Deirdre Barrett Hypnosis and Hypnotherapy Volume 1-2-2010

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Hypnosis and Hypnotherapy
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Volume 1: Neuroscience, Personality, and Cultural Factors
Deirdre Barrett, Editor
Copyright 2010 by Deirdre Barrett All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, except for the inclusion of brief quotations in a review, without prior permission in writing from the publisher. Library of Congress Cataloging-in-Publication Data Hypnosis and hypnotherapy / Deirdre Barrett, editor. p. ; cm. Includes bibliographical references and index. ISBN 978-0-313-35632-2 (hard copy : alk. paper) ISBN 978-0-31335633-9 (ebook) ISBN 978-0-313-35634-6 (vol. 1 hard copy : alk. paper) ISBN 978-0-313-35635-3 (vol. 1 ebook) ISBN 978-0-31335636-0 (vol. 2 hard copy : alk. paper) ISBN 978-0-313-35637-7 (vol. 2 ebook) 1. Hypnotism. 2. HypnotismTherapeutic use. I. Barrett, Deirdre. [DNLM: 1. Hypnosismethods. 2. Mental Disorderstherapy. WM 415 H9961 2010] RC495.H963 2010 2010015824 615.80 512dc22 ISBN: 978-0-313-35632-2 EISBN: 978-0-313-35633-9 14 13 12 11 10 1 2 3 4 5
This book is also available on the World Wide Web as an eBook. Visit www.abc-clio.com for details. Praeger An Imprint of ABC-CLIO, LLC ABC-CLIO, LLC 130 Cremona Drive, P.O. Box 1911 Santa Barbara, California 93116-1911 This book is printed on acid-free paper Manufactured in the United States of America
Contents
Acknowledgments Introduction Deirdre Barrett Chapter 1 The Hypnotic Deactivation of Self-Conscious Source Monitoring Robert G. Kunzendorf Chapter 2 Dissociaters, Fantasizers, and Their Relation to Hypnotizability Deirdre Barrett Chapter 3 Hypnosis, Mindfulness Meditation, and Brain Imaging David Spiegel, Matthew White, and Lynn C. Waelde Chapter 4 Forensic Hypnosis: A Practical Approach Melvin A. Gravitz Chapter 5 Hypnosis in Popular Media Deirdre Barrett Chapter 6 Hypnotic-Like Procedures in Indigenous Shamanism and Mediumship Stanley Krippner and J urgen W. Kremer Chapter 7 Lay Hypnotherapy and the Credentialing of Zoe the Cat Steve K. D. Eichel
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Chapter 8 Pedagogical Perspectives on Teaching Hypnosis Ian E. Wickramasekera II About the Editor and Contributors Index
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Acknowledgments
I would like to thank Debbie Carvalko from Praeger Publishers for her advocacy of this project, and for her advice, organization, and review of these volumes. I would also like to thank the books advisory board: Arreed Barabasz, PhD, EdD; Elvira Lang, MD; Steve Lynn, PhD; and David Spiegel, MD, for their help in identifying topics to be covered and advice on the best authors to cover them. Finally, I want to acknowledge the professional hypnosis societies that introduced me to the members of the advisory board and to most of the chapter authors. These organizations taught me much of the hypnosis Ive learned since my basic graduate school training, as they have for many of the chapter authors. They provide forums in which advances in hypnosis are shared in a timely manner among practitioners. The rst two societies listed here publish academic journals in which much of the research and clinical techniques summarized in these volumes has appeared. All ve conduct stimulating conferences with research presentations and workshopsfor students as well as practicing professionals. All maintain referral lists from which potential clients can locate skilled hypnotherapists in their geographic area. They constitute a rich resource for readers wishing to pursue more learning about hypnosis. The Society for Clinical and Experimental Hypnosis SCEH Executive Ofce P.O. Box 252 Southborough, MA 01772 Tel: 508-598-5553 Fax: 866-397-1839 Email: info@sceh.us Publishes International Journal of Clinical and Experimental Hypnosis
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American Society of Clinical Hypnosis 140 N. Bloomingdale Rd. Bloomingdale, IL 60108 Telephone: 630-980-4740 Fax: 630-351-8490 Email: info@asch.net Publishes American Journal of Clinical Hypnosis Society of Psychological Hypnosis Division 30American Psychological Association APA Division 30 Membership 1400 N. La Salle, Unit 3-S Chicago, IL 60610 http://www.apa.org/divisions/div30/homepage.html European Society for Hypnosis ESH Central Ofce Inspiration House Redbrook Grove Shefeld, S20 6RR United Kingdom Telephone : 44 11 4248 8917 Fax : 44 11 4247 4627 E-mail : mail@esh-hypnosis.eu http://www.esh-hypnosis.eu/index.php?folder_id14&le_id0 International Society for Hypnosis http://www.ish-web.org/page.php
Introduction
Deirdre Barrett
Hypnosis is named for the Greek god of sleep though, even in ancient times, few thought of it as literal sleepthis was simply the best analogy for an altered state so far from waking cognition and behavior. Western medicine rst called the phenomena mesmerism after Franz Mesmer, who conducted group trance inductions in eighteenth-century Europe. Mesmer attracted attention for his amboyant style and his cures of hysteria that eluded other physicians of the time. Of course, Mesmer did not invent hypnosis, he merely rediscovered techniques that had been practiced around the world since the dawn of history. A fourth-century BCE Egyptian demotic papyrus from Thebes describes a boy being induced into a healing trance by eye xation on a lighted lamp.1 Third-century BCE Greek temples in Epidaurus and Kos, dedicated to the god Asclepius whose snake-entwined staff is now our modern medical symbol, the caduceusused hypnotic-like incubation rituals to produce their dramatic cures.2 Mesmers contribution was that he reminded the Western world of this marvelous therapy. Young doctors ocked to him to study, but the medical establishment was no friendlier to alternative medicine then than now. Mesmer was exiled from medical practice, but therapists and the general public have remained fascinated with hypnosis ever since. In recent years, we have been able to understand hypnosis much better than Mesmer did with his eighteenth-century versions of magnetic and electrical elds of the body. Indeed we are able to see what real changes in brain activity occur during the process, but also a wealth of modern cognitive, linguistic, and personality research help explain it. Hypnosis and Hypnotherapy brings together the latest research on the nature of hypnosis and studies of what it can accomplish in treatment. Volume 1 addresses the question of what hypnosis is: the cognitions, brain activity, and personality traits that characterize it, as well as cultural beliefs about hypnosis. In Chapter 1, Robert Kunzendorf describes how cognitive processing differs
Introduction
during hypnosis from usual waking modes. He characterizes the core change as the deactivation of self-conscious source monitoring. This lack of awareness of the self as the origin of many perceptions during hypnosis leads to experiencing imagery as hallucinations and to alterations of memory processing including dissociation, amnesia, and hypermnesia. Kunzendorf explains how these changes can sometimes enable hypnosis to recover repressed memories but also increase the possibility of creating false ones. The most common misconception in hypnosis lore is the notion that trance, hallucinatory imagery, the will to carry out suggestionsindeed all the phenomena of hypnosisemanate from the hypnotist. In fact, it is the subject who produces these. In Chapter 2, I examine personality traits associated with the ability to enter hypnotic trance. Very few people are totally unhypnotizable, but the number able to experience the deepest hypnotic phenomenaeyes open hallucinations, negative hallucinations (failing to perceive something that is right in front of one), suggested amnesia and analgesia sufcient for surgeryis similarly small. Hypnotizability is not a present/absent dichotomy but a continuum. Many traits were historically hypothesized to determine hypnotizability such as hysteric personality, passivity, weak will, and need to please, but these actually bear little or no correlation when subjected to modern research analyses. This chapter summarizes the cluster of traits that do predict response to hypnotic induction. All of the interview and test questions that correlate highly concern hypnotic-like experiences of everyday life vividness of imagery, propensity to daydream, and the ability to block out real sensory stimuli. I also present a distinction between two types of high hypnotizablesone of whom has more of a propensity toward vivid, hallucinatory imagery, and the other toward dissociative, amnestic separation of memory. The rst group fantasizers tend to have a history of parents who read them much ction and encouraged fantasy play, while the second group dissociaters have a history of trauma or isolation during which they learned amnestic defenses. In Chapter 3, David Spiegel, Matthew White, and Lynn Waelde review the effects of hypnosis on physiologic functions. Past studies have found that induction of the hypnotic state reduces sympathetic nervous system activity and increases parasympathetic activity, as measured by the low frequency/high frequency ratio in spectral analysis of heart rate, and by increases in vagal tone. Both of these changes are associated with the ability to self-soothe. Hypnosis has also been found to affect the secretion of cortisol and prolactin and to modulate other neural and endocrine components of the stress response. The authors then describe recent brain imaging of hypnosis at their lab and other research facilities. The most consistent changes are found in the frontal attentional systems. Spiegel, White, and Waelde explain why these often track with the alterations of autonomic tone noted in the peripheral studies of hypnosis. They describe
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how hypnosis is associated with changes in the executive attention function of the anterior cingulate gyrus and involves activation rather than arousal in neurological termsand dopaminergic rather than noradrenergic in biochemical ones. This type of activation promotes chunking, or reducing the number of parallel systems, and indicates an inner rather than outer focus. Spiegel, White, and Waelde compare brain imaging ndings in hypnosis with those associated with mindfulness meditation and discuss the physiological similarity of states produced by the two techniques. Finally, they discuss shifts in brain activity associated with particular hypnotic phenomena such as alterations of pain perception and with the lessened sense of self-agency during hypnosis that was characterized as essential in Chapter 1. In Chapter 4, Melvin Gravitz describes forensic hypnosisthe role it has played in police investigation and the court system. Views of hypnosis have swung from touting hypnosis as a truth serum to seeing it as inherently invalidating witness testimony. Gravitz reviews the precedents and opinions at all levels, up to and including the U.S. Supreme Court, and offers his own balanced view of appropriate uses and safeguards. He discusses how the hypnotic alterations of memory discussed in Chapters 1 and 3, and the hypnotic-associated personality traits dealt with in Chapter 2, manifest specically during criminal witness proceedings. Next, in Chapter 5, I discuss the depiction of hypnosis in art and medialm, television, theater, music, and cartoons. These depictions emphasize behavioral control rather than rich alterations of subjective experience. Most lms cast hypnosis in a dark lightas a tool for seduction or murder. When hypnosis is portrayed positively, it is often either as a truth serumsimilar to the overly optimistic court opinions discussed in Chapter 4 (in fact, these often appear in courtroom dramas) or as endowing subjects with impossible psychological, mental, or athletic abilities. The chapter concludes with a discussion of how more realistic depictions of hypnosis in media might be encouraged. In Chapter 6, Stanley Krippner and J urgen Kremer discuss hypnotic-like practices in shamanism and folk medium traditions with illustrative examples from various North American tribes, Balinese folk customs, contemporary S ami (indigenous Scandinavian) practices and AfricanBrazilian mediumship. They describe the many similarities in these societies inductions and Western hypnosis, including verbal inductions and suggestion, sleep analogies, and heavy reliance on imagery and storytelling (the latter being characteristic mostly of Ericksonian hypnosis to be described in Volume 2, Chapter 1, rather than of all Western hypnosis). Krippner and Kremer also contrast trance-induction practices that are common in the indigenous cultures but not in Western hypnosis including chanting, percussion, dance or other ritualistic movement, and the burning of incense. They note a fundamental difference in the two types of indigenous practices of shamanism versus mediumship. Shamans are usually
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aware of everything that occurs while they converse with spirits, even when a spirit speaks through them, whereas mediums claim to lose awareness once they incorporate a spirit, and purport to remember little about the experience once the spirit departs. This distinction is similar to the two types of high hypnotizablesfantasizers and dissociaters described in Chapter 2. Krippner and Kremer describe how these cultures foster fantasy proneness and train dissociation to some degree, but that there also seem to be signicant demand characteristics to produce the culturally sanctioned behavior. Krippner has also researched individual variables of subjects within these cultures, nding some of the same characteristics associated with improvement by Western psychotherapy such as willingness to change ones behavior predict benecial outcome to treatment with shaman or medium. In Chapter 7, Steve Eichel describes the responses of the main lay hypnosis credentialing groups (those not associated with the mental health professionals, dentistry or medicine, but purporting to represent the profession of hypnosis) to applications for credentialing from a distinctly unqualied practitioner . . . his pet cat Zoe. Eichel uses the humorous ploy of getting Zoe certied with applications listing study at ImaCat U and hefty licensing fees to point out whats wrong with the concept of commercial credentialing groups unafliated with state licensing or university certication. Eichel goes on to describe why it is important to have clinicians trained in the underlying disorders that they are treating before applying hypnosis to them. Finally, in Chapter 8, Ian Wickramasekera describes in more detail how this training should be conducted. He reviews the history of how hypnosis has been taughtin Western psychotherapy and medicine, but also in the indigenous cultures covered in Chapter 6, ending with a description of the modern training guidelines established by the American Society of Clinical Hypnosis. Wickramasekera discusses how it is possible to draw together the best elements of each of these different pedagogical traditions into a training program for teaching hypnosis either within a university setting or a postgraduate certicate program. Volume 2 addresses the clinical applications of hypnosis in psychotherapy and medicine. In the term hypnotherapy, the second half of the term is as important as the rst. Except for some generalized effects on relaxation and stress reduction, it is not the state of hypnosis itself that affects change, but rather the images and suggestions that are utilized while in the hypnotic state. Because hypnosis bypasses the conscious minds habits and resistances, it is often quicker than other forms of therapy, and its benets may appear more dramatically. However, the reputed dangers of hypnotherapy are really those of all therapy: rst, that an overzealous therapist may push the patient to face what has been walled off for good reason before new strengths are in place; and second, that the therapist will abuse his or her position of
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persuasion. People come to hypnotherapy with similar complaints and hopes to those they bring to any treatment for physical or psychological problems. Despite the added role of hypnotizability, most of the same factors determine the outcome: the skill of the therapist, the patients motivation to drop old patterns, the rapport between patient and therapist, and how supportive family and friends are of change. Volume 2 begins by introducing the different branches of hypnotic psychotherapy. In Chapter 1, Stephen Lankton describes Ericksonian hypnotherapythe approach derived from the body of writing, training, and lectures of the late Milton Erickson. Ericksonian techniques include designing individualized inductions in the clients distinctive language, incorporating the clients metaphors for their disorders into the suggestions for change and using indirect suggestionwhich is ambiguous, vague, and more permissive to avoid provoking resistance. In Chapter 2, Arreed Barabasz traces the history of psychodynamic and ego psychology applications to hypnosis and then describes in more detail modern ego state hypnotherapy. Ego state theory posits that peoples personalities are separated into various segments. Unique entities serve different purposes. Ego states often start as defensive coping mechanisms and develop into compartmentalized sections of the personality, but they may also be created by a single incident of trauma. Ego states maintain their own memories and communicate with other ego states to a greater or lesser degree. Unlike alters in multiple personalities, ego states are a part of normal personalities. Conicts among states take up considerable energy, often forcing the individual into withdrawn, defensive postures. Hypnosis can facilitate communication between ego states, allow memories associated with one to become available to the whole person, and teach people to shift states more consciously and adaptively. Chapter 3 continues the discussion of psychodynamic uses of hypnosis, with my summary of the research and clinical work on hypnotic dreams and the variety of ways of combining hypnosis and dreamwork for the mutual enhancement of each. One can use hypnotic suggestions that a person will experience a dream in the trance stateeither as an open-ended suggestion or with the suggestion that they dream about a certain topicand these hypnotic dreams have been found to be similar enough to nocturnal dreams to be worked with using many of the same techniques usually applied to nocturnal dreams. One can also work with previous nocturnal dreams during a hypnotic trance in ways parallel to Jungs active imagination techniques to continue, elaborate on, or explore the meaning of the dream. Research has also found that hypnotic suggestions can be used to inuence future nocturnal dream content, and that hypnotic suggestions can increase the frequency of laboratory-veried lucid dreams. Hypnotic suggestion can also be used simply to increase nocturnal dream recall. In Chapter 4, Michael Yapko discusses the newest branch of hypnotherapy cognitive behavioraland especially its use in treating depression. He describes
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how the classic conceptualization of hypnosis as believed-in imagination is consistent with modern cognitive behavioral theory. Hypnosis can serve as a means of absorbing people in new ways of thinking about their subjective experience and as a method of replacing automatic negative thoughts with positive beliefs and expectancies. It can foster skill acquisition, breaking old associations and instilling new ones. Yapko reviews the growing body of research on the effectiveness of such techniques. Finally, because insomnia is such a common symptom of depression, he describes in detail how hypnosis can resolve insomnia by inducing relaxation and interrupting the ruminations that interfere with sleep. The remainder of the volume addresses applications of hypnosis to medical problems. In Chapter 5, Nicole Flory and Elvira Lang review the use of hypnosis for analgesia from nineteenth-century surgery prior to the discovery of ether up to modern times. The authors describe how surgery has evolved from more traditional large-incision techniques toward the insertion of surgical instruments through tiny skin openings under the guidance of X-rays, ultrasound, magnet resonance imaging (MRI), and endoscopes. They then review in detail their own carefully controlled research on utilizing hypnosis to alleviate pain, anxiety, and other distress associated with surgery in the new interventional radiological settings. Despite previous speculation by others that it would add excessive costs or time to the procedures, the authors found that teaching hypnosis-naive patients techniques on the operating table shortened procedures by decreasing patient interference and decreased costs by lowering subsequent complication rates. In addition to reducing the main target symptoms of pain and anxiety, hypnotic interventions kept patients blood pressure and heart rate more stable. Flory and Lang conclude that hypnotic techniques can be safely and effectively integrated into high-tech medical environments. In Chapter 6, Kent Cadegan and Krishna Kumar review studies on using hypnosis to treat smoking, alcoholism, and drug abuse. There is much more research on its use for smoking cessation than for any other addictive disorder. They report that results are encouraging even for two-session hypnotic smoking cessation treatment, but that there is no evidence for the efcacy of the one-session approach, though clinically, this is frequently practiced. Efcacy of hypnotherapy is less rigorously documented for other addictions, though there is growing interest in its use. Research on hypnosis to aid sobriety in alcoholics has found positive effects, but with small sample sizes and only short-term follow-up. There is less data yet on hypnotic interventions in drug addiction. In one recent study, veterans at an outpatient substance abuse treatment center benetted from training in self-hypnosis, with a very strong main effect for practicethe more regularly they practiced their self-hypnotic suggestions, the likelier they were to remain abstinent. Cadegan and Kumar predict that, with more research like this, it will eventually become possible to say to a potential client that hypnosis can help
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them control their addiction if they have certain characteristics (e.g., hypnotizability, motivation to quit, and availability of social support), and if they are willing to practice (with specication about the nature and amount of practice). Finally, in Chapter 7, Nicholas A. Covino, Jessica Wexler, and Kevin Miller briey review the research on hypnotic pain control, already described in Chapter 6 as establishing a clear efcacy for hypnosis in that area. They then review the research on hypnosis in other health related areas, such as insomnia, asthma, bulimia, and a number of more function gastrointestinal disorders such as hypermotility (leading to cramps and chronic diarrhea) and hyperemesis (uncontrolled vomiting, usually due either to cancer chemotherapy or as a complication of pregnancy). They conclude that results on all these disorders are clearly positive but need more research. They emphasize the pointwhich is true of both application of hypnosis to psychotherapy discussed earlier in this volume and to its role in medicinethat there is great promise for its use with many illnesses and conditions. However, for hypnosis to be better accepted, it is imperative that researchers in the eld update older studies with ones that pay more attention to current norms of empirically validated treatments and integrate promising strategies from related research such as the mindfulness meditation discussed in Volume 1, Chapter 3. Then this powerful technique will begin to be applied to many disorders in a way that it is currently only utilized routinely for pain control, anxiety, and smoking cessation.
NOTES
1. Grifth, F. I. & Herbert Thompson (Eds.) (1974) The Leyden Papyrus: An Egyptian Magical Book. New York: Dover Publications. 2. Hart, Gerald (2000) Asclepius: The God of Medicine. London: Royal Society of Medicine Press.
Chapter 1
The Hypnotic Deactivation of Self-Conscious Source Monitoring

Robert G. Kunzendorf
In clinical cases throughout the nineteenth century, hypnosis was associated with spontaneous manifestations of hysteria (Ellenberger, 1970), and in specic cases throughout the twentieth century, it has been associated with spontaneous occurrences of age regression (Gill, 1948), hallucination (Schneck, 1950), dissociation (Bliss, 1986), posthypnotic amnesia (Erickson & Rossi, 1974), and hypermnesia (Gruzelier, 2000). However, ever since twentieth-century behaviorists began measuring hypnotic suggestibility with experimentally controlled suggestions of regression, hallucination, dissociation, and amnesia (Barber & Calverley, 1963; Barry, Mackinnon, & Murray, 1931; Hull, 1933; Weitzenhoffer & Hilgard, 1959), the spontaneous or suggestion-free aspects of hypnosis have been overlooked in most research and omitted from most theorizing. Moreover, the behaviorists controlled suggestions introduced demand characteristics that produce cooperative faking rather than, or in addition to, genuine hypnotic responding. This chapter presents research that investigates the suggestionfree potentials of genuine hypnosis, as well as a theory that integrates both its suggestion-free potentials and its suggestion-based effects. This integrative theorythat hypnosis deactivates self-conscious source monitoring, or reality testing, much the way sleep doesis introduced and developed in the next section of this chapter. Subsequently, the theory is considered in the context of research on positive hallucinations, both spontaneous hallucinations and suggested ones. Next, the theory is discussed in the context of research on dissociative phenomena: negative hallucinations, with or without a hidden observer, and posthypnotic amnesias, including irreversible source amnesia. Then, it is considered in the context of investigations into hypnotic access to subconsciously encoded memories and
percepts. Finally, its implications for both the hypnotic recovery of traumatic memory and the hypnotic creation of traumatic pseudo-memory are addressed.
SLEEP, HYPNOSIS, AND THE DEACTIVATION OF SELF-CONSCIOUS SOURCE MONITORING

Somnambulistic phenomena during sleep and during hypnosis were described by Janet (1901, 1910) as phenomena entailing conscious sensation without self-consciousness. Following Janets lead in the case of sleep, Kunzendorf (19871988) has observed that during both the wakeful image and the dream image of a blue sky, the excitation of certain brain states results in the sensory quality of blueness. And during the wakeful image but not the dream image, the simultaneous excitation of other brain states results in the sensationless or tacit quality of waking self-consciousness. (p. 5) Similarly, in the case of hypnosis, Prince (1925) made the following observation: Now, given an hysteric of a certain type with absolute anesthesia of the skin, no tactile stimulus is felt, much less perceived, no matter how intensely the attention is concentrated on the stimulated area. . . . Now put that hysteric into another state of mind, [the sleep-like state of] hypnosis, and he recalls, rst, that there did actually occur the sensation of a prick or a touch; and, second, that when it occurred he was unaware of it. He further insists that it was a veritable sensationin-being. (p. 177) The introspective testimony of my dissociated subjects, who in that [hypnotic] condition recalled vividly and precisely these subconscious experiences, has been unanimous that these experiences were without self-consciousness. . . . The perceptions, feelings, etc., were not synthesized into a self or personality. The conscious events were just sensations. (p. 182) The theoretical issue of interest here is what purpose self-consciousness serves when it accompanies conscious sensations during normal wakefulness. Self-consciousness, according to Kunzendorf (2000), is a tacit or sensationless quality that subjectively parallels the neural process of monitoring whether sensations have a centrally imaged source or a peripherally perceived source. Thus, self-consciousness that one is imaging is the
subjective quality of a neural process monitoring the central innervation of sensations, and self-consciousness that one is perceiving sensations is the subjective quality of the same process monitoring the peripheral innervation of sensations. It is noteworthy that the source-monitoring process itself is not conscious of sensations or their source of innervation. Rather, this neural process physically monitors the source of particular sensations, and such physical monitoring is paralleled subjectively by a sensationless disposition to treat those sensations either as imaginally generated by the self or as perceptually given to the self. Present in either instance of source monitoring is the generic self-consciousness that one is having sensations in the absence of any Cartesian subject actually having sensations or being conscious of them. It is also noteworthy that, during self-conscious source monitoring, I am not aware of my self as a content of consciousness . . . but of my thoughts as mine (Cavell, 1987, p. 60). Indeed, failing to distinguish between the awareness of self as a content of consciousness and the illusion of self as a self-conscious subject of consciousness has led some researchers to the incorrect view that lucid dreams are self-consciously monitored, rather than the correct view that lucid dreams, like pseudo-hallucinations, are inferred to be imaginary on account of their contents (Kunzendorf, Treantafel, Taing, Flete, Savoie, Agersea, & Williams, 20062007). Let us now consider how the current theory advances our understanding of hypnotic hallucinating.
SPONTANEOUS AND SUGGESTED HALLUCINATING

The current theory attributes hypnotically hallucinated sensations to the attenuated monitoring of their non-perceptual source, whereas Barber (1979, 1984) and Wilson and Barber (1982) attributed hypnotically hallucinated images to the percept-like vividness of such images. Consistent with the former attribution, and contrary to Barbers, research by Kunzendorf (19851986) indicates that the sleeplike state of hypnosis deactivates source monitoring and that images generated during inactivated monitoring, whether they be vivid or faint, spontaneous or suggested, are hallucinatory images. In Kunzendorfs (19851986) research, the ability of 30 subjects to discriminate perceptual sensations from imaginal sensations was measured initially across 28 pre-hypnotic trials and then, without any suggestion of hallucinatory imaging, across 28 hypnotic trials. On each of the pre-hypnotic and hypnotic trials, an individually tested subject looked straight ahead while seeing an object on one side and imaging it on the other. Then, after rating the vividness of the imaged object, the subject was queried as to which side the imaged object (or the perceived object) was on, and the speed of his or her
discriminative response was measured to the nearest hundredth of a second. In analyzing the subjects 28 pre-hypnotic trials, each trials discrimination speed was plotted over the trials image-vividness rating, as illustrated in Figure 1.1, and the within-subject correlation between discrimination speed and image vividness was calculated. Similarly, for the subjects 28 hypnotic trials, the within-subject correlation between discrimination speed and image vividness was calculated. Prior to hypnosis, the correlation between discrimination speed and image vividness was negative on average, signicantly so. In other words, subjects prior to the induction of hypnosis discriminated percepts more quickly from vivid images than from faint images, as Figure 1.1 illustrates.
Figure 1.1 An idealized 28-trial scattergram for a hypothetical subject prior to hypnosis and for the same subject during the hypnotic deactivation of self-conscious source monitoring.
This seemingly paradoxical resultthat percepts during normal wakefulness are most quickly discriminated from those images with the most percept-like vividness and most percept-like detail in their sensationsis not only explained but anticipated by source-monitoring theory; because the number of centrally innervated sensations increases as a mental image becomes more vivid and more detailed, the centrally imaged source of a more vivid image is more reliably and more quickly registered by the neural process that monitors the source of sensations. Following the induction of hypnosis, however, the correlation between discrimination speed and image vividness became signicantly more positive for some subjectsthose who, post-induction, exhibited greater hypnotic depth on Morgan and Hilgards (19781979) Stanford Hypnotic Clinical Scale. That is, as Figure 1.1 illustrates, deeply hypnotized subjects discriminated percepts less quickly from vivid images than from faint images. Because direct monitoring of the centrally innervated source of imaged sensations is deactivated by hypnosis, the deeply hypnotized subjects in Kunzendorf s (1986) study were forced to make indirect inferences, based primarily on image vividness, and were able most quickly to infer that faintly imaged sensations were not vivid enough to be perceived sensations. But as Hilgard (1981) notes, a diaphanous [or faintly imaged] hallucination, while distinguishable from ordinary physical reality, still has perceptual reality (p. 14), because it could have been inferred to be the extraordinary percept of a ghost or wraith (p. 14). Accordingly, any image generated during the hypnotic deactivation of source monitoring is a hallucinatory image, whether it be vivid or faint, spontaneous or suggested. Remembrance of a suggestion to hallucinate can enable a subject to infer that a hallucinatory image is imaginary, just as attention to a hallucinatory images faintness can, but such an image can never be known directly to be imaginal in source. Indeed, such an unmonitored image can always be inferred to be either imaginal or perceptual, depending on the attended context and the assumed possibilities.
DISSOCIATED PERCEIVING WITH OR WITHOUT A HIDDEN OBSERVER

One consequence of the spontaneous inactivation of source monitoring following hypnotic inductions is the inability to discern immediately and directly that imaged sensations are imaginal in source. Another consequence is the inability to discern that perceived sensations are perceptual in source. This latter inability, according to Kunzendorf and Boisvert (1996), explains the evocation of hypnotic deafness and hypnotic blindness and hypnotic analgesiathree dramatic cases of dissociated perceivingin
response to hypnotic suggestions. By this account, because hypnotized subjects are not certain that their perceived sensations are perceptual in source, appropriate suggestions can convince such subjects that their auditory sensations during suggested deafness are either subconsciously perceived (by a hidden observer) or imagined, rather than perceived. Accordingly, Hilgard (1977) reported that half of his hypnotically deafened subjects subconsciously manifested a hidden observer who, during deafness, subconsciously heard every word and subsequently, during automatic writing, subconsciously wrote down every unheard word. In explaining Hilgards data without reifying the hidden observer, Kunzendorf and Boisvert (1996) showed that four hypnotically deafened subjects who could write down every unheard word, when told that their hidden observer would automatically do so, also could write down every unheard word when told simply to write down every word that they imagined hearing during deafness. Both in Hilgards research and in Kunzendorf and Boisverts research, hypnotic deafness was suggested. However, given that self-conscious monitoring of the perceptual source of perceived sounds is spontaneously inactivated following the induction of hypnosis, hypnotized persons could conceivably convince themselves that they are unable to hear their auditory sensations, without deafness being suggested by a hypnosis researcher or a hypnotherapist. Indeed, if Bliss (1986) and Prince (1925) are correct in attributing pathologically dissociated personalities to self-hypnotic states, then Walls (1991) patient exhibiting a host personality with normal hearing and an alternate personality with total deafness may be someone who, for defensive purposes, hypnotized herself and convinced herself that none of her hypnotically unmonitored auditory sensations were real. In a line of research testing for spontaneously dissociated percepts, Kunzendorf, Beltz, and Tymowiczs (19911992) 36 individually tested subjects9 deeply hypnotized subjects, 9 unhypnotized control subjects, 9 hypnosis-simulating control subjects, and 9 autistic subjects with visuospatially decient self-conceptswere told to use a televised mirror-image to move their hands together until their ngertips touched, but were not told that they were actually seeing a pre-recorded tape of their hands struggling unsuccessfully to touch. When queried immediately upon their ngertips touching, 8 of the autistic subjects and all 18 of the unhypnotized control subjects conrmed that their ngertips were touching, whereas 5 of the deeply hypnotized subjects denied that their ngertips were touching and the other 4 asserted that they didnt know whether or not their ngertips were actually touching. Based on this nding, Kunzendorf, Beltz, and Tymowicz concluded that deeply hypnotized subjects handtouching sensations, without any suggestion, are spontaneously dissociated from the immediate and incontrovertible self-consciousness that one is perceiving the hands touching (p. 129).
POSTHYPNOTIC AMNESIA
Hilgard and Cooper (1965) found that greater responsiveness to hypnotic suggestions is statistically associated with suggested posthypnotic amnesia, but not with spontaneous posthypnotic amnesia. Conrming and extending this nding, Kunzendorf and Benoit (19851986) found that greater responsiveness to hypnotic suggestions is associated with suggested posthypnotic recovery from amnesia as well as suggested posthypnotic amnesia itself, but is not associated with recovery from spontaneous posthypnotic amnesia through re-hypnosis or with spontaneous posthypnotic amnesia itself. One possibility raised by such ndings is that all hypnotic suggestions, including suggestions of posthypnotic amnesia and recovery, are contaminated by demand characteristics and cooperative responding and are not measuring the more genuine, more spontaneous manifestations of hypnosis. Consonant with this possibility, Kunzendorf (19891990) has concluded that genuine posthypnotic amnesia is a suggestion-free manifestation of the hypnotic deactivation of self-conscious source monitoring. He initially came to this conclusion when he and Michelle Benoit encountered a subject who, during spontaneous posthypnotic amnesia, confessed that she did remember her hypnotic experiences but did not want to report them because she was not sure which of her experiences were suggested by the hypnotist and which ones were simply imagined by her. Her spontaneous posthypnotic amnesia, in other words, was really spontaneous posthypnotic source amnesia. And to the extent that the induction of hypnosis spontaneously deactivates the source-monitoring process, as argued in this chapter, posthypnotic amnesia for the source of a hypnotically experienced image or percept should be, rst and foremost, spontaneousand, in addition, irreversible. Kunzendorf (19891990) proceeded to test for the possibility that all posthypnotic amnesiasrecall amnesia and source amnesia, suggested amnesia and spontaneous amnesiaare posthypnotic manifestations of the hypnotic deactivation of self-conscious source monitoring. For the 24 deeply hypnotized subjects in the rst of two studies by Kunzendorf (19891990), the suggested effect of posthypnotic amnesia for 14 words seen during hypnosis was successfully reversed by posthypnotic cuing with a prearranged signal, but the spontaneous effect of posthypnotic source amnesia for whether the 14 words were simultaneously heard or auditorily imaged during their hypnotic viewing was not reversed by such cuing. This rst nding serves to conrm that deep hypnosis spontaneously and irreversibly attenuates self-conscious source monitoring for whether sensory experiences are perceived or imaged. Kunzendorfs (1989 1990) second study serves to show how suggested posthypnotic recall amnesia and prearranged reversal cuing are attributable to irreversible posthypnotic source amnesia.
After subjects in Kunzendorfs second study were tested for suggested posthypnotic amnesia, they heard one of the following three instructions: 1. Control instruction Sometimes its hard to remember hypnotic events. In a moment, I want you to try to recall some more hypnotic events, as many of the remaining events as you can. For the next two minutes, write down as many of the remaining events as you can. 2. Try Hard instruction Sometimes its hard to remember hypnotic events, because it takes so much effort to recall them. In a moment, I want you to try to recall some more hypnotic events, as many of the remaining events as you can. But this time, try harder to remember the events. Dont be discouraged if it seems to take a lot of effort. Just try as hard as you can to remember, and, for the next two minutes, write down as many of the remaining events as you can. 3. Trust Imagination instruction Sometimes its hard to remember hypnotic events, because you are not sure whether you are just imagining events or whether you are actually remembering them. In a moment, I want you to try to recall some more hypnotic events, as many of the remaining events as you can. But this time, use your imagination to conjure up the hypnotic events. Dont worry if you feel like you are not using your memory. Just trust your imagination, and, for the next two minutes, write down as many of the remaining events as you can. Next, the 76 amnesic subjects in this studythe 23 amnesic subjects who heard the Control instruction, the 25 amnesic subjects who heard the Try Hard instruction, and the 28 amnesic subjects who heard the Trust Imagination instructionwere cued with the prearranged signal for reversing posthypnotic amnesia, and were given two more minutes of recall time. The results of this second study revealed that, prior to reversal cuing, posthypnotic recall amnesia was breached by the Trust Imagination instruction, but not by the Try Hard instruction. And when subjects who heard the Trust Imagination instruction used their imagination to recall events, they correctly recalled events for which they were posthypnotically amnesic and did not incorrectly imagine events. Based on this second nding, Kunzendorf (19891990) concludes that, when given either the Trust Imagination instruction or the prearranged reversal cue, amnesic subjects shift their recall criteriafrom a criterion rejecting possibly imaginary or sourceless memories, to a criterion accepting sourceless but familiar memories. In other words, because posthypnotic source amnesia is spontaneous and irreversible (as Kunzendorfs rst study shows), all hypnotically perceived and posthypnotically remembered
events are immediately experienced only as familiar events, not as perceived events. So in the second study, because the suggestion of posthypnotic amnesia for all hypnotic suggestions discourages subjects from reporting any suggestion not remembered as perceived, subjects tend not to report any suggestion remembered as familiar until they are encouraged to shift their recall criterion from perceived to familiar. Thus, suggested posthypnotic recall amnesia and cued or instructed recovery are ultimately attributable to the hypnotic deactivation of self-conscious source monitoring.
HYPNOTIC HYPERMNESIA FOR SUBCONSCIOUS PERCEPTS

Fechner (1860/1966) dened subliminal percepts as conscious sensations below the threshold (the limen) for self-consciousness that one is perceiving sensations. Following Fechners lead, Kunzendorf (19841985) and Kunzendorf and Butler (1992) showed that when subliminally perceived sensations bypass self-conscious source monitoring on account of their brevity or their faintness, the sensations are experienced consciously, but are interpreted as possibly imaginednot as denitely perceivedand are memorially confused with mentally imaged sensations. Pushing further, Kunzendorf and McGlinchey-Berroth (19971998) discovered that 45 subjects could recognize subliminally viewed words when instructed to discriminate the recently experienced word (the imaged or perceived word) from an unfamiliar distracter, even though they could not recognize subliminally viewed words when instructed to discriminate the recently perceived word from an unfamiliar distracter. The latter nding leads one to predict that the hypnotized subjectwhose self-conscious source monitoring is too attenuated for him or her to encode the subliminal as not denitely perceivedshould spontaneously encode subliminal sensations as experienced (without any source) and should report those sensations rather than edit them out of his or her reporting. In a test of this prediction, Kunzendorf and Montisanti (19891990) found that, unlike 24 control subjects, 6 out of 8 deeply hypnotized subjects who were given a suggestion to close their eyes upon seeing a cue word did so when the cue word was subliminally presented and, afterwards, remembered consciously experiencing the cue word. Indeed, 2 of these 6 hypnotic virtuosos spontaneously read aloud the cue word as it ashed subliminally! Moreover, the hypnotic attenuation of source monitoring enhances not only the immediate experience of subliminal stimuli presented during hypnosis, as Kunzendorf and Montisanti found, but also the memory of subliminal stimuli experienced prior to hypnosis, as Kunzendorf, Lacourse, and Lynch (19861987) discovered. Specically, the latter authors discovered that prehypnotic pictorial stimuli only 10 milliseconds in duration were recognized at chance levels before and after hypnosis, but, across 85 subjects in Experiment 1 and 60 subjects in Experiment 2, were recognized signicantly better than
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chance during hypnotic testing. Apparently, then, subliminal stimuli that have been experienced previously or just recently and have been encoded as sourceless sensations are, during the hypnotic deactivation of source monitoring and source editing, less likely to be edited out either as not previously perceived or as not just perceived.
HYPNOTIC RECOVERY OF DISSOCIATED MEMORIES AND HYPNOTIC CREATION OF FALSE MEMORIES

