in the events of hypnosis following the administration of the Harvard scale. Across both studies, the treatment of the hypnotic and simulating subjects was identical. Hypnotic and simulating subjects were run in the same groups. As part of the simulating instructions, adapted from Orne (1959), simulators were informed that if their pretence were detected, the hypnotist would tap them on the shoulder and excuse them from the experiment. All subjects were tested in groups of 4 to 8 and carefully seated in a large room in such a way that precluded observation of other subjects. Imagining subjects were not tested with the subjects in the other two groups because they did not receive a hypnotic induction. For these subjects, the experiment was described as a study of imaginative processes. Subjects were led to believe that they were recruited because of their participation in the psychology department subject pool. Subjects in the hypnotic and simulating groups were administered a modified version of the Stanford Profile Scales, Form 2 (Weitzenhoffer and Hilgard, 1967), adapted for group administration. Deepening instructions followed. Hypnotic and simulating subjects received the counterdemand instructions during hypnosis after the
S. J. LYNN ET AL.
deepening instructions were read. The imagining subjects received the instructions shortly after they were comfortably seated with their eyes closed. All subjects received the instructions which follow: "Please listen very carefully. It is important that you listen very carefully. For each of the following five suggestions, just listen as carefully and intently as you can, but be sure not to act on any of the suggestions. So, even if I suggest that you do something, you will not do it. Just think and imagine along with the suggestions, but do not actually take any actions or engage in any of the behaviors that I suggest until I give you instructions to come out of you hypnotic trance. The important thing for you to remember is that you can think and imagine along with what I suggest, but do not actually do anything I suggest to you. O.K., now we will begin with the first suggestion with you listening and imagining to the greatest extent you are capable of." After the instructions were read, raters quietly entered the room and positioned themselves about three feet in front of a subject who was sitting with eyes closed. The raters were carefully trained to record each subject's responses on a scale ranging form no movement, to some movement, to full compliance with the suggestion. Adequate interrater reliabilities were obtained on this three point continuous movement dimension. Following the reading of the instructions, the hypnotist read five motoric suggestions (head falling, hand lowering, arm rigidity, moving hands together, hand levitation). None of the subjects had prior exposure to the suggestion which involved hand levitation and balloon imagery. Following the experimental procedure, subjects were instructed to write an essay of at least one hundred words, describing their thoughts, feelings, and actions during the experimental procedure. Subjects in the second study also indicated how many suggestions they moved in response to, on a scale which ranged from 0 to 5; they also completed a corresponding scale which required them to indicate how many suggestions good hypnotic subjects respond to. These questions were embedded in a larger questionnaire which tapped the experience of hypnosis in order to reduce the salience of the key items. RESULTS AND DISCUSSION The major analyses are summarized in Table 1. In both studies, hypnotic subjects moved more than simulating subjects. In Study I, the hypnotic group moved more than both simulating and imagining subjects. The finding that hypnotic subjects move more than simulating subjects, provides strong support for the hypotheses that, when faced with a conflict between experiencing suggestions and responding behaviorally, hypnotized susceptibles resolve the conflict by following the hypnotist's suggestions. An inspection of the table also reveals that hypnotic subjects expressed more sensations, im-
NON-VOLITION AND HYPNOSIS Table 1.
Means of Behavioral and Subjective Report Data
Hypnotic Rated Movements Sensations
Imaginative Involvement Conflict
Movements self f Movements "Good Subjects"
Note: Newman-Keuls Post Tests a. b. c. d. e.
nypnotic> imagining and hypnotic and imagining> hypnotic and imagining> hypnotic and imagining> hypnotic> imagining and
Simulating simulating simulating simulating simulating
(.01) (. OS) (. OS) (. OS) (.05)
a. b. c. d. e. f. g.