The hypnotic deactivation of self-conscious source monitoring, as manifested in the experimental phenomena described earlier, has important implications for the recovered memory versus false memory dispute that has for decades divided psychological researchers, in general, and hypnosis researchers, in particular. On one side of the divide, psychodynamic researchers like David Spiegel and Richard Kluft defend the position that hypnosis facilitates the accurate recovery of dissociated memories (Butler & Spiegel, 1997; Gleaves, Smith, Butler, & Spiegel, 2004; Kluft, 1998; Kluft, 1999). On the other side, cognitively oriented researchers like Elizabeth Loftus and Steven Lynn suggest that hypnosis facilitates the construction and the encoding of false memories (Loftus, 2000; Lynn, Knox, Fassler, Lilienfeld, & Loftus, 2004). On the current account, hypnotic memory recovery and hypnotic memory construction are equally legitimate phenomena, both of which are caused by the same processthe hypnotic deactivation of source monitoring. Accordingly, the current position straddles the divide and holds out the possibility of linking together the two sides. The theoretical assumption that allows such linkage is source-monitoring theorys reinterpretation of amnesia (Kunzendorf & Moran, 19931994; Kunzendorf, 2006). Psychogenic amnesia is classically dened as a process of active repression from consciousness by a Freudian censor or some other psychodynamic mechanisma process that is supported by no scientic evidence. But according to Kunzendorf and Morans (19931994) reinterpretation of amnesia, dissociation-prone individuals respond to trauma by defensively shutting down their self-conscious source monitoringimmediately encoding the trauma not as denitely perceived, but as possibly imagined or possibly dreamed, and later experiencing not total amnesia due to active repression, but source amnesia manifesting sometimes as unbidden traumatic imaginings. In other words, dissociation-prone individuals respond to trauma by hypnotizing themselves, thereby inducing many of the effects discussed in this chapter. In empirical concordance with source-monitoring theorys reinterpretation of amnesia, Kunzendorf and Karpens (19961997) study of 141 college students showed that the real-time deactivation of source monitoring (as measured in Figure 1.1 by positive slope) is statistically associated with scoring high on the Dissociation/Amnesia factor of Bernstein and Putnams
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(1986) Dissociative Experiences Scale. In related research, Heaps and Nashs (1999) study of 55 students and Hyman and Billingss (1998) study of 44 students showed that attenuated memory for source is statistically associated with greater dissociation, as well as greater hypnotizability. And in research with 251 psychiatric outpatients, Kunzendorf, Hulihan, Simpson, Pritykina, and Williams (19971998) found that dissociative diagnoses are associated conjointly with a history of abuse and with a high score on Tellegen and Atkinsons (1974) measure of the hypnotizable personalitya measure which Rader, Kunzendorf, and Carrabino (1996) found to be predictive of unstable source monitoring. Finally, in Kunzendorf and Morans critical experiment (19931994), 148 students who were exposed to Rosenzweigs (1938, 1943) mildly traumatic procedure for making them repress the clue words to unsolvable anagrams were much less adept than the 73 control subjects at recognizing the source of perceived clue words (given imaged distracters), but were not less adept at recognizing the familiarity of perceived clue words (given new distracters). Thus, scientic evidence for deactivated source monitoring is discoverable in the context of post-traumatic amnesia, just as it is discoverable in the context of posthypnotic amnesia and other hypnotic phenomena. Based on the source-monitoring interpretation of amnesia for trauma, then, there is reason to suppose that hypnosis can facilitate recovery from post-traumatic source amnesia, just as it can facilitate recovery from posthypnotic source amnesia. As previously noted, the research subjects posthypnotic tendency to remember hypnotically perceived events as possibly imagined, and to edit them out accordingly, gives way to remembering them as familiar when he or she is put back into a hypnotic state with little source monitoring and less source editing (Kunzendorf & Benoit, 19851986). So, to the extent that a dissociatively disordered patient with post-traumatic source amnesia is experiencing his or her traumatic memories as possibly imagined and is editing them out, hypnotizing such a patient should similarly attenuate both source monitoring and source editing and should give way to the memory of his or her trauma as sourceless but familiar. The problem is that, on account of attenuated source monitoring, the hypnotized patient could generate a spontaneous or suggested hallucination of ctitious trauma that would be encoded and remembered in the same manner as the real trauma. This sobering predicamentthat the recovered memory of a dissociatively disordered patients real trauma is subjectively indistinguishable from the recovered memory of a dissociatively disordered patients confabulated traumashould give pause to extremists on both sides of the recovered memory versus false memory divide. From the standpoint of sourcemonitoring theory, this divide is not theoretically sustainablebecause both sides are substantially correct.
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REFERENCES
Barber, T. X. (1979). Eidetic imagery and the ability to hallucinate at will. Behavioral and Brain Sciences, 2, 596597. Barber, T. X. (1984). Changing unchangeable bodily processes, by (hypnotic) suggestions: A new look at hypnosis, cognitions, imagining, and the mindbody problem. Advances in Mind-Body Medicine, 1(2), 740. Barber, T. X., & Calverley, D. S. (1963). Hypnotic-like suggestibility in children and adults. Journal of Abnormal and Social Psychology, 66, 589597. Barry, H., Jr., Mackinnon, D. W., & Murray, H. A., Jr. (1931). Studies in personality: A. Hypnotizability as a personality trait and its typological relations. Human Biology, 3, 136. Bernstein, E. M., & Putnam, F. (1986). Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174, 727735. Bliss, E. L. (1986). Multiple personality, allied disorders, and hypnosis. New York: Oxford University Press. Butler, L. D., & Spiegel, D. (1997). Trauma and memory. In L. J. Dickstein, M. B. Riba, & J. M. Oldham (Eds.). American Psychiatric Press review of psychiatry, Vol. 16 (pp. II-13II-53). Washington, DC: American Psychiatric Association. Cavell, M. (1987). A response to Otto Kernbergs The dynamic unconscious and the self. In R. Stern (Ed.). Theories of the unconscious and theories of the self (pp. 5863). London: Analytic Press. Ellenberger, H. F. (1970). The discovery of the unconscious. New York: Basic Books. Erickson, M. H., & Rossi, E. L. (1974). Varieties of hypnotic amnesia. American Journal of Clinical Hypnosis, 16, 225239. Fechner, G. T. (1966). Elements of psychophysics (H. E. Adler, Trans.). New York: Holt, Rinehard, and Winston. (Original work published 1860). Gill, M. M. (1948). Spontaneous regression on the induction of hypnosis. Bulletin of the Menninger Clinic, 12, 4148. Gleaves, D. H., Smith, S. M. Butler, L. D., and Spiegel, D. (2004). False and recovered memories in the laboratory and clinic: A review of experimental and clinical evidence. Clinical Psychology: Science and Practice, 11, 328. Gruzelier, J. (2000). Unwanted effects of hypnosis: A review of the evidence and its implications. Contemporary Hypnosis, 17, 163193. Heaps, C., & Nash, M. (1999). Individual differences in imagination ination. Psychonomic Bulletin & Review, 6, 313318. Hilgard, E. R. (1977). Divided consciousness: Multiple controls in human thought and action. New York: John Wiley. Hilgard, E. R. (1981). Imagery and imagination in American psychology. Journal of Mental Imagery, 5(1), 566. Hilgard, E. R., & Cooper, L. M. (1965). Spontaneous and suggested posthypnotic amnesia. International Journal of Clinical and Experimental Hypnosis, 13, 261273. Hull, C. L. (1933). Hypnosis and suggestibility: An experimental approach. New York: Appleton-Century. Hyman, I. E., Jr., & Billings, F. J. (1998). Individual differences and the creation of false childhood memories. Memory, 6, 120. Janet, P. (1901). The mental state of hystericals (C. R. Corson, Trans.). New York: G. P. Putnams Sons.
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Janet, P. (1910). The subconsciousPart 4. In H. M unsterberg, T. Ribot, P. Janet, J. Jastrow, B. Hart, & M. Prince (Eds.). Subconscious phenomena (pp. 5370). Boston: Gorham Press. Kluft, R. P. (1998). Reections on the traumatic memories of dissociative identity disorder patients. In S. J. Lynn & K. M. McConkey (Eds.) Truth in memory (pp. 304322). New York: Guilford Press. Kluft, R. P. (1999). True lies, false truths, and naturalistic raw data: Applying clinical research ndings to the false memory debate. In L. M. Williams & V. L. Banyard (Eds.) Trauma and memory (pp. 319329). Thousand Oaks, CA: Sage Publications. Kunzendorf, R. G. (19841985). Subconscious percepts as unmonitored percepts. Imagination, Cognition, and Personality, 4, 367375. Kunzendorf, R. G. (19851986). Hypnotic hallucinations as unmonitored images. Imagination, Cognition, and Personality, 5, 255270. Kunzendorf, R. G. (19871988). Self-consciousness as the monitoring of cognitive states. Imagination, Cognition, and Personality, 7, 322. Kunzendorf, R. G. (19891990). Posthypnotic amnesia: Dissociation of self-concept or self-consciousness? Imagination, Cognition, and Personality, 9, 321334. Kunzendorf, R. G. (2000). Individual differences in self-conscious source monitoring: Theoretical, experimental, and clinical considerations. In R. G. Kunzendorf & B. Wallace (Eds.) Individual differences in conscious experience (pp. 375390). Amsterdam: John Benjamins. Kunzendorf, R. G. (2006). Universal repression from consciousness versus abnormal dissociation from self-consciousness. Behavioral and Brain Sciences, 29, 523524. Kunzendorf, R. G., Beltz, S. M., Tymowicz, G. (19911992). Self-awareness in autistic subjects and deeply hypnotized subjects: Dissociation of self-concept versus self-consciousness. Imagination, Cognition, and Personality, 11, 129141. Kunzendorf, R. G., & Benoit, M. (19851986). Spontaneous post-hypnotic amnesia and spontaneous post-hypnotic recovery in repressers. Imagination, Cognition, and Personality, 5, 303310. Kunzendorf, R. G., & Boisvert, P. (1996). Presence vs. absence of a hidden observer during total deafness: The hypnotic illusion of subconsciousness vs. the imaginal attenuation of brainstem evoked potentials. In R. G. Kunzendorf, N. P. Spanos, & B. Wallace (Eds.) Hypnosis and imagination (pp. 223234). Amityville, NY: Baywood. Kunzendorf, R. G., & Butler, W. (1992). Apperception revisited: Subliminal monocular perception during the apperception of fused random-dot stereograms. Consciousness and Cognition, 1, 6376. Kunzendorf, R. G., Hulihan, D., Simpson, W., Pritykina, N., & Williams, K. (19971998). Is absorption a diathesis for dissociation in sexually and physically abused patients? Imagination, Cognition, and Personality, 17, 277282. Kunzendorf, R. G., & Karpen, J. (19961997). Dissociative experiences and realitytesting decits in college students. Imagination, Cognition, and Personality, 16, 227238. Kunzendorf, R. G., Lacourse, P., & Lynch, B. (19861987). Hypnotic hypermnesia for subliminally encoded stimuli: State-specic memory for unmonitored sensations. Imagination, Cognition, and Personality, 6, 365377.
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Kunzendorf, R. G., & McGlinchey-Berroth, R. (19971998). The return of the subliminal. Imagination, Cognition, and Personality, 17, 3143. Kunzendorf, R. G., & Montisanti, L. (19891990). Subliminal activation of hypnotic responses: Subconscious realms of mind versus subconscious modes of mentation. Imagination, Cognition, and Personality, 9, 103114. Kunzendorf, R. G., & Moran, C. (19931994). Repression: Active censorship of stressful memories versus source amnesia for self-consciously dissociated memories. Imagination, Cognition, and Personality, 13, 291302. Kunzendorf, R., Treantafel, N., Taing, B., Flete, A., Savoie, S. Agersea, S., & Williams, R. (20062007). The sense of self in lucid dreams: Self as subject vs. self as agent vs. self as object. Imagination, Cognition, and Personality, 26, 303324. Loftus, E. F. (2000). Remembering what never happened. In E. Tulving (Ed.) Memory, consciousness, and the brain: The Tallinn Conference (pp. 106118). New York: Psychology Press. Lynn, S. J., Knox, J. A., Fassler, O., Lilienfeld, S. O., & Loftus, E. F. (2004). Memory, trauma, and dissociation. In G. M. Rosen (Ed.) Posttraumatic stress disorder: Issues and controversies (pp. 163186). New York: John Wiley & Sons. Morgan, A. H., & Hilgard, J. R. (19781979). The Stanford Hypnotic Clinical Scale for adults. American Journal of Clinical Hypnosis, 21, 134147. Prince, M. (1925). Awareness, Consciousness, Co-consciousness and animal intelligence from the point of view of abnormal psychology. Pedagogical Seminary, 32, 166188. Rader, C. M., Kunzendorf, R. G., & Carrabino, C. (1996). The relation of imagery vividness, absorption, reality boundaries and synesthesia to hypnotic states and traits. In R. G. Kunzendorf, N. P. Spanos, & B. Wallace (Eds.) Hypnosis and imagination (pp. 99121). Amityville, NY: Baywood Publishing Company. Rosenzweig, S. (1938). The experimental study of repression. In H. Murray (Ed.) Explorations in personality (pp. 472491). New York: Oxford University Press. Rosenzweig, S. (1943). An experimental study of repression with special reference to need-persistive and ego-defensive reactions to frustration. Journal of Experimental Psychology, 32, 6474. Schneck, J. M. (1950). A note on spontaneous hallucinations during hypnosis. Psychiatric Quarterly, 24, 492494. Tellegen, A., & Atkinson, G. (1974). Openness to absorbing and self-altering experiences (absorption), a trait related to hypnotic susceptibility. Journal of Abnormal Psychology, 83, 268277. Wall, S. G. (1991). Treatment of a deaf multiple personality disorder. American Journal of Clinical Hypnosis, 34, 6869. Weitzenhoffer, A. M., & Hilgard, E. R. (1959). Stanford hypnotic susceptibility scale. Palo Alto, CA: Consulting Psychologists Press. Wilson, S. C., & Barber, T. X. (1982). The fantasy-prone personality: Implications for understanding imagery, hypnosis, and parapsychological phenomena. PSI Research, 1, 94116.
Chapter 2
Dissociaters, Fantasizers, and Their Relation to Hypnotizability

Deirdre Barrett
The most common misconception about hypnosis is that trance, hallucinatory imagery, the will to carry out suggestionsindeed all the phenomena of hypnosisemanate from the hypnotist. In fact, it is the subject who produces these. Very few people cannot be hypnotized at all, but the number is similarly small who can experience the deepest hypnotic phenomenaeyes open hallucinations, negative hallucinations (failing to perceive something right in front of oneself), suggested amnesia and analgesia sufcient for surgery. Hypnotizability is not a present/absent dichotomy but a continuum. Many traits historically were believed to determine hypnotizability such as hysteric personality, passivity, weak will, and need to please. However, these actually bear little or no correlation when subjected to modern research analyses (see Spanos and Barber, 1972, review for a good outline of what doesnt correlate with hypnotizability). This chapter summarizes the cluster of traits that do predict response to hypnotic induction. Through the late twentieth century, studies on what did correlate with hypnotizability began to converge on a traitor group of closely linked traitsthat was essentially like a preexisting disposition to informal trance: vividness of imagination, absorption in imagination, and ability to block out external stimuli. Josephine Hilgard (1970, 1979) found the childhood histories of her deep trance subjects were more likely than less hypnotizable subjects to involve imaginary playmates, parental encouragement of fantasy play, and a hearty appetite for ction. Many high susceptibles also recalled being punished harshly and utilizing their fantasy ability to tune out the punishment while it was occurring or to engage in selfsoothing later. As adults, the high susceptibles were more likely than others to be avid consumers of drama, lm, and ction, to daydream more, and to be more creative.
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Hypnotic susceptibility also correlates with Tellegan and Atkinsons (1974) scale of absorption in imaginative activity, containing questions about vividness of imagery, intensity of emotional involvement in fantasy, tendency to tune out external stimuli when imaging, and experiences of synesthesia. Absorption has also been found by multiple regression analyses to account for factors such as positive attitudes toward hypnosis, which in turn have been linked to hypnotic susceptibility (Spanos & McPeake, 1975). Wilson and Barber (1981, 1983) studied 27 women, representing about the 4 percent most hypnotically responsive, and reported that all but one of them were distinguished by a constellation of fantasy-related characteristics: (1) They spent much of their waking time engaged in fantasy; most said they fantasized at least 90 percent of their waking time simultaneous with carrying on real-life activities. (2) They reported their imagery to be every bit as vivid as their perceptions of reality; 65 percent said this was the case with their eyes open; 35 percent had to close their eyes for the visual component of their imagery to look completely real. (3) They experienced physiologic responses to their images such as needing a blanket to watch Dr. Zhivago on TV in a warm room, vomiting when they (mistakenly) thought they had eaten spoiled food, and being able to reach orgasm through fantasy with no physical stimulation. The majority of their female subjects had experienced physiological symptoms of false pregnancy at least once when they had reason to suspect they might be pregnant. (4) They had unusually early ages for their rst memory, many dating back to infancy. Only one of Wilson and Barbers high hypnotizable subjects did not display this constellation of fantasy-related characteristics, and only a small minority of their low and medium susceptible subjects displayed any of them. Their study used both traditional and nontraditional scales (Barber & Wilson, 1978) in selecting the best hypnotic subjects including the rather idiosyncratic variable of the ability to go into a trance instantly or quickly as one of their criteria. This is not a criterion for any of the most widely used scales of hypnotic susceptibility, which typically give the subjects about fteen minutes of induction before beginning the specic suggestions whose responses will be scored for hypnotizability. Several other studies examined the relationship between fantasy and hypnotizabilityall nding a positive correlation but to varying degrees. Lynn and Rhue (1986) developed a fantasy-proneness scale based closely on the characteristics Wilson and Barber had described. They found that 80 percent of fantasy-prone subjects scored as highly hypnotizable, while only about 35 percent of the non-fantasizers did so. Lynn and Rhue (1988) and Huff and Council (1987) found that high and medium fantasizers did not differ on hypnotic responsiveness, while low fantasizers were less hypnotically susceptible. Spanos (1989) found an even lower degree of correlation between fantasy proneness and hypnotic susceptibility.
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Several dreamlike qualities have been suggested to be more characteristic of daydreams in high hypnotizable subjects than of those in low hypnotizables. In one of my own studies (Barrett, 1990), I found highly hypnotizable subjects to be likelier than medium hypnotizables to have daydreams containing magical or surreal content, abrupt transitions of scenes, sense of wakening with a start at their conclusions, and occasional amnesia for content. Hartmann (1984) has described frequent nightmare sufferers as having thinner boundaries in many senses including those between sleeping and waking. He reported that the concept daymare was a meaningful one to nightmare sufferers only; they reported their fantasies could take on very terrifying turns of content and be difcult for them to terminate. Frequency of nightmares correlates with hypnotic depth (Belicki & Belicki, 1984) as does Hartmanns measure for thinness of boundaries (Barrett, 1989). Other categories of dreams that research has found to correlate with hypnotizability include dreams that the dreamers believed to be precognitive and dreams in which the dreamer experiences himself or herself as outside their body (Zamore & Barrett, 1989). The same study found Tellegans Absorption Scale to correlate with dream recall, ability to dream on a chosen topic, reports of conict resolution in dreams, creative ideas occurring in dreams, amount of color in dreams, pleasantness of dreams, bizarreness of dreams, ying dreams, and precognitive dreams. In two further studies that I describe in detail in this chapter, I examined to what extent other highly hypnotizable people resembled Wilson and Barbers fantasizers and what traits might characterize deep trance subjects who were not extreme fantasizers. As being able to enter a trance instantly was the most idiosyncratic of Barber and Wilsons criteria, it was hypothesized that this might distinguish fantasizers from other deep trance subjects. In addition to exploring the replicability of Wilson and Barbers ndings about fantasy activity among high hypnotizables, other points of interest were characteristics of hypnotic experience and how these interact with a persons waking fantasy style. For the rst of these studies, 34 extremely hypnotizable subjects were selected from among approximately 1,200 undergraduate subject volunteers who had been hypnotized in the course of other research projects and demonstrations in classroom and dormitory settings over a several year period. They were selected using two standard scales: The Harvard Group Scale of Hypnotic Susceptibility, Form A (Shor & Orne, 1962); and The Stanford Scale of Hypnotic Susceptibility, Form C (Weitzenhoffer & Hilgard, 1962). All subjects scored either 11 or 12 on both scales. This constituted a very similar criterion for hypnotic susceptibility to Wilson and Barbers with the exception of not requiring instant or rapid hypnotic induction. Subjects were hypnotized a total of three to four times, depending on what the protocol in the screening project had been. Their hypnotic experiences included both ones in which an amnesia suggestion and removal
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cue were given and ones in which they were not, age regression suggestions, a hypnotic hallucination of a candle that they were asked to blow out, a post-hypnotic hallucination of a person they knew arriving at the experimental room to talk with them, and an attempted instant re-hypnosis followed by several measures of trance depth. For that rst study, these high-hypnotizable subjects were interviewed from two and a half to four hours and were asked about the fantasy-related phenomena that Wilson and Barber and J. Hilgard reported. They were also asked about the dreamlike qualities of surrealism, abrupt transitions within daydreams, startling out of them, and occasional amnesia for content that my earlier research had found (Barrett 1979, 1990). They were then asked about the daymare phenomena that Hartmann (1984) found among nightmare sufferers. They were also asked about how real and/or involuntary the hypnotic phenomena they experienced felt and about how much hypnosis was like other experiences.
FANTASIZERS
The rst subgroup of deep trance subjects was selected by their ability to enter trance instantly, since Wilson and Barber had used this as a criteria
TABLE 2.1 Waking Imagery and Hypnotic Characteristics of Fantasizers Compared with Dissociaters Fantasizers (12 Women, 7 Men) Characteristic
Waking image less than real Daydream amnesia Earliest memory > 3 Absorption score low Need time to reach deep trance Spontaneous amnesia for trance details Suggested amnesia total Hypnosis very different from other experiences Field score high
*p < .02 **p < .001
Dissociaters (10 Women, 5 Men) Yes

15 14 11 7 15 9 15 15
Yes
3 3 0 0 0 0 5 2
No
16 16 19 19 19 1 14 17
No
0 1 4 8 0 6 0 0
Chi Square df = 1 X=
20.05** 15.22** 14.44** 6.19** 30.06** 11.61** 15.06** 22.99**
11
15
6.08*
19
for the group they characterized. These 19 people, 7 male and 12 female, also had a number of other characteristics that distinguished them from subjects who did not achieve their deep trances immediately. Most of these characteristics clustered around vividness of fantasy processes, so they are referred to for the rest of this chapter by Wilson and Barbers term fantasizers.
Vivid Imagery and Fantasies

Fantasizers scored extremely high on Tellegen and Atkinsons Absorption Scale: 3237 of 37 items, with a mean of 34. During their interviews, they described ve related characteristics of fantasy-proneness that Wilson and Barber found most characteristic of their group: extensive history of childhood fantasy play, majority of adult time devoted to fantasizing, hallucinatory vividness of imagery, physiological effects from their imaging, and a variety of psychic experiences. They all described rich fantasy life as children. They had at least one, most many, imaginary companions. These included a real playmate who had moved out of state, a princess, an entire herd of wild horses, and space aliens among others. The fantasizers greatly enjoyed stories, movies, and drama; they tended to prolong their experience of these by incorporating them into their fantasy lives, providing another source of imaginary companions. For example, one subject described that, after seeing the movie Camelot, he had spent two years engaging daily in an elaborate scenario in which he was the son of Arthur and Guinevere and commanded the kings court. Periodically he would appoint new knights of his own invention to the Roundtable. His real-life brother was cast in the role of Mordred, but all the other characters were either from the lm, or completely from his own imagination. The fantasizers described these imaginary companions as every bit as vivid as real persons. In addition to ongoing fantasies, these subjects described a wide variety of brief fantasy as children, such as watching a friend blow soap bubbles and suddenly developing a fantasy about there being a fairy that lived inside one of the bubbles. Seventeen of them found this changing of realities at will so compelling that before encountering its formal philosophical discussions they had formulated their own versions of the famous musings of Chuang-tzu: One night, I dreamed I was a buttery, uttering here and there, content with my lot. Suddenly I awoke and was Chuang-tzu again. Who am I in reality: A buttery dreaming that I am Chuang-tzu, or Chuang-tzu dreaming that I was a buttery? (trans. 1970) Parents of fteen of the fantasizers were remembered as explicitly encouraging their fantasy. On a rainy day when one boy was bored, his mother would begin play suggestions with, You could pretend to be . . . Another said her parents formula response to her requests for expensive toys was, You could take this . . . (household object) and with a little
20
imagination, it would look just like . . . (that $200-whatever-Susie-justgot). And she reported, this worked for mealthough Susie couldnt quite always see it. One mother very specically trained hypnotic ability by reading trance exercises about age regression, being an animal, speeding up time, and so forth to her son from the book Mind Games (Masters & Houston, 1972). Their adult fantasy continued to occupy the majority of their waking hours. They all fantasized throughout the performance of routine tasks and during any unoccupied time. Six of them said they did not fantasize or daydream when dealing with the most demanding tasks but still continued to have vivid images in response to any sensory words. The other thirteen said they continued to have elaborate ongoing fantasy scenarios. Some experienced them superimposed and intertwined with the ongoing tasks: Im listening to my bosss directions carefully, but Im seeing the Saturday Night Live character Mockman next to him mocking all his gestures. Others experienced the fantasies as simultaneous or separate, happening on a side state, as one subject described it: somehow Im seeing the real world and experiencing my fantasy one at the same time. Fantasizers also continued to have momentary vivid fantasies inspired by ongoing events. One young man had come to the interview directly from an archery class where he described that as he shot arrows at a target and watched others do so, he would briey experience himself as the arrow being hurled by the force of the string through the air and felt himself piercing the berboard target. Another described that while passing up chocolate cake at lunch because of a diet, she momentarily became a microbe burrowing through the cake, tasting and smelling it as she devoured it, and feeling it squish around her body. She reported experiencing a sense of satiation with this fantasy indulgence. All of these subjects described some of the dreamlike, surreal content, sudden transitions, and surprise that two earlier studies had reported for deep trance subjects daydreams (Barrett, 1979, 1990). When asked whether they startled out of daydreams that they could not recall, four said they experienced this occasionally, although usually they had a tip of the tongue feeling about the fantasy and its memory would come back to them shortly. Seven of them reported that they occasionally had frightening content that seemed not to be under their control as in the daymares reported by Hartmanns nightmare sufferers. Like Wilson and Barbers subjects, they experienced physical effects from their imagery. Seven of the twelve female fantasizers had experienced false pregnancy symptoms. Even more of Wilsons subjects had experienced some such symptoms and full-blown cases (so to speak) presenting for treatment have been linked to high hypnotic susceptibility (Barrett, 1989). All of the fantasizers, male and female, described sometimes experiencing physical sensations to visual stimuli, such as shivering when seeing a painting of the
21
Alps; feeling hot, dry, and impulsively getting something to drink in response to looking at desert photos; and getting nauseated from motion sickness at a lm set on a tossing submarine. Ten of them said they tried to avoid either ctional depictions or real newsreel footage of violence and injuries because they experienced pain akin to real injuries. For four of them, this might precipitate ill feelings for hours or days. One such subject who had long ago learned to avoid television news, described several weeks previously that she had been watching a nationally televised swim meet in which a diver had unexpectedly been injured. As she described the scene, she clutched herself tightly, grimaced as if in pain, tears came to her eyes, and she described this as minimal compared to her reaction when watching the scene that had left her shaken and physically aching for hours. Fourteen of the fantasizers could experience orgasm through fantasy in the absence of any physical stimulation, and all of them reported frequent, vivid, and varied sexual fantasies. Although most of them tended to have fairly active and varied sex lives, all of them had fantasies of many more variations than they actually engaged in. Seventeen of this group were exclusively heterosexual, and two males were predominantly homosexual with a bit of heterosexual experience. However, all of the women and two of the heterosexual men mentioned homosexual fantasies. Other fantasy partners included animals, children, statues, and a variety of suggestively shaped inanimate objects. Wilson and Barber reported that their subjects often obtained greater enjoyment from their fantasized sex than their actual sexual relationships. When our group was queried, they said this was not a meaningful comparison as their two categories of sexual experience were fantasy only versus fantasy superimposed on real activity, of which the latter was often preferred. Real partners were heard to utter imaginary sexy comments, were dressed in hallucinatory erotic attire, had movie stars faces (and occasionally other parts) superimposed onto theirs, were joined by additional imaginary partners, and were transformed into science-ction creatures and circus animals. Only two subjects (one male, one female) said they tried not to fantasize during real sex, and both of them said they often failed. Fantasizers all had some experiences that they considered psychic: 14 had premonitions about events that were going to happen, 12 said that they could sometimes sense what signicant others were thinking or feeling at a distance, 9 had dreams that came true, 13 had out-of-body experiences, and 8 had seen ghosts. Fifteen rmly believed these experiences were real paranormal phenomena, and the remaining four said they were undecided about their reality.
Early Memories and Parental Discipline

The earliest memories of the fantasizers were all identied as being before the age of three, and before the age of two for eleven subjects. For the purposes of this study, subjectively believed age and detail of rst
22
memories were compared. This study was not set up to denitely check whether the ages were accurate or whether indeed the memory was directly recalled rather than fantasized from stories told by parents. For randomly selected college students, the average of subjectively recalled rst memory is about three and a half and two to six is the usual range (Barrett, 1980, 1983). The youngest memory that had a specic time estimate was of age eight months. This subject remembered two scenes: one in which he was being carried by his father down a hospital corridor and another in which he was lying on his back with one green-gowned man prodding his stomach while another pressed a plastic mask over his nose and mouth. He remembered excruciating pain in both scenes. He was quite convinced that these were memories of an appendectomy he had undergone at eight months, and that he had remembered details of this, which surprised his parents the rst time they discussed it with him. More typically, the incidents were too minor to be remembered by parents or to be tied to an exact date but sounded like those of a preverbal or early verbal childfor example, one incident that the subject estimated as before age two: I remember being in my crib, which was pushed against a wall with a window above it. I was looking up at the window and it must have been raining outside because water drops were running down the outside of it. I was fascinated because Id never noticed the window doing this before. This was a stage when I would point at things and ask whah? and my mother would say the name for it. I pointed at the water drops and said shah? and my mother said window. I already knew this word so I frustratedly pointed again at the glass with the drops on the outside and repeated whah? I guess she thought I meant the pane of glassor maybe she even said rain and I misunderstoodbecause what I heard her say was pain. I thought I recognized the word for when I hurt myself and I realized that the drops were like the tears that ran down my face at those times. I watched amazed that the window could cry with pain like me. I think it was a long time before I corrected this impression and came to connect the drops with the rain that fell when I was outside and that could also run down the windows pane. Several of this groups earliest memories were of surreal events, most likely memories of fantasies or dreams such as this one: I remember waking up in the middle of the night. In the air over me there were these big neon letters of the alphabet, maybe eight inches tall dancing around. They looked so wonderful. I recognized an A and a D because I knew the rst few letters, but most of them were shapes I didnt know from later in the alphabet. They seemed to be oating into my room from the hall. I got out of bed and went into the hall where there were more neon letters in a line coming from my parents room. I followed the line into my parents bedroom. They were coming out of the drain on the oor; one by one they would pop up out of the drain and dance out of the room. I watched them
23
there for a while and then I went back to my room and watched them in bed until I fell asleep again. I remember thinking I must tell my parents about this in the morning, but I dont know if I did. I must have been about to turn three because I could say the alphabet by three years old. When asked about how their parents had disciplined them, eleven of the subjects said that their parent had disciplined them solely by some combination of two strategies: (1) rewards or withholding of rewards, and (2) reasoning with them, often emphasizing empathy: One time Id gotten in a ght at nursery school with another little girl because there was this doll there that was her favorite or regular toy to play with. Id gotten it rst that day; she tried to take it away from me and I pushed her down. The teacher called my mother and told her about it. Mother told me I should think about what she had felt like when she fell down, and it became like I really was her hitting the oor scraping one knee, and crying. I could also feel her desperation and thinking it really was her doll (even though it was the schools); she had named it and everything. After that I wouldnt have done that again. Eight of this group reported discipline that they experienced as harsh such as spankings, being locked in their rooms for extended periods, and verbal belittling. They typically used fantasy and imaginary companions to restore self-esteem after these incidents. Wilson and Barber (1978) reported that their subjects fantasies in these situations did not revolve around retaliation except indirectly toward other objects. In the present sample, more than half of these fantasies were of retaliation against parents, albeit tempered by leniency on the part of the offended child. One child fantasized producing electric shocks to repel spankings. More typically, some other powerful being intervened against the parent sometimes because of punishing the child, sometimes for some other reason. Parents were kidnapped by aliens, chained in King Arthurs dungeon, arrested by the police, or sent back to grade school. In most cases, however, the next step was that the child intervened on the parents behalf and the parents were released feeling repentant and/or indebted.
Fantasizers Experience of Hypnosis

Despite being such deep trance subjects, these 19 people scored only just above average (mean 18) on the Field Inventory and very low on the subgroup of Field Items that reported surprise at hypnotic phenomena. Nine of the 19 described hypnosis as not different than what they experienced in their waking fantasy activity, and the remaining ten found hypnosis mildly different by being somewhat more intense in some aspect but still similar to their other imagery experiences. These differences included hypnotic imagery being more consistently hallucinatory for six subjects, and two saying they felt much more subjective time had gone by in
24
hypnosis than it would if they were fantasizing for a similar amount of real time. One drama major said, Hypnosis is a lot like what I do with method acting only you can get more into it. When Im doing an acting exercise, I can only get so far into the experience because some part of me has to keep watching that I dont become the character so much that Id just walk out of the class if he was mad, but with the hypnosis you dont have to watch that sort of thing at all. During the age regression I could leave my adult self behind completely. These subjects were all quite aware that what they experienced during hypnosis were phenomena they produced themselves. None of them conceptualized it at all in terms of something the hypnotist was doing to them. Hypnosis was a lot like what I do when Im daydreaming or experiencing something from the past except its even easier because your voice conjures up the images automatically, said one subject. The fantasizers generally seemed proud of their ability at hypnosis. All of them enjoyed the hypnotic experiences, although several remarked that the lengthy interviews about fantasy and memory were more personally signicant to them. Seeing the things you described in hypnosis is nice but pretty much like my daydreaming all the time, but talking about what my daydreams are like and how big a part of my life they are isnt something Ive ever gotten to do before in this much detail. Fantasizers experienced hypnotic amnesia only when it was specically suggestedand not always absolutely then. Six of the eight fantasizers scoring 11 rather than 12 on the HGSHS-A had the amnesia suggestion as their only failed item. Some had partial recall although they had formally passed it. Others described that it seemed not as completely real an effect as the other hypnotic phenomena, citing working to keep items out of consciousness or being very aware they could counter the suggestion if they chose. The fantasizers were also likely to know hypnotic hallucinations were not real without needing to be told this. When asked how they were sure they knew there had not been a real candle lit in the room for instance, fourteen of them cited some cognitive strategy that they had long practiced for differentiating the hallucinations of their waking fantasies from reality. Nine of them also usually retained the knowledge that the hypnotist had given verbal suggestions to hallucinate what they then experienced, which made the deduction simple. In response to the HGSHS-A suggestion about hallucinating a y during his rst group induction, one subject had the following experience: When you told us there was a y buzzing around us, one appeared circling my head. Then I realized you had suggested it to everyone, and I saw and heard fty of them circling around each student in unison. At the same time, the rock group Kansas song The Gnat Attack began to play as if there was a stereo in the room. I thought all this was delightful and very funny. As soon as you said we could shoo the ies away, the music stopped too.
25
This group showed a moderate degree of muscular relaxation during hypnosis akin to what an average person might look like awake but at rest. There was not a dramatic loss of muscle tone, all of them remained seated in their chair without problem, and most shifted position occasionally during the trance. They only moved easily when asked to do so for candle-blowing and for tasks while age regressed. When asked to, they also talked readily in trance, some of them with a bit softer or more monotone voice than awake, but no one in the group was difcult to understand. All subjects in this subgroup woke from the trance immediately alert. Some began talking about their trance experience before the experimenter asked questions. The most immediate response upon awakening from hypnosis for the fantasizers was a big smile.
DISSOCIATION GROUP
The other subgroup of fteen subjects was selected for scoring as very highly hypnotizable on standard measures of hypnosis (scores of 11 or 12 on the HGSHS-A and SSHS-C) but not meeting Wilson and Barbers additional criteria of being able to enter a trance instantly. They scored about average (range 1633, mean 26) on the Absorption Scale and did not display many of Wilson and Barbers fantasizers characteristics. In fact, the most distinctive quality to this subgroups descriptions of fantasizing was the amnesia that had been noted for some subjects in a previous study (Barrett, 1989). The majority of them said their fantasizing was often characterized by inability to remember some or all of the content. Six of them said the only reason they knew they just daydream was that they were often startled to be spoken to, or otherwise have their attention summoned to the real world, with a sense that their mind had been occupied elsewhere. The reports of this group were quite dissimilar to most characterizations of fantasy proneness and high absorption. They had so much more in common with the dissociative phenomena emphasized in Ernest Hilgards (1977) neodissociation theory of hypnotic susceptibility that this subgroup is referred to as the dissociaters for the remainder of this discussion.
Fantasies, Early Memory, and Parental Discipline

The fantasies that the dissociaters did recall from both childhood and the present were more mundane than the other subgroups. They tended to be pleasant, realistic scenarios about events they would like to happen in the near future. None of them said these fantasies were as real in their sensory imagery as their perception of reality. Dissociaters were somewhat more like the fantasizers in how they reacted to external drama. They described that as both children and adults, they could become so absorbed in books, lms, plays, and stories being told to them that they could lose track of time, surroundings, or their usual sense of identity. Their lack of
26
equal vividness in self-directed fantasy seemed to stem partly from an external locus of control. It just did not seem to them that vivid images could be their own production, and so they tended to experience them mainly in response to others lead as in hypnosis or in listening to stories. Sometimes this absorption in external stimuli was intertwined with amnestic phenomena; several subjects commented that they thought they got very caught up in horror movies, but then could not remember their content shortly afterwards. One of the most dramatic incidents of amnesia was recounted in answer to a routine inquiry of one of the dissociaters as to whether she had ever been hypnotized before. She answered maybe and described the following experience: One time, my boyfriend and I were watching a police show on TV. There was this scene where they were going to use hypnosis with a witness. The detective began to swing a watch and tell the witness that he was going to go into deep sleep. I dont remember anything after that until I started awake and said what happened about twenty minutes later. My boyfriend says the show continued with questions during the hypnosis, several scenes of what other characters were doing, commercial break, and then came back to the scene where the detective was waking the witness up. But I dont remember any of that. I guess I was hypnotized by the watch. Other amnestic experiences seemed to be triggered by more personal associations. One suggestion subjects were given in hypnosis was that they would see a book . . . with something important for you in it. You may take it down from the bookshelf and open it. One woman reported the book she saw was Sybil. She had opened it in the trance but couldnt recall anything she had read then. She also said that in reality, she had bought the book two years before and was sure she had read it but could not remember anything about it. When asked if she could produce even a single sentence about the main topic of the book, she insisted she had no idea. The obvious diagnostic questions suggested by this will be discussed later in the section on dissociative disorders. The way in which the dissociaters appeared most like the fantasizers was in the frequency of their dramatic psychophysiologic reactions. Five of the ten women had experienced symptoms of false pregnancy. They reported getting cold watching arctic scenes and becoming nauseated after eating supposedly spoiled food that they later learned was ne. One developed a rash after being told by a prankster friend that a vine she had handled was poison ivy. Three of them also reported feeling pain when witnessing others traumas. This might have been true of more of them, as six remarked that they often could not remember moments around witnessing injuries. After a swine u vaccination (back in the scare of the 1970s), one subject had a hysterical conversion-like episode of ascending paralysis that mimicked Guillain-Barr e syndrome, but which had remitted after a few minutes of reassurance from her physician about the safety of the vaccine.
27
None of this group said they achieved orgasms solely from fantasy. All of them reported sexual fantasies, but six subjects remarked that they sometimes couldnt remember them afterward. The interview did not specically ask for examples of sexual fantasies. The fantasizer subgroup, as already described, volunteered voluminous content in the course of answering questions about frequency and vividness of these fantasies. The dissociaters rarely volunteered much detail, so less characterization was possible of their fantasy content. Most of the ones that were mentioned were mundane. The few who volunteered details consistently seemed to do so in the context of wanting reassurance about their normality. One subject was worried that she fantasized about anyone besides her boyfriend, and a male was bothered by thoughts of his girlfriends attractive mother. A woman who in her early teens had been a victim of sexual abuse, now in her early twenties, found herself fantasizing about the abuse in an arousing manner during masturbation and intercourse. She seemed reassured to hear that was not uncommon among abuse and rape victims and that it did not invalidate her perception that the sexual contact had been predominantly frightening and unwanted at the time it occurred. Childhood sexual abuse may have been a common event as will be discussed later in the section on abuse. Fewer subjects in this subgroup believed they had psychic experiences, and for nine of the eleven who did so, these experiences were conned solely to altered states of consciousnessdreams most commonly for several of them, automatic writing for two, and trance-like s eance phenomena for two. One subject reported that the spirit of her father, who had died when she was nine, regularly appeared to her in dreams dressed in the uniform in which he was buried and gave her advice on current problems. During hypnosis, when she was told that she could open her eyes and see someone that you know and like seated across from her, she had opened her eyes and seen her father. She felt certain that her nocturnal visitations were real but was not certain whether the hypnotic hallucination was her fathers spirit or not. The earliest memories of the dissociaters were later than average (mean 5 and for six subjects between the ages of 6 and 8). This was the opposite trend away from the general population mean than for the fantasizers. When asked about parental discipline, seven of the fantasizers recalled spankings and other corporal punishment, and 5 more of the others said they could not recall. Abuse and other clearly traumatic incidents will be discussed further in a subsequent section.
Dissociaters Experience of Hypnosis

This subgroup scored very high on the Field questionnaire, mean 33, usually answering true to all six items that express surprise and amazement at hypnotic phenomena. They were much likelier to conceptualize hypnotic phenomena as due to some amazing talent of the hypnotist rather than as
28
produced by themselves. They were resistant to hearing that it was something within their control, and in some sense this may really be less true for this group, for them it is less consciously controlled. Six of them asked many questions seeking reassurance that their hypnotic susceptibility was normal. Two described hypnosis as partially unpleasant, not in terms of any specic content being negative but they did not like the concept that they were hallucinating. All described hypnosis as the more striking and interesting part of the experimental process; much of the interview about fantasy and imagery was not of great personal relevance. These subjects frequently experienced spontaneous amnesia for hypnotic events. Amnesia was consistent and total for them whenever it was suggested, and it sometimes persisted even once removal cues had been given. Half of them experienced some degree of spontaneous amnesia for trance events when it had not been suggested. Dissociaters were often surprised at some of their hypnotic experiences, especially hypnotic hallucinations. They were much likelier than fantasizers to believe their hypnotic hallucinations were real until told otherwise. The few who realized they were not real distinguished them on the basis of their implausibility rather than by any other method for telling hallucinations from reality. They almost never remembered the verbal suggestions for the hallucinations, and when they did, still ignored the association with their perceptions. One subject remained convinced that, coincidentally at the moment that I suggested the HGSHS-A y hallucination to a roomful of subjects, a real y happened to begin buzzing around him. The dissociaters exhibited an extreme loss of muscle tone during trance, often slumping; two needed to be propped up so they did not fall out of their chairs. When asked to move or speak during the trance, their voices and movements were markedly subdued; four were partially inaudible. Six reported that their trance had to lighten for them to be able to move or speak at all. When they were instructed to awaken, they would usually open their eyes, but most blinked and looked confused at rst. Four asked disoriented questions such as What happened? or Where was I? They appeared to need almost to struggle to talk, and were slow to begin to answer questions. All these behaviors were transient, and all subjects were fully alert within a couple of minutes.
FOLLOW-UP: COMPARISON WITH HIDDEN OBSERVER DISTINCTION, DREAM PHENOMENA, AND DISSOCIATIVE DISORDERS
In a later follow-up study (Barrett, 1996) with 24 subjects who were still geographically available (15 women, 9 men), they were hypnotized again, given suggestions of hypnotic deafness before the rst four lines of a recorded nursery rhyme were played at a clear volume, and then tested for the Hilgards hidden observer phenomena (Hilgard, 1979). These 24 were then
29
interviewed with detailed queries about childhood trauma, dream content, and diagnostic questions for dissociative disorders. Chi square analyses were employed where expected cell size allowed. For smaller subsamples, signicance was computed by Fishers exact probability test. All of both groups still tested as highly hypnotizable. Two of the dissociater group reported more-consciously controlled and better-recalled imagery than they had at the time of the rst study. However, even these two did not show the fantasizer trait of instant-trance-entry and no one in either group had totally shifted group characteristics. The hidden observer phenomenon was slightly more common in dissociaters (see Table 2.2). Seven of nine dissociaters manifested a hidden observer, while seven of fteen fantasizers did What was much more clearly pronounced was the difference in content of hidden observers for dissociaters versus fantasizers. All dissociaters who manifested a hidden observer gave accurate descriptions of the stimulus. Four recited it awlessly, two rst named it or said nursery rhyme, and when asked for the complete rhyme recited it with only minor mistakes. Three dissociaters gave hidden observer responses in a at monotone similar to all other requested vocalizations they had ever made in trance. Two spoke in a more childlike voice than usually characterized these waking or trance vocalizations. The nal dissociater with a hidden observer responded quite dramatically to the suggestion: opening her eyes (not suggested), saying Hi, I think Im who you want to talk to in a much more aggressive demeanor than the subjects usual waking or hypnotized style, reciting the rhyme in a sarcastic tone, glaring for about 15 seconds, and then closing her eyes again. This response will be discussed later in the section on dissociative diagnoses. None of the 6 dissociaters remembered the rhyme or their hidden observer responses upon awakening, nor did the 3 who failed to exhibit a hidden observer recall the rhyme upon awakening.
TABLE 2.2 Hidden Observers, Nightmares, and Trauma of Fantasizers Compared with Dissociaters Fantasizers (9 Women, 6 Men) Characteristic
Some hidden observer response Hidden observer with detailed accuracy Recurring nightmares Trauma known Trauma known or suspected
Yes
7 7 0 2 2
No
8 8 15 13 13
Dissociaters (6 Women, 3 Men) Fischer Exact Probability Yes No Test p <

7 4 6 5 9 2 5 3 4 0 .10 .85 .005 .05 .005
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The four fantasizers who gave fairly realistic accounts also describe an intentional strategy of not listening. A typical response was, It was the rhyme Twinkle, Twinkle, Little Star. The voice was there but I kept telling myself I didnt hear it. Three fantasizers said something additional in response to hidden observer suggestions that did not contain the majority of the poem. All of these contained some confabulated, visual, or dream-like content either related or unrelated to the poem. One contained a star in the night sky, one heard a nursery rhyme that they could not name or recite while experiencing apparently unrelated rich visual imagery, and the third heard . . . something about diamonds; I know I could have heard more but I tried not to listen. After awakening from hypnosis, all seven of the fantasizers had some memory of the rhyme and their hidden observer responses. They appeared integrated with the hidden observer identity although they could also still recall the point in time at which they had been unable to recall the stimulus. For them, the hidden observer seemed to have much the same effect as a simple amnesia removal cue.
Dreams
When asked to recount the most recent dream that they could recall clearly, 11 of the 15 fantasizers gave a dream from the previous night. All others were from the previous four days. They were typically lengthy, fantastic accounts. There was one out-of-body account, one lucid dream, and a false awakening. All of these are very rare categories, albeit ones that I had found to correlate with hypnotizability in another study on a different sample (Zamore & Barrett, 1986). Three of the dreams were sexual (another rare category), most were pleasant, and none were nightmares. When asked if they had nightmares, 4 fantasizers reported that they had at least one a month. None of them reported any recurring nightmares. In contrast, when dissociaters were asked to recount the most recent dream they could recall, many had trouble thinking of one. Although two recalled dreams from the previous night, several dated the last dream they could recall as years before. One gave a recurring nightmare that had happened only a few times as the only dream she believed she had ever recalled in her lifetime. Two more dissociaters gave a recurring nightmare as their most recent well-recalled dream, and 3 others reported they experienced recurring nightmares at least once a month. All of these subjects also reported nonrecurring nightmares, and one additional dissociater reported nonrecurring nightmares only. Three reported sexual content in their most recent dreams, but these were all within the context of nightmares or other unpleasant dreams. Their nightmares had even more obviously disturbing
31
content than those of the fantasizers including things such as suffocating, the dreamers body coming apart, and horribly injured babies and children.
Trauma Histories
None of the 19 fantasizers reported any severe beatings or sexual abuse by immediate family or caretakers. Two female subjects in this group did report abusive sexual behavior on the part of other adults, in one case a social acquaintance of the family, and in the other, a stranger. Fantasizers in this study actually reported less physical and sexual abuse than the approximately 20 to 25 percent rate reported in general college populations (NIJ & CDC, 1998). Their higher-than-average recollection for early childhood events would make it unlikely they are underreporting, although this nding is inconsistent with Lynn and Rhues nding that a history of abuse correlates with their fantasy-proneness questionnaire (Lynn & Rhue, 1988). Four of the 15 dissociaters initially remembered abusive behavior. For three of them this involved physical violence, and for two of them it involved sexual abuse. In addition to these 4 with direct memories, 2 subjects said they didnt remember but had been told that they had been battered as children (in one case, an older sibling remembered witnessing this; in another case, a social worker had monitored the parents following a teachers report of abuse). One additional subject in the group described a severe history of early childhood multiple fractures and burns for which his parents presented improbable explanations to othersand which he did not recall the origins of. Another subject experienced nausea and vomiting whenever anyone touched a certain portion of her thigh. Six of the remaining 7 subjects reported some signs such as the recurring nightmares outlined in the previous section and the lack of recollections before the ages of 7 or 8 described earlier. These signs have been associated with an increased likelihood of childhood abuse (Belicki & Cuddy, 1996; Barrett & Fine, 1980). Two of the dissociaters reported regaining abuse memories in the four years between the initial and follow-up interviews, which further suggests the rate for this group may approach 100 percent. In addition to this suggestion that between 6 and 14 of the dissociaters had been abused by parents, 3 of them reported other major traumas in childhoodin one case a very painful and extended medical condition, and for 2 the deaths of a parent when they were under 10.
Dissociative Diagnoses and Post-Traumatic Stress Disorder

No fantasizer came close to meeting DSM3-R (revised) Dissociative Disorder or Post-Traumatic Stress Disorder, although 100 percent of the fantasizers t what would constitute Dissociative Disorder Not Otherwise Specied: trance states, i.e. altered states of consciousness with markedly
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diminished or selectively focused responsiveness to environmental stimuli (APA 1987, p. 277). However, DSM denes mental disorders to be diagnosed as A psychological syndrome with present distress or disability . . . or increased risk of suffering (APA 1987, p. xxii). The fantasizers do not appear to be distressed by their ability for selectively focused responsiveness. Although the interview did not include all diagnostic questions for every other possible disorder less obviously related to content of the study, fantasizers did not obviously meet any other diagnoses. Two fantasizers did demonstrate some bipolar tendencies, and one some schizotypal ones; however, in no case did they exhibit enough of the criteria and/or the severity of distress or impairment necessary for the formal diagnosis. Overall, the fantasizers appeared to be a mentally healthy group of people. Four dissociaters met Dissociative Disorder NOS criteria, one with features of multiple personalitythe person whose hidden observer exhibited such autonomy and distinctness had other brief amnestic episodes of speaking as a very different persona. A fth dissociater met formal criteria for Psychogenic Amnesia. Again, most of the remaining dissociaters could be seen as meeting the symptom criteria for this disorder by their daydream amnesia alone except that they did not appear to experience distress or impairment from their amnestic tendencies. Even the 5 dissociaters with enough distress to qualify for dissociative diagnoses were toward the mild level of impairment from these disorders. Only one of them had sought long-term psychotherapy or therapy directed at trauma and dissociative symptoms. One of the other four with diagnoses and two others in this study have married abusive spouses, been unable to hold a job, made serious suicide attempts, or been hospitalized in psychiatric settings. However, all these events are common for other people with a serious trauma history and/or dissociative disorders.
CONCLUSIONS
In summary, there seem to be two distinct subgroups of people who are highly hypnotizable. Wilson and Barbers concept of the majority of highly hypnotizable people having vivid fantasy and imagery ability is sound. However, it appears there is another, somewhat similar group characterized by amnesia and dissociative phenomena, who do not achieve trance as rapidly but are nevertheless capable of eventually reaching as deep a trance as do fantasizers. This distinction does not seem to be synonymous with the one between hypnotic subjects who manifest Hilgards hidden observer phenomena versus those who do not. Although the two dissociaters who developed some fantasizer-type imagery suggest these people may have some of the same fantasy ability masked by amnesia, for the most part these seem to be remarkably separate groups. The present author and other clinicians have occasionally seen
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patients who seem like hybrids of the two typeswith dissociative disorders but with vivid voluntary imagery (Schatzman, 1980; Barrett 1998) however, this seems to be rare. It seems most accurate to think of high hypnotizables as composed of two groups whose life histories have specialized them primarily toward one of the major phenomena: hallucinatory imagery or dissociative abilities.
REFERENCES
American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed. RevDSM-R.), Washington, DC. Barber, T. X., & Wilson, S. C. (1978). The Barber Suggestibility Scale and the Creative Imagination Scale: Experimental and clinical applications. American Journal of Clinical Hypnosis, 21, 84108. Barrett, D. L. (1979). The hypnotic dream: Its content in comparison to nocturnal dreams and waking fantasy. Journal of Abnormal Psychology, 88, 584591. Barrett, D. L. (1980). The rst memory as a predictor of personality traits. Journal of Individual Psychology, 36, 136149. Barrett, D. L. (1983). Early recollections as predictors of self-disclosure and interpersonal style. Journal of Individual Psychology, 39, 9298. Barrett, D. L. (1988). Trance-related pseudocyesis in a male. International Journal of Clinical and Experimental Hypnosis, 36, 256261. Barrett, D. L. (1989). Thick vs. thin boundaries: A concept related to hypnotic susceptibility. Paper presented at Eastern Psychological Association Meeting, Boston, MA, March. Barrett, D. L. (1990). Daydreams of deep trance subjects: They strikingly resemble night time dreams. Paper presented at APA, Div. 30. August. Barrett, D. L. (1991). Deep trance subjects: A schema of two distinct subgroups. In R. Kunzendorf (Ed.) Imagery: Recent Developments (101112). New York: Plenum Press. Barrett, D. L. (1992). Fantasizers and dissociaters: An empirically based schema of two types of deep trance subjects. Psychological Reports, 71, 10111014. Barrett, D. L. (1996). Fantasizers and dissociaters: Two types of high hypnotizables, Two imagery styles. In R. Kusendorf, N. Spanos, & B. Wallace (Eds.) Hypnosis and Imagination. New York: Baywood. Barrett, D. L. (1996a). Dreams in multiple personality. Chapter in D. Barrett (Ed.) Trauma and Dreams. Cambridge, MA: Harvard University Press. Barrett, D. L. (1998) The pregnant man: Tales from a hypnotherapists couch. New York: Times Books/Random House. Barrett, D. L., & Fine, H. J. (1980) A child was being beaten: The therapy of battered children as adults. Psychotherapy: Theory, Practice, and Research, 17, 285293. Belicki, K., & Belicki, D. (1984) Predisposition for nightmares: A study of hypnotic ability, vividness of imagery and absorption. Journal of Clinical Psychology, 42, 714718. Belicki, K., & Cuddy, M. (1996). Identifying sexual trauma histories from patterns of sleep and dreams. In D. Barrett (Ed.) Trauma and dreams (pp. 4655). Cambridge, MA: Harvard University Press.
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Breuer, J. & Freud, S. (1937). Studies in hysteria (Trans. by J. Strachey). New York: Basic Books. Chuang-tsu. (trans 1970). Madly singing in the mountains. London: Arthur Waley. Field, P. (1965). An Inventory Scale of Hypnotic Depth. International Journal of Clinical and Experimental Hypnosis, 13, 238249. Frankel, F. (1990). Hypnotizability and dissociation. American Journal of Psychiatry, 147(7), 823829. Hall, C., & van de Castle, R. (1966). The content analysis of dreams. New York: Appleton-Century-Crofts. Hartmann, E. (1984). The nightmare: The psychology and biology of terrifying dreams. New York: Basic Books. Hilgard, E. R. (1977). Divided consciousness: Multiple controls in human thought and action. New York: John Wiley. Hilgard, E. R. (1979). Divided consciousness in hypnosis: The implications of the hidden observer. In E. Fromm & R. E. Shor (Eds.) Hypnosis: Developments in research and new perspectives (2nd ed.). Chicago: Aldine. Hilgard, J. (1970). Personality and hypnosis: A study of imaginative involvement. Chicago: University of Chicago Press. Hilgard, J. (1979). Imaginative and sensory-affective involvements: In everyday life and in hypnosis. In Erika Fromm and Ronald E. Shor (Eds.) Hypnosis: Developments in research and new perspectives (519565). New York: Aldine. Huff, K., & Council, J. (1987, August). Hypnosis, fantasy activity and reports of paranormal experiences in high, medium and low hypnotizables. American Psychological Association, New York. Lynn, S. J., & Rhue, J. W. (1986). The fantasy prone person: Hypnosis, imagination and creativity. Journal of Personality and Social Psychology, 51, 404408. Lynn, S. J., & Rhue, J. W. (1988). Fantasy proneness: Hypnosis, developmental antecedents, and psychopathology. American Psychologist, 43, 3544. Masters, R., & Houston, J. (1972). Mind games: The guide to exploring inner space. New York: Viking Press. National Institute of Justice & Centers for Disease Control & Prevention. Prevalence, Incidence and Consequences of Violence Against Women Survey. 1998. Puysegur, A. M. Marquis de. (1837). An essay of instruction on animal magnetism (Trans. by J. King). New York: J. C. Kelley. Schatzmann, M. (1980). The story of Ruth. New York: Putnam. Shor, R. E., & Orne, E. C. (1962). Harvard Group Scale of Hypnotic Susceptibility, Form A. Palo Alto, CA: Consulting Psychologists Press. Spanos, N. P. (1971). Goal-directed fantasy and the performance of hypnotic test suggestions. Psychiatry, 34, 8696. Spanos, N. P. (1989). Imaginal dispositions and situation-specic expectations in strategy-induced pain reductions. Imagination, Cognition, and Personality, 2, 147. Spanos, N. P., & Barber, T. X. (1972). Cognitive activity during hypnotic suggestion: Goal-directed fantasy and the experience of non-volition. Journal of Personality, 40, 510524. Spanos, N. P., & McPeake, J. D. (1975). Involvement in everyday imaginative activities, attitudes toward hypnosis, and hypnotic suggestibility. Journal of Personality and Social Psychology, 31, 247252.
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Spanos, N. P., & McPeake, J. D. (1977). Cognitive strategies, goal-directed fantasy, and response to suggestions in hypnotic subjects. American Journal of Clinical Hypnosis, 20, 114123. Tellegan, A., & Atkinson, G. (1974). Openness to absorbing and self-altering experiences (absorption), a trait related to hypnotic susceptibility. Journal of Abnormal Psychology, 83, 268277. Wilson, S. C., & Barber, T. X. (1981). Vivid fantasy and hallucinatory abilities in the life histories of excellent 1,981 hypnotic subjects (somnabules): A preliminary report. In Eric Klinger (Ed.) Imagery: Vol. 2: Concepts, results, and applications. New York: Plenum Press. Weitzenhoffer, A. M., & Hilgard, E. (1962). The Stanford Scale of Hypnotic Susceptibility, Form C. Palo Alto, CA: Consulting Psychologists Press. Wilson, S. C., & Barber, T. X. (1983). The fantasy-prone personality: Implications for understanding imagery, hypnosis, and parapsychological phenomena. In A. A. Sheik (Ed.) ImageryCurrent theory, research, and application. New York: John Wiley & Sons, Inc. Zamore, N., & Barrett, D. L. (1989). Hypnotic susceptibility and dream characteristics. Psychiatric Journal of The University of Ottawa, 14, 572574.
Chapter 3
Hypnosis, Mindfulness Meditation, and Brain Imaging

David Spiegel, Matthew White, and Lynn C. Waelde
INTRODUCTION
Hypnosis, begun as a therapeutic discipline in the eighteenth century, was the rst Western conception of a psychotherapy (Ellenberger 1970). Hypnosis is a state of highly focused attention coupled with a suspension of peripheral awareness (Spiegel & Spiegel, 2004). This ability to attend intensely while reducing awareness of context allows one to alter the associational network linking perception and cognition. The hypnotic narrowing of the focus of attention (Spiegel, 1998) is analogous in consciousness to looking through a telephoto lens rather than a wide-angle lensone is aware of content more than context. This can also facilitate reduced awareness of unwanted stimuli, such as pain, or of problematic cognitions, such as depressive hopelessness (Spiegel & Spiegel, 2004). Such a mental state enhances openness to input from othersoften called suggestibilityand can increase receptivity to therapeutic instruction. In this chapter, we review research on effects of hypnosis and related data on mindfulness meditation on peripheral and central nervous system functioning, emphasizing studies utilizing brain imaging techniques. Hypnotizability, the individuals degree of responsiveness to suggestion during hypnosis (Green et al., 2005), is a highly stable and measurable trait (Spiegel & Spiegel, 2004). In one study, hypnotizability was found to have a .7 test-retest correlation over a 25-year interval, making it a more stable trait than IQ over such a long period of time (Piccione, Hilgard, & Zimbardo, 1989). The trait of hypnotizability is a crucial moderating variable in pain treatment response, both that involving hypnosis directly (Hilgard & Hilgard, 1975), and in augmenting placebo response (McGlashan, Evans, & Orne, 1969).
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There is widespread belief that mental state has an effect on health. Healing ceremonies in many cultural traditions involve inducing an alteration in mental state. Most mind/body techniques employed in the West involve inducing a change in mental state coupled with instructions to control symptoms such as pain or anxiety, or even to improve the course of a disease. Yet, we know very little about the neurophysiological basis of these mental state alterations. There is considerable evidence that hypnosis affects clinically important aspects of somatic functioning. The oldest and best established effect is on pain, dating back to the pioneering work of Esdaile (Esdaile, 1846; reprinted 1957). This nding has been replicated in numerous studies (Lang et al., 2000; Spiegel & Bloom, 1983). A randomized controlled clinical trial among 241 patients undergoing invasive radiological procedures demonstrated that, compared to either routine care or structured attention, hypnosis produced signicant reductions in pain, anxiety, complications, and procedure time, while requiring only half of the analgesic medication used in the other groups (Lang et al., 2000). Hypnosis is also a highly effective tool in treating various kinds of somatic dysfunction, such as irritable bowel syndrome (Colgan, Faragher, & Whorwell, 1988). Hypnosis can cause signicant increases and decreases in gastric acid secretion (Klein & Spiegel, 1989). Hypnosis has been employed to diagnose and control nonepileptic seizures as well (Barry, Atzman, & Morrell, 2000; Barry & Sanborn, 2001). Studies have also shown that hypnosis can directly affect autonomic functioning. For example, highly hypnotizable subjects show evidence of greater vagal tone (DeBenedittis et al., 1994; Harris et al., 1993), which is associated with the ability to self-soothe (Porges, 1995; Porges, Doussard-Roosevelt, & Maiti, 1994). Furthermore, induction of the hypnotic state reduces sympathetic and increases parasympathetic activity, as measured by the low-frequency/ high-frequency ratio using power spectral analysis of heart rate (DeBenedittis et al., 1994). Hypnotic induction of emotional states also affects the secretion of the stress hormones cortisol and prolactin (Sobrinho et al., 2003). Thus, hypnosis has the potential to modulate neural and endocrine components of the stress response.
Neuroimaging of Hypnosis
We have not yet identied a brain signature of the hypnotic state per se. However, many studies have demonstrated that hypnotic alteration of perception changes perceptual processing in the brain. Changing the wording of a pain-directed hypnotic instruction from you will feel cool, tingling numbness more than pain to the pain will not bother you shifts activation from the somatosensory cortex to the dACC (Rainville et al., 1997, 1999). Similarly, in a positron emission tomography (PET) study, Kosslyn and collegues have shown that hypnotic suggestion can alter visual color
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perception and affect activation in color processing regions of the brain (Kosslyn et al., 2000). They asked hypnotized subjects to see a gray-scale pattern in color; under hypnosis, color areas in the ventral visual processing stream were activated, whether they were shown colors or the gray-scale stimulus. Believing was seeing. Among the brain regions implicated in hypnosis, the best evidence to date points to frontal attentional systems, especially the dACC and the DLPFC. Along with the frontoinsular cortex (BA 47/12), activity in the dACC tends to track with changes in autonomic tone occurring in the setting of cognitively demanding or emotionally salient tasks (Critchley, 2005; Seeley et al., 2007). Highly hypnotizable subjects performing a cognitive or perceptual task under hypnosis tend to show altered activation in the dACC (Rainville et al., 1999; Szechtman et al., 1998; Raz, Fan, & Posner, 2005). Raij et al. found that DLPFC, dACC, and frontoinsular activation correlated with the degree of pain experienced under hypnotic suggestion (Raij et al., 2009). Raz et al. have found the dorsolateral prefrontal cortex (DPPFC) and dACC to be instrumental in suggestive interpretation of bistable gures with two opposing perceptual interpretationslike the vase/face drawing (Raz et al., 2007). Using PET, Faymonville implicated many regions including the dACC and DLPFC in hypnosis and hypnotic reduction in pain perception (Faymonville et al., 2000). However, it is difcult to assess whether previously identied task-related differences in dACC and DLPFC activation are a generalized signature of hypnotic trance or an associated effect of the specic hypnotic suggestion.
MINDFULNESS MEDITATION Health Benets of Meditation

There is reason to believe that there are many analogies between hypnosis and mindfulness. Meditation has been practiced in many forms for health and healing for thousands of years. Meditation is dened as a family of selfregulation practices that focus on training attention and awareness (Walsh & Shapiro, 2006). A recent operational denition of mindfulness meditation (MM) emphasizes self-regulation of attention on immediate experience and cultivating curiosity, openness, and acceptance of that experience. As such, MM requires the ability to sustain attention on the breath and to switch the attention back to the breath once thoughts, feelings, and sensations have been detected and acknowledged, without further elaboration (Bishop et al., 2004). Mindfulness-based stress reduction (MBSR) is a widely used skillsbased educational intervention that combines mindfulness with hatha yoga exercises to enhance health and well-being (Kabat-Zinn, 2005). MM has been investigated in a broad range of health conditions, including pain, immunological, and dermatological conditions, and as supportive
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therapy in cancer care. A meta-analysis found ve controlled studies of MM for physical health conditions that included the following diagnoses: chronic pain, bromyalgia, and coronary artery disease that had a mean effect size of d 0.5 (Grossman et al., 2004). Effects of MM on pain were demonstrated in a study of chronic musculoskeletal pain (Plews-Ogan et al., 2005). A controlled study of MBSR for bromyalgia patients found pre/post and three-year follow-up reductions in visual analog pain, coping with pain, and somatic complaints (Grossman et al., 2007). A randomized, controlled trial of MBSR for psoriasis found that patients who used MBSR during light treatments experienced more rapid skin clearing than those with light treatments alone (Kabat-Zinn, 2005). A recent review concluded that MM shows promise for cancer supportive care (Smith et al., 2005). Benecial effects of MBSR for endocrine, immune, and autonomic parameters were demonstrated in a series of trials with early stage breast and prostate cancer patients. Participants were assessed at pre- and post-intervention and at 6- and 12-month follow-up. Over the course of follow-up, cortisol, Th1 (pro-inammatory) cytokines, and systolic blood pressure decreased (Bishop et al., 2004; Carlson et al., 2003, 2007).
Neuroimaging and Mindfulness Meditation

Neuroimaging studies of MM using structural magnetic resonance imaging (MRI), functional magnetic resonance imaging (fMRI), and PET suggest that MM, like hypnosis, involves regulation of regions associated with attention and interoception, particularly the dACC, the DLPFC, and the frontoinsular cortex. Structural imaging studies of experienced meditators have demonstrated increased grey matter in regions associated with experiential self-monitoring and interoception, in particular the left temporal gyrus, right frontoinsular cortex, and right hippocampus. Lazar (Lazar et al., 2005) compared twenty Buddhist Insight practitioners to fteen non-meditators and found increased cortical thickness in right middle and superior frontal cortex, right frontoinsular cortex, and left superior temporal gyrus. Holzel et al. also reported increased grey matter density of the left inferior temporal gyrus, right frontoinsular cortex, and right hippocampus in a voxel-based morphometry (VBM) study (Holzel et al., 2008). Larger volumes in the left inferior temporal gyrus and right hippocampus were replicated by Luders (Holzel et al., 2007), who utilized VBM to compare 22 long-term practitioners of diverse forms of MM (Zazen, Vipassana, Samatha) to 22 age- and gender-matched controls. They also found larger volumes for meditators in the right orbitofrontal cortex and right thalamus, regions implicated in emotion regulation. In terms of functional imaging, similar to the literature on hypnosis, activations of the dACC and DLPFC are the most consistent ndings in experienced practitioners of MM. In a small fMRI study of ve subjects,
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Lazar found increased activation during MM in many regions including DLPFC, dACC, and striatum, regions associated with attention and autonomic control (Lazar et al., 2000). Holzel et al. found increased activation during meditation (compared with mental arithmetic) in the dACC and dorsal medial PFC in experienced Vipassana meditators compared with controls (Holzel et al., 2007). Baron-Short et al. found no difference in regional activation between longer term MM practitioners and controls using standard whole-brain comparisons with stringent thresholds; however, using a region-of-interest (ROI) analysis, they found signicantly more sustained activation in the dACC and DLPFC, an effect that was more pronounced for more experienced meditators (Baron-Short et al., 2007).
Hypnotic Changes in Attention Systems

Thus we know that hypnosis involves neural mechanisms related to arousal and attention, but is not simply the product of them, since arousal and attention occur frequently unrelated to hypnosis. Activity in the frontal lobes and the anterior attentional system (Posner and Petersen, 1990), especially the anterior cingulate gyrus, seems to be involved. Posner and colleagues (Posner and Petersen, 1990; Fan et al., 2002) describe three components of attention: executive attention, alerting, and orienting. Executive attention, modeled as target detection, is related by Posner to the anterior cingulate gyrus. Based on their work, this attentional subsystem is a spotlight, narrowing the focus of attention. The second component, alerting, is a characteristic of the anterior attention system and is characterized by rapid response with an increase in error rates. This component is tied to the right medial aspect of the frontal lobe. The third and most posterior involves orienting, and is located in the anterior occipital/posterior parietal region. This area has strong connections from the superior colliculus and the thalamus. Lesions in these lower connections result in a difculty in orienting, focusing attention on the target, and avoiding distraction. Furthermore, there is a hemispheric difference in the type of orienting, with a right hemisphere bias toward global processing and a left bias toward local processing. Hypnotic concentration is more associated with activation of the anterior as opposed to the posterior attention system, in Posners terms, especially the executive attention function of the anterior cingulate gyrus. In Pribrams terms, this means activation rather than arousal (Pribram & McGuinness, 1975). Pribrams earlier conceptualization, quite consistent with Posners, links arousal to noradrenergic activity and parsing, which means activating multiple systems, with emphasis on external perception. Activation, on the other hand, is described by Pribram as largely dopaminergic, and involves chunking, or reducing the number of parallel systems, and emphasizes an inner rather than outer focus. There is evidence, in fact, that hypnotizability
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is correlated with levels of homovanillic acid (HVA) in the cerebrospinal uid (Spiegel & King, 1992). HVA is a metabolite of dopamine, so this nding provides evidence linking hypnosis to dopaminergic activity. Furthermore, the hypnotizability of schizophrenics, who have abnormalities in dopamine activity and the D2 receptor (Lidow & Goldman-Rakic, 1997), is substantially lower than normal (Pettinati et al., 1990; Lavoie and Elie, 1985). The anterior cingulate gyrus is rich in dopaminergic neurons (Williams & Goldman-Rakic, 1998), providing converging evidence that the hypnotic state, which involves both arousal and focusing, may be associated with activity in the anterior cingulate gyrus. This is consistent with Rainvilles PET study showing involvement of the anterior cingulate during hypnotic analgesia of the type that involves reducing discomfort rather than pain perception itself (Rainville et al., 1997, 1999; Hofbauer et al., 2001). However, these studies show hypnotic analgesia associated with decreased concern about the pain (as opposed to decreased perception of the pain) is associated with decreased activity of the anterior cingulate. So based upon this evidence, hypnosis does not simply involve turning on the anterior cingulateindeed hypnotic analgesia seems to work in part by turning it off.
RESTING STATE NETWORKS OF INTEREST IN HYPNOTIC TRANCE AND MINDFULNESS MEDITATION

Convergent, multimodal data point to the dACC and DLPFC and the frontoinsular cortex as critical regions of interest in both hypnotic trance and MM. These regions do not operate in isolation, but rather constitute core regions in two distributed brain networks that have undergone intensive recent study by our group and others: the salience network and the executive control network. A recent study by Farb et al. (Farb et al., 2007) suggests that network approaches may be fruitful in studying MM and hypnosis. Using a functional connectivity analysis of fMRI data during a self-referential task, they found that experienced meditators reduced functional connectivity between the frontoinsular cortex and the medial prefrontal cortex (MPFC), a region implicated in self-referential cognition. The MPFC is a core region in a third well-characterized network using resting state fMRI known as the default-mode network (DMN) (Seeley et al., 2007).
RESTING STATE fMRI AND CANONICAL BRAIN NETWORKS

Biswal and colleagues rst demonstrated that spontaneous, low-frequency blood oxygen level-dependent (BOLD) signal uctuations measured in the left motor cortex of a subject resting quietly in the scanner were strongly correlated with BOLD signal uctuations in the contralateral motor cortex (Biswal et al., 1995). This was the initial demonstration of within-subject
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functional connectivity in the absence of an externally cued task. Restingstate functional connectivity has since been demonstrated (and replicated) in several additional resting-state networks (RSNs), each with distinct spatial and temporal proles that correspond to critical functions including vision, audition, language, episodic memory, executive function, and salience detection among others (Seeley et al., 2007; Beckmann et al., 2005; Hampson et al., 2002). Of these several canonical RSNs, we now wish to focus primarily on the salience network, the executive control network, and the DMN. It should be noted that connectivity in these RSNs is present in mild sedation and the early stages of sleep and so is not considered to reect conscious processing but rather basal connectivity required to maintain critical networks in a primed state. As such, resting-state connectivity is often interpreted as reecting the functional architecture that supports trait characteristics rather than real-time, state-based cognitive or sensory processing. The DMN was initially described by Raichle and colleagues as a set of brain regions whose activity consistently decreased during most cognitively demanding tasks (Raichle et al.). We rst conrmed his hypothesis that these regions constituted a tonically active RSN by selecting the posterior cingulate cortex as an ROI during a resting-state scan and showing functional connectivity with the other DMN regions (Greicius et al., 2003). Subsequent work from our group and others has shown that the DMN likely mediates episodic memory and self-referential processing given that it includes the hippocampus as a key node, is activated by episodic memory and self-referential tasks, and is disrupted by Alzheimers disease. Unlike the DMN, which is typically deactivated by cognitive tasks, the executive control and salience networks are typically activated during tasks. Their frequent co-activation has led to the assumption that they constitute a single, unitary network. Critchley and colleagues have argued that the frontoinsular cortex and the dACC monitor and/or modulate autonomic responses to salient stimuli encountered during task performance. These functions should be separable from the cognitive processing functions mediated by the dorsolateral prefrontal-lateral parietal network. To disentangle these two networks that tend to be co-activated during standard task-activation analyses, we isolated two regions activated by the same working memory task: one in the right frontoinsular cortex, and one in the right DLPFC (Seeley et al., 2007). In a separate resting-state functional connectivity analysis, we showed that the two regions yielded distinct RSNs. Further, connectivity within these RSNs showed a double dissociation of function (as measured outside the scanner): the executive control network (incorporating the DLPFC node) correlated with performance on an executive control task but not with subject anxiety level, whereas the salience network (incorporating the frontoinsular node) correlated with subject anxiety but not with executive task performance (Seeley et al., 2007).
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In sum, the executive control network includes the DLPFC and bilateral superior parietal cortex and is critical for tasks that involve focused attention and working memory. The salience network, joining the dACC and frontoinsular cortex to subcortical regions like the hypothalamus, has a role in monitoring and adjusting the autonomic nervous system based on salient internal or external stimuli. The DMN, consisting of the posterior cingulate cortex (PCC), hippocampus, and MPFC, appears to mediate self-referential processing and episodic memory retrieval. These networks are tonically active and generally dissociable in resting-state fMRI. In task settings, these networks interact such that the DMN and executive control network appear to alternate during states of internally directed and externally directed attention, respectively, with this toggling directed, perhaps, by the salience network. They thus should have salience in the understanding of both hypnosis and mindfulness, and help us understand how hypnosis can affect peripheral autonomic function as well as CNS activity.
Hypnotic Effects on Automaticity

There is recent evidence that hypnosis can effectively decontextualize lexical perception and eliminate the delay in reaction time seen in the classical Stroop interference paradigm (Raz, Fan, & Posner, 2005; Raz et al., 2002, 2006). This is surprising, since the Stroop color-word interference task is one of the most robust phenomena in psychophysiology. In these hypnosis experiments, high hypnotizables were instructed that the words they would see were written in a foreign language and would have no meaning, thereby attempting to bypass the automatic lexical processing of the color meaning of the word (e.g., green written in red). This instruction eliminated the standard lexical processing delay in naming the color of a word that describes a different color. This nding is consistent with our own that a hypnotic instruction to focus on just a portion of the letter reduces Stroop interference (Nordby et al., 1999), and with earlier work by Sheehan and colleagues (Sheehan, Donovan, & MacLeod, 1988). The one contradictory nding (Dixon & Laurence, 1992) can be accounted for by differences in hypnotic instruction. Dixon and Laurence tested strategic versus automatic Stroop response, instructing subjects how to predict which color would come next based on the previous one, while assuming that a short interstimulus interval (ISI) would render the strategic approach impossible. They thus gave instructions to alter anticipation of the color, rather than perception of the word written in a contradictory color. They found more Stroop interference for highs than lows during the short ISIs, but in fact highs were better at reducing Stroop interference by using the color prediction strategy at the longer ISIs than were lows. So even in their hands, strategy trumped automaticity in the eyes of highs. They were better than lows at reducing the presumably automatic lexical
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Stroop interference. This is crucial for interpreting studies of hypnotic effects, as we have seen in earlier studies of the effects of hypnotic suggestion to change olfactory perception on olfactory event-related potentials (Barabasz & Lonsdale, 1983). These Stroop studies suggest that hypnosis can reduce the automaticity of lexical processing. This may seem odd given that hypnotic performance is typically seen as inducing automaticity, while in this case it reduces the automaticity associated with word reading. The key feature of hypnosis may be its ability to alter automaticity rather than the prior notion that simply increases it. What hypnosis may do is modulate the sense of agency. In hypnosis one takes experiences that would ordinarily be tied to a sense of agency, such as lifting ones hand, and makes them seem automaticthe hand seems to rise by itself because the subject has been given and is afliating with the instruction that his hand will feel light and buoyant like a balloon (Spiegel & Spiegel, 2004). The subject exerts control over perceptual processing that is unusualenhancing agency over perceptionwhile the usual sense of control over motor function is reduced, because the motor activity is driven by the perceptual alteration. Intentionality in the brain is largely driven by the frontal lobes, and typically the portion of the brain in front of the central gyrus is most associated with agency and actionpredominantly motor activity and speech. The posterior portion of the cortexpost-central gyrus, temporal, and occipital lobes, are primarily sensory and receptiveprocessing somatic sensation, hearing, and vision. In hypnosis, there is greater potential to rearrange these relationships, exerting agency, perhaps through altered activity of the frontal cortex and anterior cingulate gyrus, on the perceptual portions of the brain, while reducing perceived control over anterior regions, including motor cortex. The anterior cingulate, which focuses attention, is a context generator, and in hypnosis it may shift attention to manipulation of perceptions rather than actions. Better understanding of the effects of hypnosis on functional activities of these portions of the brain among high hypnotizables and during hypnotic experience is an exciting opportunity for future research designed to elucidate brain function in general and hypnosis in particular.
HYPNOTIC INVERSION OF AGENCY: RESPONDING TO WORDS AND MANIPULATING IMAGES

Hypnosis seems to involve an inversion of our usual means of processing words and images (Spiegel, 1998). In normal mental states we respond to images and manipulate words, whereas in hypnosis we respond to words and manipulate images. In a trance we accept verbal input relatively uncritically (suggestibility), but are capable of transforming images and perceptions to an unusual degree. Much of the power of the hypnotic state involves the uncritical acceptance of the implausible, for example, being
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able to reduce or eliminate pain despite the persistence of the same unpleasant stimulus. One can think of the brain as being divided into an anterior effector portion involving thought and motor functionwhat one can do to the world and a posterior receptive portionsensory information received from the world. Autobiographical memory commences in the frontal lobes with a search strategy and works its way posterior toward activation of images in the occipital lobes. This is controlled, desired activity accompanied with willing invoking a sense of agency. By contrast, situations involving helplessness, such as PTSD, seem to move from back to front, with unbidden intrusive images that are experienced as uncontrolled and unwelcome (Horowitz, Field, & Classen, 1993; Mueser & Butler, 1987). Brain imaging in PTSD (Rauch & Shin, 1997) shows hyperactivation of hippocampus (memory), amygdala (emotion), and occipital cortex (imagery), and hypoactivation of Brocas area (speech). Thus the deep and posterior portions of the brain are activated, while the motor systems, especially speech, are inhibited, adding to the sense of helplessness and involuntariness in PTSD. Such individuals feel they are being retraumatized by their memories. There would seem to be a paradox: agency would seem to be enhanced by efferent activity rather than passive perception. Yet it is not uncommon that people engaged in motor performance lack self-awareness, for example, actors, athletes, and other people in ow states (Csikszentmihalyi, 1991). Thus, agency does not uniformly accompany activity, even voluntary activity. One way to resolve this apparent paradox is to conceive of self-awareness as a perception. Even if agency is best demonstrated by action, it may not be perceived if there is some inhibition of perception, for example, if perceptual processing is saturated with intrusive imagery, or redirected through hypnotic instruction. Motor activity can occur in hypnosis without the perception of agency. The well-established ability of hypnosis to alter perception may account for its less-well understood ability to alter identity, memory, and consciousness, which is really self-perception. Perception of motor activity is complexit involves expectation of a response to a motor act initiated. For this reason, we cannot tickle ourselves. Thus altering perception has great potential to alter the awareness of agency in regard to our own actions. It is noteworthy that mindfulness and meditation practices have as their very aim the reduction of the sense of agency. Another way to think about the evidence is that systems are affected that both respond to and manipulate perceptions. Typically, we respond to perceptions and manipulate words. In hypnosis, by contrast, we seem to respond to words and manipulate perceptions. The majority of Stroop studies reviewed herein indicate that words can be delexicalized by altering perception, but this is done in response to verbal instructions that in some ways do not make sensethe words are in English but they are perceived as unreadable, and Stroop interference decreases (Raz, Fan, & Posner, 2005;
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Raz et al., 2002, 2003, 2006). In fact, Raz found that reduced Stroop interference in hypnosis was associated with reduced activity in the anterior cingulate gyrus, similar to Rainvilles observation involving the type of analgesia that involves reduced distress rather than perception (Rainville et al., 1999; Hofbauer et al., 2001).
CONCLUSION
We know that the states of hypnosis and meditation are associated with important health-related aspects of somatic regulation, including pain perception, gastrointestinal function, immune function, endocrine function, and autonomic function. We know far less about the brain regions intrinsic to hypnotic attention and to mindfulness meditation. Previous attempts to reveal the neural underpinnings of these states have been hampered by (a) the reliance on block designs that have limited naturalistic validity, (b) small sample sizes, and (c) a focus on specic brain regions rather than interactions within and across brain networks. Both mindfulness and hypnosis are cultivated special states that must rest upon underlying neural capabilities. Clearly hypnosis has powerful effects on neural structures involved in the processing of perception. Ironically, the state often associated with loss of control is one that provides means for enhancing control over physical and mental states once thought to be beyond conscious neural control, such as pain, lexical perception, and even gastro-intestinal function. Interactions among the prefrontal cortex, the anterior cingulate gyrus, and various sensory-processing regions are clearly involved in hypnosis. Use of newer and more sophisticated functional brain imaging techniques should help us to elucidate the brain networks involved in the hypnotic state and its effects on perception, identity, memory, and consciousness.
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Smith, J. E., Richardson, J., Hoffman, C., et al. (2005). Mindfulness-Based Stress Reduction as supportive therapy in cancer care: Systematic review. Journal of Advanced Nursing, 52, 31527. Sobrinho, L. G., Simoes, M., Barbosa, L., et al. (2003). Cortisol, prolactin, growth hormone and neurovegetative responses to emotions elicited during an hypnoidal state. Psychoneuroendocrinology, 28, 117. Spiegel, D., & Bloom, J. R. (1983). Group therapy and hypnosis reduce metastatic breast carcinoma pain. Psychosomatic Medicine, 45, 3339. Spiegel D. (1998). Hypnosis and implicit memory: Automatic processing of explicit content. American Journal of Clinical Hypnosis, 40, 231240. Spiegel, H. and Spiegel, D. (2004). Trance and treatment: Clinical uses of hypnosis. Washington, D.C.: American Psychiatric Publishing. Spiegel D., Detrick, D., & Frischholz, E. (1982). Hypnotizability and psychopathology. American Journal of Psychiatry, 139, 4317. Spiegel D., & King R. (1992). Hypnotizability and CSF HVA levels among psychiatric patients. Biological Psychiatry, 31, 9598. Spiegel, D. (1998). Hypnosis. Harvard Mental Health Letter, 15, 56. Szechtman H., Woody E., Bowers K. S., et al. (1998). Where the imaginal appears real: A positron emission tomography study of auditory hallucinations. Proceedings of the National Academies of Science, US, 95, 195660. Walsh R., & Shapiro, S. L. (2006). The meeting of meditative disciplines and Western psychology: A mutually enriching dialogue. American Psychology, 61, 22739. Williams, S. M., & Goldman-Rakic, P. S. (1998). Widespread origin of the primate mesofrontal dopamine system. Cerebral Cortex, 8, 32145.
Chapter 4
Forensic Hypnosis: A Practical Approach

Melvin A. Gravitz
INTRODUCTION
For more than two centuries, the modality known today as hypnosis has been applied effectively to the treatment of a wide array of psychological and medical conditions that are described in other sections of this book and elsewhere (Rhue, Lynn, & Kirsch, 1993). These clinical uses are based on the many phenomena of hypnosis, especially hypermnesia, which refers to the increase in memory that can be elicited through hypnosis. It is this aspect of the modality that has been particularly helpfuland controversialin the legal eld, as well as in psychotherapy, where retrieval of repressed memories is an important treatment technique. The term generally given to such application is forensic hypnosis, although investigative hypnosis has sometimes been used (Reiser, 1980). Both descriptors refer to essentially the same process. For more than a century, scientic investigators and clinicians have noted the potential for memory distortions associated with hypnosis. Moll, a noted nineteenth-century authority, commented that Retroactive hallucinations are of great importance in law. They can be used to falsify testimony. People can be made to believe that they have witnessed certain scenes, or even crimes (Moll 1889/1958, pp. 345346). The pioneer hypnosis practitioner, Bernheim, observed, I have shown how a false memory can cause false testimony given in good faith, and how examining magistrates can unwittingly cause false testimony by suggestion (Bernheim, 1891/1980, p. 92). Similar ndings have been observed by later legal commentators, as will be noted the following discussion. The rst documented application of hypnosis in the investigation of a crime in the United States was reported in 1945 when it was used to obtain information from a witness concerning a theft (Gravitz, 1983). Another
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case was published in 1848 and involved an interview with a witness in a murder trial; the hypnotically obtained testimony was admitted by the court without any issue (Anonymous, 1948). But it was not until July 25, 1976, that a sensational case in California made headlines throughout the country and lent to forensic hypnosis a resurgence that has continued. A busload of 26 school children and their adult driver was abducted off a country road by three masked men near the farming community of Chowchilla. The victims were then taken in several vans to a repositioned enclosure that had been partially buried in a quarry. The driver and two of the older boys eventually succeeded in digging their way out, and they made their way to the nearby highway where they contacted the authorities. During the investigation that followed, the driver was hypnotized, as a result of which he was able to identify a license plate on one of the vans. With the exception of one transposed digit, this number was matched to the vehicle of a man who, together with two accomplices, was subsequently convicted and sentenced to life imprisonment (Kroger & Douce, 1979). In my own experience, the correct retrieval of a license tag number is difcult to obtain, probably because such a combination of letters and numbers is usually non-meaningful information for all practical purposes; scientic research has amply demonstrated that meaningful stimuli are learned faster, retained better, and remembered in greater detail than that which is nonmeaningful (Council of Scientic Affairs, 1985).
VARIETIES OF FORENSIC HYPNOSIS

There are a number of modern uses of hypnosis in the legal arena (Gravitz, 1980). Foremost of these is that it can be a helpful method to develop leads in police investigations by interviewing witnesses and victims of crime (Johnson, 1981; Shaw, 1991). The modality has also been employed in the enhancement of the memory of parties in civil actions (Hughes, 1991). While such use does not assume the truth, the whole truth, and nothing but the truth, important details about a case frequently can be recalled. Hypnosis is not a lie detector, and in fact it is possible for a subject to dissemble. Another application is to lift the veil of amnesia and thereby to aid in the preparation of the defense of an accused whose recollections may be faulty, perhaps because of the repressive impact of trauma. Hypnosis can also be utilized as an aid in the evaluation of a persons state of mind, specic intent, or mental condition (mens rea, in the legal sense), as for example, in the differentiation between malingering and the claim of multiple personality disorder. In every application, it should just be recognized that hypnosis is not necessarily complete or infallible, but then no psychological method is. The forensic hypnotist may be called upon to perform other services. As an expert in the eld, he or she may be asked to comment on or testify about hypnosis interviews conducted by someone else. In this instance, a
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recording or typescript would be reviewed, or the expert could listen to testimony in court and then be examined on that. Qualied forensic hypnotists may be asked to train law enforcement ofcers and other professionals in the criminal justice system in the proper utilization of the method. The training would not instruct in how to do hypnosis, since that would be inappropriate, but rather how to work effectively with the psychologist who performs the actual interview. Another area of function is to advise others about the effects and the implications of hypnosis. As an example, a psychologist was asked by an attorney for an expert opinion on the possibility of harm being done to someone listening to a television advertisement by a political candidate who sought, as a public service, to hypnotize the audience to vote. The psychologist reviewed the relevant scientic ndings that addressed the question and prepared a written statement, which the law rm then incorporated in its defense of a television station that had been sued for declining to sell air time for such purposes. The spurned candidate had accused the station of infringing on his right to speak on his own behalf, and the defendants defense was based on the possibility that a listener could experience an undue or even harmful reaction for which the station could then be held liable. The responsible federal government regulatory agency upheld the defendants position. The candidate lost the election.
MEMORY AND HYPNOSIS