hypnotic) simulating hypnotic> simulating hypnotic> simulating hypnotic==simulating hypnotic> simulating hypnotic> s~mulating hypnotic> simulating
(.05) (.05) (.05) (n.s.) (.001) (.06) (.09)
aginative involvement, and experienced non-volition in their testimony than simulators, across both studies. The finding that simulators, in Study 2 (in contrast to the first in which they did not simulate testimony) report as much conflict about responding as the hypnotic subjects, indicates that simulators are able to recognize the conflict inherent in the complex instructions employed in this paradigm. The striking hypnotic-simulating differences secured in this study are as impressive as any reported in the literature (e.g., Evans, 1979; Evans and Orne, 1971; Orne et al., 1968; Peters, 1973). The finding that imagining subjects reported feeling as absorbed and involved in imaginings as hypnotic subjects but resisted responding is unsupportive of Arnold's (1946) position that imaginative processes are a crucial link between suggestion and involuntariness. The results are more consistent with the position advanced by Spanos and his colleagues that subjects' imaginings do not directly cause their actions. The hypnotic induction may be instrumental in translating imaginative involvements into behavior. This role could, perhaps, be one of legitimizing change, however, the relationship is not simple, since simulators also behaved like subjects with imagination instructions. The findings that hypnosis, as opposed to simulation or imagination, results in involuntary experiences is consistent with Hilgard's (1977, 1979) position. The experience of diminished behav-
S. J. LYNN ET AL.
ioral control is reflected in hypnotic subjects' reports of involuntariness and difficulty ignoring the behavioral pull of suggestions relative to imagining subjects who report similar conflict and suggestion-related involvements. However, the experience of nonvolition was not shown to be an invariable concommitant of hypnosis in that more than a third of the hypnotic subjects' movements were in the no response category. Further, hypnotic subjects reported conflict comparable to imagining subjects, a finding suggestive of active cognitive processing about the appropriateness of responding and situational task demands. The differences between the hypnotized and the simulating subjects suggests that the differences between the hypnosis and the imagination group may not be an artifact of demand characteristics and may instead reflect a true difference between hypnotized and unhypnotized individuals. However, the findings of Study 2 suggest that hypnotic and simulating differences may be mediated by differences in expectancies about appropriate responding. Inspection of Table 1 indicates that hypnotic subjects, compared with simulators, tended to rate both themselves and good hypnotic subjects as moving in response to more suggestions. Further, for both hypnotic and simulating subjects, self and observer rated movements are highly correlated with subjects' judgements about how good hypnotic subjects respond. The correlation between self-rated movements and perceptions of good subjects' movements for hypnotic subjects was .88; the corresponding correlation for simulators was .92. The correlation for observer-rated movements was .81 for hypnotic subjects and .65 for simulating subjects. These findings seem to be consistent with the view that the hypnotic and simulating procedures produce different demands (e.g., Spanos, 1981) and the view that susceptible subjects may be particularly adept at responding in terms of subtle cues and communications that simulators may fail to detect (e.g., Sheehan, 1977, 1980; Sheehan and Perry, 1976). Indeed, the behavioral findings secured in this study are entirely congruent with the position that hypnotic subjects are specially motivated to respond to the subtle communications of the hypnotist and resolve conflict in hypnosis in favor of the hypnotist and his or her intent (e.g., Dolby and Sheehan, 1975; McConkey, 1979; Sheehan, 1971, 1977, 1980). Imagining and simulating subjects may not behave accordingly because they are not comparably involved in the hypnotic relationship and the events of hypnosis (Dolby and Sheehan, 1975; McConkey, 1979; Sheehan and Dolby, 1975, 1979; Sheehan, 1980). As a function of such differences in involvement, subjects in hypnotic, imagining, and simulating contexts may develop different expectancies about responding. In Study 2. involvement indicators of simulating subjects' experience of group hypnosis were fairly highly correlated with their later tendency to resolve hypnotic conflict in favor of responding to
NON-VOLITION AND HYPNOSIS