At this point, it will be useful to consider the mechanisms of memory and how hypnosis impacts them. While our modern understanding of these mechanisms is incomplete and not fully understood, there is a theoretical paradigm that provides a working frame of reference. This model assumes that an individual acquires and processes incoming information from various conscious and unconscious sensory sources, as well as certain prior experiences that have been stored in a bioelectrical memory bank. Based on the needs of the individual, there is then a rapid preliminary sorting of this information that results in short-term memory (STM). Some of these STMs are personally meaningful and are therefore retained (coded) in the form of a memory trace in long-term memory (LTM). But some of the incoming information is not coded as personally signicant and is therefore not retainedit is permanently forgotten and cannot ever be retrieved, either by hypnosis or other means. These experiences that are stored in LTM, however, may be retrieved by a variety of means including hypnosis, provided there has been no organic deterioration. Thus, memory is an active process of acquisition, retention, and retrieval. It is also a function of the needs and condition of the person at the time the original event occurredthis memory is state dependent. The latter may include mood, affect, stress, and biochemical factors, such as drugs and alcohol.
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In the process of recollection, there is a restructuring of the memory traces for LTM; therefore, memory is more or less naturally imperfect, and perfect reproduction cannot be assured. There may also be gaps in memory, and these are subject to confabulation, which refers to the process whereby one lls in the gaps based on ones needs and past experience. Memory is not a photograph-like or lm/tape recorder-like exactness, even though some who use hypnosis may erroneously claim that is so. The enhancement of memory by hypnosis, then, may produce a m elange of fact and fancy in proportions that cannot be determined or separated either by the subject or an observer. These recollections may have the force of truth for the subject, as well. Accordingly, hypnotically facilitated memories should be corroborated so independent verication may be obtained. While many police ofcers have been impressed by hypnosis because they have observed rsthand how useful it can be in certain cases, jurors tend to be skeptical (Greene, Wilson, & Loftus, 1989; Labelle, Lamarche, & Laurence, 1990). Certain inaccuracies of memory that may occur in whole or in part, including non-hypnotic recollections that are found to be invalid, however, may lead in turn to the uncovering of new and valid information and evidence. Since it has been observed that individuals are capable of simulating or faking hypnosis and of making willful false statements while hypnotized, care must be exercised in attesting that a subject is in hypnosis or not. While some in the eld question the very existence of hypnosis as an altered state, others seem to consider virtually any human behavior as evidence of the condition (Lynn & Rhue, 1991). A more reasoned approach was offered by a study panel convened by the American Medical Association (Council for Scientic Affairs, 1985), which concluded that hypnosis can be recognized by administering a series of different test suggestions of varying degrees of known difculty, typically involving alterations of perception, motor control, or memory. The degree to which these suggestions were followed and experienced as real and involuntary indicates the extent to which hypnosis has taken place (p. 1919). Accordingly, in forensic cases it is important to consider any information that may be developed as a lead, which must then be subject to further investigation. In this regard, the forensic hypnotist is not an appropriate investigative ofcer. Labelle, Lamarche, and Laurence (1990) and others have found that hypnotized witnesses display greater condence in the validity of their recollections than do control subjects, regardless of accuracy; and the effect of condence is greater in highly hypnotizable persons. Since not all research has disclosed a difference between normal and hypnotized subjects in their level of condence, it appears that this effect is a potential and into a per se accompaniment of hypnosis. Complicating the acceptance of hypnotically obtained reports as valid is the fact that confabulation appears to be a normal component of human
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memory. The hypnotized subject may incorporate these confabulated recollections as part of his or her memory and then tend to accept such recollections with condence and as the truth. Even when such memories are in fact false, hypnosis may produce a greater degree of condence or belief that they are real (Dywan & Bowers, 1983).
LABORATORY EXPERIMENTS
There are a number of laboratory investigations that have been designed to study the nature and effectiveness of hypnotically inuenced memory. These have been reviewed by Pettinati (1988) and Smith (1983). In general, these research studies have been based on contrived, analogue methodologies using uninvolved laboratory volunteer subjects and not real-life events and people who were personally involved, as in a crime. The laboratory experiments have tended to show limited and even negative results from the use of hypnosis.
REAL-LIFE STUDIES
There is a relative paucity of published reports of hypnotic efcacy based on real-life cases, which may be explained in part by the fact that practitioners as a group do not publish their clinical ndings as frequently as do their academic colleagues. Even so, a number of such reports are available. In a review of experiences in the Los Angeles Police Department, Reiser (1980) reported more than 90 percent verication of the additional information obtained by hypnosis. In one sample of 67 interviews, new investigative leads were obtained in 78 percent of these cases, and the solutions of 16 percent of these cases were directly attributable to the hypnosis. In another series of 348 cases, 79 percent yielded additional information not previously known. In further comment on the hypnosis program in the Los Angeles Police Department, Reiser and Nielson (1980) revealed that in some 374 interviews, 92 percent of subjects reached a light to deep hypnotic depth; 85 percent improved recollections from a slight to signicant degree; and 80 percent produced additional information with hypnosis, two-thirds of which was considered important to the case. Where corroboration was possible, 91 percent was found to be accurate and seven percent was determined to be inaccurate. Hypnosis was considered a signicant factor in the resolution of 65 percent of these cases. Another nding was that no subject experienced ill effects from the interview, while 40 percent felt emotional relief or benet. Similar psychological benet is frequently reported by others. Yuille and Kim (1987) reported results of a Canadian study of 41 cases. Hypnotic interviews nearly tripled the amount of total information obtained, and every subject displayed an increase. Accuracy was found in
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82 percent of the recollections. They also noted that 80 percent Of the information provided in the initial (i.e., nonhypnotic) interviews was repeated in the hypnotic interviews. This repeated information constituted only 32.1 percent of the facts recalled under hypnosis, which means that 67.9 percent of the facts from the hypnosis interview were new. Of the information that was comparable between the two interviews, 94.1 percent was consistent (p. 424). Kleinhauz, Horowitz, and Tobin (1977) described a series of Israeli police cases in which hypnosis was instrumental in increasing recollections in 24 of 40 instances. Sixteen of these 24 cases were further studied to ascertain the accuracy of the memories, and of these, 14 showed a signicant increase. In a symposium presentation at the 1992 annual meeting of the Society for Clinical and Experimental Hypnosis, Gravitz, Ault, Gelles, and Hibler (1992) reported on efcacy outcomes in investigative hypnosis interviews conducted by several law enforcement agencies. Successful results were found in 1075 percent of the cases. It is evident that hypnotic interviews in real-life cases can be a useful technique in assisting the resolution of police cases that, typically, were at a dead end in their investigation.
LEGAL ISSUES
There are several principal areas of legal concern that pertain to the admissibility of hypnotically based testimony in a court of law (Worthington, 1979). These include the general acceptance by the scientic community involved that such evidence is reliable (the Frye Rule), the allegation that the use of hypnosis denies an accused the constitutional right of confrontation and cross-examination, the possible denial of due process since the hypnotized subject is said to be vulnerable to suggestion, and the legal theory that material evidence in the form of a memory trace may be either negligently or deliberately damaged or destroyed. While the rst of these concerns is the one that is most often raised, the others could be introduced, and the expert witness must be prepared to confront them. A number of landmark legal decisions have shaped developments in the eld (Worthington, 1979). If a court rules that the testimony of a witness who has been hypnotized was not admissible, then judicial and law enforcement authorities understandably would be averse to utilizing the method, as that could then prevent victims and witnesses from testifying and could thereby negatively impact their case. While various courts over the past hundred years have ruled for and against hypnosis, there has been a mitigating trend especially over the past quarter century toward greater acceptance, since the California Supreme Court in People v. Ebanks (1897) ruled that all testimony by a hypnotist was excludable because the law of
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the United States does not recognize hypnotism (p. 1053) in the matter of a defendant who, while hypnotized, had denied his guilt. Following that early decision, there have been a series of cases that either supported or were critical of the use of hypnosis in assisting recollection. In Leyra v. Denno (1954), confessions obtained by hypnosis were rejected on the grounds that such statements were per se involuntarily given, a belief consistent with the contemporary understanding of hypnosis. Likewise, the claim that hypnosis renders all statements true has also been consistently rejected (People vs. Blair, 1979). In People v. Quaglino (1977), a California trial court permitted and the Court of Appeals upheld a conviction for murder, in part because the defense had failed to object to the use of hypnosis. In State v. McQueen (1978), a North Carolina court held hypnotic testimony to be admissible and left it to the jury to determine the weight to be assigned to the evidence. In that decision, the court ruled that hypnotically refreshed memory did not render the witness incompetent to testify regarding present recollections. Hypnotic regression as an uncovering technique was upheld in the civil case of Wyler v. Fairchild Hiller Corp. (1974), although here too the court held that it was up to the jury to determine the credibility and reliability of the testimony. In the Maryland case of Harding v. State (1968), the court permitted the testimony of a rape victim who had remembered important details following hypnosis. The appeals court ruled that the admissibility of expert testimony is basically a matter for the hearing judge to determine, and it emphasized the importance of the professional credentials and expertise of the psychologist who had administered the hypnosis. In State v. Jorgenson (1971), an Oregon court held that hypnosis of a prosecution witness was admissible provided that an adequate cross examination was possible by the defense. In the civil suit of Kline v. Ford Motor Company (1975), an accident victim who had sustained head trauma and amnesia recalled in full the events leading up to the injury. Although the trial court excluded this testimony on the grounds that hypnosis per se made the subject incompetent to testify to the facts recalled after hypnosis, the appellate court found this ruling to be erroneous. In Cornell v. Superior Court (1959), the court upheld the position that an accuseds rights to counsel included the right to be hypnotized in order to aid in the preparation of his defense, and the sheriff was ordered to provide appropriate facilities for the interview. In a highly unusual case (State v. Nebb, 1962), a defendant testied while in hypnosis in the courtroom. As a result of the disclosures made in that testimony, the prosecution reduced the charges against him. In this instance, the court ruled that hypnotically obtained evidence would be excludable if it incriminated the witness. In the landmark case of State v. Hurd (1981), the New Jersey Supreme Court recognized the risks of confabulation and suggestibility, but it sought
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to minimize or negate these problems by requiring procedural guidelines. The facts in this important case were that the sole prosecution witness, who had been the victim of a knife attack during the night in her home, was unable or unwilling to identify her assailant. At the initiative of the prosecutor, the victim was hypnotized to refresh her memory, and during an emotional revivication she identied her attacker as the defendant, her former husband. Although she later expressed some doubts about her retrieved recollections, she reafrmed her identication and the defendant was indicted. On appeal, the New Jersey Supreme Court found that the purpose of hypnosis was not to obtain truth, as a polygraph . . . is supposed to do, but rather to overcome amnesia and restore the memory of a witness (State v. Hurd, 1981, p. 92). Furthermore, Hypnosis can be considered reliable if it is able to yield recollections as accurate as those of an ordinary witness, which likewise are often historically inaccurate (p. 92). That was a critical point, since all human memory and nonhypnotic witness testimony in general is inherently non-literal, reconstructive, and therefore subject to distortion (Loftus, 1979). In a thoughtful and well-researched opinion, the Hurd court concluded that hypnosis was admissible if it was conducted properly, in support of which it adopted six procedural guidelines. These were that: the hypnosis should be conducted by a psychologist or psychiatrist trained in hypnosis; the qualied professional should be independent of the prosecutor, defense, or investigator; information provided to the professional should be in a written form; the professional should obtain from the subject a pre-hypnosis account of the facts as they are remembered; all contacts between the professional and the subject should be properly recorded; and only the professional and the subject should be present during any phase of the hypnotic session. The court also noted the importance of independent verication of hypnotically induced recollections. Many other courts subsequently adopted the Hurd rules, or similar steps, as these procedural requirements have been called. The 1982 California case of People v. Shirley (1982) was particularly important and instructive in its time. A woman claimed that she had been raped, and the night before the trial she was hypnotized to refresh her memory, after which she modied important aspects of her story. Heavily basing its decision on a critical law review article (Diamond, 1980), which claimed that hypnosis per se rendered an individual inherently unreliable and vulnerable to inuence, the state Supreme Court not only excluded hypnotic testimony in that matter but also ruled that no witness or victim who had been hypnotized could testify in the future. Shirley has been faulted for a number of reasons. During the situation in question, the alleged victim admitted that she had been intoxicated to the point of blackout. She also had sat nude in the company of the defendant in her apartment, where the alleged crime had occurred, after the
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alleged rape and during the interval when he had left the premises to buy more beer. Despite the opportunity provided by his absence, the plaintiff did not then contact authorities but, instead, did so only after a friend had encouraged her to le a complaint. Furthermore, the hypnotist was a lawyer who possessed no professional qualications in hypnosis but was himself a member of the states prosecutorial team and therefore not a disinterested party to the legal proceedings. Several months after its initial ruling on Shirley, the California Supreme Court issued a modication of opinion in 1982 in which it held that When it is the defendant himselfnot merely a defense witness who submits to pre-trial hypnosis, the experience will not render his testimony inadmissible if he elects to take the stand (People v. Shirley, 1982, p. 3). This change was adopted in order to uphold the constitutional right of an accused to defend oneself. The modication of Shirley and its emphasis on the right of a defendant to testify on his own behalf was soon followed by the Rock case. Vicki Rock, an Arkansas resident, was accused of killing her husband during an argument. She claimed that the shooting was an accident and that she had not had deliberate intent. To aide her defense, she was twice hypnotized by a psychologist, and as a result she was then able to recall that her nder had not been on the trigger when the weapon discharged but that the gun had red after her husband grabbed her arm. As a consequence of that recollection, an expert on guns examined the weapon in question and determined that it had a defective trigger mechanism that was apt to re when struck even slightly, as during the altercation that had preceded the shooting. Reecting the inuence of Shirley, a lower court in that state had ruled that the gun expert could not testify as to his ndings because they arose as a result of hypnosis, which was allegedly inherently unreliable, and Vicki Rock was convicted. That decision was upheld by the Arkansas Supreme Court. The case was eventually brought to the U.S. Supreme Court, and in a split decision, the highest tribunal ruled that the defendants right under the constitution to testify in her own behalf had been violated by the previous per se exclusion of hypnotically derived testimony. This decision turned to the Fifth Amendment, which guarantees the right of an accused to call witnesses in ones behalf and the Fourth Amendment, which pertains to the applicability of the Sixth Amendment to the states as well as to the federal government (Rock v. Arkansas, 1987; Udolf, 1990). Although limited in certain respects, the Rock decision helped pave the way for a more enlightened and careful use of forensic hypnosis, and the frequency of applications increased together with a greater acceptance of hypnotic-based testimony. In the federal courts, guidance had been provided by a set of procedural standards established by the Federal Bureau of Investigation and approved
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by the United States Department of Justice. This has been termed the Federal Model and has been used since 1968 with virtually no controversy (Ault, 1980; Hibler, 1984a, 1984b). Investigators, known as coordinators, are present during the interview and are responsible for making the arrangements for the procedures. Also, hypnosis can be used with special cases and then only after approval by higher administrative and legal authorities, the session must be recorded, the induction and interview itself are conducted by a psychologist or psychiatrist with special qualications in hypnosis, and the records are maintained in a chain of custody. A complete description of these Federal Model requirements is available in Ault (1980). The previous discussion is not intended to be an exhaustive compilation of relevant case law. That is available in Hughes (1991) who has analyzed civil cases, Shaw (1991), and Warner (1979) who has considered issues of admissibility in criminal matters. In summary, various courts have advanced three positions regarding hypnotically facilitated memory (Udolf, 1983). Some jurisdictions have treated hypnosis like any other method of memory refreshment and have relied on the trier of fact (judge and/or jury) to determine its reliability and the amount of weight that it should be given. Other courts have admitted hypnotic testimony provided that certain specied preconditions or procedural rules were followed to minimize the potential for error, and yet other courts have regarded all testimony of a previously hypnotized witness as inherently unreliable and therefore inadmissible. The practice of forensic hypnosis is advanced by adherence to a set of procedures that the courts will accept, for unless the testimony enabled by hypnosis is admissible, then there could be a negative impact on a case. Since the Hurd Rules and the Federal Model present certain practical problems, the following are recommended as meeting the essentials of both, as well as incorporating changes that enhance application and admissibility in the event the case progresses to that point.
Conducting the Interview

The following procedures are recommended for the conduct of a forensic hypnosis interview. They are based on experience and are within the context of the relevant legal rulings discussed previously. While it is preferable to have the referral for forensic hypnosis submitted in written form, this may not be practical since the initial contact with the professional is usually accomplished by a telephone call. At that time, the availability of the clinician is established and a brief outline of the purpose of the interview is described. Appropriate records must be made and maintained from the rst contact. The forensic hypnotist should be well qualied as a mental health professional and should therefore be either a clinical psychologist or psychiatrist
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with special training and experience in hypnosis; most forensic hypnosis is presently being performed by psychologists (Gravitz, Ault, Gelles, & Hibler, 1992). Possession of a specialty diploma awarded by either the American Board of Psychological Hypnosis or the American Board of Medical Hypnosis is highly desirable, as are other indications of achievement recognized by professional peers. The interviewer should be qualied to intervene and manage any undue emotional expression, such as catharsis, on the part of the subject. Such credentials serve to underscore the professional and legal qualications of the clinician as an expert. The location of the interview should preferably be on neutral ground, such as the professionals ofce. In certain circumstances, use of otherwise appropriate facilities elsewhere may be used. Furniture, such as chairs, should be comfortable, and lighting should not be glaring. Noise level should be minimal. The clinician should not be an agent of either the prosecution, defense, or investigating authority, even though the fee for services may be paid by any of these parties. Most of all, the professional should have no vested interest in the outcome of the investigation. Preferably only the subject and the hypnotist should be present in the room when the hypnosis is undertaken. For practical reasons, however, other personnel might include an investigative ofcer who has background information about the event in question, a video camera technician, or a police artist. In certain cases, the subjects legal counsel may attend to protect a clients rights (see the following case). Since distraction is to be as limited as possible, the video camera is optimally used through a one-way screen; this would remove the requirement for the presence of a camera technician. Other involved parties could observe the process through the one-way screen or on a video monitor in another room. The entire interview with the subject should be recorded, preferably by video, and the recording may be retained in the custody of the clinician in order to safeguard the chain of evidence. The interviewer may make notes during the session, and these should be made part of the case record. It is best not to undertake the interview if the subject is hungry, tired, or has to use the lavatory facilities. Inquiry prior to the hypnosis should clarify this possibility. The psychologist or psychiatrist should assure that the subject is aware of the purpose of the interview and is otherwise in good mental condition. Persons who are not of sound mind, in the legal sense, or are otherwise unduly stressed, should not be hypnotically interviewed, although situational anxiety is not infrequently observed at the onset. Such discomfort generally fades as the interview progresses. Unwilling subjects should also not be hypnotized, until and unless their reluctance is resolved. The subject should be asked to sign a release for the procedure based on informed consent. The release should also note that a report of the results of
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the interview will be communicated to the appropriate law enforcement agency or other referral source, as indicated. In the case of a minor, the release may be executed by a parent or legal guardian. Obtaining a release is not intended to convey that hypnosis is a dangerous procedure, but is rather meant to ensure that the subject is a willing and informed participant. The subject should be asked for his or her understanding of a possible experience with hypnosis. Misconceptions should be claried, and if there has been prior experience, the induction techniques used previously may be utilized in the forensic interview. Any questions posed by the subject should be answered as fully and candidly as possible. The subject should be asked for a non-hypnotic statement of the event in question prior to induction of hypnosis. Later, when the pre-hypnotic account is compared with that obtained in hypnosis, the extent of the information obtained by hypnosis can be ascertained. The induction of hypnosis then ows. When this is completed, the subject is asked for his or her account of the event being investigated. There are a variety of techniques that may be used, which have previously been discussed, and are illustrated in the several cases that are presented in a later discussion. Hypnosis should not be undertaken as a routine procedure but should be reserved for use in cases where traditional investigative procedures have already been attempted.
Forensic Hypnosis Techniques

There are a number of methods that are useful in hypnotic memory retrieval. Primary among these is the development at the onset of rapport with the subject, since a positive relationship is a prerequisite for success. Generally, a helping and supportive attitude on the part of the forensic hypnotist is indicated; however, in working with certain personality types, a different approach may be more effective. For example, a passive-dependent man was unable to recall details of an event until he was strongly directed to do so by the hypnotist. I also employ what may be termed contextual positioning, which refers to aiding the subject to perceive externally the peripheral circumstances of time, place, person, and other conditions as they existed at the time the situation to be retrieved had originally occurred. The recall of context variables surrounding an event facilitates memory. These include the time of day, temperature, physical characteristics of the surroundings, how the subject felt, preceding events, and so on. In addition, Bower (1981) has found that reinstatement of the original mood that accompanied an event aids the subsequent recall of that event. These set the stage for the original experience and assist greater recollection of information. In beginning a forensic hypnosis interview, a nondirective, free-recall approach is generally best, with inquiry for more specic information
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introduced as the interview progresses. Thus, one starts with a broad outline and then gradually spirals down to greater detail. Not only is the encouragement of imagery helpful in contextual positioning, but it is useful in helping the subject to retrieve details of the particular circumstances that are being sought. Such instructions to the hypnotized subject as, look around and describe what you see and hear, can be facilitative. Time regression, sometimes called age regression, is another important technique. This refers to the process whereby the subject is asked to re-experience an event by mentally returning to it. This does not necessarily guarantee accuracy, as with a reconstructed memory, confabulation and fantasy could result. Typically the regression proceeds better the less time has elapsed between the original situation and the hypnosis interview, but I have had successful valid recollections retrieved as long as ten years post-incident. Since forensic hypnosis tends to be a method of last resort, after more traditional techniques have been tried, it is not unusual for an interview to be conducted several months after an original event occurred. Revivication is related to regression but is fundamentally different. This refers to the re-experiencing or re-living of the effect attached to a traumatic incident. Memory regression may occur without revivication and vice versa; it is best if both can be facilitated simultaneously. Because the retrieval of repressed feelings can be disruptive to an individuals emotional equilibrium, the forensic hypnotist should be prepared to encounter and to help the subject cope with any undue psychological expressions that may arise when and if traumatic feelings are released. (See the case of the state trooper discussed later.) For this reason and others, forensic hypnotists should be qualied mental health professionals with experience in the assessment and treatment of emotional problems. Police ofcers, attorneys, and other lay persons do not possess these qualications. The affect bridge is a technique that can help the subject trace current feelings back to their origins (Watkins, 1971). It is not unusual to observe that an individual has certain emotions that are not consciously attached in the present to their past origins, and the affect bridge method aids in establishing such connections. When affect is attached to memory, more vivid, veridical, and greater amounts of information can be elicited. Releasing the subject prior to the request for information reduces the level of anxiety and thereby lowers the defenses against the retrieval of painful detail about an event that was traumatic at the time it occurred. Verbal encouragement and support are related useful methods: Youre safe now, and its all right to tell me what happened. Ideomotor signals and automatic writing can also be employed to circumvent the defenses against traumatic pain that an individual tends to erect (Gravitz, 1985a).
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Free association under hypnosis can also be an effective method to lead the subject from one detail to another, from relatively supercial and less important to deeper and more important information. There are other techniques that can be applied. Several of these are metaphorically modeled after the functions of a camera lens. A subject can be asked to zoom onto a portion of a scene, such as a face or vehicle, or to widen the angle of the image. Action can be slowed down or rolled back. Volume of sound, such as spoken words, can be turned up and made more audible, while the lighting of a scene can be made brighter. In turn, distracting peripheral noise can be reduced. Using metaphors such as stopping the tape and rolling back the action is not meant to imply that this is the manner in which memory is organized. All memory by its very nature is reconstructed and thereby inexact and in a sense distorted. Yet, certain subjects will feel more secure and consequently do better in their recall if there is distance between themselves and the recollection of a traumatic event. For such persons, asking them to visualize the incident unfolding on a television or cinema screen can help them do better. The use of such metaphors as these is not meant to infer that memories themselves are stored as in a tape recorder or videotape. This theory of memory as a static phenomenon was formulated by Peneld (1975) and is accepted today by few workers in the eld. It proposes that past experiences are somehow stored in the mind in their entirety. Hypnosis, according to this theory, enables these memories to be reproduced as an exact copy of the original experience. The tape recorder model of a machine-like memory not only lacks scientic validity, but it may mislead triers of fact and other responsible forensic agencies. In contrast to this static concept of memory as an exact mechanical device, it is best to conceptualize it as selective, reconstructive, incomplete, and subject to distortion. Scientic research has demonstrated that in hypnosis there is an increase in the quantity of both valid and fantasized recollections (Pettinati, 1988). Ones condence in the accuracy of recollections does not necessarily reect literal accuracy, a point that was made by Bartlett (1932) more than fty years ago. Thus, a hypnotized person cannot always distinguish between real and confabulated memories. It has been found that recollection can also be enhanced without hypnosis: encouragement, personal needs, free association, conscious effort, and prolonged concentration can all aid in the retrieval of forgotten experiences (Pettinati, 1988).
THERAPEUTIC SERENDIPITY
While forensic hypnosis is not intended to be a therapeutic method, the professional using such techniques must be capable of intervening and
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managing the unexpected and undue emotional reactions that may result, since hypnosis can be a powerful tool for accessing the repressed recollections and feelings of a victim or witness (Putnam, 1992). Requiring that the hypnotist be a qualied mental health professional lessens the risk to the subject that emotions that had been psychologically controlled prior to the interview could be brought to surface expression with possibly deleterious effects on well-being. An example follows: A 38-year-old state trooper was among a group of law enforcement ofcers who were taking a seminar designed to acquaint them with the applications of hypnosis in their work within the context of the model used by federal agencies (Gravitz, Ault, Gelles, & Hibler, 1992). The participants were not learning how to administer hypnosis but instead how to work with the psychological professional who did. In seeking to demonstrate the induction process, the course leader who was a clinical psychologist asked for a volunteer from the audience, and the trooper agreed to serve in that role. He proved to be a good subject, and induction proceeded uneventfully. The psychologist then sought only to elicit the memory of a prior experience and asked the hypnotized trooper to go back to an earlier time that was important to you. After a brief pause, the subject began to display overt signs of distress, including tears, sobbing, clenching of both sts, and overall bodily tension. At that time, he was on routine patrol in his vehicle on a state highway when he received a radio message directing him to assist with the management of an automobile accident. Upon arriving at the scene, he observed a passenger car on re and was told by onlookers that the driver of the vehicle was unconscious and unable to exit. When the ofcer rushed to the car to remove the driver, he found that the doors were either jammed or locked and could not be opened. Consequently, he had to watch helplessly and in horror as the vehicle became engulfed in ames and the passenger burned to death. Evidently, the subject repressed the memory and effect of that situation, for over the following years he had no conscious recollection of it. Only when he was hypnotized in the relative security of a classroom and in the presence of a psychologist was he able to surface the extreme frustration, fear, and guilt feelings that he had had at the time of the original experience. The demonstration was of course terminated, and the subject was provided with the private opportunity to discussnallyhis reactions at the scene of the fatal accident. He was also referred to the Employee Assistance Program of his unit for further counseling.
RESISTANCE
Despite expressions of positive motivation, desire to cooperate, and the fact that nearly all persons may be regarded as hypnotizable (Hilgard, 1965), subjects may display resistance in the forensic hypnosis situation.
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There are a number of determinants for such behavior (Gravitz, 1985b), including the following: 1. Distraction in the environment. This includes such factors as noise inside and external to the location where the hypnotic interview is conducted, temperature that may be uncomfortable, inappropriate lighting, and even furnishings and d ecor. In general, the fewer individuals in the ofce where hypnosis is being done, the less will be the distraction and the better will the interview progress. All evident sources of distraction should be avoided or removed. 2. Inappropriate methods of induction. Certain imagery may stimulate negative associations in the subject; for example, suggesting a usually relaxing image of a warm and sunny beach may prove counterproductive to an individual who is phobic of swimming. In such instances, the utilization of more appropriate imagery content or other methods of induction is indicated. 3. Negative transference. If a subject has negative feelings, such as fear of or hostility toward authority gures, these may be transferred to the hypnotist. Preliminary inquiry can be useful in uncovering such dynamics. 4. Shame and embarrassment. A victim of crime may be reluctant to discuss openly certain experiences because of their personal implications. For example, a female rape victim may resist describing her experience with a male interviewer. In that event, using a hypnotist of the same gender could facilitate the process. 5. Obsessive personality traits. There are some persons who are so concerned with making a perfect and non-mistaken identication that they block in recall. It would be helpful in such cases to ask the subject to begin their account in a general way and only subsequently to become more specic about particulars. 6. Misconceptions about hypnosis. Resistance may arise when there is the belief that hypnosis is a form of mind control or mental coercion. There may also be a concern about inadvertently slipping back into a past life or that there will be an inability to be alert when the interview is concluded. Reluctance to proceed because of such factors can be managed by preliminary noting that it is the subject who basically controls the hypnotic situation (Gravitz, 1971). 7. Fear. This can arise from several sources. Some witnesses or victims may have been threatened with physical harm to themselves or others if they identify a perpetrator. Other subjects may seek to maintain control over the expression of underlying emotional expression, and they may be reluctant to display powerful affect. 8. Religious belief. A few denominations teach their adherents that hypnosis is a satanic scheme and that it deprives one of self-determination. While such misconceptions have no scientic basis, if clarifying explanations are
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unsuccessful, then other means of eliciting information may have to be considered, since the forensic hypnotist should be respectful of a subjects personal beliefs. 9. Culpability. In general, suspects in a criminal matter are not considered appropriate for forensic hypnosis because of Fifth Amendment concerns. However, if they willingly and knowingly agree to such a stipulated interview, it may be undertaken because the retrieval of information could serve to clear a suspect of personal involvement (Mutter, 1990). In summary, there are a variety of both conscious and unconscious reasons why a subject may be resistant. In such situations, resistance should be recognized as a defense mechanism, and resolution of such difculty should be attempted.
ILLUSTRATIVE CASES
There are many cases that can be cited to illustrate the effectiveness of forensic hypnosis. Most of these typically concern the description of an alleged perpetrator, vehicle, crime scene, or other circumstances surrounding an event under investigation by law enforcement authorities (Gravitz, 1985a). Other cases, however, are not so typical.
Case A
An attorney asked a psychologist if hypnosis could help his client, a 28-year-old woman, to refresh her memory in order to obtain additional information about an incident that had resulted in her arrest and conviction of murder in the rst degree. The attorney was preparing an appeal but could nd no circumstances that had not been brought out in the original trial. The original police report showed that several months previously the client had been involved in an altercation with another younger woman whom she confessed to having stabbed to death with a knife. While this appeared to be another instance of impulsive-driven street crime, there was no motive, no witness had come forward, and the client was unable to recall more than that she had become lost in a strange part of the city while on her way to visit a relative, and before I knew it she and the victim, who was unknown to her, had begun to ght. The client did not deny having killed the victim, but she could not identify the knife used as belonging to her. The conviction was based mainly on circumstantial evidence and the clients ready confession to the authorities. The subject was interviewed in the psychologists ofce, and the proceedings were videotaped. In hypnosis using a time-regression approach, the subject was asked to return to where she had been prior to nding herself in the strange neighborhood. Using the present tense, she then related
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that she was taking a bus to visit a relative who lived across town. She mistakenly got off the bus at what she believed was her transfer point, but instead found herself lost in an unfamiliar locale. Seeking to phone her relative for directions, she found that she had no change in her purse, so she went to the door of a nearby apartment building intending to ask if she could use someones phone. On entering the buildings lobby, she encountered several teenage girls who rushed her and attempted to snatch her purse. In panic, the client ed with the teenagers in pursuit. The subject in hypnosis voiced her fear as she ran that she would be robbed or worse. She managed to outrun all but one of the girls, and as the latter caught up with her, the two of them collided and both fell to the pavement. As the client struggled to disengage herself, her pursuer drew a knife from her coat. At that point in the interview, the client screamed out that she was going to be killed, and she made motions indicating that she was pushing her assailants hand away. It was then that the subject apparently turned the knife against her pursuer. A passing police cruiser arrested her as she ed still clutching the knife with which the victim had been stabbed. After the psychologists report, including the videotape, was made available to the trial judge, he reduced the charge to involuntary manslaughter and the sentence to time served. The client was then released.
Case B
In a civil action, two parties to a collision of automobiles early one morning were suing each other for damages, each alleging the responsibility of the other. There were no immediate witnesses to the accident. The two damaged vehicles were both situated on the painted median strip, and both drivers were found unconscious. One of the parties asked to be hypnotized in order to retrieve her memory for the incident. She proved to be a good subject, responding to classical induction procedures. Time regression was the investigative method employed, and the subject was able to report considerable detail concerning her automobiles progress prior to and up to the time of the collision. No new information was initially obtained, however, and although she faulted the other driver, this could be construed as self-serving. The subject was then asked to repeat her account of the events, and she was told to look about even more, bearing in mind that prodding a subject may lead to confabulation. At that point, the client remarked that a second car was being driven behind the other across the street, a report that she had not previously made. She was asked to describe the second vehicle, which she did, and she also noted that it had a windshield sticker of a variety used for parking purposes at a local hospital, which was nearby. She also revealed that the driver was a white blur. With the aid of the description of the second car and its driver, an investigator was able to identify a nurse at that local hospital who
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admitted that she had witnessed the accident while on her way home that morning after working the night shift and still wearing her white uniform. She was tired and hungry and did not want to become involved, so she had not stopped at the time. When interviewed further by the investigator, the nurse reported that she had observed that the car in front of her had swerved into the path of the client. The trial judge, a federal jurist since the hearing took place in the District of Columbia, heard the new testimony and then ruled in favor of the subject, awarding her a considerable sum for damages.
Case C
In another case, the attorneys for a public gure requested hypnosis to aid in the retrieval of information concerning the disposition of a large sum of money. The Internal Revenue Service had alleged that their client had received the funds seven years previously, and the government was seeking back income tax, interest, and penalties on that amount. The government was agreeable to dropping its charges if the client could prove, as he claimed but could not recall, that he had disbursed the money that he acknowledged receiving to various other individuals for certain services performed by them. When the client arrived at the psychologists ofce, he was accompanied by his two attorneys, who asked that they be present during the interview to ensure that their client made no self-incriminating statements and otherwise to protect his rights under law. This was a legitimate request, and they were permitted to remain in the room but out of sight of both the client and the clinician. Each of the two attorneys operated a hand-held audio recorder. The subject was an excellent hypnotic subject, who responded quickly to an optical-xation mode of induction. Soon after his eyes closed, however, he spontaneously opened them, but when the interviewer asked if he was hypnotized, the client replied in the afrmative, so the interview continued. Direct questioning of the client proved to be nonproductive, so another strategy was undertaken. The subject was hypnotically regressed back to the ofce that he had occupied at the time seven years previously when he had admittedly received the funds. The interviewer then identied himself as and played the role of the subjects secretary. In that role, the client was told that the secretary was preparing a budget based upon the amounts of money disbursed to whom and for what purposes. The client immediately rose to his feet from the chair where he had been sitting and began to pace the oor with his eyes open. He then dictated at length and in good detail the budgetary items to the secretary and was successful in accounting for the bulk of the information required by the Internal Revenue Service. After he had completed the listing, he was asked by the interviewer to
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return to the seat and close his eyes, which he did. The subject was then gradually and uneventfully alerted by a numerical count-up method, and he was then asked how he felt. His rst words were an apology for not having been able to be hypnotized, and it quickly became apparent that the subject was posthypnotically amnestic for what had transpired, including the dictation of the budget. While the entire interview covered two hours, the subject after alerting gave the estimated time interval as 10 minutes. The lawyers who were present laughed and one of them partially played back his tape recording of the interview. Expressing astonishment, the subject then acknowledged that he must have indeed been hypnotized. There was no further contact with the subject, but several months later a newspaper story reported that the Internal Revenue Service had accepted his accounting and had closed its claim against him. In other cases, subjects have been assisted in recalling conversations by asking them to turn up the volume, words painted on the backs of trucks have been retrieved to identify vehicles, and events occurring in dim light have been brightened for greater clarity. While most forensic hypnosis interviews have been administered to adults, it is also feasible to apply the method to appropriate children. As Hilgard (1965) has shown, children tend to be good hypnosis subjects, perhaps even better than older persons. In my experience, a child as young as four years old was able to draw the picture of a man whom she had seen in the company of her mother shortly before the latter was found murdered. An investigative ofcer recognized certain facial features on the drawing as those of someone he knew, who was subsequently identied as the mothers assailant. In another case, a ve-year-old boy was able to describe in sufcient terms the man who had abducted him from his home in the middle of the night and whose identity was previously undetermined. At times, a retrieved forgotten memory may be valid but irrelevant. As an example, a 32-year-old woman who was a Latin American immigrant briey overheard, and then observed, the automobile of a male who was suspected by the police of a series of assaults on children in the neighborhood. During hypnosis, she was able to recall what she described as the vehicle tag of the suspects car. Upon investigation, the tag number was found to be that of her own husbands car, which had been sold two years previously and which she had forgotten. As is common in many forensic hypnosis cases, however, a seemingly minor peripheral nding during this interview proved to t a suspect who was later apprehended for the offensesshe was able to identify the Spanish-accented English of the man whom she had overheard as that of one who came from a certain country in South America.
ETHICAL CONSIDERATIONS
The ethical issues associated with the practice of forensic hypnosis have been discussed by Gravitz, Mallet, Munyon, and Gerton (1982) and Meyer
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(1992). These are based upon the overall guidelines established by the practitioners own profession and the major hypnosis societies that have formulated their own standards (International Society of Hypnosis, 1979; Society for Clinical and Experimental Hypnosis, 1979). Where the contents of a case, including notes, recordings, reports, and expert testimony, may later become a matter before the courts, the clinician should inform the client of this possibility and its implications. As noted elsewhere in this chapter, a written release based upon informed consent should be obtained from the subject early in the process. Legal advice should not be provided by the interviewer, but instead such questions should be referred to the clients counsel. The practitioner must be knowledgeable of the relevant research, especially that which pertains to the potential distortions of memory. In that regard, there should be awareness that the mere wording of a question must also recognize the possibility of subtle and unintentional communication to the subject by verbal or other cues. In addition, there must be sensitivity to the fact that the subject matter involved in a forensic hypnosis interview frequently involves traumatic past experiences, certain of which may be unresolved. Consequently, the need to know must be carefully balanced against the needs of the individual with respect to the events under investigation. Because the practice of hypnosis is virtually unregulated by statute, the eld is open to inltration by persons with less than thorough qualications, the latter including education, training, experience, competence, and integrity. This makes it all the more necessary for the ethical professional in forensic hypnosis, and indeed all professionals who use hypnosis, to perform their services in the most circumspect manner with full regard for the rights and well-being of the individual with whom they are working,
SUMMARY
This chapter has presented an overview of the applications of forensic hypnosis from a practice-oriented viewpoint. Its early origins in the nineteenth century and its resurgence in the 1970s are discussed, together with landmark legal decisions that have shaped the development of the eld. Based on the psychology of memory and its operations as they are understood today, the phenomenon of hypermnesia is reviewed together with such possible consequences as confabulation, selective reconstruction, and enhanced level of condence. Areas of application and specic techniques are described. Experimental analogue research from the laboratory on hypnotically facilitated recall is cited, as are the results reported by a number of law enforcement agencies that have been derived from real-life cases with personally involved witnesses and victims. The differences in outcome between these two methods of research are noted. A set of procedures for the conduct of forensic hypnosis interviews is described, and these have been designed to mesh with and be acceptable to the requirements
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established in important legal decisions, notably the Shirley, Hurd, and Rock cases in recent years. A number of cases illustrating the techniques and experiences are presented, along with comments on resistance and the ethical implications of the method.
REFERENCES
Anonymous. (1848). Trial for murder. Mysterious disclosures. American Journal of Insanity, 4, 303346. Ault, R. L. (1980). Hypnosis: The FBIs team approach. FBI Law Enforcement Bulletin, 49, 58. Bartlett, F. C. (1932). Remembering: A study in experimental social psychology. Cambridge: Cambridge University Press. Bernheim, H. (1891/1980). New studies in hypnotism (Translated from the French). New York: International Universities Press. Bower, G. H. (1981). Mood and memory. American Psychologist, 36, 129148. Cornell v. Superior Court of San Diego County (1959). 52 Cal. 2n 338P 2d 447. Council of Scientic Affairs. American Medical Association. (1985). Scientic status of refreshing recollection by the use of hypnosis. Journal of the American Medical Association, 252, 19181923. Diamond, B. L. (1980). Inherent problems in the use of pretrial hypnosis on a prospective witness. California Law Review, 68, 313349. Dywan, J., & Bowers, K. S. (1983). The use of hypnosis to enhance recall. Science, 222, 184185. Gravitz, M. A. (1971). Psychodynamics of resistance to hypnotic induction. Psychotherapy: Theory, Research, and Practice, 8, 185197. Gravitz, M. A. (1980). The uses of forensic hypnosis. American Journal of Clinical Hypnosis, 23, 103111. Gravitz, M. A. (1983). An early case of hypnosis used in the investigation of a crime. International Journal of Clinical and Experimental Hypnosis, 31, 224226. Gravitz, M. A. (1985a). A case of forensic hypnosis: Implications for use in investigation. In J. M. Dowd & E. T. Healy (Eds.), Case studies in hypnotherapy (pp. 213221). New York: Guilford Press. Gravitz, M. A. (1985b). Resistance in investigative hypnosis: Determinants and management. American Journal of Clinical Hypnosis, 28, 7683. Gravitz, M. A. (1991). Early theories of hypnosis: A clinical perspective. In S. J. Lynn & J. W. Rhue (Eds.), Theories of hypnosis: Current models and perspectives (pp. 1942). New York: Guilford Press. Gravitz, M. A. (1993). Etienne Felix dHenin de Cuvillers: A founder of hypnosis. American Journal of Clinical Hypnosis, 36, 711. Gravitz, M. A., Ault, R., Gelles, M., & Hibler, N. S. (1992). Real-life experiences with forensic hypnosis. Symposium presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington, Virginia. Gravitz, M. A., Mallet, J. E., Munyon, P., & Gerton, M. I. (1982). Ethical considerations in the professional applications of hypnosis. In M. Rosenbaum (Ed.), Ethics and values in psychotherapy (pp. 297312). New York: Free Press-Macmillian.
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Greene, E., Wilson, L., & Loftus, E. F. (1989). Impact of hypnotic testimony on the jury. Law and Human Behavior, 13, 6178. Harding v. State (1968). 5 Md. App. 230, 246A 2d 302. Hibler, N. S. (1984a). Forensic hypnosis: To hypnotize or not to hypnotize, that is the question. American Journal of Clinical Hypnosis, 27, 5257. Hibler, N. S. (1984b). Investigative aspects of forensic hypnosis. In W. C. Wester & A. H. Smith (Eds.), Clinical hypnosis: A multidisciplinary approach (pp. 525557). Philadelphia: Lippincott. Hilgard, E. R. (1965). Hypnotic susceptibility. New York: Harcourt Brace and World. Hughes, L. Z. R. (1991). Hypnosis in the civil case: The problem of confabulating plaintiffs and witnesses. Florida Bar Journal, 65, 2530. International Society of Hypnosis (1979). Resolution adopted August 1979. International Journal of Clinical and Experimental Hypnosis, 27, 453. Johnson, J. A. (1981). Hypnosis as a criminal technique in the Department of Defense. Armed Forces Law Review, 22, 2058. Kleinhauz, M., Horowitz, I., & Tobin, Y. (1977). The use of hypnosis in police investigation. Journal of the Forensic Sciences Society, 17, 7780. Kline v. Ford Motor Company (1975). 523 F. 2d 1067. Kroger, W. S., & Douce, R. G. (1979). Hypnosis in criminal investigation. International Journal of Clinical and Experimental Hypnosis, 27, 358374. Kroger, W. S., & Douce, R. G. (1980). Forensic uses of hypnosis. American Journal of Clinical Hypnosis, 23, 8693. Labelle, L., Lamarche, M. C., & Laurence, J. (1990). Potential jurors opinions on the effects of hypnosis on eyewitness identication. International Journal of Clinical and Experimental Hypnosis, 38, 315319. Leyre v. Denno (1954). 347 U. S. 556, 74 S. Ct 716, 98 L Ed. 948. Loftus, E. F. (1979) Eyewitness Testimony. Cambridge: Harvard University Press. Loftus, E. F., & Zanni, G. (1975). Eyewitness Testimony: The inuence of the wording of a sentence. Bulletin of the Psychonomic Society, 5, 8688. Lynn, S. J., & Rhue, J. W. (Eds.). (1991). Theories of hypnosis: Current models and perspectives. New York: Guilford Press. Meyer, R. G. (1992). Practical clinical hypnosis. New York: Lexington Books. Moll, A. (1889/1958). The study of hypnosis. (Translated from the German). New York: Julian Press. Mutter, C. B. (1990). Hypnosis with defendants: Does it really work? American Journal of Clinical Hypnosis, 32, 257262. Peneld, W. (1975). The mystery of the mind. Princeton, NJ: Princeton University Press. People v. Blair (1979). 89 Cal. App. 3d 563, 152 Cal. Rptr. 646. People v. Ebanks (1897). 117 Cal 652, 49 P. 1049. People v. Quaglino (1977). Crim. No 29766 (Cal. App. 2nd Ds unrep.). People v. Shirley (1982) 31 Cal. 3d 18, 641 P2d 775; modied 918a (1982). Pettinati, H. M. (Ed.). (1988). Hypnosis and memory. New York: Guilford Press. Putnam, F. W. (1992). Using hypnosis for therapeutic abreactions. Psychiatric Medicine, 10, 5165. Reiser, M. (1980). Handbook of investigative hypnosis. Los Angeles: LEHI Publishing. Reiser, M., & Nielson, M. (1980). Investigative hypnosis: A developing specialty. American Journal of Clinical Hypnosis, 23, 7577.
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Rhue, J. W., Lynn, S. J., & Kirsch, I. (Eds.). 1993 Handbook of clinical hypnosis. Washington: American Psychological Association. Rock v. Arkansas (1987). 107 S. Ct. 2704 (Reprinted in International Journal of Clinical and Experimental Hypnosis [1990] 38, 219238). Shaw, G. M. (1991). The admissibility of hypnotically enhanced testimony in criminal trials. Marquette Law Review, 75, 177. Smith, M. C. (1983). Hypnotic memory enhancement of witnesses: Does it work? Psychological Bulletin, 94, 387407. Society for Clinical and Experimental Hypnosis (1979). Resolution adopted October 1978. International Journal of Clinical and Experimental Hypnosis, 27, 452. State v. Hurd (1981). 86 N.J. 525, 432 A. 2d 86. State v. Jorgenson (1971). 49 Pac. 2d 312 (Oregon App.). State v. McQueen (1978). 295 N.C. 96, 244 S.E. 2d 414. State v. Nebb (1962). No 39540 (Ohio Com. Pl. Franklyn Co. May 28, 1962). Udolf, R. (1983). Forensic hypnosis: Psychological and legal aspects. Lexington MA: Heath. Udolf, R. (1990). Rock v. Arkansas: A critique. International Journal of Clinical and Experimental Hypnosis, 38, 239249. Warner, K. E. (1979). The use of hypnosis in the defense of criminal cases. International Journal of Clinical and Experimental Hypnosis, 27, 417436. Watkins, J. G. (1971). The affect bridge: A hypnoanalytic technique. International Journal of Clinical and Experimental Hypnosis, 19, 2127. Worthington, T. S. (1979). The use in court of hypnotically enhanced testimony. International Journal of Clinical and Experimental Hypnosis, 27, 402426. Wyller v. Fairchild Hiloer Corp (1974). 503 F. 2d 506 (9th Cir.). Yuille, J. C., & Kin, C. K. (1987). A eld study of the forensic use of hypnosis. Canadian Journal of Behavioral Sciences, 19, 418429.
Chapter 5
Hypnosis in Popular Media