the hypnotist's repeated suggestions. That is, the more the simulators appeared to be involved in the group hypnosis prior to the counterdemand study, the more they moved in response to suggestion. Observer-rated movements correlated .70 with the overall degree of involvement with the suggestions, .66 with the amount of fantasy or imagery experienced during hypnosis, .61 with rapport with the hypnotist, and .65 with how closely the hypnotist's suggestions were followed. Hypnotic and imagining subjects may appraise and resolve experienced conflict in very different ways. In the imagining condition, with few demands for suggestion-related involuntariness (e.g., Radtke-Bodorik, et al., 1979; Spanos 1981), conflict may serve as a cue to remind subjects of the instructions not to respond. In the hypnotic context, which encourages self-attributions of responsiveness to trance or involuntariness (e.g., Bowers, 1973; Coe and Sarbin, 1977; Spanos, 1981, 1982), conflict may be resolved by not inhibiting involvement and moving in response to the hypnotist and the behavioral pull of the suggestions. This interpretation is consistent with Spanos' position which empahasizes contextual determinants of involuntariness and the views of Sheehan and his colleagues regarding the special motivation of the hypnotic subject in relation to the resolution of hypnotic conflict. Future research efforts might explore the relationship between rapport and involvement indicators and sustained imaginings, expectancies about appropriate responding, and reports of involuntariness in hypnotic and nonhypnotic contexts. much more research is needed to understand better the antecedents of experienced involuntariness and to resolve the question of whether reports of involuntariness are "real" or "illusory." REFERENCES Arnold, M. B., 1946, On the mechanism of suggestion and hypnosis, J.abnorm.soc.Psychol., 41:107-128. Bowers, K. S., 1973, Hypnosis, attribution, and demand characteristics, Int.J.clin.exp.Hypnosis, 21:226-238. Coe, W. C., and Sarbin, T. R., 1977, Hypnosis from the standpoint of a contextualist, Annals of the New York Academy of Sciences, 296:2-13. Dolby, R. M., and Sheehan, P. W., 1975, Cognitive processing and expectancy behavior in hypnosis, J.abnorm.Psychol., 86:334345. Evans, F. J., and Orne, M. T., 1971, THe disappearing hypnotist: The use of simulating subjects to evaluate how subjects perceive experimental procedures, Int.J.clin.exp.Hypnosis, 19:277-296. Evans, F. J., 1979, Contextual forgetting: Posthypnotic source amnesia, J.abnorm.Psychol., 88:556-563.
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Hilgard, E. R., 1977, Divided consciousness: Multiple controls in human thought and action, Wiley, New York. Hilgard, E. R., 1979 Divided consciousness in hypnosis: The implications of the hidden observer, in: "Hypnosis: Developments in Research and New Perspectives," (2nd Ed.)., E. Fromm and R. E. Shor, eds., Aldine, New York. Kihlstrom, J. F., Evans, F. J., Orne, E. C., and Orne, M. T., 1980, Attempting to breach posthypnotic amnesia, J.abnorm.Psychol., 89:603-616. McConkey, K. M., 1979, Conflict in hypnosis: Reality versus suggestion, in: "Hypnosis, 1979", G. D. Burrows, D. R. Collison, and L. Dennerstein, eds., Elseiver/North Holland Biomedical Press, Amsterdam. Orne, M. T., 1959, The nature of hypnosis: Artifact and essence, J.abnorm.soc. Psychol., 58:277-299. Orne, M. T., Sheehan, P. W., and Evans, F. J., 1968, Occurrence of posthypnotic behavior outside of the experimental setting, J.Person.soc.Psychol., 9:189-196. Peters, J. E., 1973, Trance Logic: Artifact or essence in hypnosis, Unpublished doctoral dissertation, Pennsylvania State University. Radtke-Bodorik, H. L., Spanos, N. P., and Haddad, M. C., 1979, The effects of spoken versus written recall on suggested amnesia in hypnotic and task-motivated subjects, Amer.J.clin.Hypnosis, 22:8-16. Sheehan, P. W., 1971, Countering preconceptions about hypnosis: an objective index of involvement with the hypnotist, J.abnorm. Psychol., 78:299-322, (Monograph). Sheehan, P. W., 1977, Incongruity intrance behavior: a defining property of hypnosis? Annals of the New York Academy of Sciences, 296:194-207. Sheehan, P. W., 1980, Factors influencing rapport in hypnosis, J.abnorm.Psychol., 89:263-281. Sheehan, P. W., and Dolby, R. M., 1975, Hypnosis and the influence of most recently perceived events, J.abnorm.Psychol., 84: 331-345. Sheehan, P. W., and Dolby, R. M., 1979, Motivated involvement in hypnosis: The illustration of clinical rapport through hypnotic dreams, J.abnorm.Psychol., 88:573-583. Sheehan, P. W., and Perry, C. W., 1976, Methodologies of hypnosis: A critical appraisal of contemporary paradigms of hypnosis, Hillsdale, N. J.: Erlbaum. Shore, R. E., and Orne, E. C., 1962, The Harvard group scale of hypnotic susceptibility (Form A), Consulting Psychologists Press, Palo Alto, Ca. Spanos, N. P. Hypnotic responding: automatic dissociation of situation-relevant cognizing? in: "Imagery: volume 2, Concepts, Results, and Applications,"E. Klinger, ed., Plenum Press, New York.