Deirdre Barrett
Hypnosis has a dark and lascivious history in literature, lm, and even song. For the past two centuries, ctional mesmerists have swung watches, twirled spiral discs, and transxed the unsuspecting with their piercing gaze. Maidens surrendered their virtue and good men staggered away, glassy-eyed, to steal and killwhile those of us familiar with real hypnosis convulsed with laughter or indignation. This chapter chronicles the negative stereotypes of hypnosis in novels, lm, television, the visual arts and even music, and examines the handful of positive exceptions. I will compare this to the more positive portrayal of psychotherapy and dreams in the arts and explore why theres such a contrast in portrayals of these similar realms. George du Mauriers Trilby (1894) has been the most inuential prototype for both literary and lm hypnosis. The novel topped British and American bestseller lists at the advent of cinematography. It describes mesmerist Svengali seducing naive young Trilby while endowing her with an unearthly singing voice. At least eight versions have been lmedmost titled Svengali rather than Trilby, signifying how powerfully the hypnotist captured the popular imagination. These ranged from a 1911 silent melodrama to a 1983 made-for-TV movie with Jodie Foster as Trilby (Svengali 1911; Kolm & Fleck, 1912, 1914; Righelli & Grund, 1927; Mayo, 1931; Langley, 1955; Svengali, 1981; Harvey, 1983). The most successful was the 1931 version with John Barrymore in the title role. Numerous lms featured similar plots of malevolent males using hypnosis to seduce and control hapless heroines including The Hypnotic Eye (Blair, 1947) and Hipnosis (Martin, 1963). Later lms starring Barrymore, such as Rasputin and the Empress (Boleslavsky, 1932) and Dr. Jekyll and Mr. Hyde (Robertson, 1920), showed gratuitous hypnosis scenes that were not in the original material because this had become such a quintessential aspect of his lm persona.
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The second most popular application of hypnosis in lm has been to compel innocentsmale or femaleto commit murder. In the classic silent lm, The Cabinet of Dr. Caligari (Weine, 1919), the title character has a carnival act in which he controls a somnambulist for the audiences amusement. By night, he sends the somnambulist to murder sleeping men and women. At the end of the lm, the whole scenario is revealed to be a delusion of a man who expects to be the next victimDr. Caligari is actually his psychiatrist. Cabinet was so successful that Fear in the Night (Shane, 1947), Nightmare (Shane, 1956), Hipnosis (Martin, 1963), and Mask of Dijon (Landers, 1946; Mask, 1993) all featured variants of this plot, usually with the hypnotic murders treated as real. Whirlpool (Preminger, 1949) introduced self-hypnosis when villain Jos e Ferrer applied the technique immediately after major surgery, endowing himself with supernatural powers of recovery so he could leave his bed and commit murder without falling under suspicion. Sometimes, instead of requiring murder, the cinematic hypnotist compels his subject to harm himself or herself. In Orson Welless Black Magic (1949), Count Cagliostro learns hypnosis from Mesmer, and then uses it to force his enemies to suicide during the rule of Louis the XIV and Marie Antoinette. In The Hypnotic Eye (Blair, 1947), a stage hypnotist selects attractive young women from the audience, brings them on stage for innocuous antics, and then gives them secret suggestions to return home and mutilate themselves. He, in turn, is under the hypnotic control of a once beautiful performer who has suffered disguring burns. . . . Eye makes overt what is an implied premise of much of the hypnosis-for-murder genre: the hypnotist is a bitter person who would be ineffectual without this extraordinary skill. Eye was the most popular hypnotic lm of all time, with the exception of Cabinet. Eye was subtitled or dubbed into twenty languages, and the depiction of hypnosis as light entertainment masking dark destruction was disseminated around the world. Hypnosis is also a subplot in much horror and science ction. It is utilized by villain Fu Manchu in several lms bearing his name in their titles. In the original Bram Stoker novel Dracula (1897), the only episode of hypnosis is by heroic Doctor von Helsing when he hypnotizes bite-victim Lucy to get her to reveal Draculas daytime refuge. However, in all but one of the lm versions, this scene is omitted, and, instead, Dracula is the one practicing hypnosis (Browning, 1931; Melford 1931; Hillyer, 1936; Siodmak, 1943). In multiple Flash Gordon lms (Stephani, 1936; Beebe & Taylor, 1938, 1940), Flashs love, Dale, is hypnotized by the villain. With typical fties restraint, marriage is always the ultimate nefarious goal. Flash inevitably shows up just in time, carrying Dale from the wedding stiff as a board in one lm, and limp in another. Two unabashedly sensational spoofs of the genre, Invasion of the Space Preachers (Boyd, 1990) and I was a Zombie for the FBI (Penczner, 1982) featured, respectively, aliens and spies utilizing hypnosis to achieve criminal manipulation of crowds.
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The villainous use of hypnosis to commit crimes also shows up in mainstream comedies such as Abbott and Costello lms (Barton, 1948, 1949, 1951), and most recently in Woody Allens Curse of the Jade Scorpion (2001) in which Allen volunteers for a turbaned stage hypnotist and ends up compelled to commit a series of jewelry thefts.
INDUCTIONS IN FILM
When murder and other asexual malfeasance was the goal, the induction was usually accomplished by magnetic passes of the hypnotists hands close to the subjects bodymuch like those Mesmer employed sometimes elaborated to resemble a puppeteers control of a marionette. Sleepwalking was the model for the subjectclosed or glassy eyes, automaton movements. Caligari, The Bells (Apfel, 1913; The Bells, 1914; Warde, 1918; Young, 1918) and The Mask of Dijon (Landers, 1946) are all examples of this style of hypnosis. In the Svengali genre where the hypnotist is invariably male and the subject a nubile female, the induction features an intense stare by the hypnotist that is indistinguishable from what Eibl-Eibesfeldt (1989) termed the copulatory gaze. Ethologists have observed that when any two animals, including humans, stare at each other unblinkingly for more than three seconds, they are invariablyto quote one behavioral coding systemabout to either ght or fk. On the silver screen, a third alternative is that one is about to fall into a deep hypnotic trance controlled by the other. Films occasionally employ the primal applications of the stare: in 1940s Westerns, cowboys froze and locked eyes just before the shootout and Rudolph Valentinos reputation as the Great Lover was built partly on his trademark smoldering gaze. More often, however, lm reserved unbridled murderous or sexual eye contactor an ambiguous combination of the twofor the mesmerist. Eibl-Eibesfeldt (1989) noted that during the copulatory gaze, the pupils dilate. To mimic this for the mesmerist, lmmakers lined their eyes with black pencil. The metaphoric sense of energy radiating from the eyes was concretized with lighting effects. In Svengali, (Mayo, 1931) there is a glow around the eyes of the mesmerist. In animated lms, rays emanate from the eyes of the hypnotist while those of the subject spiral or go white. The lms also borrow from folk traditions about the evil eye. The Hypnotic Eyes performer holds a glass one on, and the buffoonish villain in Abbott and Costello Meet the Killer (Barton, 1949) hypnotizes the heroine with a pair of rings mounted with glass eyes. The hypnotic stare has become so much of a clich e that the 1979 comedy Love at First Bite featured dueling hypnotists commanding, Look into my eyes. No, you look into my eyes. No. There is usually a verbal inductionshorter than any in real practice but containing components of standard authoritarian ones. Hypnosis is
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depicted as irresistible and absolute in its power over the subject. The only exceptions come late in the lms when a hapless protagonist may learn how to resist and fake hypnosisor to turn it on the villain. Road to Rio (McLeod, 1947) features one of the odder versions of this resolution. Heroine Dorothy Lamour has been under the life-long hypnotic control of her evil auntwho wields a pendulum, also a popular hypnosis prop. When Lamour falls in love with Bing Crosby, the aunt hypnotizes her into hating him. His buddy Bob Hope observes this, steals the aunts pendulum, and uses the same hypnotic induction to get her to leave the aunt and marry him. Signicantly, this is the only lm in which Hope rather than Crosby got the girl in their Road to series. Several lms of the 1930s1960s have a young woman ending up with a man shes been hypnotized to desire. This is depicted as an appropriate happy ending as long as its a likeable protagonist who performed the hypnosis himself, as in Eternally Yours (Garnett, 1939), How to be Very, Very Popular (Johnson, 1955), and The Pirate (Minnelli, 1948), or beneted from a third partys suggestions, as in Dont Go Breaking My Heart (Patterson, 1999) and Ein Ausgekochter Junge (Schonfelder, 1931).
STEREOTYPES OF HYPNOSIS
Even when hypnosis is depicted as having benecial effects, it is still portrayed as terrifyingly powerful, and many false stereotypes are perpetuated. The Search for Bridey Murphy (Bernstein, 1956), a book about a real-life suspected reincarnation case, was made into a highly successful lm of the same name (Langley, 1956). Several ctional versions followed including The Devil Rides Out (Fisher, 1967), On a Clear Day You Can See Forever (Minnelli, 1970), Audrey Rose (Wise, 1977)and most recently, Dead Again (Branagh, 1991). The message is that unsuspecting people may seek hypnosis for entertainment (Murphy) or smoking cessation (Clear Day) and end up reliving dramatic experiences from their earlier incarnations. An absolute postulate of these lms is that material recalled under hypnosis is unerringly accurate no matter how farfetched. She Creature (Corman, 1956) took the premise into the realm of the cult classic when a beautiful woman discovered under hypnosis that her past life was as a huge-breasted prehistoric monster and she began to revert to this state unpredictably. A similar age regression occurs in the recent K-Pax (Softley, 2001) when Kevin Spacey is hypnotized to determine why he believes himself to be an alien. Though the lm leaves some ambiguity as to the answer, the hypnotic recall of a traumatic event is taken as absolute; the only lingering question is whether trauma caused Spacey to develop a dissociative belief that an alien had taken over his body or whether a helpful extraterrestrial really did intervene. In Purple Storm (Chan, 1999), police hypnotists are able not only to extract real memories from a major terrorists son, but also
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to implant elaborate false ones that make him believe hes a police agent working against his father. In Shallow Hal (Farrelly & Farrelly, 2001), the title character wants to date only physically perfect women until he is stuck on an elevator with self-help guru Tony Robbins. Robbins hypnotizes him with an induction beginning Demons be gone! and tells Hal he will now see a womans inner beauty manifested concretely. This lmwhich overtly preaches that one shouldnt judge people by their weight or appearanceserves partially as a vehicle for two hours of fat jokes. Hypnosis is again all powerful. One saving grace is that it does attempthowever perfunctorily and unrealisticallyto portray the subjective effects of hypnotic suggestions rather than just the observers perspective. Hal hallucinates his massively obese girlfriend as looking like Gwyneth Paltrow. Hypnosis has also been featured in pornographic lmsalmost always with the theme only implied in Svengali or Flash Gordon: women are compelled to satisfy the hypnotists every kinky whim. She Did What He Wanted (n.d.), Suggestive Behavior (n.d.), Hypnotic Passions (n.d.), Stripnotized (n.d.), and Hypnotic Hookers I and II (n.d.) all follow this formula. This theme has been reversed at least once for masochistic male viewers in Wanda the Sadistic Hypnotist (Corarito, 1969). Almost every genre has ventured into hypnosis. The childrens cat-andmouse cartoons eventually produced Svengalis Cat (Donnelly, 1946). A Caligari-like clown, Dr. Bozo, attempted evil in a Scoobie-Doo (1982) episode.
HYPNOSIS AND TELEVISION

Television has been equally harsh on hypnosis; its used most often by the villain of the week in crime dramas. Several episodes of Hart to Hart (1979), including the pilot, solved a murder by nding out the apparent perpetrator had beenhypnotized. In a sophisticated variation, one Columbo (1975) episode depicts the rumpled detective becoming suspicious when he learns that a suicide took off her watch and shoes before diving off a building; shed been hypnotized to see a swimming pool in front of her. When the heros the target, the hypnotically suggested murder is foiled at the last minute. Emma Peel almost kills Steel after being hypnotized in one Avengers episode. A co-ed almost kills Hawaii Five-O (1968)s McGarrett after her psychology professor (!!) hypnotizes her to do so. Television, like lm, perpetuates the myth that trance memories are infallible. One Perry Mason (1957) episode depicts hypnotic memory recovery from a witnessperformed by the defense attorney live before the court. Under his all-powerful suggestion, she recollects witnessing a murder that clears Masons client. Hypnosis was also used by comedic villains in shows including Dukes of Hazard (Amateau & Asher, 1979) and
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Gilligans Island (Amateau & Arnold, 1964) and has been popular in horror/science ction shows such as the cult-classic daytime soap opera Dark Shadows (Curtis, 1966) to the recent X-Files (1993).
HYPNOSIS IN SONG AND MUSICAL THEATER

In 1893, J.M. Barrie (who had yet to write Peter Pan) and Arthur Conan Doyle (already wildly famous for Sherlock Holmes) collaborated on the libretto for an opera at the Savoy Theatre. Who contributed which part has been lost to posterity. Barries biographers assume the hypnosis theme was contributed by him as he had a longstanding interest in the subject.1 In any case, the result, Jane Annie,2 tells the story of a young woman who has the hypnotic eye from childhood and later uses it to seduce beaus into proposing and schoolmasters into providing money and aid for an elopement. The pivotal songs lyrics are: JANE ANNIE. When I was a little piccaninny, Only about so high, Id a babys bib and a babys pinny And a queer little gimlet eye. They couldnt tell why that tiny eye Would make them writhe and twist, They found it so, but how could they know That the babe was a hypnotist? ALL. Now think of that! this tiny bray Was a bit of a hypnotist! JANE A. And as I grew my power grew too, For we were one, you see, And what I willed the folk would do At a wave or a glance from me. I could suggest what pleased me best, And still can, when I list, And Madam Card will nd it hard To beat this hypnotist! ALL. Oh, think of it! This little chit Is a mighty mesmerist! American Tin Pan Alley songs at the turn of the century often featured hypnosis in seduction mode. Hypnotizing Man practices the copulatory
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gaze on unsuspecting women, Oh those wonderful eyes, how they seem to tantalize. When that feeling oer you does creep, your eyes are open but youre fast asleep . . . til eventually, I must obey, I hear him say, You are mine today (Brown & von Tilzer, 1911). This song enjoyed a cult revival in the 1970s when Tiny Tim recorded a goofy version of it with his trademark ukulele and tinny falsetto. In Hip Hip Hypnotize Me the young woman plays a less innocent role: A Hypnotist once in a Vaudeville Show was admired by a maid in the very front row . . . she said, if you hypnotize me, then I wont know . . . I dont care what you do; Ill take my chances with you, if Im hip, hip hypnotized, hypnotized (Dillion & von Tilzer, 1910). In It Must Have Been Svengali in Disguise, Hypnotism is the force by which the world is ruled. It heals the sick and by its use, the wisest men are fooled. Every imaginable achievement is attributed to it from making someone relinquish a bus seat to the act of Adam and Eve eating from the tree of knowledge: They say the snake had whiskers and knew how to hypnotize . . . it must have been Svengali in disguise (Bryan & von Tilzer, 1910). Other media, when it depicts hypnosis, makes it either sinister and/or the butt of jokes. Innumerable cartoons depict hypnotists able to bend others to their will for ill purposes. In January 2007, the Atlantic Monthly ran a cover story titled, Why Presidents Lie. An accompanying cartoon showed an intensely staring George W. Bush swinging a gold pocket watchwith no caption; obviously, hypnosis and lying were understood to be synonymous.
REALISTIC CINEMA HYPNOSIS

Are there any positive or realistic depictions of hypnosis in lm? Well, yesa very few. Cinema, probably just because of holding the most examples, tends to contain the occasional positive one. Mesmer (Spottiswoode, 1994) presented a sympathetic depiction of its protagonist and realistic information about why his method worked and why his theory didnt. The multiple personality lms Three Faces of Eve (Johnson, 1957), Sybil (Petrie, 1976), and numerous obscure spin-offs have included hypnosis scenes in which it is portrayed fairly realistically and positively. In Agnes of God (Jewison, 1985), Meg Tilly plays a young nun who has apparently given birth to a baby and murdered it. Psychiatrist Jane Fonda hypnotizes her to unlock the series of events that led to this act. All of these lms use inductions that are dramatized a bit for the camera and feature atypically neat solutions to unconscious conictsbut they stay closer to the truth than most. Probably the best depiction of hypnotherapy is in Equus (Lumet, 1977). Some atypical details are used for visual interest: there is an unusual induction with a rhythmically tapping pen and the patient is asked to act out memories in age-regression. However, the initial explanation of hypnosis
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by psychiatrist Richard Burton and his patients subsequent experience of it are remarkably realistic. They elucidate the steps in the young mans formation of delusions about the all-seeing horse-god Equus to explain his blinding a stable full of horses in the middle of the night. One lm that is quite negative about hypnosis but unusually realistic in what it selects as its dangers is the very dark comedy Storytelling (Solondz, 2001). The neglected youngest son of a dysfunctional middle-class family approaches his father after his favored older brother has been brain damaged in a football accident. He asks if he can hypnotize him, and his dazed father mutters, Sure, whatever. The boy begins a crude induction much like what one would nd in a pop book on the topic. The highly suggestible and recently traumatized father goes rapidly into a trance. Storytelling plays out the fantasies of parental favor and all the ice cream one can eat more amusingly, but also more realistically, than an earlier lm with virtually the same plot, No Dessert, Dad, until You Mow the Lawn (McCain, 1994). Even when the depiction of hypnosis is positive, the emphasis is virtually always on it as a means to inuence or control another persondepicted from an observers vantagenot on the altered state of consciousness from the subjects perspective. Omitting the feeble attempt in Shallow Hal (Farrelly & Farrelly, 2001), the one main effort at depicting the subjects experience is the lm Stir of Echoes (Koepp, 1999). Though it eventually spirals into a supernatural thriller, theres a realistic early scene in which Kevin Bacon argues about the reality of hypnosis with a lay hypnotherapist and then agrees to try being hypnotized. During the induction, the hypnotist tells Bacon hes in a theater. Viewers see Bacons imagerya well lit auditorium with red seats. The hypnotist says, It is dark, and the lights dim, The seats are black, and their color changes. When Bacon wakes up amnesic for some of the childhood embarrassments hes relived and the pin the hypnotist has stuck in his hand, his confused discomfort is palpable. The lm is unique in its vivid depiction of the subjective experience. When he begins to receive supernatural impressions, Bacon learns that the hypnotist has given him a suggestion to be more open; the danger of an ambiguous suggestion is quite realistic even if the specic outcome is preposterous. One other lmmaker who brought the experience onto the screen was Werner Herzog. Herzog was not concerned with overtly depicting hypnosis, however, but rather with using it to depict other issues. Before each days lming for Heart of Glass (Herzog, 1976), he hypnotized all but one of the cast members to inuence their performances. They move with excruciating slowness, eyes rolled up into their heads, which caused one reviewer to describe it as the most tedious lm ever made with the possible exception of a couple of Andre Tarkovskys efforts (Anonymous, 1999). Herzog wanted to begin the lm with a clip in which he would hypnotize the audience and conclude it with one awakening them from trance. His nancial backers wisely vetoed this idea.
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Lars von Trier begins a lm, alternately circulated under the titles Europa (von Trier, 1991) and Zentropa, with Max Von Sydows voice giving hypnotic relaxation suggestions and counting. Sydow then tells viewers, You are in a train, in Germany . . . and the lm story unfolds in a more traditional manner with only occasional voice-overs by the hypnotic voice but ends with wake-up suggestions. While a few highly susceptibles might go into a trace while viewing Europa/Zentropa, others have been more serious about actually hypnotizing viewers1990s Russian television featured hypnotists doing mass hypnosis of viewers. In the early 1970s, an obscure Georgia gubernatorial candidate paid for late-night television time to hypnotize viewers and suggest they vote for him. Table 5.1 presents 230 lms utilizing hypnosis and categorizes them in terms of a few of the variables that have been discussed.
TABLE 5.1 Films Featuring Hypnosis1 Genre: C Comedy D Drama H Horror M Mystery P Pornography SF = Science Fiction Coercive Inuence: Cr Commit Crime Sed Seduction Transformation: Mem Recover Memories Rein Past Life Regression Sp Increase Sports Performance Th Psychotherapy Oth Other dramatic gains in artistic, intellectual or physical abilities Title/Year
Abbott & Costello Meet Frankenstein (1948) Abbott & Costello Meet the Invisible Man (1951) Abbott & Costello Meet the Killer (1949) Agnes of God (1985) Allan Quartermain (1937) Anastasia The Story of Anna (1956) Audrey Rose (1977) Ein Ausgekochter Junge (1931) The Bells (1913) The Bells (1914) The Bells (1918) The Bells (1926) Bewitched (1945) Bez Konca (1984) Big Trouble in Little China (1986) Black Magic (1949) Black Sunday (1961) Blind Alley (1939) Blink of an Eye (1991)
Genre
C C C D D D D D M M M M M D H M H D D
Coercive Inuence
Cr, Sed
Transformation
Cr Th, Mem Cr Mem Rein Sed Mem Mem Mem Mem Mem Cr Cr Cr Th Oth (Continued)
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TABLE 5.1 (Continued) Title/Year

Body of Inuence (1992) Bostonians, The (1984) Broadway Danny Rose (1984) Bufords Beach Bunnies (1993) Calling Dr. Death (1943) Carefree (1938) The Case of Becky (1921) Casino Royale (1967) Cat People (1943) Chandu the Magician (1932) Charlie Chan at Treasure Island (1939) Charlie Chan in Rio (1941) Charlie Chan: Meeting at Midnight (1944) The Climax (1944) Coach (1978) Cold Turkey (1971) Condemned to Death (1932) The Court Jester (1956) Cult Rescue (1994) Cure (1999) Curse of the Jade Scorpion (2001) Dark Tower (1942) Daughter of the Dragon (a Fu Manchu lm) (1931) Dead Again (1991) Dead on Sight (1994) Deadly Lives of the Ninja (undated) Death Warmed Up (1985) The Devil Doll (1964) The Devils Undead (1972) Dick Tracy (1937) Divorce American Style (1967) Dont Go Breaking My Heart (1999) Dr. Mabuse, the Gambler (1922) Dr. Mabuse, The Testament of (1932) Dracula (1931) Dracula (1931 Spanish) Dracula (1979) Draculas Daughter (1936) Dying to Remember (1993) The Element of Crime (1984) Equus (1977)
Genre
D D D C M C D C H H M M M C C M C D M C D M M M D M H M M C D M M H H H H M M D
Coercive Inuence
Transformation
Th Oth
Sed Cr Th Sed Th Mem Cr Cr Cr Sp Th Oth Cr Cr Sed Cr Rein Mem Cr Cr
Cr Sed Sed Cr Cr
Rein Mem Th
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Escapement (1958) Eternally Yours (1939) Europa (a.k.a. Zentropa) (1991) The Exorcist II: The Heretic (1977) Far Out, Man (1990) Fear in the Night (1947) Feast of the Devil (1987) Fingers at the Window (1942) Flagpole Jitters (1956) Flash Gordon (1936) Flash Gordon (1980) Flash Gordon Conquers the Universe (1940) Flash Gordons Trip to Mars (1938) Foreign Tongues: Mesmerized (undated) Freud (1962) Fright (aka Spell of the Hypnotist)(1956) Frozen Ghost, The (1945) The Garden Murder Case (1936) Geisha Girl (1952) Ghost Chasers (1951) Ghosts on the Loose (1943) Going Berserk (1983) Goldy III, The Legend of the Golden Bear (1994) Guilt of Janet Ames (1947) Guilty of Treason (1949) Hannusen (1988) Haunting Fear (1990) Heart of Glass (1976) Here Come the Co-eds (1945) High Anxiety (1977) Hipnosis (1963) Hitz (1988) Hocus Pocus (short: 1949) Hold that Hypnotist (1957) Horrors of the Black Museum (1959) The Hot Rock (1977) Hot Under the Collar (1991) Houdini (1953) How to be Very, Very Popular (1955) How to Make a Monster (1958)
Genre
D C D H C M D M C SF SF SF SF P D M M M C C C C C M/D D M M D C C M C C C H C C D C C
Coercive Inuence
Sed
Transformation
Oth Cr Cr Sed
Sed Sed Sed Th
Mem Cr Mem
Cr Oth
Oth Th
Cr Sed
Cr Sed Oth Sed Cr (Continued)
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Hypnosis (1963) The Hypnotic Eye (1960) The Hypnotic Monkey (1915) Hypnotic Murders (1998) Hypnotic Passions (1993) Hypnotic Power (1914) Hypnotic Sensations (1985) The Hypnotic Violinist (1914) The Hypnotic Wife (1909) Hypnotism (1910) The Hypnotist (1957) I Was a Zombie for the FBI (1982) Im From the City (1938) In Like Flint (1967) In the Grip of a Charlatan (1913) Incredibly Strange Creatures That Stopped Living and Became Mixed-Up Zombies (1964) Intruders (1992) Invasion of the Space Preachers (1990) The Invisible Ghost (1941) The Ipcress File (1965) Irma Vep (1997) Jones Hypnotic Eye (1915) Keeper (1975) The Killing Jar (1996) Kiss the Girls (1997) Lets Do It Again (1975) Lets Kill Uncle (1966) The Lightning Incident (1990) Liquid Dreams (undated) Lizzie (1957) London After Midnight (1927) Looker (1981) Lord Love a Duck (1966) Lost in a Harem (1944) Love at First Bite (1979) The Magician (1926) The Magician (1959) Le Magnetiseur (aka The Hypnotist at Work (USA); aka While Under the Hypnotists Inuence) (UK) (1899) The Maltese Bippy (1969)
Genre
H H H M P H P H D D D C D M M H
Coercive Inuence
Cr Cr Cr Sed Cr Sed
Transformation
Oth Sed Cr Cr Cr Cr Cr Mem
C H M D D M M M C C D P D H C C C D D
Cr Cr Cr Cr Cr Cr Th Mem Sp Cr Oth Sed Th Cr Oth Cr Sed Oth
D C
Sed Cr
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The Manchurian Candidate (1962) The Mask of Diijon (1946) The Mask of Diijon (1993 Spanish) Maurice (1987) Max Hypnotize (1910) Mesmer (1994) Midnight Eye Golem (1964) Misadventures of Merlin Jones (1964) Mr. Hex (1946) The Mummy (1932) Murder in Mind (1997) The Naked Gun (1988) The Natural (1984) Night of the Living Babes (1987) The Night They Killed Rasputin (1962) Nightmare (1956) Nights of Cabiria (1956) No Dessert, Dad, Until You Mow the Lawn (1994) Ofce Space (1999) On a Clear Day, You Can See Forever (1970) Palmy Days (1931) The Peeper, The Hypnotist, and the Model (1972) The Pirate (1948) Play It As It Lays (1972) Problem Child 2 (1991) Promise to Carolyn (1996) Purple Storm (1999) Raising Cain (1992) Rasputin (1996) Rasputin and the Empress (1932) Rasputin: The Mad Monk (1966) The Razors Edge (1984) The Reanimator (1985) Remains to Be Seen (1953) The Resurrection Syndicate (aka Nothing But the Night;aka The Devils Undead) (1972) Return (1985) The Return of Captain Invincible (1983)
Genre
D H H D D D D C C H M C D P D M D C C D C C C C C M D D D D D D H D
Coercive Inuence
Cr Cr Cr
Transformation
Th Th Cr Cr
Cr Cr Sp Sed Cr
Th
Cr Sed Sed Cr Th, Mem Th, Mem
Cr Oth
M D C
Mem Rein, Mem Cr (Continued)
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Rock and the Money Hungry Party Girls (1989) Running Wild (1927) Santa Sangre (1989) Savage (1973) Screwballs (1983) The Search for Bridey Murphy The Secret Diary of Sigmund Freud (1984) Seventh Heaven (1998) Seventh Veil (1946) Sex Kittens go to College (1960) Shallow Hal (2001) Shaman (1987) The She-Creature (1956/8) She Did What He Wanted (undated) Silent Conict (1948) Silly Scandals (1931) Sisters (1973) Slave of a Foreign Will (1919) Son of Dracula (1943) Spellbound (1945) Splitz (1984) Spy Chasers (1955) Starship Invasions (1977) Stir of Echoes (1999) Strange Brew (1983) Stripnotized (undated) Sucker Money (1933) Suggestive Behavior (undated) Svengali (1911) Svengali (1914) Svengali (1931) Svengali (1955) Svengali (1981) Svengali and Trilby (1983) Swing Fever (1944) Tales of Hoffman (1951) Taste the Blood of Dracula (1970) The Three Faces of Eve (1957) The Two-Souled Woman (1918) The Undead (1958) Up the Front (1972)
Genre
C/P C D D C D C D D C/P C D H P D D D D H M P C SF D C P P D D D D D D C D H D D H C
Coercive Inuence
Sed
Transformation
Sed Rein Th
Sed Th Rein Sed Cr Cr Cr Th, Mem Sed
Oth Cr Sed Cr Th Cr, Sed Cr, Sed Cr, Sed Cr, Sed Cr, Sed Cr, Sed Cr Cr Th Sed Rein Oth
Sp
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Les Vampires (1915) Wanda the Sadistic Hypnotist (1969) Whirlpool (1949) Whoops! Apocalyspe (1986) Will Any Gentleman? (1954) A Wind from Wyoming (1994) The Woman in Green (1946) Zelig (1983)
1
Genre
M P M C C C M C
Coercive Inuence
Cr
Transformation
Oth
The author has watched the majority of these lms. However, this table is compiled most directly from synopses in two lm reference books (Katz, 2000; Matlin, 2005) and two Internet reference sites (The Internet Movie Database; The Missing Link).
CONCLUSIONS AND IMPLICATIONS

It is clear that the main interest of lm and television is in hypnosis as absolute control over others. This obviously plays to popular fears and fantasies. Most of us at least occasionally wish for greater inuence upon the behavior of others than we can effect with ordinary social skills. We also fear undue control by others. When hypnosis is viewed as this metaphor for ultimate control, the lmmakerand hence his (or occasionally her) audiencewants to identify with the observer, not the subject of this overwhelming phenomena. Obviously there is something to the idea Theyre only movies; lms purpose is to entertain and its not entirely realistic on any subject. But the distortion and vilication of hypnosis go far beyond that of other psychological phenomena. Dreams have suffered the indignities of the Nightmare on Elm Street series (Craven, 1984, 1985, 1987, 1988, 1989, 1991, 1994). Psychotherapists are occasionally depicted as killing patientswhile cross-dressing as in Dressed to Kill (De Palma, 1980) or as a prelude to cannibalism in Silence of the Lambs (Demme, 1991). However, these lms are offset by numerous others that depict positive aspects of dreaming, such as Dreams (Kurosawa, 1990), or psychotherapy, as with Ordinary People (Redford, 1980), and which portray the subjective experiences of each richly (Barrett, 2001, 19912006; Gabbard & Gabbard, 1987; Petric, 1998). There are also lms in which a character recounts a dream in passing or a minor scene shows someone talking to their therapist we never see hypnosis depicted in this understated manner. Hypnosis is always there for its metaphoric possibilitieslarger than life and usually up to no good. The most likely cause of this difference is that everyone dreams andin Hollywood at leastalmost everyone is in psychotherapy.
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There are two possible routes by which hypnosis in lm might be rehabilitated. The rst is if hypnosis ever became widespread enough that most every director or screenwriter had used it for smoking cessation or headache relief. If the press regularly ran factual, non-sensational articles about hypnosis, it would likely develop a more realistic presence in lm. We already see a hint of this reected in the fact that hypnosis lms in the rst half of the twentieth century were unrelentingly negative, and all examples of positive and/or realistic depictions come from the second half. However, the inuence of real life use of hypnosis upon cinema is not the direction in which we are most interested. If hypnosis ever becomes completely recognized for all its potential benets, wed probably care little what liberties the cinema takes with it. Were more interested in how realistic depictions of hypnosis might educate viewers and inuence real-life attitudes toward hypnosis. Hollywoods raison d^ etre is box ofce success; the plots of hit movies are recycled endlessly. If there was a successful lm in which the protagonist beneted from hypnotherapy or one that depicted the trance state with the appeal meditation regularly receives, more would follow. One good screenplay or adaptable novel would go a long way toward changing stereotypes. Half of all lms are based on novels. However, most positive hypnosis lms have been based on nonction books (Dissociative Identity Disorder case studies, Mesmer biographies, etc.) and the remainder on stage plays (Equus; Agnes of God). Theres as great a dearth of novels that are hypnosis friendly as of lms. Short of beginning to pen screenplays and ction, hypnotherapists would do well to emphasize positive hypnosis themes to people involved in these media. Herbert Spiegel served as consultant to the lm version of Equus, enhancing the authenticity of the hypnosis that was already moderately realistic in the stage play. We might all do well to take every opportunity to get involved in the popular depictions. In trying to discourage false beliefs about hypnosisdiscounting stage hypnosis, past life, and alien abduction phenomenawe may, at times, veer too far toward making hypnosis sound boring. Information on actual dramatic developments within the eld and descriptions of how enjoyable and fascinating the experience of hypnosis can be may be more effective at combating false images than is relentless debunking.
NOTES
1. Barrington, Rutland (1908). Rutland Barrington: A Record of 35 Years Experience on the English Stage. London: G. Richards. http://www.archive.org/ details/rutlandbarringto00barrrich. Preface by W. S. Gilbert. 2. http://math.boisestate.edu/GaS/other_savoy/jane_annie/jane_annie_home. html.
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REFERENCES
Allen, W. (Director), (2001). Curse of the Jade Scorpion [Motion Picture]. United States: Dreamworks. Amateau, R. & Arnold, J. (Directors). (1964). Gilligans Island [Television Show]. United States: Columbia Broadcasting System. Amateau, R., & Asher, W. (Directors). (1979). Dukes of Hazard [Television Show]. United States: Columbia Broadcasting System. Anonymous. (1999). review retrieved on March 24, 2006 at http://www.imdb.com. Apfel, O. (Director). (1913). The Bells [Motion Picture]. United States: Reliance. Avengers [Television Show]. (1965). United Kingdom: British Broadcasting Company. Badham, J. (Director). (1979). Dracula [Motion Picture]. United States. Barrett, Deirdre. (2001). Dreams that money can buy: Filmmaking and theater. In The Committee of Sleep (pp. 2440). New York: Crowne. Barrett, Deirdre. (19912006). The Dream Videophile column in Dream Time. Berkeley, CA: The Association for the Study of Dreams. Electronic version at http://www.asdreams.org/videol.htm. Barton, C. (Director). (1948). Abbott and Costello Meet Frankenstein [Motion Picture]. United States: Universal. Barton, C. (Director). (1949). Abbott and Costello Meet the Killer [Motion Picture]. United States: Universal. Barton, C. (Director). (1951). Abbott and Costello Meet the Invisible Man [Motion Picture]. United States: Universal. Beebe, F. & Taylor, R. (Directors). (1938). Flash Gordons Trip to Mars [Motion Picture]. United States: Universal. Beebe, F. & Taylor, R. (Directors). (1940). Flash Gordon Conquers the Universe [Motion Picture]. United States: Universal. The Bells (1914). [Motion Picture]. United Kingdom: Gaumont. Bernstein, M. (1956). The Search for Bridey Murphy. New York: Doubleday. Blair, G. (Director). (1947). The Hypnotic Eye [Motion Picture]. United States: Allied Artists. Boleslavsky, R. (1932). Rasputin and the Empress [Motion Picture]. United States: Metro Goldwyn Mayer. Boyd, D. (Director). (1990). Invasion of the Space Preachers [Motion Picture]. United States: Rhino Home Video. Branagh, K. (Director). (1991). Dead Again [Motion Picture]. United States: Paramount. Brown, L. & von Tilzer, A. (1911). That Hypnotizing Man. New York: The York Music Company. Browning, T. (Director). (1931). Dracula [Motion Picture]. United States: Universal. Bryan, V. & von Tilzer, A. (1910). Dont Take Me Home. New York: Harry von Tilzer Publishing Co. Chan, T. (Director). (1999). Purple Storm [Motion Picture]. Hong Kong: Media Asia Films, Ltd. Columbo [Television Show]. (1975). United States: Columbia Broadcasting System. Corarito, G. (Director). (1969). Wanda the Sadistic Hypnotist [Motion Picture]. United States: Caio Productions, Distributed by Something Weird Videos.
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Preminger, O. (Director). (1949). Whirlpool [Motion Picture]. United States: 20th Century Fox. Redford, R. (Director). (1980). Ordinary People [Motion Picture]. United States: Paramount. Righelli, G., & Grund, H. (Directors). (1927). Svengali [Motion Picture]. Germany: Terra Film. Robertson, J. (Director). (1920). Dr. Jekyll and Mr. Hyde [Motion Picture]. United States: Lasky, Distributed by Famous Players. Schonfelder, E. (Director). (1931). Ein Ausgekochter Junge (trans. A Young Goodfor-Nothing). [Motion Picture]. Germany: Engels & Schmidt Tonlm. Scoobie-Doo [Television Show]. (1982). United States: Ruby-Spears Productions. Shane, M. (Director). (1947). Fear in the Night [Motion Picture]. United States: Paramount. Shane, M. (Director). (1956). Nightmare [Motion Picture]. United States: PineThomas. She Did What He Wanted (n.d.). [Motion Picture]. United States. Siodmak, R. (Director). (1943). Son of Dracula [Motion Picture]. United States: Universal. Softley, I. (Director). (2001). K-Pax United States: Pathe. Solondz, T. (Director). (2001). Storytelling [Motion Picture]. United States: New Line Cinema. Spottiswoode, R. (Director). (1994). Mesmer [Motion Picture]. United States: Accent. Stephani, F. (Director). (1936). Flash Gordon [Motion Picture]. United States: Universal. Stoker, B. (1897). Dracula. Westminster, England: Archibald Constable and Co. Stripnotized (n.d.). [Motion Picture]. United States. Suggestive Behavior (n.d.). [Motion Picture]. United States. Svengali [Motion Picture]. (1911). United Kingdom. Svengali [Motion Picture]. (1981). United States. von Trier, L. (1991). Europa. Los Angeles: Touchstone Home Video. Warde, E. (Director). (1918). The Bells [Motion Picture]. United States: Pathe. Welles, O. (Director). (1949). Black Magic [Motion Picture]. United States: Lions Gate. Wiene, R. (Director). (1919). The Cabinet of Dr. Caligari [Motion Picture]. Germany: Decla-Bioskop. Wise R. (1977). Audrey Rose [Motion Picture]. United States: Metro Goldwyn Mayer. X-Files [Television Show]. (1993). United States: Fox Broadcasting Company. Young, J. (Director). (1918). The Bells [Motion Picture]. United States: Chadwick.
Chapter 6
Hypnotic-Like Procedures in Indigenous Shamanism and Mediumship 1