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Spanos, N. P., 1982, Hypnotic behavior: A cognitive, social psychological perspective, Research Communications in Psychology, Psychiatry, and Behavior, 7:199-213. Spanos, N. P., and Bodorik, H. L., 1977, Suggested amnesia and disorganized recall in hypnotic and task-motivated subjects, J.abnorm.Psychol., 86:295-305. Spanos, N. P., Rivers, S. M., and Ross, S., 1977, Experienced involuntariness and response to hypnotic suggestions, in: "Conceptual and Investigative Approaches to Hypnosis and Hypnotic Phenomena," W.E. Edmonston Jr., ed., Annals of the New York Academy of Science, 296:208-221. Weitzenhoffer, A. M., and Hilgard, E. R., 1967, Revised Stanford profile scales of hypnotic susceptibility (Form 2). Consulting Psychologists Press, Palo Alto, Ca.
VISUAL MEMORY PROCESSING DURING HYPNOSIS: DOES IT DIFFER FROM WAKING? Helen J. Crawford and Steven N. Allen Department of Psychology University of Wyoming Laramie. Wyoming. 82071. USA Abstract Cognitive processing differences in waking and hypnotic states have been suggested by several studies. While previous studies have examined self-reports of imagery vividness (Coe et al •• 1980; Sanders. 1967). this paper presents a series of investigations using more objective visual memory tasks to investigate the hypothesis that hypnosis can facilitate imagery processing such that either visual memory is better encoded or the preferred mode of scanning visual information is shifted within the highly hypnotizable individual. Two studies. using low hypnotizables (6 and 10 Ss) and high hypnotizables (6 and 10). as assessed by the Standford Hypnotic Susceptibility Scale. Form C. studied visual memory processing in counterbalanced conditions of waking and hypnosis. Based on the methodology of Gur and Hilgard (1975). subjects were presented Meier Art Design (Meier. 1940) pictures successively. such that subjects viewed one picture for 10 seconds. saw nothing for 10 seconds. and then were given a second picture with one object changed from the first. In both studies the lows and highs did not differ in the waking state, but during hypnosis the highs were able to identify significantly more often the object difference in the picture than were the lows. Self reports of visual memory strategy used indicated that both lows and highs reported a predominant detail memory encoding strategy during the waking state. During hypnosis the lows continued doing the same strategy, but the highs reported a shift to a predominant holistic image memory encoding strategy. A third study, now in progress, investigates the full range of hypnotizability with conditions of task motivation instructions and simulating subjects. Similar tasks are being used. 119
H. J. CRAWFORD ET AL. Results are discussed as being complementary to Paivio's (1971) imagery based dual-coding theory and to the hypothesis that hypnosis may facilitate a shift towards holistic. imaginal cognitive functioning.