Stanley Krippner and J urgen W. Kremer
The term hypnosis was popularized by James Braid (17951860), an English physician. Braid disliked the term mesmerism, which had been named after its originator, Franz Anton Mesmer (17341815), an Austrian physician. Braid concluded that Mesmers purported cures were not due to animal magnetism as Mesmer had insisted, but to suggestion. He developed the eye-xation technique (also known as Braidism) of inducing relaxation. Earlier French writers had called similar procedures hypnotisme (after Hypnos, the Greek god of sleep) because they thought that these phenomena were a form of sleep (Gravitz, 1984). Later, realizing this error, Braid tried to change the name to monoeidism (meaning inuence of a single idea), however, the original name stuck. In other words, semantics and social construction played an important role in the history of hypnosis and actually directed the way that this modality was practiced and conceptualized. Contemporary discussions and denitions can be found in the materials of the Society of Psychological Hypnosis (Division 30 of the American Psychological Association; see especially the 2004 statement of its Executive Committee). The Society denes hypnosis as a procedure involving cognitive processes (such as imagination) in which a participant is guided by a hypnotist to respond to suggestions for changes in sensations, perceptions, thoughts, feelings, and behaviors. Sometimes, people are trained in self-hypnosis in which they learn to guide themselves through a hypnotic procedure. (It is important to note that psychologists hold a wide variety of opinions on how to dene hypnosis and on why hypnosis works; psychoanalytic, neo-dissociative, socio-cognitive, and transpersonal approaches provide different theories and denitions.)
1 Several segments of this chapter appeared in S. Krippner (2004). Hypnotic-like procedures used by indigenous healing practitioners. Hypnos, 31, 125135. Used by permission.
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The hypnotic procedure can be seen as consisting of two parts: (1) induction, and (2) suggestions given. During the induction, the participant (patient, client, or research volunteer) is guided to relax, concentrate, and/ or to focus his or her attention on some particular item. Some hypnotic practitioners believe the purpose of the induction is to induce an altered state of consciousness, while others believe the induction is a social cue that prompts the participant to engage in hypnotic behaviors. The suggestions given provide guidance to undergo changes in experience, such as to experience a motor movement (ideomotor suggestions), or changes in sensations, perceptions, thoughts, or feelings. Challenge suggestions may also be given (e.g., subjects are told they will not be able to engage in some particular activity and then are asked to perform the prohibited activity). Answers to the question whether people in hypnosis enter an altered state remain contentious; however, research suggests that there is a trait that is associated with an individuals responsiveness to hypnotic procedures (e.g., Barber, 1969). The use of hypnotic procedures in a clinical setting is generally conned to verbal instructions in an ofce or similar venue. By contrast, indigenous shamanic practices commonly involve a very different setting with inductions and suggestions proceeding in a multiplicity of dimensions. These practices reach back to tribal rituals directed by native shamans, those socially designated practitioners who voluntarily shift their attentional states to obtain information not available to other members of their community (Krippner, 2000). Agogino (1965) stated, The history of hypnotism may be as old as the practice of shamanism (p. 31), and described hypnotic-like procedures used in the court of Pharaoh Khufu in 3766 BCE. Agogino added that priests in the healing temples of Asclepius (commencing in the 4th century BCE) induced their clients into temple sleep by hypnosis and auto-suggestion, while the ancient Druids chanted over their clients until the desired effect was obtained (p. 32). Vogel (1970/ 1990) noted that herbs were used to enhance verbal suggestion by native healers in pre-Columbian Central and South America (p. 177). However, Krippner (2004, 2009) has suggested that the procedures described by Agogino, Vogel, and others be referred to as hypnotic-like because they differ considerably from procedures utilized in standard hypnosis. The setting for rituals or ceremonies may be outdoors or in traditional structures very different from the ofce of a counselor, psychiatrist, or clinical psychologist, even though contemporary shamanic practitioners may conduct healing ceremonies in hospitals or in nontraditional living quarters. In addition to verbal instructions, singing or chanting, the use of instruments (particularly percussion instruments), drama, movement, body-painting, tactile, olfactory and/or gustatory stimulation, dietary practices (mind-altering herbs, emetics, fasting, etc.), shifts in waking and sleeping cycles, and cleansing procedures (such as sweating and purging) play an instrumental role. The use of a wide variety of implements or
Hypnotic-Like Procedures in Indigenous Shamanism and Mediumship
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utensils is also common, for example, feathers, bundles, crystals, and in the verbal dimension, storytelling (including joking and teasing), can all play a signicant role. In addition to specic suggestions provided by the shaman or other indigenous practitioner, the cultural context (such as the cosmology of the ritual venue or stories told or alluded to in songs) gives guidance during the hypnotic-like procedures employed by shamans. Language issues quickly arise when we move cross-culturally to investigate hypnotic-like phenomena, especially given the diversity and complexity of indigenous languages. While we are intent on using indigenous peoples explanations of their own practices, we cannot help but resort to concepts that have their own history in the English language. For example, the word consciousness, like hypnosis, is a social construct, one that has been dened and described differently by various groups and writers. When it is translated into a non-English language, the problem intensies, as some languages have no exact counterpart to the term. From our perspective, the English noun consciousness can be dened as the pattern of perception, cognition, and affect characterizing an organism at a particular period of time. However, some denitions equate consciousness with awareness, while other denitions focus on intentionality, attention, or some other aspect of the phenomenon. So-called alterations in consciousness or altered states of consciousness (often described as observed or experienced changes in peoples usual patterns of perception, cognition, and/or affect) have been of great interest both to practitioners of hypnosis and to anthropologists. Rock and Krippner (2007) have deconstructed the phrase altered states of consciousness, claiming that it confuses consciousness with its content, especially if a phrase such as shamanic states of consciousness is used. They prefer the phrase patterns of phenomenological properties as it avoids what they call the consciousness/content fallacy, and places the emphasis upon experience itself (p. 485). Regardless of the term used, various indigenous (i.e., native, traditional) people engage in practices that they claim facilitate encounters with divine entities and contact with the spirit world. Many Western observers have been reminded of hypnosis by some of these procedures, especially those in which individuals have appeared to be highly suggestible to the practitioners directions have seemed strongly motivated to engage in imaginative activities and have become engaged in shifts in attention, all of which are common to Western hypnotic practices. In any event, these behaviors and experiences reect expectations and role enactments on the part of the individuals or a group. The practitioner invites these individuals to attend to their own personal needs while attending to the interpersonal or situational cues that shape their responses. However, it is an oversimplication of a very complicated set of variables to refer to the practices of shamans and other indigenous practitioners as hypnosis, as many authors have done (e.g., Agogino, 1965).
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Native practitioners and their societies have constructed an assortment of terms to describe activities that, in some ways, appear to resemble what Western practitioners refer to as hypnosis. To indiscriminately use the term hypnosis to describe exorcisms, the laying-on of hands, dream incubation, and similar procedures does an injustice to the varieties of cultural experience and their historic roots. Hypnosis, the hypnotic trance, and the hypnotic state have been reied too often, distracting the serious investigator from the cross-cultural uses of human imagination, suggestion, and motivation that are worthy of study using a native practitioners own terms (Krippner, 1993). It is important to take account of the entire range of procedures that are part of shamanic practices (as well as those from folk mediumship) and to include indigenous denitions and accounts rather than to abstract them from culturally signicant understandings (Kremer, 1994). We agree with Gergen (1985) who observed that the words by which the world is discussed and understood are social artifacts, products of historically situated interchanges among people (p. 267). This caveat also applies to the word indigenous, a term for which there is no universal denition (Kuper, 2007). We apply indigenous to descendents of original inhabitants of a land, as well as to groups only partially related genetically to those people but who have also suffered discrimination from a societys powerful elite.
HISTORICAL AND CROSS-CULTURAL ISSUES

We have explored practices found in North American shamanism (Krippner and Kremer), Balinese folk customs (Krippner), contemporary S ami traditions (Kremer), and African-Brazilian mediumship (Krippner), and will use our data to illustrate the multisensory nature of indigenous hypnotic-like procedures. A survey of these practices and others in the social science literature indicates that there are elements of native healing procedures that can be termed hypnotic-like. This is due, in part, to the fact that so-called alterations in consciousness are not only sanctioned but are also deliberately fostered by virtually all indigenous groups. For example, Bourguignon and Evascu (1977) read ethnographic descriptions of 488 different societies, nding that 89 percent were characterized by socially approved alterations of consciousness, or if you will, changed patterns of phenomenological properties. The use of different terms throughout this chapter is an attempt to present the reication of such appellations as altered states of consciousness. The ubiquitous nature of hypnotic-like procedures in native healing also demonstrates the ways in which human capacitiessuch as the capability to strive toward a goal and the ability to imagine a suggested experiencecan be channeled and shaped, albeit differentially, by social interactions. Concepts
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of sickness and of healing can be socially constructed and modeled in a number of ways. The models found in indigenous cultures frequently identify such etiological factors in sickness as soul loss and spirit possession, each of which are diagnosed (at least in part) by observable changes in the patients behavior, mentation, or mood (Frank & Frank, 1991, ch. 5). For example, there is no Western equivalent for wagamama, a Japanese emotional disorder characterized by childish behavior, emotional outbursts, apathy, and negativity. Nor is there a counterpart to kami, a condition common in some Japanese communities that is thought to be caused by spirit possession. Susto is a malaise common in Peru and several other parts of Latin America and thought to be caused by a shock or fright, often connected with breaking a spiritual taboo. It can lead to dire consequences such as the loss, injury, or wounding of ones soul, but there is no equivalent concept in Western psychotherapy manuals. Cross-cultural studies of native healing have only started to take seriously the importance of understanding indigenous models of sickness and their treatment, perhaps because of the prevalence of behavioral, psychoanalytic, and allopathic medical models. None of these has been overly sympathetic to the explanations offered by indigenous practitioners or to the proposition that Western knowledge is only one of several viable representations of nature (Gergen, 1985). Kleinman (1980) commented, The habitual (and frequently unproductive) way researchers try to make sense of healing, especially indigenous healing, is by speculating about psychological and physiological mechanisms of therapeutic action, which then are applied to case material in truly Procrustean fashion that ts the particular instance to putative universal principles. The latter are primarily derived from the concepts of biomedicine and individual psychology. . . . By reducing healing to the language of biology, the human aspects (i.e., psychosocial and cultural signicance) are removed, leaving behind something that can be expressed in biomedical terms, but that can hardly be called healing. Even reducing healing to the language of behavior . . . leaves out the language of experience, which . . . is a major aspect of healing. (pp. 363364) Similarly, Faris (1990) criticized attempts to t indigenous beliefs and practices into some variety of universal schemareducing its own rich logic to but variation and fodder for a truth derived from Western arrogances even if their motivations are to elevate it (p. 12). In using the terminology of hypnotic-like procedures we have attempted to point to the importance of the local construction of practices and their interpretations. Most illnesses in a society are socially constructed, at least in part, and alleged alterations of consciousness (or changed patterns of phenomenological properties) also reect social construction. Because native models
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of healing generally assume that practitioners, to be effective, must shift their attention (e.g., journeying to the upper world, traveling to the lower world, incorporating spirit guides, conversing with power animals, retrieving lost souls), the hypnosis literature can be instructive in fathoming these concepts.
MULTI-SENSUAL PERSPECTIVES ON HYPNOTIC-LIKE PROCEDURES

Observing hypnotic-like procedures closely we nd that induction and suggestion occur in ways notably different from the setting and procedures of hypnosis in clinical settings. The following list highlights some of the most obvious dimensions that are part of hypnotic-like ritual endeavor (see Kremer, 2002a, for a more lengthy discussion).
Cultural Context
The application of hypnotic procedures in Western clinical settings does not occur in the context of a shared cultural mythology or shared stories and ritual practices; it is specic to the individual. By contrast, indigenous ceremonies are enacted in a rich cultural context in which the patient participates. These mythic stories (especially their understanding of the healing process, the origin of symptoms, and the goal of health or balance) provide a rich context that may or may not be verbalized or made present during the ceremony, but is, nonetheless, the operative background of hypnotic-like procedures.
Sacred Geography
Oftentimes healing rituals occur within a geography that is invoked, literally traveled to, or replicated in the place of ceremony (such as the Din e hogan or the S ami lavvu); the macrocosm of the cultural sacred geography is oftentimes mirrored in the sacred layout of the place of ceremony (as in Din e sand paintings).
Storytelling
Stories are frequently used to invoke cultural context, to explain illness, and to guide healing. They may also serve to shift attention, very much like in the practice of Milton Erickson (Erickson, Rossi, & Rossi, 1976) or in the adaptation of indigenous practices in counseling and psychotherapy (see Krippner, Bova, Gray, & Kay, 2007; Krippner Bova, & Gray, 2007).
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Verbal Instructions
In most situations, specic verbal instructions (e.g., as induction or suggestion) form the smallest part of the proceedings.
Singing or Chanting
Songs or repetitive chanting as part of invocations, afrmations, or suggestions both provide direction, invoke stories, spirits, or cosmologies, and shift the participants attention.
Percussion and Other Musical Instruments

Research (e.g., Neher, 1961) has demonstrated that the repetitive use of a percussion instrument, such as drumming, can lead to alterations in phenomenological awareness. Such isolated use of an induction seems extremely rare in indigenous practices. These powerful ways to shift attention (drumming, rattling, bullroarer, click sticks, whistles, etc.) are usually only one aspect of a multisensory design of healing procedures.
Ritual Implements
These may include feathers, amulets, crystals, and wands, among many others, all considered to have special powers or spiritual importance.
Olfaction
The most common event is probably the use of herbs as incense or offering (such as sage), or the smoking of herbs (such as tobacco), as well as the use of re and its ensuing smoke.
Gustatory Stimulation and Dietary Practices

The ingestion of mind-altering plants or other herbal remedies with specic alleged healing properties, as well as changes in diet (fasting, dry fasting, or other restrictions) are an important aspect of many indigenous healing ceremonies.
Cleansing
This may involve such activities as ingesting emetics, washing (such as with yucca suds), bathing, standing under a waterfall, and sweating (in a sauna, Native American sweat lodge, etc.).
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Tactile Stimulation
This may include various forms of massaging, stimulating pressure points, slapping, simple touching, and related procedures.
Movement
Dance, particularly repetitive dance, is probably the most common use of movement; however, there are various stylized postures and interactive movements that fall into this category as well.
Body Painting
The patient and/or shamanic practitioner as well as other participants may use temporary or permanent designs evocative of particular presences or various mythological stories.
Drama
Dramatic enactments may be part of the invocation of story, notions of health and balance, or the cosmology within which a hypnotic-like procedure occurs.
Waking-Sleeping Cycles
Many ceremonies occur during the evening, late into the night, or during the entire night. Wakefulness to ritual proceedings at a time when participants usually sleep and dream also facilitates changes in attention. In some traditions we may nd many of these dimensions present during native ceremonies, but in others only a few are effectively employed for the sake of healing. The examples discussed next illustrate the range of multidimensionality of hypnotic-like procedures in sample cultures.
PROCESSES OF HYPNOTIC-LIKE PROCEDURES

Clottes and Lewis-Williams (1998/1996) have proposed three stages of what they call shamanic consciousness (see also Lewis-Williams, 2002). This is consistent with Tarts (1975) discussion of the process of altered states and Winkelmans (2000) discussion of the neuropsychological bases of rock art. Figure 6.1 combines the work of Clottes and Lewis-Williams, Tart, and Kremer (2002b). It illustrates the stages of shamanic consciousness during hypnotic-like procedures using an abstract depiction, images from contemporary Western processes, European Paleolithic cave art, San rock art, and Din e rock art. The left column presents images of consensual, everyday reality,
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Figure 6.1 (Chart assembled and drawn by J urgen Kremer based on images and inspiration from: Clottes, J. & Lewis-Williams, D. (1997). Schamanen. Sigmaringen, Germany: Thorbecke; Tart, C. (1975). States of Consciousness. New York: Dutton; Grant, C. (1978). Canyon de Chelly: Its People and Rock Art. Tucson, AZ: University of Arizona Press.)
while the columns toward the right show increasing alteration of attention and shifts in ones pattern of phenomenological properties. In Stage One, people move from alert consciousness to a light alteration, beginning to experience geometric forms, meandering lines, and other phosphenes or form constants, so named because they appear to be hard wired into the central nervous system. For example, the Tukano people of South America use a series of undulating lines of dots to represent the Milky Way (Reichel-Dolmatoff, 1971). In Stage Two, people begin to attribute complex meanings to these constants. Practitioners enter the next phase in several waysby crossing a bridge, going through a whirlpool, or entering a hole. In Stage Three, these constants are combined with images of people, animals, spirits, and mythical beings. Experients began to interact with these images, often feeling themselves to be transformed into animals, either completely or partially (e.g., the celebrated prehistoric Les Trois Fr eres animal/human depiction); shamanic journeys are generally felt to be more feasible in this form (Clottes & LewisWilliams, 1998/1996, p. 19). Various chambers of Upper Paleolithic caves seem to have been restricted to advanced practitioners; some caves have spacious chambers embellished with large, imposing images while elsewhere
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there are often small, sparsely decorated diverticules into which only a few people could congregate (p. 20). From an epistemological perspective, the shaman gained knowledge from his or her journeys into other realms of existence, and communicated the results to members of the community (Flaherty, 1992, p. 185). Shamans provided information from a database consisting of their dreams, visions, and intuitions, as well as their keen observations of the natural and social world. Sansonese (1994) suggested that there was a degree of genetic predisposition for falling into trance and that this ability made a signicant contribution to social evolution (p. 30). For example, there was a succession of Indo-European shamans whose traditions included parent-to-child transmissions of shamanic lore that, in turn, institutionalized extendedfamily shamanic groups (Ibid.).
MULTIDIMENSIONALITY OF DIN E CHANTWAYS

Din e (Navajo) chantways represent a complex system of ceremonies that can, in some sense, be seen as exemplars for the multidimensionality of hypnotic-like procedures in indigenous traditions. Hat a al in the Din e language means chant and hataaii means medicine person, singer, or chanter. There are about 60 distinct Din e names for various chantways and chantway branches, many of them now considered extinct (Young & Morgan, 1987). The chants are usually grouped into four basic categories: Blessing Way, Holy Way, Night Way, and Evil Way. The specic names of chants are indicative of a particular mythology, symptom, or intervention, ranging from Red Ant Way, Raven Way, Game Way, and Big Star Way to Hand Trembling Way and Prostitution Way. Ceremonies typically last several days, with the longest lasting up to nine days. The performance of a hat a al is expected to be carried out following the precise instructions and special procedures in order to counteract any errors that have occurred. This gives them a avor that is liturgical rather than improvised, inspired, or spontaneous as in other indigenous shamanic practices (although ceremonies connected with the oldest layer of the Navajo traditions, such as those involving crystal gazing and hand trembling, belong in the latter category (see Luckert, 1975). Faris (1990), in discussing the Night Way, stresses that these healing procedures which order, harmonize and reestablish and situate social relationsare in local knowledge prior to other concerns. And it is only in careful attention to local beliefs and local knowledge that Navajo conceptions of order and beauty can be understood (p. 3; italics in original). The Coyote Way (ma iij hat a al) has been documented in great detail, including an extensive photographic record, by Luckert (1979). It is worth exploring this example in some detail to exemplify the intricate multidimensionality of hypnotic-like procedures that exist in certain cultural
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practices. Coyote Way is a nine-day ceremony that involves Unraveling Ceremonies (so named because during the rst four evenings and nights, bundles of herbs and other ingredients are unraveled to loosen the illness), Fire Ceremonies (occupying the rst four mornings and noon), BasketDrum Ceremonies (occupying the second four evenings and nights), Sand Painting Ceremonies with one or more god impersonators or y eii (occurring on the second four mornings and noon), and a nal Basket Drum Ceremony on the ninth night. Coyote Way involves 161 chants and prayers (including repetitions) and two different sand paintings (at least in the ceremony documented by Luckert, 1979). Like other chantways, Coyote Way is traceable in history, possibly, to a point in time when several formerly shamanic traditions became amalgamated into the conglomerate healing ceremonials of later priestly hataaii or singers (Luckert, 1979, p. 3). Communication with spirits in an altered state is now replaced by learned liturgy of the poetic chantway; discussion of altered states or spirits is not part of the proceedings. In fact, it might be seen as problematic if a participant were to report the sighting of a spirit (Faris, 1988, personal communication). Many of the specic procedures used, based on extant research, can be seen as conducive to changes of various aspects of consciousness (such as rattling or repetitive chanting or the shift in waking cylce) or they can be interpreted as social cues that prompt the patient to engage in appropriate behavior (with no apparent signs of alterations in ones patterns of phenomenological properties). The origin myth of Coyote Way, however, clearly indicates the inspired or shamanic origins of the now highly structured priestly performance and can be seen as the account of an earlier shamanic visionary experience (see Winkelman, 2000, for a differentiation of shamans and priests). The beginning of one version of the story talks about the origin of chantways in dreams. It describes a journey through the sacred landscape of the Din e people. A boy has exhausted his hunting luck and follows coyote tracks in hopes that they might lead him to some game. He arrives at a frozen pond and follows the tracks down a ladder. In this underworld, he receives detailed instructions on how to perform Coyote Way, and the ceremony is performed over him. He then teaches the Earth People the ceremony before returning to the Coyote People. This myth exemplies a four-yearlong shamanic underworld journey, as the story goes (analogous to the prolonged initiations during shamanic illness among Siberian tribes; Vasilevi c, 1968) and sets the cultural context for the ritual. It should be noted that the Great Coyote previously had much more positive connotations as a trickster and hunter than it has today. Coyote illness originates with the Great Coyote beyond the East and is brought to humans via predators from Sun and Moon. The basic symptoms seem to be mania, nervous malfunctions, and rabies, with such symptomatic behavior as twisted mouth, cross-eyed vision, weakened eyesight,
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loss of memory, and fainting. Faris (1990) has extensively argued for the importance of situating ceremonial practices and reliance on the authority of practitioners of local knowledge (as opposed to the use of Jungian or other perspectives alien to Din e cultural practices). The absence of a formal induction does not prevent the client from becoming receptive to a suggestion and motivated to follow it, just as most, if not all, hypnotic phenomena can be evoked without hypnotic induction (Kirsch, 1990, p. 129). Contributing to this procedure is the multimodal approach that characterizes Navajo chants, as well as their repetitive nature and the mythic content of the words, which are easily deciphered by those clients well versed in tribal mythology. Sandner (1979) described how the visual images of the sand paintings and the body paintings, the audible recitation of prayers and songs, the touch of the prayer sticks and the hands of the medicine man, the taste of the ceremonial musk and herbal medicines, and the smell of the incense all combine to convey the power of the chant to the patient (p. 215). A hataaii usually displays a highly developed dramatic sense in carrying out the chant but generally avoids the clever sleight of hand effects used by many other cultural healing practitioners to demonstrate their abilities to the community (p. 241). The following four sections describe the multidimensionality of hypnotic-like procedures in the Coyote Way.
Unraveling Ceremony
This involves a number of bundles (made of feathers and plants), a watery mixture to be consumed (made from corn and other plants), and a rub-on medicine (made from herbs). At the beginning of the ceremony, cornmeal is sprinkled to represent the world inside the hogan. The patient circles the re and sits in this microcosm of the world made present through the cornmeal design. Songs evoke the origins of the Coyote Way, They were given, they were given . . . He brought it back, he brought it back (Luckert, 1979, p. 37). The bundle gets pressed against the body of the patient in important places and the bundles are loosened to loosen the knots in the patients body. Then the patient drinks the watery mixture and the rub-on medicine is applied to the body while songs commemorate the shamanic initiation of the original practitioner into the Coyote Way. This ceremony concludes, as do all ceremonies that are part of the Coyote Way, with a feather burning rite.
Fire Ceremony
The re is made with re sticks while chanting is going on. Reed-prayer stick bundles are prepared (which include various bird feathers, pollen, and tobacco); through this smoke the Holy People are tricked and they
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burn the arrow, which is smuggled into the bundlean arrow that has affected the patient negatively; the patient carries these items about half a mile in each of the cardinal directions and deposits them. The chanting recounts the exploits of the rst shaman as he walks in the four directions. In addition, plant bundles are also used on the body of the patient. A sweating rite follows and an emetic drink (made from juniper, pine, spruce, algae, berry, and other plant ingredients) is prepared and consumed and rubbed on the body after the sweat. Songs guide in the identication with the Great Coyote, and the ceremony literally proceeds inside this cosmic being.
Basket Drum Ceremony

Two large yucca leaves are knitted together into a drumstick for use on an upside-down wedding basket. The healing progresses, as indicated by chants like I am reviving my mind in the presence of the Sun. . . . The blessing is given, the blessing is given. Each basket-drum session ends with a feather burning rite.
Sand Painting Ceremony

During these ceremonies, the y eii or gods or holy people appear. The sand paintings represent the cosmos in a controllable form. The image recounts the emergence of humans as well as the origin of the Coyote Way. The sand painting, depicting Holy People and corn, is an image of balance, and the patient is placed on it while the y eii work on him or her by administering medicines. In this way, the patient is literally, physically moved from a place of imbalance and ill health onto a place of balance and healing (by sitting in the balanced cosmos of the sand painting). Hypnotic-like procedures affect the mentation of both the hataaii and the patient during the chant. Sandner (1979) pointed out that the hataaiis performance empowers the client by creating a mythic reality, an invocation of cosmic balance, through the use of chants, dances, and songs (often accompanied by drums and rattles), masked dancers, purications (e.g., sweats, purgings, herbal infusions, ritual bathings, sexual abstinence), and sand paintings. Joseph Campbell (1990) described the colors of the typical sand painting as those associated with each of the four directions and a dark centerthe abysmal dark out of which all things come and back to which they go. When appearances emerge in the painting they break into pairs of opposites (p. 30). The Navajo chants were considered by Sandner (1979) to facilitate suggestibility and shifts in attention through repetitive singing and the use of culture-specic mythic themes (p. 245). These activities prepare participants and their community for healing sessions. As we have seen in the
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previous example, these healing sessions may involve symbols and metaphors acted out by performers, enacted in purication rites, or executed in dry paintings (a more accurate term, since other substances are also used) composed of sand, corn meal, charcoal, and owersbut destroyed once the healing session is over. Some paintings, such as those used in the Blessing Way chant, are crafted from ingredients that have not touched the ground (e.g., corn meal, ower petals, or charcoal). Toppers (1987) study of Navajo hataaii indicated that they raise their clients expectations through the example they set of stability and competence. Politically, they are authoritative and powerful; this embellishes their symbolic value as transference gures in the psychoanalytic sense, representing a nearly omniscient and omnipotent nutritive grandparental object (p. 221). Frank and Frank (1991) have stated it more directly: The personal qualities that predispose patients to a favorable therapeutic response are similar to those that heighten susceptibility to methods of healing in non-industrialized societies, religious revivals, experimental manipulations of attitudes, and administration of a placebo (p. 184). The hypnotic-like procedures strengthen the support by family and community members as well as the clients identication with gures and activities in Navajo cultural myths, both of which are powerful elements in the attempted healing. But do these procedures deserve a description that indicates a major shift in conscious functioning? Sandner (1979) found that his informants were insulted when it was suggested that Navajo hataaii change their state of consciousness to such an extent that their sense of identity is lost; such a shift would distract the practitioners from the attention to detail and the precise memory needed for a successful performance. (This comment supports the utility of such less-loaded phrases as attentional shifts and changed patterns of phenomenological properties.) Arguably, the self-concept of indigenous people and modern observers are different (Cushman, 1995; Kremer, 2004); the apparent greater inclusiveness and uidity (as far as boundaries to everyday consensual reality are concerned) may make shifts in attention on certain occasions less dramatic or less apparent, with the experient judging them to be quite normal (rather than dramatically different). Both of us observed the intertribal Cherokee/Shoshone medicine man Rolling Thunder by all indications uidly moving in and out of profoundly different states of consciousness while answering questions in conversation. At best, the hataaii appear to modify their attentional states and their patterns of phenomenological properties rather than to alter all of their subsystems of consciousness, or their consciousness as a totality. Attention determines what enters someones awareness. When attention is selective, there is an aroused internal state that makes some stimuli more relevant than others and thus more likely to attract ones attention. A trait that is more characteristic of shamans than a shamanic state of consciousness
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might be the unique attention that shamans give to the relations among human beings, their own bodies, and the natural worldand their willingness to share the resulting knowledge with others (Krippner, 2002, p. 967).
HYPNOTIC-LIKE PROCEDURES IN BALI

Belo (1960) claimed to have observed similarities between the behavior of Balinese shamans and mediums and those of hypnotized subjects. Although there was no trained observer of hypnosis on Belos eld trips, a hypnotic practitioner observed several of her lms and claimed to notice similarities between hypnotic trance and mediumistic trance. In these otherwise useful descriptions, we can observe the proclivity of Western observers to use such terms as hypnosis and trance in describing shamanic procedures rather than simply making direct behavioral comparisons or utilizing the social groups own explanations and phenomenological descriptions. In traditional Balinese practice, the name of the main temple ceremony is nyimpen, and the dance of Calon Arang often is performed during nyimpen. There are several variations of the story of Calon Arang, but all center on her revenge against the people of the ancient Hindu Javanese kingdom of Daha after its ruler (or Raja) insults her by retracting an offer to marry her daughter. Calling up her demon legions, she transforms herself into a frightening gure with ponderous hanging breasts, bulging eyes, a long aming tongue, and a mass of unruly owing hair. Waving her magic cloth, she has become Rangda, the queen of the witches, and wreaks havoc with her powers. Understandably, this is one of the most powerful plays in sacred Balinese drama, and its performance is typically charged with energy and emotion. Thong (1994), a psychiatrist who organized the rst mental hospital on Bali, noted that at the end of a performance of this dance it often takes the efforts of a pemangku (village priest) to gently bring the dancers as well as the spectators back to their ordinary mode of functioning. With the help of his assistants, and armed only with holy water, the pemangku wanders through the crowd sprinkling the entranced revelers; the sacred water quickly revives them. Could this phenomenon be categorized as mass hypnosis? Such a label would be less than accurate because, from Krippners perspective following his witnessing of several performances, there was no direct, overt goal-orientation of the affected individuals. Nor was there anyone who guided participants to respond to suggestions. Therefore, the APA Division 30 denition of hypnosis does not seem to apply to this phenomenon, even if stretched to its limits. In Thongs (1994) opinion, the Balinese peoples repressed emotions nd an outlet in dance and dramaan outlet the culture has provided for them to abreact, either vicariously or directly. Classical dance and drama in Bali, based on legends and myths, are well attended and the more contemporary
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dramatic presentations are even more widely attended. In both the classical and contemporary performing arts, one can encounter every possible Balinese emotionlove, joy, anger, reverence, and others. One can observe intrigue, sexual passion, jealousy, and the violation of all the cultural taboos. Not only do the players benet from expressing these emotions and breaking the taboos, but the audience attains catharsis as well. From Thongs perspective, the other Balinese artspainting, sculpture, the creation of festival offeringsalso help the Balinese to maintain a healthy frame of mind. These art forms have retained their vitality; without them, and their related cultural manifestations, the uniqueness of Bali would have crumbled long ago. Thong concluded that in the altruistic trance states, a dancer responds to the needs of another person or a group of people. This state is usually reached during or after the performance of a ritual and, in Bali, would encompass all hypnotic-like phenomena during religious or healing ceremonies as practiced by the balian, or shamanic practitioner. The practitioners in this group rarely show signs of psychopathology. Egoistic trance states, on the other hand, are entered in response to an individuals personal needs. They are not preceded by a ritual and tend to occur spontaneously. In Bali, this state is believed to be brought about by the possession of an individual by a bebai or evil spirit. Thong concluded that in Balinese ritualistic dancing, the I gives way to a loss of ego boundaries and a change in the body image. The Barong dance ends with the dancers pressing kris knives against their chests as the malevolent Rangda attempts to inuence the dancers to harm themselves. The Barong, a benevolent animal helper, however, offers them protection. Thong determined that these hypnotic-like experiences could be divided into three stages. During the rst stage, dancers are consciously or unconsciously preparing themselves; they have not yet lost reective consciousness and still retain voluntary control and decision-making capabilities. The second stage brings intensication, at which time sense is lost and consciousness is altered. During the third stage, the dancer falls into a condition of deep exhaustion but may be capable of returning to the second stage if sufciently aroused. The change from one stage to another can usually be recognized by distinct somatic clues such as sighs, sobs, hisses, shouts, or body movements. According to Thong, the most important factor in moving from one stage to another is the charged and expectant atmosphere that surrounds shifting ones attention. In other words, the social setting and expectancy seem to be more critical than any physiological maneuver. The leaders of the community play an important role because it is often the head of the village, the sadeg, or some other important personage who rst goes into a trance state, serving as a role model for the others.
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Perhaps the occurrence of hypnotic-like procedures cross-culturally is so frequent because it plays an important cultural role. In Bali, so-called trance dancing serves as a useful emotional outlet both for the dancer and the observer. What Thong termed altruistic trance states are preceded by a ceremony in which an attentional shift is expected and accepted as an integral element. The trancers in these dances are usually ordinary members of the community with no more than the average number of psychological or physical problems. These ceremonies facilitate social cohesion because they are performed on behalf of the entire community. What Thong called egoistic trance states occur outside of the ordinary cultural context. They may involve malicious magical practices, in which attempts are made (or are perceived to have been made) to inuence, coerce, or harm community members. These trancers show a tendency for attacks of hysteria, even acute psychotic reactions and schizoid episodes. The Balinese themselves recognize these two types of trancers and react differently toward each of them.
CONTEMPORARY SHAMANIC PRACTICES IN S APMI

The S ami traditions are probably best known for their use of elaborately designed shamanic drums. The S ami people, who speak several distinct languages, live in S apmi, located in the Scandinavian Fennoscandia region and on the Kola Peninsula. Rydving (1993) published a book entitled The End of the Drum-Time that discusses the religious change at the end of the seventeenth century with the intensication of Christianization; at that time, the drums had to be hidden and numerous drums were destroyed or were taken and ended up in museum collections. In recent decades, the use of the drum has resumed, and some artisans (such as Lars Pirak) make drums and sell them only with the promise of use (but not for show or as mere museum pieces). The shaman is called noaidi (the one who sees, from oaidnit, to see), and he or she works with the drum, govadas, meaning an instrument to develop pictures with (govva means picture) (Kallio, 1997). The drums are instrumental in facilitating attentional shifts and modications of the noaidis pattern of phenomenological properties. Valkeap a a (1991) has probably provided the most detailed evocation of a contemporary traditional S ami worldview, which poetically celebrates the power of the sun, beaivi; the title of the book is The Sun, My Father. It is a work of healing that is effected by bringing old pictures taken by anthropologists from museum archives back to the land of the S ami people, S apmi. It is a shamanic work of art that utilizes traditional chanting (yoiking), sounds of nature, poetry, and imagery to immerse the reader in the S ami world. Nils-Aslak Valkeap a a is usually just known by the honoric Ailu or
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Ailoha s, and his shamanic gifts are apparent in his numerous publications and compact discs (CDs). Places of offering, sieddit, play an important part in S ami traditional practices; they can be found all over S apmi. Frequently these are cracks in rocks, and coins and other objects can usually be found in them. A rock carving in Jiepmaluokta (Bay of Seal Cubs, near Alta, Norway) depicts the offering of a reindeer eye to the earth (it dates to approximately 4200 3600 BCE). One of the most interesting offering stones can be found at the -gi (Fish Oil Stone), identies a center of a spiral. Its name, Ceavccagead place where offerings of gratitude for a good catch were and are made (it is located on the northernmost fjord, Varangerfjord, opposite the Kola Peninsula). In the S ami worldview, every person has an immortal f arrosa s, a journey companion. The shaman or noaidi has three animal helpers: saivoloddi, a bird that shows where to go; saivoguolli, a sh that helps enter the underworld; and saivosarva, a reindeer, which could ght on behalf of the noaidi (Kallio, 1997; Siri, 1998). Pirak (1996, personal communication) related a dramatic tale of a shamanic ght that involves several instances of shape shifting, including the transformation of one noaidi into a powerful loon. Ultimately, one of the shamans who were standing trial for shamanizing or noaidivuohta is absolved of wrongdoing because the judge acknowledges how benecial his actions were. For the S ami, shamanic traditions are returning in various ways, including dreams that contain shamanic elements such as eagles, sunbeams, and humans with wings spread (Siri, 1998, p. 34). Rock carvings showing people with wings have been found in Scandinavia. The S ami traditions see the sun as the giver of light, warmth, and fertility; sunbeams create soul and spirit that travels to First Father who sends it on to First Mother who creates a body for the soul. Kallio comments: The rst shaman was a woman, the daughter of Sun and Eagle. Today this woman lives in a tree, and that is where the shamans get their education (in Siri, 1998, p. 34). The design of old drums frequently has the sun at its center; it is understood as the gateway or portal into the spirit world (Kallio, 1996, personal communication); reindeer commonly stand right next to it. White reindeer carry particular shamanic signicance. The drum is used in two distinct ways: (1) to prophesizewith the help of a ring, reindeer bone, or frog skin that moves across the drumhead during drumming and lands on particular images that then get interpreted (this use of the drum is illustrated in the movie Pathnder, where it is used to determine who is to kill a bear); and, (2) as an instrument for shamanic journeying, where it is often used together with chanting. Kremer experienced noaidivuohta (shamanic activity) on numerous occasions in S apmi along the river Deatnu. For one such ceremony, the setting was a lavvu, the traditional S ami tipi out on the tundra by a lake. The ceremony commenced late in the evening when the midnight sun was low,
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above the horizon. The drum used by Biret M aret Kallio was contemporary in design and had been given to her by another noaidi; the images reected, as in older designs, the S ami worldview and animal helpers with whom she has a particular relationship. The initial conversation covered a variety of shamanic topics, including how many white reindeer Kremer had encountered during this trip. The birch wood re with its particular smell, together with the smoke of the local juniper (reatk a), were at the center. Coffee was offered to S ar ahkk a, arguably the most important female spirit in daily life; she lives in the re and is one of three daughters of M att ar ahkku (the Tribal Mother or Mother Earth). Old drums frequently depict the three sister spirits in the center. The offering to the hearth ( arran) was mandatory before beginning the shamanic journeying work. The drumming was accompanied by chanting, at times overtone chanting, and repeated loud invocations of the bear, guov za. The combination of the setting, timing, smells of the re, drumming, and chanting facilitated a profound alteration of consciousness and intense experiences of visual imagery. At the end, the three participants shared their experiences. Kremer noticed profound attentional shifts; some of them hypnotic-like in nature. By contrast to Din e chantways or other Native American ceremonies, such as those held by the Native American Church, the observations of S ami noaidivuohta were characterized by informality and a spontaneous or inspirational approach. Other settings included work with groups in the lavvu and shamanizing using the drum in order to protect threatened prehistoric sites. These procedures are complex performances that are not covered by Division 30s denition of hypnosis, but call for appreciation in their own right.
AFRICAN-BRAZILIAN MEDIUMSHIP PROCEDURES

Unusual experiences were common in early West African cultures where individuals were considered to be closely connected with nature, the community, and their communal group. Each person was expected to play his or her part in a web of kinship relations and community networks. Strained or broken social ties were held to be the major cause of sickness. A harmonious relationship with ones community, as well as with ones ancestors, was important for health. At the same time, an ordered relationship with the forces of nature, as personied by the orix as or deities, was essential for maintaining the well-being of the individual, the family, and the community. West Africans knew that disease often had natural causes, but believed that these factors were exacerbated by discordant relationships between people and their social and natural milieu. Long before Western medicine recognized the fact, Africas traditional healers took the
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position that ecology and interpersonal relations affected peoples health (Raboteau, 1986). West African healing practitioners felt that they gained access to unusual powers in three ways: by making offerings to the orix as, by foretelling the future with the help of an orix a, and by incorporating an orix a (or even an ancestor) who then diagnosed illnesses, prescribed cures, and provided the community with warnings or blessings. The person through whom the spirits spoke and moved performed this task voluntarily, claiming that such procedures as dancing, singing, or drumming were needed to surrender their minds and bodies to the discarnate entities. The slaves brought these practices to Brazil with them; despite colonial and ecclesiastical repression, the customs survived over the centuries and eventually formed the basis for a number of robust Afro-Brazilian spiritual movements. Books about spiritualism by a French educator, Alan Kardec, were brought to Brazil, translated into Portuguese, and became the basis for a related spiritistic movement (Spiritism or Espiritismo). There were followers of Mesmer in this group, but Kardec proposed that spirits, rather than Mesmers invisible uids, were the active agent in altering consciousness, removing symptoms, and restoring equilibrium (Richeport, 1992, p. 170). Contemporary iyalorix as or m~ aes dos santos (mothers of the spirits) and babalawos or p~ aes dos santos (fathers of the spirits) still teach apprentices how to sing, drum, and dance in order to incorporate the various deities, ancestors, and spirit guides. They also teach the ia^ os (children of the orix as) about the special herbs, teas, and lotions needed to restore health, and about the charms and rituals needed to prevent illness. The ceremonies of the various African-Brazilian spiritistic groups (e.g., Candombl e, Umbanda, Batuque, Quimbanda, and Xang o) differ, but all share three beliefs: humans have a spiritual body (that generally reincarnates after physical death); discarnate spirits are in constant contact with the physical world; humans can learn how to incorporate spirits for the purpose of healing (Krippner, 2000). Shamans predated mediums in prehistory; Winkelman (2000) has provided a useful delineation and description of these two groups of practitioners and how their functions both differ and overlap. Once the apprentices begin to receive instruction in mediumship, such experiences as spirit incorporation, automatic writing, out-of-body travel, and recall of past lives lose their bizarre quality and seem to occur quite naturally. Socialization processes provide role models and the support of peers. A number of cues (songs, chants, music, etc.) facilitate spirit incorporation, and a process of social construction teaches control, appropriate role taking, and communal support. Richeport (1992) observed several similarities between these mediumistic behaviors and those of hypnotized subjects, for example, high motivation, the positive use of imagination, and frequent amnesia for the experience. However, the guidance given apprentices by their mentors only shows a supercial resemblance to
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Division 30s denition; for example, there is no formal induction, yet the ceremony is more directive and structured than what one nds in Ericksonian hypnosis and related procedures. It should be noted that mediums resemble shamans in many ways but lack the control of their attention that characterizes shamans. For example, shamans are usually aware of everything that occurs while they converse with the spirits, even when a spirit speaks through them. Many mediums claim to lose awareness once they incorporate a spirit, and purport to remember little about the experience once the spirit departs. The traits most admired by fellow mediums and the larger community resemble those traits that facilitate ordinary social interactions. Leacock and Leacock (1972) observed that the Brazilian mediums in their study usually behaved in ways that were basically rational, communicated effectively with other people, and demonstrated few symptoms of hysteria or psychosis. They engaged in intensive training and, as mediums, pursued hard work that often put them at risk with seriously ill individuals (p. 212). Such training and discipline are not likely to be the favorite pastimes of fragile personalities or malingerers. In dozens of African-Brazilian ceremonies and rituals that Krippner has witnessed, a trance was induced by the rhythmic drumming and movement as well as by the assault on the senses produced by the music, incense, ickering candles, andin some templespungent cigar smoke. But it was apparent to him that powerful demand characteristics were also at work. The very reason for the mediums presence was the incorporation of spirits; as Kleinman (1980) argued, providing effective treatment for disease is not the chief reason why indigenous practitioners heal. To the extent that they provide culturally legitimated treatment of illness, they must heal (p. 362). In addition, the community of believers depended on the mothers, fathers, and children of the orix as to provide a connection to the spirit world that would ensure the well-being of the temple, prevent illness among those who were well, and bestow healing upon those who were indisposed. Krippner observed that when one medium incorporated an orix a or spirit, an entire series of incorporations soon followed, domino like. Just as many participants in hypnotic sessions seem eager to present themselves as good subjects (Spanos, 1989), the mediums in Afro-Brazilian healing sessions may be eager to present themselves as good mediums, and to enact behaviors consistent with this interpretation. Krippner also noticed that the presence of visitors appeared to increase both the speed and the dramatic qualities of spirit incorporation. A fairly consistent similarity among mediums is their supposed inability to recall the events of the incorporation after the spirits have departed. However, Spanos (1989) has pointed out that this amnesic quality could just as easily be explained as an achievement; each failure to remember
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adds legitimacy to a subjects self-presentation as truly unable to remember, hence as deeply in trance (p. 101). In other words, the interpretation of hypnotic phenomena as goal-directed action is helpful in understanding mediumship as an activity that meets role demands, as mediums guide and report their behavior and experience in conformance with these demands. It may not be that they lose control over the behavior as they incorporate a spirit, but rather that they engage in an efcacious enactment of a role that they are eager to maintain. An alternative point of view would hold that the mediums actually do lose control over their behavior, entering a trance state that allows hidden parts of themselves to manifest as secondary personalities or, in the case of the Brazilian mediums, as spirits. But some Brazilian practitioners with whom Krippner discussed these issues made comments that indicated that both the role-playing and dissociative paradigms merely describe the mechanisms by which a medium actually incorporates the orix a, discarnate entity, or spirit. It is the incorporation itself, and the subsequent behavior of the spirit, that represent the crux of mediumship. African-Brazilian spiritistic ceremonies enable clients and mediums to arrive at a shared worldview in which an ailment can be discussed and treated (Torrey, 1986). In some spiritistic traditions, there are mediums who specialize in diagnosis, mediums who specialize in healing through a laying-on of hands, mediums who specialize in purported distant, nonlocal healing, and mediums who specialize in intercessory prayer. Treatment may also consist of removing a low spirit from a clients energy eld, integrating ones past lives with the present incarnation, the assignment of prayers or service-oriented projects, or referral to a homeopathic physician. All of these procedures contain the possibility of enhancing clients sense of mastery, increasing their self-healing capacities, and replacing their demoralization with empowerment (Frank & Frank, 1991; Torrey, 1986). The mediums are not the only ones who appear to manifest hypnoticlike effects. Their clients also demonstrate apparent attentional shifts, especially while undergoing crude surgeries without the benet of anesthetics; however, Greeneld (1992) has observed that the Brazilian mediums make no direct effort to alter their clients awareness during these interventions. Greeneld has observed that no one is consciously aware of hypnotizing . . . patients . . . , and unlike the mediums, patients participate in no ritual during which they may be seen to enter a trance state (p. 23). However, there are a number of cultural procedures that Greeneld found to be hypnotic-like in nature. One of them was the relationship of client and healer, characterized by trust, and resembling that between hypnotist and client (p. 23) in that these clients act positively in response to what the medium tells them. Another procedure is the provision of a context that allows the client to become totally absorbed in the intervention, a healing ritual that galvanizes the clients attention, and distracts
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him or her from feeling pain. Greeneld added that the spiritistic aspects of Brazilian culture foster fantasy proneness because large numbers of people believe that preternatural entities are helping (or hindering) them in their daily lives (p. 24). Rogers (1982) has divided native healing procedures into several categories (p. 112): nullication of sorcery (e.g., charms, dances, songs); removal of objects (e.g., sucking, brushing, shamanic surgery); expulsion of harmful entities (e.g., ghting the entity, sending a spirit to ght the entity, making the entity uncomfortable); retrieval of lost souls (e.g., by soul catchers, by shamanic journeying); eliciting confession and penance (e.g., to the shaman, to the community); transfer of illness (e.g., to an object, to a scapegoat); suggestion and persuasion (e.g., reasoning, use of ritual, use of herbs); and shock (e.g., sudden change of temperature, precipitous physical assault). There are hypnotic-like segments of these procedures that utilize symbols, metaphors, stories, and ritualsespecially those involving group participation.
CONCLUSION
Hypnosis is a noun while hypnotic-like is an adjective, hence the use of the former term lends itself to abuse more easily than utilization of the latter. This distinction is important when one reads such accounts as that by Torrey (1986) who surveyed indigenous practitioners, concludingon the basis of anecdotal reportsthat many of them are effective psychotherapists and produce therapeutic change in their clients (p. 205). Torrey observed that when the effectiveness of therapeutic paraprofessionals has been compared, professionals have not always been found to demonstrate superior therapeutic skills. The sources of the effectiveness of professional psychotherapists, paraprofessional therapists, and native healing practitioners are four basic components of psychotherapya shared worldview, impressive personal qualities of the healer, positive client expectations, and a process that enhances the clients learning and mastery (p. 207). We would suggest that an adjective such as psychotherapist-like would be a more accurate term than Torreys use of the noun psychotherapist in describing native practitioners; however, we are quite comfortable with Strupps (1972) description: The modern psychotherapist . . . relies to a large extent on the same psychological mechanisms used by the faith healer, shaman, physician, priest, and others, and the results, as reected by the evidence of therapeutic outcomes, appear to be substantially similar (p. 277). Especially valuable are qualitative analyses of the experiences of both practitioners and their clients. Krippner (1990) has used questionnaires to study perceived long-term effects following overseas visitors trips to Filipino and Brazilian folk healers, nding such variables as willingness to change ones behavior to signicantly correlate with reported benecial modications in health. Cooperstein (1992) interviewed ten prominent
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alternative healers in the United States, nding that their procedures involved the self-regulation of their attention, physiology, and cognition, thus inducing altered awareness and reorganizing the healers construction of cultural and personal realities (p. 99). Cooperstein concluded that the concept that most closely represented his data was the shamanic capacity to transcend the personal self, to enter into multiform identications, to access and synthesize alternative perspectives and realities, and to nd solutions and acquire extraordinary abilities used to aid the community (p. 121). Indeed, the shamans role and that of the alternative healer are both socially constructed, as are their operating procedures and their patients predispositions to respond to the treatment. It is not only important to study the effects of the hypnotic-like procedures found in native healing, but to accurately describe them, and understand them within their own framework. Kremer and Krippner (1994) have used questionnaires and self-reports to assess alterations and shamanic journeying content of inexperienced subjects assuming purported trance postures and were only able to partially support Goodmans (1990) claims as to the specicity of the experience induced by different postures (which were based on shamanic sculptures and rock carvings). The professionalization of shamanic and other traditional healers demonstrates their similarity to practitioners of Western medicine (Feinstein & Krippner, 1997). Nevertheless, the differences cannot be ignored. Rogers (1982) has contrasted the Western and native models of healing, noting that in Western medicine, Healing procedures are usually private, often secretive. Social reinforcement is rare. . . . The cause and treatment of illness are usually regarded as secular. . . . Treatment may extend over a period of months or years. In native healing, however, Healing procedures are often public: many relatives and friends may attend the rite. Social reinforcement is normally an important element. The shaman speaks for the spirits or the spirits speak through him [or her]. Symbolism and symbolic manipulation are vital elements. Healing is of limited duration, often lasting but a few hours, rarely more than a few days (p. 169). Rogers (1982) has also presented three basic principles that underlie the indigenous approach to healing: The essence of power is such that it can be controlled through incantations, formulas, and rituals; the universe is controlled by a mysterious power that can be directed through the meticulous avoidance of certain acts and through the zealous observance of strict obligations toward persons, places, and objects; the affairs of humankind are inuenced by spirits, ghosts, and other entities whose actions, nonetheless, can be inuenced to some degree by human effort (p. 43). This worldviewone that fosters the efcacy of hypnotic-like proceduresvaries from locale to locale but is remarkably consistent across indigenous cultures. The ceremonial activities produce shifts of attention for both the healer and the client. The cultures rules and regulations produce a
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structure in which the clients motivation can operate to empower them and stimulate their self-healing aptitudes. Western practitioners of hypnosis utilize the same human capacities that have been used by native practitioners in their hypnotic-like procedures. These include the capacity for imaginative suggestibility, the ability to shift attentional style, the potential for intention and motivation, and the capability for self-healing made possible by neurotransmitters, internal repair systems, and other components of mind/body interaction. These capacities often are evoked in ways that resemble Ericksonian hypnosis (Erickson, Rossi, & Rossi, 1976) because of their emphasis on narrative accounts. Hypnosis and hypnotic-like activities are complex and interactive, and hence take different forms in different cultures. Yet, as with any form of intervention, the mask . . . crafted by the groups culture will also t a majority of its members (Kakar, 1982, p. 278). The multidimensionality of indigenous hypnotic-like approaches can be seen as an important characteristic that appear to apply cross-culturally. It has become increasingly apparent to cross-cultural psychologists that the human psyche cannot be extricated from the historically variable and diverse intentional worlds in which it plays a co-constituting part. Supposedly, writing makes reality accessible by representing consensual reality, but far too often it becomes a substitute for the reality it purports to represent (Krippner, 1994). Therefore, we are dismayed when we see Western terms haphazardly applied to frenetic actions; for example, amok in Indonesia has been called a trance-like state and latah a condition akin to hysteria (Suryani & Jensen, 1993). The cross-cultural exploration and knowledge exchange about hypnotic-like procedures poses signicant paradigmatic and epistemological challenges that both authors have explored in other places (Kremer, 1994, 1996, 2000, 2002b, 2004; Krippner, 2000, 2004; Krippner & Winkler, 1995). By investigating ways in which different societies have constructed diagnostic categories and remedial procedures, therapists and physicians can explore novel and vital changes in their own procedures hypnotic and otherwisethat have become obdurate and rigid. Western medicine and psychotherapy have their roots in traditional practices and need to explore avenues of potential cooperation with native practitioners of those healing methods that may still contain wise insights and practical applications. Using APA Division 30s useful denition as a guide, we hope that Western terms will not be superimposed on indigenous shamanic and mediumistic practices that deserve to be studied and appreciated in their own context.
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Barber, T. X. (1969). Hypnosis: A scientic approach. New York: Van Nostrand Reinhold. Belo, J. (1960). Trance in Bali. New York: Columbia University Press. Bourguignon, E., & Evascu, T. (1977). Altered states of consciousness within a general evolutionary perspective: A holocultural analysis. Behavior Science Research, 12, 199216. Campbell, J. (1990). Transformations of myth through time. New York: Harper & Row. Clottes, J., & Lewis-Williams, D. (1998). The shamans of prehistory: Trance and magic in the painted caves (S. Hawkes, Trans.). New York: Harry N. Abrams. (Original work published 1996). Cooperstein, M. A. (1992). The myths of healing: A summary of research into transpersonal healing experience. Journal of the American Society for Psychical Research, 86, 99133. Cushman, P. (1995). Constructing the self, constructing America. Reading, MA: Addison-Wesley. Di oszegi, V. (Ed.). Popular beliefs and folklore tradition in Siberia (pp. 339350). Bloomington: Indiana University Press. Erickson, M. H., Rossi, E. L., & Rossi, S. H. (1976). Hypnotic realities: The induction of clinical hypnosis and the indirect forms of suggestion. New York: Irvington. Executive Committee, Division 30. (2004, Winter/Spring). Division 30s new denition of hypnosis. Psychological Hypnosis, p. 13. Faris, J. C. (1990). The nightway. Albuquerque: University of New Mexico Press. Feinstein, D., & Krippner, S. (1997). The mythic path. New York: Tarcher/Putnam. Flaherty, G. (1992). Shamanism and the eighteenth century. Princeton, NJ: Princeton University Press. Frank, J. D., & Frank, J. B. (1991). Persuasion and healing (3rd ed.). Baltimore: Johns Hopkins University Press. Gergen, K. J. (1985). The social constructionist movement in modern psychology. American Psychologist, 40, 266275. Goodman, F. (1990). Where the spirits ride the wind. Bloomington: Indiana University Press. Gravitz, M. (1984). Origins of the term hypnotism prior to Braid. American Journal of Clinical Hypnosis, 27, 107110. Greeneld, S. M. (1992). Hypnosis and trance induction in the surgeries of Brazilian spiritist healer-mediums. Anthropology of Consciousness, 2(34), 2025. Kakar, S. (1982). Shamans, mystics and doctors: A psychological inquiry into India and its healing traditions. New York: A.A. Knopf. Kallio, B. M. (1997). The one who sees. ReVision, 19(3), 3741. Kirsch, I. (1990). Changing expectations: A key to effective psychotherapy. Pacic Grove, CA: Brooks/Cole. Kleinman, A. (1980). Patients and healers in the context of culture. Berkeley: University of California Press. Kremer, J. W. (1994). Seidr or trance? ReVision, 16(4), 183191. Kremer, J. W. (1996). The possibility of recovering indigenous European perspectives on native healing practices. Ethnopsychologische Mitteilungen, 5(2), 149 164.
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Kremer, J. W. (2000). Shamanic initiations and their lossdecolonization as initiation and healing. Ethnopsychologische Mitteilungen, 9(1/2), 109148. Kremer, J. W. (2002a). Radical presence. ReVision, 24(3), 1120. Kremer, J. W. (2002b). Trance als multisensuelle Kreativit atstechnik. In P. Luckner (Ed.) Multisensuelles design. Eine anthologie (pp. 591620). Halle, Germany: University Press of Burg GiebichensteinHochschule f ur Kunst und Design. Kremer, J. W. (2004). Ethnoautobiography as practice of radical presence Storying the self in participatory visions. ReVision, 26(2), 513. Kremer, J. W., & Krippner, S. (1994). Trance postures. ReVision, 16(4), 173182. Krippner, S. (1990). A questionnaire study of experiential reactions to a Brazilian healer. Journal of the Society for Psychical Research, 56, 208215. Krippner, S. (1993). Cross-cultural perspectives on hypnotic-like procedures used by native healing practitioners. In J. W. Rhue, S. J. Lynn, & I. Kirsch (Eds.) Handbook of clinical hypnosis (pp. 691717). Washington, DC: American Psychological Association. Krippner, S. (1994). Cross-cultural treatment perspectives on dissociative disorders. In S. J. Lynn & J. W. Rhue (Eds.) Dissociation: Clinical and theoretical perspectives (pp. 338361). New York: Guilford. Krippner, S. (2000). Cross-cultural perspectives on transpersonal hypnosis. In E. Leskowitz (Ed.) Transpersonal hypnosis: Gateway to body, mind, and spirit (pp. 141162). New York: CRC Press. Krippner, S. (2002). Conicting perspectives on shamans and shamanism: Points and counterpoints. American Psychologist, 57, 960977. Krippner, S. (2004). Hypnotic-like procedures used by indigenous healing practitioners. Hypnos, 31, 125135. Krippner, S. (2009). Indigenous health care practitioners and the hypnotic-like healing procedures. Journal of Transpersonal Research, 1, 718. Krippner, S., Bova, M., & Gray, L. (Eds.) (2007). Healing stories. Charlottesville, VA: Puente. Krippner, S., Bova, M., Gray, L., & Kay, A. (Eds.) (2007). Healing tales. Charlottesville, VA: Puente. Krippner, S., & Winkler, M. (1995). Postmodernity and Consciousness Studies. Journal of Mind and Behavior, 16(3), 255280. Kuper, A. (2007, January/February). Misguided medicine. Foreign Policy, 9698. Leacock, S., & Leacock, R. (1972). Spirits of the deep: Drums, mediums and trance in a Brazilian city. Garden City, NY: Doubleday. Lewis-Williams, D. (2002). The mind in the cave. New York: Thames & Hudson. Luckert, K. (1975). The Navajo hunter tradition. Tucson: University of Arizona Press. Luckert, K. (1979). Coyoteway. Tucson: University of Arizona Press. Neher, A. (1961). A physiological explanation of unusual behavior in ceremonies involving drums. Human Biology, 34, 151160. Raboteau, A. J. (1986). The Afro-American traditions. In R. L. Numbers & D. W. Amundsen (Eds.) Caring and curing: Health and medicine in Western religious traditions (pp. 539562). New York: Macmillan. Reichel-Dolmatoff, G. (1971). Amazonian cosmos. Chicago: University of Chicago Press.
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Richeport, M. M. (1992). The interface between multiple personality, spirit mediumship, and hypnosis. American Journal of Clinical Hypnosis, 34, 168 177. Rock, A., & Krippner, S. (2007). Shamanism and the confusion of consciousness with phenomenological content. North American Journal of Psychology, 9, 485500. Rogers, S. L. (1982). The shaman: His symbols and his healing power. Springeld, IL: Charles C Thomas. Rydving, H. (1993). The end of drum-time. Stockholm: Almqvist & Wiksell. Sandner, D. (1979). Navaho symbols of healing. New York: Harcourt Brace Jovanovich. Sansonese, J. N. (1994). The body of myth: Mythology, shamanic trance, and the sacred geography of the body. Rochester, VT: Inner Traditions International. Siri, V. (1998). Dreaming with the rst shaman (noaidi). ReVision, 21(1), 3439. Spanos, N. P. (1989). Hypnosis, demonic possession, and multiple personality: Strategic enactments and disavowals of responsibility for actions. In C. Ward (Ed.) Altered states of consciousness and mental health: A cross-cultural perspective (pp. 96124). Los Angeles: Sage. Strupp, H. H. (1972). On the technology of psychotherapy. Archives of General Psychiatry, 26, 270278. Suryani, L. K., & Jensen, G. D. (1993). Trance and possession in Bali: A window on Western multiple personality. New York: Oxford University Press. Tart, C. (1975). States of consciousness. New York: Dutton. Thong, D., with Carpenter, B., & Krippner, S. (1994). A psychiatrist in paradise: Treating mental illness in Bali. Bangkok: White Lotus Press. Topper, M. D. (1987). The traditional Navajo medicine man: Therapist, counselor, and community leader. Journal of Psychoanalytic Anthropology, 10, 217249. Torrey, E. F. (1986). Witchdoctors and psychiatrists: The common roots of psychotherapy and its future. New York: Harper & Row. Valkea a a, N.-A. (1991). Beavi, ah c a zan [The sun, my father]. Guovdageaidnu, Norway: DAT. Vasilevi c, G. M. (1968). The acquisition of shamanistic ability among the Evenki (Tungus). In V. Di oszegi (Hg.) S. 339349. F. Vos, Die Religionen Koreas. Vogel, V. J. (1990). American Indian medicine. Norman: University of Oklahoma Press. (Original work published 1970). Winkelman, M. (2000). Shamanism. Westport, CT: Bergin & Garvey. Young, R. W., & Morgan, W. (1987). The Navajo language A grammar and colloquial dictionary. Albuquerque: University of New Mexico Press. Preparation of this chapter was supported by the Chair for the Study of Consciousness, Saybrook Graduate School and Research Center, San Francisco, California.
Chapter 7
Lay Hypnotherapy and the Credentialing of Zoe the Cat

Steve K. D. Eichel
Just a ball of confusion, oh yeah, thats what credentialing is today. (Apologies to The Temptations)
The issue of credentialing in hypnosis has always been a confusing one. It reects the intermittent battle between lay hypnotists and health professionals who utilize hypnosis (clinical hypnotists).1 Recent attempts to establish a solid credentialing process, such as the certication programs established by the American Society of Clinical Hypnosis (ASCH), may have inadvertently made the situation even worse. I dont know if I helped matters. I spent nearly a decade serving on the board of governors of the Greater Philadelphia Society of Clinical Hypnosis. During those years, I grew increasingly uneasy with the growing acceptance lay hypnosis seemed to be enjoying in the media, despite some of its spokespersons clearly dubious claims and equally questionable backgrounds. Publications in the alternative health eld were especially welcoming to lay hypnotists, and often lauded and promoted lay hypnosis associations (and their unsupported claims) in their reference and referral sections, typically without mentioning the groups most often associated with clinical hypnosis. I started paying closer to the questionable credentials many lay hypnotists seemed to claim. I grew tired of sounding defensive to therapist-shopping clients who challenged me with something on the order of: I found somebody with all these certications and diplomas who charges a fraction of what you psychologists charge, and promises to cure me in one or two sessions. In 2002, in a somewhat rash attempt to deal with my growing frustrations, I decided to prove a point. I got my cat certied. There is a back story to my actions. I had become involved in a lay hypnosis association, the Association to Advance Ethical Hypnosis (AAEH),
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back in the early 1980s. I did not qualify for membership in ASCH because, at the time, they did not accept masters-level practitioners (even though I was a licensed psychologist). My experience with AAEH brought me in touch with several other lay associations (there seem to be signicant crossmemberships). I found much to like, and sometimes more to dislike, in these associations. For one, most of them supported and even encouraged stage hypnosis (AAEH did not, which is one of the reasons I gravitated toward it). I did receive some good training. However, some of the training was dubious. For example, I was instructed in highly simplistic methods for dealing with some fairly serious psychological issues, including chronic depression, trauma, and addiction. Research in support of many of these methods consisted of anecdotal reports from practitioners. Other methods had empirical support but were taught out of context. The majority of the people I met at various meetings and workshops sponsored by lay associations had no training whatsoever in a healing art, yet were being taught intensive therapeutic techniques, like hypnotic regression to treat trauma. As I became more familiar with people considered to be master hypnotists and leaders within the lay associations, I discovered that a signicant number of them claimed degrees and credentials that were suspect and, in some cases, unearned.2 I became even more disturbed. After two years, I severed my relationship with these associations. The independent practice of psychology is a competitive activity, albeit (compared with other endeavors and even professions) a relatively genteel one with fairly strict rules. I was used to answering questions from potential clients about my practice, experience, and qualications without saying anything about my competitors. However, I was unprepared to deal with inquiries about certied hypnotherapists who appeared to have impressive credentials that I believed were bogus. Believed is the operative term here; I had no real proof. So in late 2001, I decided to get some. Getting Zoe certied as a hypnotherapist was easier than I imagined. All it took was some creativity and a credit card. First, I needed a full name. I decided on a tongue-in-cheek name, Zoe D. Katze. In German, die katze literally translates into the cat, so my pets name literally meant Zoe the cat. I had no problem authorizing Zoe D. Katze to use my credit card. The rest was fairly easy. I went to the Web sites of what seemed to be the three largest lay hypnosis associations: the National Guild of Hypnotists (NGH), the American Board of Hypnotherapists (ABH), and the International Medical & Dental Hypnosis Association (IMDHA). I answered their questions, which included making up training and workshop experiences, falsifying dates, and so forth. I (or Zoe) was never asked for proof of the training experiences, a professional license of any sort, or for that matter any kind of proof of anything. All that seemed to really matter was having a valid credit card number.
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Within a few weeks, Zoes certicates arrived. One attested to her having completed the required studies in order to be found by the Board of Directors to possess the qualications to be a certied hypnotherapist. Two certicates alluded to an actual examination process by stating she had been found by the Board of Examiners to possess the education and training qualications . . . or that she demonstrated knowledge and prociency satisfactory to the Examining Committee. One of the certicates proclaimed her as authorized to the lawful professional title of Certied Hypnotherapist. Needless to say, the only examination Zoe could have passed would have been by a veterinarian. Having obtained several hypnosis certications, I then decided to extend my experiment to an organization I resigned from after concluding that it was nothing more than a credentials mill. This time, I was applying for board certication in psychotherapy through the American Psychotherapy Association (not to be confused with the American Psychological Association). In medicine, board certication (also known as Diplomate status) is understood to be the highest level of competency that can be formally assessed. It is a postgraduate, post-licensure process that involves a review of credentials, experience (in medicine, usually a postgraduate fellowship) and then an intensive examination by a panel of ones peers. The examination is considered to be more rigorous than the professions licensing exam. It is the equivalent of moving from journeyman to master craftsman.
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After lling out another Internet application and authorizing payment of the requisite fee, Zoe received a call a few days later (the fact that her name was not on my answering machine did not seem to raise any suspicions) advising her that she would need to submit a curriculum vitae (CV) to complete her examination process. I decided to have some fun with this. Of course, I rst gave her an academic history, including a PhD from a made-up university. Not content with the clue inherent in her name, I peppered her CV with various other clues to Zoes real identity, including such gems as an academic appointment at Gareld School of Nursing and an employment history that included positions with Lagata Community Mental Health Center, St. Felix Home for Children, and my personal favorite, Tacayllaermi Friends School (Tacayllaermi being Im really a cat spelled backwards). A few weeks later, Zoe received her diploma. Her congratulatory letter proclaimed that achieving Diplomate status is limited to a select group of professionals who, by virtue of their extensive training and expertise, have demonstrated their outstanding abilities in regard to their specialty. Having contented myself that I now had proof of what I had long suspected about the illegitimacy of some hypnosis and psychotherapy
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credentialing services, I initially sat on this information, not knowing what (if anything) to do next. However, my question was soon answered as the referrals to Dr. Zoe D. Katze began to come in. Zoe was even approached to do an interview for a major magazine about hypnobirthing. I eventually grew tired of explaining why Dr. Katze could not see clients or grant interviews, and in 2002 decided to post an article (Eichel, 2002) on my personal Web site so I could refer people to it rather than be engaged in lengthy discussion. I am unsure how Mark Hansen, a legal affairs writer for the American Bar Association, found my article. Two years previous to my article, Hansen had published Expertise to Go, an article highly critical of the American College of Forensic Examiners (ACFE). The organization that board certied Zoe was the American Psychotherapy Association, an offshoot of the ACFE. Mark called me after he read my article and interviewed me extensively. In October 2002, Hansen published See the Cat? See the Credentials? Psychologists Scam Gets His Pet Board-Certied. Hansen concentrated primarily on Zoes board certication as a psychotherapist; to me, her certication as a hypnotherapist seemed equally problematic. The Bar Associations electronic journal is far more conspicuous than my personal Web site. Since her debut in Hansens article, Zoes story has appeared in hundreds of Web articles, a variety of university psychology courses, several licensing board citations, numerous articles, and at least one book. Sources as diverse as the James Randi Foundation and Skeptical
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Inquirer, John Bear (a former FBI expert on diploma mill scams), and the False Memory Syndrome Foundation have picked up this story. At least two editorials have been written about me in a major lay hypnosis journal, and on one occasion I had to threaten legal action against a lay hypnotist who referred to me as an immoral liar and cheat in an online publication. In 2005, I wrote a follow-up article for an online hypnosis information clearinghouse (Eichel, 2005) in which I further detailed some of the aftermath of Zoes fame. In July 2009, Zoes story and pictures (including her certicates) appeared on a news program in San Diego, California, in connection with a civil suit led against a custody evaluator who is alleged to have bogus certications. In August 2009, I was interviewed by BBC reporter Andy Smythe, who conducted a similar experiment in Great Britain and successfully got his own cat (George) certied by various United Kingdom lay hypnosis associations.
A BRIEF HISTORY OF HYPNOSIS CREDENTIALING

Credentialing in hypnosis has a complicated history. Following the debunking of Mesmer and his assertion that animal magnetism was the basis of mesmerism, the medical use of hypnosis was treated with benign neglect (when not actively discouraged) despite some fairly signicant claims attesting to its usefulness, especially in surgery (as an anesthesia). In European psychiatry and neurology, hypnosis continued to be taught and pioneered by Jean-Martin Charcot, Hippolyte Bernheim, and Pierre Janet. Joseph Breuer and his colleague Sigmund Freud pioneered hypnoanalysis. However, Freud later disavowed hypnosis and claimed it was vastly inferior to his new analytic technique, free association. Generations of psychiatrists trained in the Freudian tradition followed suit. In surgery, advances in chemical anesthesia rendered the labor-intensive and less reliable induction of hypnosis all but moot. Hypnosis enjoyed a resurgence following World War II when it was used by some psychiatrists to facilitate abreaction in cases of war neurosis or battle fatigue (later recognized as post-traumatic stress disorder). However, for most Americans hypnosis was primarily associated with stage entertainers, charlatans, and horror/science ction movies. As medicine disavowed or merely ignored hypnosis, and with the nascent eld of clinical psychology still rmly under the boot of psychiatry, others outside the medical eld quickly lled the void. First to arrive on the scene were the stage hypnotists. Their goal was to entertain, not to heal; they had little or no dedication to the professionalization or scientic exploration of hypnosis. In fact, just the opposite was true. Many stage hypnotists, including prominent lay hypnotist Ormond McGill, encouraged the association of hypnosis with supernatural powers as a way of increasing its mystique and stage appeal (McGill, 1996). Further sullying the reputation of hypnosis,
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many stage entertainers began utilizing the title Doctor to promote their art; Ormond McGill, for example, used the stage name Dr. Zomb. (To this date, there are many lay hypnotists who claim doctorates, often from diploma mills or schools that are not accredited by an agency recognized by the U.S. Department of Education or foreign equivalents.3)
LAY HYPNOSIS CREDENTIALING

The rst lay hypnosis certication in the United States was probably the National Guild of Hypnotists (NGH), founded in 1951 by Rexford North. The Association to Advance Ethical Hypnosis (AAEH), founded in 1956 by Harry Arons, also began certifying lay hypnotists (called Hypnosis Consultants) in the late 1950s. Part of Aronss motivation was his belief that lay hypnotists need an ethics code, one that explicitly forbids its Hypnosis Consultants from practicing outside their area of expertise or from claiming degrees from unaccredited universities.4 It also discouraged members from engaging in stage hypnosis for entertainment purposes (AAEH, 2009). To date, the NGH claims to be the single largest hypnosis association that has credentialed the largest number of certied hypnotherapists in the United States. For many years, the second largest lay hypnosis credentialing organization was the American Council of Hypnotist Examiners (ACHE). The ACHE grew out of the California-based Hypnotist Examining Council, founded in 1973. With Gil Boyne as its rst president, the ACHE went national in 1980. Boyne claims a PhD in transpersonal psychology from Westbrook University in New Mexico, an unaccredited institution that has been called a diploma mill by FBI DipScam consultant Dr. John Bear (2003). He also lists honorary degrees from Newport University and the University of Humanistic Studies in California5; the former has been accused of committing academic fraud.6 Another California-based organization, the American Board of Hypnotherapy (ABH) began life in 1982 as the California Board of Hypnotherapy, founded by A. M. Krasner. A year earlier, Krasner had founded the American Institute of Hypnotherapy, which later morphed into American Pacic University, another unaccredited school/diploma mill according to Consumer Fraud Reporting Organization (2009) and the Oregon Department of Education.
PROFESSIONAL HYPNOSIS CREDENTIALING

Although experimental psychologists, most notably Clark Hull (1933, 2002), studied hypnosis in the early half of the twentieth century, the medical and allied clinical professions lagged behind. The rst professional hypnosis association, the Society for Clinical and Experimental Hypnosis (SCEH), was founded in 1949. In 1955, the British Medical Association
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was the rst to recognize hypnosis as a scientically legitimate therapeutic technique. In 1957, the American Society of Clinical Hypnosis (ASCH) was founded by Milton Erickson, MD. Membership in either SCEH or ASCH required a doctorate in medicine, dentistry, or psychology.7 For many years, the only formal credential for health professionals was the diploma (board certication) in hypnosis issued by one of the constituent boards of the American Boards of Hypnosis (now called the American Boards of Clinical Hypnosis), which formed in the late 1950s. The ABCH consists of four constituent boards, the American Board of Medical Hypnosis, the American Board of Psychological Hypnosis, the American Board of Hypnosis in Dentistry, and the American Hypnosis Board for Clinical Social Work. Each board conducted both written and oral examinations; successful completion of these examinations led to board certication in hypnosis and Diplomate status. The diploma from the ABCH has been formally recognized by the International Society of Hypnosis (ISH), ASCH, SCEH, and the American Psychological Association. Prior to 1972, psychologists applying for board certication also had to be diplomates of the American Board of Professional Psychology (ABPP), perhaps because some states still did not have psychology licensing laws on their books. Most health professionals did not feel the need for board certication in hypnosis, but instead seemed satised that their licenses and memberships in ASCH and/or SCEH were sufcient to communicate their training and competence in hypnosis. In order to qualify for membership in either ASCH or SCEH, professionals were required to obtain appropriate training as clinicians and/or researchers. They had to show proof of licensure (when applicable) and/or full membership in their professional association. However, lay hypnotists, perhaps realizing that medicine and psychology were not going to include them, were eager to claim hypnosis as a separate and independent profession. The largest lay hypnosis association, the National Guild of Hypnotists (NGH), was founded in 1951, two years after SCEH and six years before ASCH. Several factors combined to lead ASCH to institute its own certication program. First, there was a growing awareness of a need for a middle path between ASCH/SCEH membership and ABCH board certication, one that would be meaningful but attainable without the obstacle of a cumbersome board certication exam. According to some ASCH ofcers with whom I have spoken, there was also a realization that many health professionals were seeking and obtaining hypnosis certication and that ASCH had essentially ceded this market to the lay associations. ASCH was also losing membership and revenue, and there were some who believed a certication program might be one way of reinvigorating the association by drawing in both new members and a new revenue source. ASCH developed a unique certication plan, with two levels.8 Both certifications require a minimum of a masters degree from a regionally accredited institution, licensure or certication as a health professional, and
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membership in ones professional association. The entry level certication (Certication in Clinical Hypnosis) requires a minimum of 40 hours of ASCH-approved workshop training, a minimum of 20 hours of individualized training/consultation with an ASCH-approved consultant, and a minimum of two years of independent practice utilizing clinical hypnosis. The second and more advanced level of certication, called Approved Consultant in Clinical Hypnosis, is for those professionals who want to train and supervise9 professionals seeking the entry level certication. It requires a minimum of 60 additional hours of ASCH-approved workshop training, a minimum of ve years of independent practice utilizing clinical hypnosis, and a minimum of ve years of membership in ASCH, SCEH, or equivalent (ASCH, 2009). Two other associations, the National Board for Certied Clinical Hypnotherapists and the American Psychotherapy and Medical Hypnosis Association, state their certication programs are limited to graduate-level and/or state-licensed health practitioners. Both are relatively small programs and/or do not seem to impact the eld of clinical hypnosis in an identiable, organized fashion. At present, lay certied hypnotherapists far outnumber those certied by ASCH or ABCH. I counted over 40 lay hypnosis associations in the United State10 that together claim to have certied over 40,000 people, including apparently an unknown number of teenagers.11and at least one cat.
WHATS THE BIG DEAL?

Furthermore, America suffers not only from a lack of standards, but also not infrequently from a confusion or an inversion of standards. Irving Babbit
In an editorial I published in the 1997 newsletter of the Greater Philadelphia Society of Clinical Hypnosis, I strongly questioned the war between professional hypnosis and lay hypnosis societies (Eichel, 1997, 2009). Twelve years later, my arguments still seem relevant. The ofcial position held by ASCH, SCEH, ISH, and APA Division 30 is that lay hypnosis and the training of lay hypnotists constitutes unethical practice. The ASCH by-laws and ethics code are clear and specic: hypnosis is a treatment modalitynot a treatment in and of itselfthat should be strictly limited to qualied practitioners of the healing arts. Of course, ASCH has over the years modied its view of who is qualied. Masterslevel licensed psychologists and professional counselors were not considered qualied for ASCH membership until fairly recently. To qualify for certication as a lay hypnotist, no education or training are required other than a specied number of hours of hypnosis training. Apparently, even this requirement can be waived (or ignored), as my cat experiment proved.
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Given the lax procedures followed by the lay associations, it seems that their certied members need not be literate (or, based on the results of my experiment, human). I could not nd any reliable estimate as to how many lay people have been trained in hypnosis, and how many of those are practicing lay hypnotists. The claims made by some of the better-known trainers (which reach into the millions) seem exaggerated. NGH claims thousands of certied members. It is safe to assume that there are several thousand more that have been trained and certied by other lay hypnotist organizations. I do not know how many people have paid for the services of lay hypnotists over the past two decades or so, but it is probably safe to assume they number well into the tens of thousands. At worst, this means thousands have received incompetent and possible harmful treatment. Certainly, lay hypnotists have (inappropriately, according to clinical hypnotists) cut into the practices (and incomes) of health professionals.
CONFLICTING PARADIGMS
There are two fundamentaland deningdifferences that distinguish the paradigms of hypnosis espoused by lay versus clinical hypnotists.
Commitment to Science
Clinical hypnosis is predicated on rigorous scientic investigation. SCEH and ASCH distinguish between soft science (e.g., case studies, nonexperimental research) and hard science (e.g., quasi- and true experimental research), and share the belief of all formal sciences that the latter is ultimately more valid than the former. Lay hypnosis does not appear to make this distinction. There is a very clear preponderance of uncontrolled anecdotal studies in the lay hypnosis articles I have read. In fact, hard research is almost entirely missing from this literature, and in some cases is even denigrated. The exception (in my limited reading) has been when hard research appears to support the aims and purposes of lay hypnosis (e.g., I found several references to NIHs recent positive review of hypnosis as a valuable adjunct to traditional medical treatment of cancer and pain).
Hypnosis as a Distinct Profession

The other difference between lay and clinical hypnotists is more politically volatile. ASCH and SCEH are quite adamant in their belief that hypnosis is a valuable clinical activity but does not by itself constitute treatment. Lay hypnotists vehemently disagree. They view hypnosis as a treatment that can be used apart from other medical and/or psychological treatments, thus hypnosis is viewed as a distinct profession. The ABH
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informational brochure, for example, states that among its purposes are to promote the recognition of hypnosis as a viable therapeutic modality and to promote the recognition of hypnotherapy as a separate and distinct profession (American Board of Hypnotherapy, 1994). The political ramications of this paradigm dispute are manifold. If one accepts hypnosis as a distinct profession, then hypnotists can and should be separately trained and credentialed, and perhaps even licensed. In a sense, this question can be reframed as, Who owns hypnosis? There are several precedents for this conict. Organized medicines initial opposition to the licensing of psychologists was based on a rejection of clinical psychology as a distinct profession separate from the practice of medicine. Physicians further objected to psychologists rendering diagnoses independent of psychiatric supervision. A similar battle has been waged by organized psychology against the licensing of counselors; several state psychology associations argued that counselors and other masters-level therapists should not be licensed because counseling or psychotherapy are activities performed by psychologists, and as such do not merit recognition as distinct professions. I imagine organized psychology might have taken clinical social work to task on this point as well, had well-recognized forms of social work credentialing (e.g., the ACSW) not preceded psychology licensure in many states.12 During its early battles for licensure, organized psychology successfully pointed to organized medicines inability to prove that patients were being harmed by psychologists who in fact were already practicing independently (or under very nominal medical supervision). Organized counseling made the same argument when faced with the opposition of state psychology associations to counselor licensure. The same arguments have been voiced by organized clinical hypnosis against lay hypnotists. It is important to note here that anecdotal evidence of harm has been found by most state legislatures to be an inadequate argument against licensure of a new health profession. For the same reason, state attorneys have been hesitant to prosecute uncredentialed/unlicensed mental health practitioners on the sole ground of practicing a healing art without a license. Clearly, one hears far more anecdotal complaints against physicians and psychologists than against lay hypnotists. Lay hypnotists have noted the lack of hard evidence that they are harming people. Some claim this battle is merely part of a larger turf war waged to protect practitioners (as opposed to consumers) in an era of shrinking health care dollars.
PROBLEMS GALORE
The lay hypnosis organizations I have studied profess to dene, support, and adhere to a limited scope of practice. An article about the Council of Professional Hypnosis Organizations (COPHO), a lay hypnosis umbrella
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organization that until recently included the National Guild of Hypnotists, states that: The member organizations in COPHO [the Council of Professional Hypnosis Organizations] teach hypnotherapy as a vocational practice. That is, hypnosis is understood as a helping tool to assist persons with non-clinical or non-medical issues such as routine smoking cessation, minor weight management, the nding of lost objects, general relaxation, time management and performance enhancement at work. The member organizations of COPHO do not teach or allow members (unless qualied to do so by another credential) to use hypnosis as a tool for the diagnosis or treatment of mental or medical conditions. (Giles, 1995, p. 10) However, after studying lay hypnosis literature, I nd that lay hypnotists consistently violate their purported limited scope of practice and training with what appears to be the approval of their lay hypnosis organizations. In 1995, I analyzed the content of the NGH Annual Convention and Educational Conference and Summer Institute published in the June 1995 issue of the Journal of Hypnotism. The Summer Institute listed 30 courses, 12 of which were concerned with material I would consider appropriate only for graduate-level counselors or therapists (e.g., The Application of Hypnoanalytic Technique in the Practice of Clinical Hypnosis, Addictions Hypnotherapy, Parts Therapy as Practiced by Charles Tebbets). The conference itself listed well over 100 seminars and workshops. Some (with titles like Hypnosis for Drug Addiction, Rational [-Emotive] Hypnotherapy, and Dealing with Traumatic Memories in Hypnotherapy Practice) sounded completely inappropriate for lay hypnotists. Other seminars and workshops appeared to involve attempts to teach medical practice. The 2007 NGH Annual Convention brochure listed topics like Borderlines among Us, Improve Your Success with Alcohol & Drug Issues, Waking Hypnosis for Panic and Anxiety Disorders, none of which were taught by individuals with a graduate degree. In 2009, the NGH annual convention listed What to Do When the Alcoholic Calls You, Double Binds, Real Medical Hypnosis Made Simple, Returning Vets Dealing with PTSD, The Affect Bridge Technique, Applications of Clinical Medical Hypnosis, and Pediatric HypnotismUsing Hypnosis to Help Transform Childrens Lives.
WHAT DO CREDENTIALS MEAN, REALLY?