INTRODUCTION Hypnotically responsive individuals commonly report that during hypnosis their imagery is more vivid. spontaneous. and effortless than during the waking state. Some also report that they are less analytical and more holistic when processing information. Such phenomenological reports suggest that hypnosis allows some individuals to shift from a more verbal. detail-orientated encoding system during the normal state to a more visual, image-orientated encoding system during hypnosis. Our laboratory has been conducting a series of studies which are concerned with whether or not information is processed differently during hypnosis, and if so, what is different about it. This paper will address some research on visual memory processing in and out of hypnosis. Since there is ample evidence in the literature (Paivio. 1971; Richardson. 1980) that imagery can be a mediating variable in the performance of certain memory and visuospatial tasks, as well as there being performance differences between low and high imagers on these tasks. it can be expected that during hypnosis responsive individuals should perform significantly better on tasks which seem to require imagery in their mediation. Several experimental approaches provide some support for this hypothesized shift in cognitive functioning during hypnosis. Increases in primary process thinking. as reflected by the Rorschach (Bowers. 1968; Fromm. et al., 1970) and the TAT and hypnotic dreams (e.g •• Levin and Harrison. 1976). have been reported during hypnosis. Gur and Reyher (1976) reported enhanced performance on figural. but not verbal. creativity during hypnosis. While moderate relationships between hypnotic susceptibility and self-reported vividness and controllability of imagery are often reported (for review. see Sheehan, 1979), enhancement of imagery vividness during hypnosis as reported on these same questionnaires has met with mixed findings (e.g., Coe. et al., 1980; Crawford, 1979; Sanders, 1967; Starker. 1974). Such self-reports can be influenced by demand characteristics, subject expectations, and social desirability (e.g., Divesta et al., 1971). Order effects (Coe et al •• 1980) and ceiling effects (Crawford. 1979) have also been noted. Thus. it is important to use more objective measures of imagery processing. Several studies (Nomura et al •• 1981; Wallace et al •• 1976; Wallace. 1978) found that a very few high hypnotizables can
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successfully produce eidetic imagery, using the nonfakable Julesz (1971) seterograms, during the hypnosis state even though they cannot during the waking state, although Spanos et ale (1979) were unable to obtain eidetic imagery in their subjects. Since it was only selfreported childhood eidetikers who exhibited eidetic imagery during hypnosis, and then only a few of them, this research suggests that hypnosis allows some individuals to access the "lost" ability to image eidetically, possibly through a shift in cognitive strategies. Crawford et ale (1981) found no significant differences between low and high hypnotizables across waking and hypnosis conditions on a timed spatial memory test. When postexperimental inquiries about strategies were analyzed, they found that those subjects who reported a significant shift from a detail-orientated strategy during waking to a more holistic-orientated strategy during hypnosis showed a significantly higher spatial memory mean enhancement score than those who did not report such a shift. Thus, in such research it is important to assess individual differences in self-reported information processing strategies. The research we shall report on in this paper is an extension of previous work by Crawford (1979). She examined waking and hypnotic performance on a visual memory discrimination task, which had been developed from the Meier Art Judgement Tests (Meier, 1940) by Gur and Hilgard (1975). Subjects were shown one of a pair of pictures for 10 seconds. They then closed their eyes for five or 10 seconds. Upon opening their eyes, they were presented a second picture of the pair which was changed so that the shade or perspective was different or a detail was missing, added, or changed. Subjects were instructed to indicate as quickly and as accurately as possible the change they saw. Reaction time was not significantly different across low and high hypnotizables, either in waking or hypnosis counterbalanced conditions. While lows and highs showed no significant difference in the number correct during the waking condition, high hypnotizables showed a significant increase in their mean number correct during hypnosis while lows showed no change or a significant reduction in performance. As Berger and Guanitz (1979) have pointed out in the same task, there were two main strategies reported: (I) a detail memory encoding strategy, and (2) a holistic imagery strategy. Low hypnotizables reported maintaining a predominantly detail-orientated strategy during both waking and hypnosis conditions. Highs reported a significant shift from a predominantly detail-orientated strategy during waking, which did not differ significantly from lows, to a predominantly image-orientated strategy during hypnosis. In the present study we examined the whole range of hypnotic responsiveness. So that a "holding back" phenomena would not occur due to expectations (Zamansky et al., 1964), groups of low, medium and high hypnotizables were tested in either waking - waking or waking - hypnosis groups, without their knowing that hypnosis might
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be involved during the waking conditions. Additional high hypnotizabIes were assigned to hypnosis - waking and hypnosis - hypnosis groups. Since reaction time was not an important variable in prior research. all subjects were permitted to examine the second picture for 15 seconds. Based upon prior research. it was anticipated that high. and possibly medium. hypnotizables would show a significant enhancement in mean number correct on the visual memory discrimination task. We expected a positive correlation between the amount of enhancement and hypnotic susceptibility scores. We also expected a shift towards a predominant holistic strategy during hypnosis for the high. and possibly medium. hypnotizables. METHOD
Subjects Subjects were 80 university student volunteers who had been screened for hypnotic susceptibility on both the Harvard Group Scale of Hypnotic Susceptibility (Shor and Orne. 1962) and the Stanford Hypnotic Susceptibility Scale. Form C (SHSS:C; Weitzenhoffer and Hilgard. 1962). From each of three stratified SHSS:C hypnotic levels. subjects were randomly selected and assigned to experimental groups. This resulted in 20 low hypnotizables (SHSS:C scores 0 to 4). 20 medium hypnotizables (SHSS:C scores 5 to 8). and 40 high hypnotizables (SHSS:C scores 9 to 12). They received either extra credit for a psychology course or $3 per hour for their participation. Procedure Each subject was contacted by telephone and asked to participate in an experiment that would assess individual differences in visual memory during the waking state. Within each stratified SHSS:C hypnotic level. subjects were randomly assigned to groups. The 20 low. 20 medium. and 20 high hypnotizables were divided into two groups: 10 to waking - waking and 10 to waking - hypnosis groups. The experimenters were blind as to their hypnotic levels. Of the remaining 20 high hypnotizables. 10 were assigned to hypnosis - waking and 10 to hypnosis - hypnosis groups. Alternate forms of the task were counterbalanced within subj ect groups. Each subject was seen for one session of approximately 50 minutes by one of two experimenters. Upon arrival. tasks were discussed and practiced prior to signing a consent form. For those subjects in which waking conditions occurred first or solely. consent forms made no mention of hypnosis. If hypnosis was introduced as an experi-
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mental condition. subjects were informed that if they did not want to be hypnotized they could participate in a waking condition. A second consent form was signed by those who indicated a willingness to be hypnotized. Two subjects refused hypnosis and were replaced by other subjects. During all conditions subjects were asked to perform as well as possible. The hypnotic induction was based upon the SHSS:C induction. with all references to sleepiness removed. and with additional instructions that the subject would become deeply hypnotized but remain alert and attentive as in the normal state of awareness. After the hypnotic induction. subjects practiced opening their eyes and looking around while maintaining a similar hypnotic depth to what they felt with their eyes closed. A five minute break occurred between conditions; this was particularly important if the subject had been hypnotized in the first condition. The visual memory discrimination task was similar to that used by Crawford (1979). This task involved 15 pairs of pictures which are reproductions of original works of art (Meier. 1940). with one pair slightly changed so that the shade or perspective is changed or details are missing. added. or changed. Subjects looked at the first picture for 10 seconds and then closed their eyes for an interstimuIus interval of five seconds. At the experimenter's request. the subjects then opened their eyes and were shown the second slide. Subjects were instructed to indicate what was different in the second picture from the first within a 15 second period. guessing if they were unsure at the end of the period. Slides were presented 150 cm. from the subject within a projection area of 50 by 70 cm. Not reported in the present paper was a same-different simultaneous task using similar pictures which followed the discrimination task. No memory encoding instructions were given. Following the experiment proper. subjects were interviewed as to the approaches or strategies used in the tasks. Subsequently. they were asked to indicate to what degree they had used detail or holistic strategies during the two presentations. RESULTS We will first look at the number correct on the visual memory discrimination task. Out of 15 possible. the range was from 6 to 14 across subjects and conditions. A summary of the data across the groups and conditions is presented in Table 1. Performance when Conditions are Same Across the waking - waking groups. subjects did significantly poorer the second time. ~(29) = 2.84. ~