In most health professions, the basic credential is a license. Psychotherapy and hypnotherapy are activities that appear to be very difcult to regulate. With the possible exception of psychological testing, they do not
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require an ability to utilize a clearly dened or unique technology (like surgery) or a tangible asset (like pharmaceuticals). Instead, they rely primarily or exclusively on communication and human interaction. Ultimately, then, we are up against an extremely challenging proposition: How does one license a form of human interaction?13 Mental health licensing boards have taken on this improbable task with varying degrees of effectiveness, and they typically do not attempt to dene or enforce any set of behaviors except upon those who submit to licensing. Of course, there are strong incentives to becoming licensed, like the ability to qualify for insurance reimbursement or for certain agency, health care service, or government positions. But by and large one can get by without a license to practice, especially if one has other sources of income. Some unlicensed practitioners have succeeded quite handsomely, thank you; unlicensed therapist-cum-author John Gray is one of the prime examples, and neurolinguistic programmer and motivational speaker Anthony Robbins is another. For the thousands of private practice hypnotherapists who are engaged in what is essentially a small part-time business or even a hobby, licensing is largely superuous andwith its rigid experience requirements, laborious application and examination procedures, and continuing education requirementsperhaps even an irritant. In fact, for some who wish to call themselves doctor, even traditional graduate schools seem to be a waste of time. State licensure requires an accredited graduate degree in a clearly professional health eld. Accredited graduate degrees take time, money, and signicant effort. But if one never expects to get licensed, why bother? A quickie degree from an unaccredited school or even a mail-order diploma will sufce, especially if one feels entitled to it because of age, experience, or the belief that one is uniquely talented or gifted. In psychology and mental health, research on whether licensing actually assures competence has yielded inconclusive results. Nevertheless, licensing and certication are minimally capable of doing two things: (1) guaranteeing that an individual has mastered a journeymans level of knowledge about the eld (at least at the time of the examination) and shares a somewhat common educational/training experience; and (2) providing a system of accountability to the public. Lay hypnotists and, sadly, many mental health professionals as well, can take advantage of a veritable smorgasbord of credentials. Compared with the conservative, rigidly regulated and highly structured world of medicine, counseling and psychotherapy are the Wild West of credentialing. When a physician claims board certication, her patients can be reasonably assured that their doctor has completed a fairly uniform course of training and has passed a tough examination. In mental health, credentialing is a far more varied and amorphous affair. Until relatively recently,
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board certication meant one was either a Diplomate of the American Board of Professional Psychology (ABPP) or, if a social worker, of the American Board of Examiners in Clinical Social Work. There were also a small number of prociency certications available (e.g., rehabilitation counseling, career counseling) to those who completed substantial training requirements (and usually an examination) in that area. However, something happened in the 1980s and 1990s that led directly to the proliferation of credentialing (and pseudo-credentialing) in mental health. First, the advent of managed care, coinciding with the proliferation of graduate school programs in mental health (especially at the masters degree level), led to uncontrolled growth in the supply of practitioners while demand became increasingly restricted. As a result, many mental health practitioners began to scramble for a means (any means) to distinguish themselves and be perceived as above the common horde. Second, the last 20 years have seen a proliferation of specialties and techniques, some valid, others more questionable. Some appear to be the peculiar invention of their creators. New specialties such as trauma treatment, neuropsychology, and forensic psychology, developed as a result of advances in the science as well as the practice of psychology. However, the 1980s and 1990s also saw the advent of specialties that seemed to be responses to popular trends and even superstitions rather than advances in science. The health elds experienced an explosion of certied specialists that included energy therapists, alien abduction therapists, and past life regression therapists. How confusing this must be to clients and consumers of our services. And how frustrating this is to the legitimate clinician who might be left feeling credential challenged or even intimidated by the hypnotherapist who advertises himself or herself with multiple impressive-sounding credentials.
CONCLUSIONS
If we are to have such a discipline we must have standards, and to get our standards under existing conditions we must have criticism. Irving Babbit
Hypnosis as Technology
Although many questions about the nature of hypnosis remain, the one characteristic all experts seem able to agree on is that hypnosis involves a specialized form of rapport. Rapport is the core ingredient of all therapeutic conversations. Therefore, hypnosis can be described as a specialized form of therapeutic conversation. In other words, clinical hypnosis
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involves the purposeful combination of rapport with a systematic mode of communicating in order to guide clients internal experience to achieve therapeutic goals. The organized clinical hypnosis community has occasionally engaged in some double-talk about the potential dangers of hypnosis. For example, many false memory syndrome proponents contend that clinical hypnosis is a dangerous therapeutic modality because it produces false memories. Clinical hypnotists have countered that there is a growing body of research indicating that hypnosis is no more likely to produce memory distortions than other forms of therapeutic conversations. So while most of us contend that clinical hypnosis is no more dangerous than any other form of therapeutic conversation, we also say it is too dangerous to allow individuals without graduate-level training to learn and utilize it. If hypnosis is no more dangerous than other forms of therapeutic conversation, we should be able and willing to teach it to the same populations we teach counseling toincluding, for example, addictions counselors, BA-level mental health workers, and peer counselorsin other words, lay people. There was a time when the technology of psychotherapy (e.g., techniques for establishing and maintaining empathy and rapport) was considered too complex and nuanced to learn outside formal graduate-level training programs. Many psychologists were suspicious of programs that involved training peer or lay counselors. As peer counseling programs like Women in Transition and Women Organized against Rape proliferated in the 1960s and 1970s, however, a growing body of research began to allay our fears. With supervision, and when generally limited to problem-focused and/or time-limited approaches (e.g., short-term support groups), well-trained lay counselors were found to be at least as effective as professionals with a broad range of problems, including some serious psychological disturbances (DAndrea & Salovey, 1983; Covert & Wangberg, 1992; Everly, 2002; Moore, 2005). I am unaware of any research indicating that lay counselors pose a greater threat to client well-being than professional therapists. Therefore, I wonder what would be the harm in teaching the technology of hypnosis to lay people, especially if the content of their education were regulated, and the practice of hypnotechnology were supervised, by professionals? At present, however, there seems to be little or no motivation on the part of either lay or clinical hypnotists to advocate for this practice model. Still, there is the matter of Zoe D. Katze. When the news of Zoes certifications became public, the responses from the burned hypnosis associations were understandably angry. However, all of their anger has been directed at me. An ofcer of the IMDHA actually contacted my credit card company and told them I was using my own credit card fraudulently. My credit card company sent me his letter with a note stating they were confused and did not see how they could take action, since the payee and
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not the payer made the complaint. (And, by the way, all the organizations kept my money.) The NGH published two highly critical editorials about me, and one member referred to me as the dishonest, misrepresenting, liar named Steve K. D. Eichel on an NGH-sponsored listserv. As far as I can tell, in the seven years since Hansens article in the ABA eJournal, not one of these associations has initiated a substantive and critical examination of their certication process. Some supercial changes have been made. In my opinion, additional laws are unlikely to help. In fact, I cannot think of a legal or legislative solution that would positively affect credentialing without creating even worse problems. Unlike physicians, who often deal with immediate life and death issues, mental health clinicians typically treat more subtle and (with the exception of a relatively small percentage of critical emergencies) less immediately dangerous situations. As a result, the public and our lawmakers are less likely to worry about the inated or even implausible claims made by some hypnotherapists. In addition, even traditional and licensed psychotherapists tend to loathe guidelines, treatment manuals, or any external agent claiming to be able to judge or measure our competence. We do not want anything beyond broad-and-inclusive suggestions when it comes to external agents telling us what constitutes good versus bad therapy. We have good reasons. Human behavior and the mind are more complicated than the liver or a broken bone. What is good and bad for the psyche is often less easily dened than what is good for the liver or bad for the bula. Psychotherapists continue to argue and debate treatment issues, and many value this marketplace of ideas. Those who claim to know the absolute truth about the human psyche are more likely to be psycho-demagogues and therapy cult leaders than benevolent role models. With the possible exception of the most outrageous forms of certied therapies, we may be forced to tolerate an extremely broad array of credentialing bodies, from the legitimate to the questionable to those that are outright shams. It is up to each of us to examine our own motivations for obtaining credentials, to police ourselves and our own professions, and to do our best to educate the public. Still, one has to ask: What value can a credential hold when it can be obtained for a common household pet? The unmasking of Dr. Zoe D. Katze, Certied Hypnotherapist, has made some people very angry. Unfortunately, to my knowledge, their anger has not yet resulted in serious changes to the credentialing processes they employed. Following the publicity surrounding Zoes certication, the NGH began to require applicants for membership to include a photocopy of their drivers license (or some other ofcial identication), presumably to screen out nonhumans and people below the age of 16. There is no evidence that they attempt to conrm the validity of these documents any more than they conrmed the
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(non)existence of the Tacayllaermi Friends School or the Gareld School of Nursing. I have been told that NGH also withdrew from COPHO, so they will no longer certify by reciprocity (the recognition of another associations certication as sufcient for ones own certication). Otherwise, I could not nd a substantive change in their Internet membership and certication process. The other associations do not appear to have made any changes whatsoever. Reform in the near future appears unlikely. Professional hypnosis associations will need to continue to educate the public on the issue of how lay hypnotists differ from clinical hypnotists. Zoes story certainly had an effect on the public and other professionals. Similar research might keep the heat on lay hypnosis associations and eventually lead to some real change. Finally, professional hypnosis associations should strongly consider supporting research that will (hopefully) provide evidence that their credentialing processes (e.g., ASCH certication, ABCH board certication) actually assess competence and protect the public.
NOTES
1. Clinical hypnotists are individuals who possess at least a masters degree from a regionally accredited program in the healing arts, and whose training (if not received directly from an ASCH-approved organization or individual) matches the guidelines set forth in Standards of Training in Clinical Hypnosis (Hammond and Elkins, 1994). A lay hypnotist is anyone who is not trained and credentialed as an advanced-degree health professional, and practices hypnosis or hypnotherapy. Since ASCH will not train anyone who is not at least in formal training toward an advanced degree in the health sciences, it is safe to assume that lay hypnotists are generally trained by one of the myriad of lay hypnosis training institutes and/or organizations, many of which also offer some form of credentialing in hypnosis and/or hypnotherapy. 2. In my various interactions with lay hypnosis associations, I once met a lay hypnotist who had obtained a doctor of naturopathy degree from a mailorder college in England. He referred to himself as doctor and on several occasions was actually granted temporary hospital privileges in order to visit ill patients. His hypnotherapy and naturopathy practices were very small; his primary occupation was selling bull semen. 3. For example, when most people see St. Johns University, they think of the well-known, accredited university in New York. However, there is another St. Johns University. It exists in an ofce in Springeld, Louisiana, and is, according to Floridas St. Petersburg Times (Bousquet & Matus, 2007), an unaccredited diploma mill. A number of lay hypnosis leaders claim degrees from St. Johns, however I could not nd them listed in any public document as alumni of St. Johns in New York.
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4. The AAEH Code of Ethics states, in part, that, The Association permits the practice of hypnosis for medical or diagnosable mental ailments only by those members who are qualied to do so by virtue of their education and training and/or state licensure. Use or granting of nonacademic titles and degrees is unethical and shall be considered cause for expulsion. A member may not use any letter designation after his/her name which implies a degree or license, unless the member has such an academic degree or ofcial license. Recognized degrees are those awarded by accredited academic institutions of higher learning. Demonstrations shall be conducted in a dignied and professional manner and shall not include bizarre or humiliating or hazardous effects. 5. According to Gil Boynes biography, retrieved on September 6, 2009, from http://www.hypnotistexaminers.org/about_gb.html. 6. In July 2007, the Secretariat of Public Education of Mexico issued an alert accusing eleven schools of being diploma mills that commit academic fraud; Newport University was among them. 7. ASCH has since changed its membership requirements to include nondoctoral level, licensed/certied health professionals with at least a masters degree (e.g., social workers, professional counselors, and nurse practitioners). 8. Other professional associations have apparently approved of and copied this bi-level certication program, most notably the EMDR International Association, which now certies professionals as EMDRIA Certied Therapist and Approved Consultants in EMDR. The American Association of Marriage and Family Therapists was the rst to adopt this certication model. 9. Since all applicants for ASCH certication are licensed at the independent practice level, legally their training in hypnosis cannot be called supervision. ASCH therefore adopted the term consultation to refer to the required twenty hours of individualized, face-to-face training. The professionals providing the training are therefore called consultants rather than supervisors. 10. By my count, there are over forty certifying hypnosis associations in the United States. The associations offering certication include: 5-PATH1 Hypnotherapists Association, 5-PATH1 International Association of Hypnosis Professionals, Alchemical Hypnotherapy Association, American Association of Professional Hypnotherapists, American Board of Clinical Hypnotherapy, American Board of Hypnotherapy, American Council of Hypnotist Examiners, American Hypnosis Association, American International Association, American International Association of Hypnosis, Association for Integrative Psychology, Association for Past Life Research and Therapies, Association for Transpersonal Psychology & Hypnotherapy, Association of Professional Hypnosis and Psychotherapy, Association of Registered Clinical Hypnotherapists, Association to Advance Ethical Hypnosis, Atlantic Board of Hypnosis, Clinical and Therapeutic Hypnosis Association, International Association for Regression Research & Therapies, International Association for Teenage Hypnotists (!!), International Association of Counseling Hypnotherapists, International
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Association of Counselors and Therapists, International Association of Healing Professionals, International Association of Medical and Therapeutic Specialists, International Certication Board of Clinical Hypnotherapy, International Hypnological Association, International Hypnosis Association, International Hypnosis Federation, International Hypnosis Hall of Fame Guild, Inc., International Medical and Dental Hypnotherapy Association, National Association of Certied Hypnosis Counselors, National Association of Clergy Hypnotherapists, National Association of Transpersonal Hypnotherapists, National Board of Hypnosis Education and Certication, National Board of Professional and Ethical Standards, National Council of Hypnotherapy, National Federation of NeuroLinguistic Psychology, National Guild of Hypnotists, Professional Board of Hypnotherapy, Texas Association for Investigative Hypnosis, Time Line Therapy Association (NLP). 11. The most bizarre (in my opinion) lay hypnosis association is the International Association for Teenage Hypnotists, which states on its Web site that it is an international association strictly for teenagers who want to learn hypnosis that has created a teenage hypnotist certication program that allows the more ambitious and talented members of the IATH to attain formal and ofcial recognition for their achievements in the study of hypnosis (IATH, 2009). This statement leads me to wonder if the IATH would make an exception for precocious 11- and 12-year-olds who are not technically teenagers? 12. A primary issue here involves two terms whose presence in a licensing law are central to the health professionals right to independent (i.e., medically unsupervised) practice: diagnosis and treatment. Since treatment ensues from diagnosis, to be truly independent a health professional must be legally authorized to perform both. Just as physicians once argued that, without formal medical training, psychologists are not competent to diagnose and then treat mental disorders, psychologists have argued that counselors are inadequately trained to diagnose and treat individuals with psychological problems. 13. It can be argued that the professions of education and law also rely almost entirely on interaction and communication, and indeed until the twentieth century, teachers were not licensed, and people who read law or clerked and then passed the examination could be admitted to the bar without any formal legal education. However technologies specic to teaching developed and public education became fairly standardized. It is not necessary to be certied as a teacher to work as one in private schools. Law became increasingly complex, and began to require skills and knowledge that necessitated formal legal education.
REFERENCES
American Board of Hypnotherapy. (1994). American Board of Hypnotherapy [Brochure]. Irvine, CA: Author. American Society of Clinical Hypnosis (ASCH). (2009). ASCH certication. Retrieved 9/6/09 from http://asch.net/certication.htm.
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Association to Advance Ethical Hypnosis (AAEH). (2009). Ethics code. Retrieved on 9/6/09 from http://aaehonline.org/code.html. Bear, J. (2003). Bears guide to college degrees by mail & Internet. Berkeley, CA: Ten Speed Press. Bousquet, S. & Matus, R. (2007, October 27). Degree inspires little faith: Floridas juvenile justice chief draws praise. But his degree doesnt. St. Petersburg Times, St. Petersburg, FL. Retrieved 9/6/09 from http://www.sptimes.com/ 2007/10/27/news_pf/State/Degree_inspires_littl.shtml Consumer Fraud Reporting Organization. (2009). Retrieved 9/6/09 from http://www .consumerfraudreporting.org/Education_Degree_Scams_Unaccreddited.php. Covert, J., & Wangberg, D. (1992). Peer counseling: Positive peer pressure. In G. W. Lawson & A. W. Lawson (Eds.) Adolescent substance abuse: Etiology, treatment, and prevention (pp. 131139). Gaithersburg, MD: Aspen. DAndrea, V. J., & Salovey, P. (1983). Peer counseling: Skills and perspectives. Palo Alto, CA: Science and Behavior Books. Eichel, S. (1997, 2009). Clinical vs. lay hypnosis: A hopeless battle? GPSCH In Touch, pp. 23. Retrieved 9/6/09 from http://apmha.com/layvspro.htm. Eichel, S. (2002). Credentialing: It may not be the cats meow. http://www.dreichel .com/Articles/Dr_Zoe.htm Retrieved 9/5/09. Eichel, S. (2003). Credentialing the lay hypnotist: One cats experience. Psychological Hypnosis, 12(1), 23. Eichel, S. (2005). This cat is not a hypnotist, or How to nd a qualied hypnotherapist. http://www.hypnosisnetwork.com/library/cat_hypnosis.php Everly, G. S. (2002, Spring). Thoughts on peer (paraprofessional) support in the provision of mental health services. International Journal of Emergency Mental Health, 4(2), 8992. Eye Movement Desensitization & Reprocessing International Association (EMDRIA). (2009). Training and certication in EMDR. Retrieved 9/6/09 from http://www.emdria.org/. Giles, C. S. (1995). Legislative and governmental concerns. Journal of Hypnotism, 10(2), 1011. Hammond, D. C., & Elkins, G. R. (1994). Standards of training in clinical hypnosis. Des Plaines, IL: American Society of Clinical Hypnosis. Hull, C. (1933, 2002). Hypnosis and suggestibility: An experimental approach. Carmarthen, Wales: Crown House Publishing. International Association for Teenage Hypnotists (IATH). (2009). Retrieved 9/6/ 09 from http://teenagehypnosis.com/ McGill, Ormond (1996). The new encyclopedia of stage hypnosis. Bethel, CT: Crown House Publishing, p. 506. Moore, B. (2005). Empirically supported family and peer interventions for dual disorders. Research on Social Work Practice, 15, 231245.
Chapter 8
Pedagogical Perspectives on Teaching Hypnosis

Ian E. Wickramasekera II
The tradition of hypnosis has reached a critical point in its history where educational and training efforts are now of extraordinary importance to its future. This chapter contains an historical review of a number of pedagogical perspectives on teaching mental health professionals, medical personnel, scientists, and others about how to utilize hypnosis. Many different traditions of hypnosis and hypnotic-like practices have emerged over the past centuries of human history. Many of these traditions have often employed some strikingly different pedagogical methods of instruction and espoused radically different viewpoints on the nature of hypnotic phenomena. This chapter reviews them, starting with the hypnotic-like practices of various mystical traditions and ending with the modern training guidelines established by members of the American Society of Clinical Hypnosis. The chapter concludes with a discussion of how it is possible to draw together some of the best elements of each of these different pedagogical traditions into one training program for teaching hypnosis within a graduate school setting.
TEACHING HYPNOSIS IS THE CHALLENGE OF OUR TIMES

We live within an extraordinary and exciting period of time within the overall history of hypnotism. Many of our forebears in the tradition of hypnosis dedicated their lives to establish the scientic legitimacy of hypnosis in basic research, medical practice, and psychotherapy (Barabasz & Watkins, 2005; Forrest, 2001). We stand upon a mountain of evidence today about the value of hypnosis in basic science (as discussed in Chapters 16 of this volume and by Posner & Rothbart, 2010) and in clinical work (reviewed in Volume 2 of this book and in Barabasz & Watkins, 2005, and Rainville &
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Price, 2003). We know that hypnosis is a very useful treatment for patients with pain (see Vol. 2, Ch. 5; Montgomery et al., 2002; Patterson & Jensen, 2003), and we even have a good initial understanding of the neurophysiology underlying hypnotic analgesia (Rainville et al., 1997). Hypnosis has also been shown to be useful in alleviating some of the most common psychological complaints such as depression (Vol. 2, Ch. 4; Kirsch, Montgomery, & Sapirstein, 1995). In short, hypnosis has been shown to be helpful to many patients with the most common medical and psychologically oriented problems seen by clinicians today. The scientic tradition of hypnosis has clearly succeeded in producing large amounts of the kinds of scientic data on the nature and utility of hypnosis that would surely have pleased our forbears such as Clark Hull (1933). However, it has become painfully obvious that somehow the hypnosis community has not been growing much in recent years despite the great amount of progress that has been made in establishing the clinical and scientic legitimacy of hypnosis. In fact, recent membership trends in hypnosis organizations such as the Society of Psychological Hypnosis (Division 30 of the American Psychological Association) suggest that the numbers of people seriously interested in using hypnosis is declining (Wickramasekera, 2008). Many of the most respected professional and scientic organizations that are dedicated to hypnosis have lower levels of membership than they did in the past. There also seems to be a signicant graying of the eld of hypnosis given that these organizations have far fewer students and younger-aged members than they did in the past. Ironically, there is a real danger that the community of hypnosis may continue to decline further even at a time when the scientic underpinnings of clinical hypnosis are stronger than ever. Teaching hypnosis has become one of the real challenges of our times. Educational and training efforts are now as important to our future as are the continuing efforts to establish the scientic and clinical legitimacy of hypnosis. This chapter is meant to help serve as an aid to those who would answer the call to help bring about growth in the hypnosis community through teaching hypnosis to others. We will rst begin with an historical examination of the various pedagogical perspectives that have been employed to teach others about how to use hypnosis and hypnotic-like practices (Krippner, 2005) in the remote and recent past. A number of different approaches have been advanced over the years to teaching about hypnotic phenomena, and we shall try to draw out some of the best elements of each pedagogical perspective. Finally, we shall conclude with a brief look at how we can synthesize the best elements of the previous traditions into one training program for use within a graduate school setting. I will endeavor to create an outline of a training model that I created for use in establishing a certicate program for teaching hypnosis within a graduate school of clinical psychology setting. It is my belief that we can
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learn about how to teach hypnosis from following the methods of our forbears. My model is meant to be a synthesis of both ancient and relatively recent pedagogical perspectives on teaching hypnotic phenomena. So let us now begin with an examination of the historical perspectives on teaching hypnosis to begin building the foundations of my approach to teaching hypnosis.
HISTORICAL PERSPECTIVES
The Western tradition of hypnosis may rightly be said to have started from the efforts of pioneering individuals like Franz Anton Mesmer, Jos e Cust odio de Faria (Abb e Faria), and James Braid over 200 years ago (Forrest, 2001). The pedagogical methods of these early pioneers were quite different than those of our current modern training organizations such as the American Society of Clinical Hypnosis (ASCH) and the Society of Clinical and Experimental Hypnosis (SCEH). However, hypnotic-like practices, such as mindfulness meditation, had been taught for thousands of years long before any of these individuals had established their doctrines and methods of pedagogy with hypnosis (Kvaerne, 1995; Rahula, 1974; Ray, 2002). In this section, we will examine some of the critical and unique pedagogical perspectives that teachers of hypnosis and hypnotic-like practices have employed from ancient to recent times.
Ancient Pedagogical Perspectives on Teaching Hypnotic-Like Practices

Human beings have been practicing and teaching others how to use hypnotic-like practices, such as mindfulness meditation, for thousands of years. Literally millions of people have been taught how to practice and teach others about meditation since the time of the early sages, such as Shakyamuni Buddha (Rahula, 1974) and Tonpa Shenrab (Kvaerne, 1995). However, I do not wish in any way to equate hypnotic-like practices, such as mindfulness meditation, with actually being forms of hypnotism. Clearly there are very meaningful cultural, phenomenological, psychophysiological, and spiritual differences between hypnotic-like practices and hypnosis (Krippner, 2005). However, there is enough evidence to suggest that practices like mindfulness meditation are very similar to hypnosis (see Chapter 2 of this volume and Holroyd, 2003) in their overall nature. I therefore assert that there is something that the tradition of hypnosis can learn from the ancient pedagogical perspectives on teaching meditation to others that we may use in reviving the tradition and community of hypnosis. In this section, I will focus on the critical pedagogical perspectives of the meditative traditions of Tibetan Buddhism and B on-Buddhism. I have selected Buddhism and B on-Buddhism since I am personally familiar with
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them and I understand them far better than any of the other ancient traditions of hypnotic-like meditative practices. The traditions of Buddhism and B on-Buddhism are also comparatively well preserved today amongst the ancient traditions. The reader will therefore be free and able to explore anything that they see reected in these words if they wish to. I will leave it to others to write down their own observations of the similarly unique pedagogical perspectives that come from appreciating the value of other ancient mystical traditions such as Gnosticism, Quaballah, Susm, or Tantra. The ancient Buddhist and B on-Buddhist methods of pedagogy for teaching meditation are often quite different from the methods that we employ in hypnosis today. Meditation teachers in these schools employ a radically different epistemology in talking about how we can learn the truth about our minds potential and our personal psychology. Meditation teachers in Buddhist and B on-Buddhist schools also typically employ a much closer relationship with their students. This relationship style could best be compared with the relationship between a therapist and their client in Western clinical psychotherapy (Wickramasekera, 2004). Let us now examine these two key areas of Buddhist and B on-Buddhist pedagogy more closely regarding epistemology and the teacher-student relationship. Curiously, Buddhist and B on-Buddhist teachers have traditionally eschewed adopting a materialistic outlook on determining the nature of truth regarding our mind and our own unique psychology. Instead, an individual is supposed to seek out the nature of ones own mind through a course of disciplined introspection within ones practice of meditation. This is not to say that one is taught to trust ones own psychological experience entirely at face value. In fact, a good deal of instruction is given to students regarding the nature of self-deception (Trungpa Rinpoche, 1973). One is supposed to work through ones tendencies toward self-deception through encountering it directly in ones meditation practice and in post-meditation experiences in everyday life. Consider the following quotes from the modern-day B on-Buddhist teacher Tenzin Wangyal Rinpoche (1998): All of our experience, including dream, arises from ignorance. It is ignorance of our true nature and the true nature of the world, and it results in entanglement with the delusions of the dualistic mind. (p. 24) If we are not careful, the teachings can be used to support our ignorance. That is why practice is necessary, in order to have direct experience rather than just developing another conceptual system to elaborate and defend. (p. 26) The ancient traditions tell us that practicing meditation is really the only way to learn about its nature or to learn about how to teach it to others. The most revered teachers of meditation in Buddhism and
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B on-Buddhism are usually people who have devoted many years to their meditation practice. These teachers have also commonly undertaken long, continuous retreats that may last as long as three years or more. A meditator who develops a good conceptual understanding of the meditation literature, but who has not experienced these concepts directly in their own practice, would generally be considered a fraud in the Buddhist and B on-Buddhist communities. We can see that an injunction to engage in personal practice is a clear-cut pedagogical method of the ancient traditions of hypnotic-like practices. These teachers tend to be very skeptical of people who let either their conceptual understanding or their experiential understanding dominate their perception of phenomena. All of this of course is the exact inverse of our Western tradition of experimental psychology. Western psychology has thrived on using materialistic and empirical methods of investigating the mind. Modern experimental psychologists traditionally have tended to characterize methods of introspection and phenomenology as being inherently unscientic and unreliable. So perhaps it is not too surprising that the Western tradition of hypnosis has not usually employed personal practice as a pedagogical method that commonly. The emphasis in most hypnosis training programs actually seems to be on learning about hypnosis through learning to hypnotize others rather than learning through cultivating a practice of self-hypnosis. The original critique of introspection in Western psychology came from the early Behaviorists rejection of the experimental tradition of Gestalt psychology (Skinner, 1987). However, over time, modern researchers in psychology and clinical neuroscience have returned to being interested in using introspective and phenomenological data (Pekala, 1991; Rainville & Price, 2003). Mentalistic terms like trance and consciousness that we use commonly in hypnosis are not nearly as criticized as they once were in science (Skinner, 1987). Our modern-day tradition of hypnosis may (twice in this sentence) benet from following some of the ancient perspectives of Buddhism and B on-Buddhism now that a respect for introspection and phenomenology are once again returning to psychology and science. We can therefore place more value on teaching our students about hypnosis through encouraging their practice of self-hypnosis. In this way, we can follow the pedagogical methods that the ancient meditative traditions have endorsed for thousands of years while also inviting our students to engage in a lifetime practice that will help them deal with the stresses of their own life. The pedagogical methods of the ancient Buddhist and B on-Buddhists can also be distinguished from the contemporary pedagogical methods of hypnosis regarding how they develop a teacher-student relationship. Buddhist and B on-Buddhist teachers of meditation are taught to establish a very close relationship with their students. A great teacher is said to be a very special person who possesses at least three essential qualities, such as unlimited friendliness (maitri), empathy, and being completely authentic in their
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interactions with students and in their realization (Wickramskerea, 2004). Chogyam Trungpa Rinpoche (1974) once wrote that a good teacher is: Anyone who can reect you as a mirror does, and with whom, at the same time, you have a relationship as a personal friend. (p. 171) Supposedly this person is such a spokesman (for the enlightened state of mind), soaked in the awake state of being himself. (p. 23) These three qualities of maitri, empathy, and authenticity are of course quite similar to the three core conditions that Carl Rogers (1957) named as positive regard, empathy, and congruence when establishing his ideas about the core elements of client-centered psychotherapy (Wickramasekera, 2004). Furthermore, Rogerss work on these three elements of the therapeutic relationship have been almost universally adapted into all other forms of psychotherapy (Horvath & Luborsky, 1993; Keijsers, Schaap, & Hoogduin, 2000). I refer the reader to my earlier article on this subject (Wickramasekera, 2004) where I discuss these striking similarities in more depth. However, sufce it to say that being with ones meditation teacher should ideally be an experience where one feels very comfortable and intimate. I have no doubt that most people who are now practicing and using hypnosis have at one time or another had a special relationship like this with a hypnosis instructor. This may commonly be a clinical supervisor or dissertation adviser who has been charged to provide them with supervision after they have received some initial training in hypnosis. The American Society of Clinical Hypnosis has wisely created an approved consultant program to encourage this kind of close mentorship between students and their teachers. SCEH and the Society of Psychological Hypnosis have also attempted in the past to match mentors with mentees through various programs. A panel led by Dr. Michael Nash at the 2008 annual meeting of SCEH in Philadelphia, Pennsylvania, elicited many spontaneous personal recollections from the audience members about their treasured relationships with mentors. Many of the spontaneous recollections discussed the primary importance that such close personal relationships had played in introducing and sustaining their involvement with the hypnosis community. Sadly, there is a limited number of teachers who are actually capable of serving as mentors. The need for such teachers appears to exceed the current resources that we now have in the hypnosis community. Therefore, we should all look for ways in which we can personally serve as mentors to the new people coming into the community of hypnosis.
The Public Demonstration of Hypnosis: An Early Pedagogical Method

Many of these early pioneers of hypnosis, such as Mesmer, Abb e Faria, and James Braid, utilized public demonstrations of hypnotic phenomena
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extensively as a critical element of their pedagogical methods. A close reading of many of these early hypnotists methods suggests that they did this for a variety of reasons involving the mass appeal of the phenomena to the public. One reason that the early hypnotists seemed to enjoy using public demonstrations was to reach as many people as possible to inform them about their views of hypnosis. Hypnosis and hypnotic phenomena became one of the top areas of fascination during the period of the early hypnotists (Forrest, 2001), and their demonstrations drew very large public audiences and inspired many dramatic works and newspaper articles. It may be said that some of these early pioneers may have held more prurient reasons for trying to reach as many people as possible (Forrest, 2001), however, I will leave these ethical considerations to the side for now. Abb e Faria is a good example of one such early hypnotist who seems to have had a very genuine desire to use his public demonstrations to inform the public about the nature of hypnotic phenomena. It is said that Abb e Faria began all his public demonstrations of hypnosis with a half-hour lecture about the nature of the phenomena. His lecture was supposed to have emphasized a message that the real power of hypnosis lies within the abilities of the hypnotic subject rather than in himself as the hypnotizer (Carrer, 2004). Abb e Faria was thus one of the rst of the early hypnotists to try and use public demonstrations to counteract peoples misconceptions about the nature of hypnotic phenomena. Unfortunately, most of the people putting on public demonstrations of hypnosis today seem to have no other purpose than entertainment in mind (Barber, 1986). However, there is still an undeniable appeal for public demonstrations of hypnosis, and that appeal can be used to reach new people in an ethical fashion. For example, a recent public demonstration of hypnosis put on by Dr. Guy Montgomery at the 2009 annual meeting of the APA in Toronto drew a very large audience that was much larger than that seen at any other session related to hypnosis that year (Wilmarth, 2009). A quick show of hands from the audience that day revealed that most of the participants had never received any prior formal introduction to hypnosis despite being psychologists or graduate students of psychology. Many of the audience members reported afterwards that they came to the demonstration out of a simple desire to see a demonstration of hypnotic phenomena and to learn something about it from a reputable source.
Standards of Training for Hypnosis and the Spiral Curricula Method

The establishment of professional organizations devoted to hypnosis and hypnotic-like practices in the West began at the same time that the early hypnotists were giving their demonstrations. Mesmer formed a group that came to be known as the Society of Harmony (Forrest, 2001). The Society
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of Harmony employed a kind of graded series of initiations into Mesmers ideas about animal magnetism. The structure and content of these initiations were held in some secrecy so that overall the Society of Harmony somewhat resembled similar organizations of Freemasonry that were popular at the time (Forrest, 2001). Many other organizations have continued to spring up in the 200 years since Mesmers Society of Harmony. These organizations have varied wildly in their commitment to science on one end of the spectrum and in their encouragement of mysticism on the other end. Many of these organizations did organize classes on how to use hypnotic and hypnotic-like practices although curiously none of them appears to have crafted a rigorous and detailed set of training standards (Wark & Kohen, 2002) for use in perpetuating their methods. In 1992, Gary Elkins, PhD, and Corydon Hammond, PhD, began a new project within the American Society of Clinical Hypnosis that has become one of the most important contributions to the teaching of hypnosis (Elkins & Hammond, 1994; Wark & Kohen, 2002). Their aim was to create a highly rigorous and detailed set of academic standards for teaching others about hypnosis. They began their project by contacting 242 internationally distinguished scholars of clinical and experimental hypnosis. They surveyed these experts for their opinions on topics such as how course content should be prioritized, how much time should be allotted for each topic, and many other similar issues. Elkins and Hammond (1994) put together all this information and created the rst real standards for teaching hypnosis. Their standards employed a format using two intensive 20-hour classes with introductory and intermediate levels. These standards are now known as the Standards of Training in Clinical Hypnosis (SOTCH), and they have been adopted and endorsed by both ASCH and SCEH. The introductory level version of the SOTCH contains 15 content areas such as theory, induction methods, and ethics (Hammond & Elkins, 1998). The intermediate-level version of the SOTCH contains more advanced-level content from the rst class, as well as more emphasis on clinical applications with psychological and medical disorders. One of the best qualities of the SOTCH standards is that they teach about hypnosis from within all the major traditions of hypnosis. No one approach or theory of hypnosis predominates in the curriculum since the authors took great pains to include balanced information about all the clinical and theoretical traditions of hypnosis. However, both versions of the SOTCH do leave out some information and training experiences that some experts might consider highly essential elements of a basic or intermediate-level class in hypnosis. For instance, participants are not given instruction in how to administer, score, and interpret a variety of hypnotic assessment instruments in either class. This is an unfortunate state of affairs as it seems to contribute to the relative neglect of the use of standardized hypnotic testing instruments in research and clinical practice.
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Many people never appear to take the additional classes that would be necessary to learn about hypnotic assessment (Pekala & Wickramasekera, 2007), even though the material is quite simple to learn. A number of individuals have attempted to rene the SOTCH standards into even more useful formats. Wark and Kohen (2002) developed a pedagogical method of employing the SOTCH standards within a framework that they describe as the spiral curriculum. The authors adapted some of the pedagogical perspectives of David Kolb (1984) into a exible approach that was designed to accommodate a variety of learning styles. The hallmark of their approach is of course how they employ the spiral, which is the idea of teaching about hypnosis in a series of graduated steps. The authors describe the spiraling element of their pedagogical method in stating: The actual teaching is presented in a way that accommodates many learning styles. After the entry level concepts are presented, instruction is spiraled up to the next level with appropriate review, adding more complexity and detail, again in a way designed to reach participants regardless of learning style. This process then continues, reviewing and adding levels and details to related concepts (p. 124). The authors applied the spiral methods to the SOTCH standards and have created a exible version of the SOTCH. This way of teaching the SOTCH seems very well suited for adaptation at weekend sessions; this approach to teaching hypnosis is very popular.
A TRAINING PROGRAM FOR TEACHING HYPNOSIS WITHIN GRADUATE SCHOOLS

We are now in a good position to put together a synthesis of some of the best pedagogical methods for teaching hypnosis. In this section, I will provide the reader with a brief outline of my development of a certicate program for teaching hypnosis within a graduate school setting. This certificate program was designed to be a relatively exible adaptation of the SOTCH standards while using the spiral curriculum approach to add additional and more advanced material.
A Three-Class Model
The hypnosis training program that I am presenting here was initially developed at the Adler School of Professional Psychology in Chicago, Illinois, and was approved by both ASCH and SCEH. The training program is a synthesis of many materials that I had been fortunate enough to receive in my own training such as the SOTCH standards (Elkins & Hammond, 1998) and the spiral curriculum methods of Wark & Kohen (2002). The SOTCH standards call for an individual to complete two 20-hour training classes (introductory and intermediate levels) in order to receive a basic
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level of education in hypnosis that would allow one to apply for a basic level of prociency in hypnosis. However, the model being presented here is of a three-course model with each course providing 36 hours of instruction on using hypnosis at the basic, intermediate, and advanced levels. My desire was to create a program that would exceed the SOTCH standards in its depth of instruction while also providing the students with many additional hours of practice time within a safe and comfortable environment. The rst two courses utilized the SOTCH standards completely for their framework. I was able to use the additional time (16 hours) that I had in this format to modify each class to the unique interests of each group of students that were coming through the program. For example, in some classes the students reported being very interested in applied psychophysiology and biofeedback. I was able to use some of the extra time in these classes to give lectures and demonstrations on the psychophysiology of hypnosis. This lecture naturally led to a discussion of the relative merits of integrating the methods of biofeedback with hypnosis for patients with challenging symptom presentations. However, I reserved the majority of the additional time in the basic and intermediate courses for additional practice sessions and experiential exercises. In this way the students were able to devote a much greater amount of time to developing a conceptual and experiential understanding of what hypnosis is. The third class was designed to present more advanced material than is usually taught in the SOTCH standards, such ego state therapy, age regression, assessment of psychophysiological disorders, methods of hypnoanalysis, and the Stanford Hypnotic Susceptibility Scale: Form C (SHSS:C; Weitzenhoffer & Hilgard, 1962).
Emphasis on Personal Practice and Enriching the Mentorship Opportunities

It is primarily within the context of the additional practice time that I attempted to actualize two of the critical pedagogical perspectives that we encountered when reviewing how Buddhists and B on-Buddhists teach hypnotic-like practices. It was easy to implement these traditions emphasis on personal practice just by increasing the amount and frequency of the in-class practice time. I also asked the students to practice self-hypnosis and to keep a daily record of their practice. The students were required to write down their spontaneous phenomenological observations of how each session went. The nal assignment of each of these three classes called for the students to describe how various theories of hypnosis might conceptualize what they were reporting in their personal journals. In this way the pedagogical methods that I employed all placed an increased value on deepening the students personal practice of hypnosis just as the Buddhist and B on-Buddhist teachers recommend.
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I try to spend as much time as possible being with each student in their practice sessions and getting to know their style as a hypnotist as well as their personal experiences of hypnosis. I do attempt to utilize a personcentered approach to teaching when conducting these sessions. Ive found that this seems to reduce many of my students apprehensions about giving a live demonstration of their skill as a hypnotist and also to allow them to have a genuine experience of hypnosis. Initially, the students often worry about so many extraneous things such as whether or not they have found a good hypnotic voice. I have often found that establishing a friendly, empathic, and congruent relationship with my students does seem to help them get past the initial awkwardness that many students experience upon rst learning about and experiencing hypnosis. I have also attempted to augment the mentorship opportunities that are available to my students in other ways. For instance, I encouraged all the students to seek out other mentors besides myself in the Chicago hypnosis community. I handed out membership applications to ASCH, SCEH, and personally paid for their rst year of membership in the Society of Psychological Hypnosis upon their completion of the three-course sequence.
Providing Demonstrations of Hypnosis and Other Hypnotic-Like Practices

It never ceases to amaze me how easy it is to gather a large group of people if you simply mention beforehand that there will be a live demonstration of hypnosis. I scheduled a free lecture and demonstration of hypnosis for all members of the Adler community at the start of each academic year. The title of this lecture was What is hypnosis? and its intent was to pair a brief lecture on the true nature of hypnotic phenomena with a brief and unobtrusive group administration of hypnosis. I timed the lecture to occur in the rst week of the trimester so the students would have a few weeks to decide if they might want to take my basic level class. This class usually was taught over the course of two weekends that were scheduled in such a way as to not conict with any other popular weekend-format courses. I also provided demonstrations of hypnotic-like practices such as mindfulness meditation on a regular basis at Adler. For instance, I initiated a weekly mindfulness meditation group that was open to all members of the Adler community. People who are interested in meditation are also frequently interested in hypnosis. The mindfulness group also became another avenue for me to engage in mentorship with the hypnosis students, in which I was also able to encourage their personal practice. Both of these types of demonstrations were well attended, and I tend to think that they were very helpful in encouraging the popularity of the hypnosis training program at Adler.
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Use of the Spiral Curriculum Method to Deepen the SOTCH Material

I drew upon Wark and Kohens (2002) spiral curriculum model quite extensively when designing the three-course sequence of topics. In each class I attempted to enrich the students previous understanding of hypnosis by introducing them to new course content and experiential practice exercises that matched their current level of understanding and expertise with hypnosis. I often devoted some of the additional time that I had in these classes to cover topics in more depth that a given group of students might nd interesting or have might have trouble understanding. I often simply changed the learning format from didactic to experiential or from experiential to didactic when I noticed that a class had become stuck on understanding a given topic. For example, I often role-played some of the original experiments that led Ernest Hilgard (1977/1986) to develop his neo-dissociation theory of hypnosis. This allowed the students to see a live demonstration of the phenomena that Hilgard actually had in mind when crafting his theory. I also extensively used the spiral curriculum method when I added a module on hypnotic assessment into all three classes. I believe strongly in the value of hypnotic assessment (Pekala & Kumar, 2000) and I wished to devote some of the additional time that I had available to teach the students about how to employ hypnotic assessment in their clinical work and research. All of the students were taught to administer, score, and interpret the Phenomenology of Consciousness Inventory-Hypnotic Assessment Procedure (PCI-HAP; Pekala, 1995), the Harvard Group Scale of Hypnotic Susceptibility (HGSHS; Shor & Orne, 1962), and the Stanford Hypnotic Susceptibility Scale: Form C (SHSS:C; Weitzenhoffer & Hilgard, 1962) throughout the three-course sequence. The instruments were taught in order of the relative difculty of the skill required to administer them as well as the knowledge required to fully appreciate the hypnotic phenomena being elicited by the testing procedures. The students rst learned about hypnotic assessment through mastering the administration and interpretation of the PCI-HAP in the rst class. The PCI-HAP appears to be the best instrument to teach introductory students about hypnotic assessment due to the ease of administration and its inherent pedagogical value in teaching methods of hypnotism (Pekala & Wickramasekera, 2007). I then followed up with teaching the Harvard and Stanford instruments in the second and third classes, respectively. Starting with the PCI-HAP in the introductory class and then building to the Stanford Form C in the advanced class appeared to help the students build a foundation of skill and understanding about hypnotic phenomena. Using the spiral approach seemed to help the students not only to master using the instruments but also to understand its relevance in clinical practice and research.
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CONCLUSION
Hypnosis and hypnotic-like practices have been practiced and taught to others for many thousands of years. In this chapter we have reviewed some of the critical pedagogical perspectives and methods of many different traditions. Teachers of hypnotic-like practices such as mindfulness meditation have often placed a value on developing a personal practice in order to properly understand the true nature of the phenomena. These teachers have also strived to develop a special relationship with their students that is very similar to the person-centered approach of Carl Rogers (Wickramasekera, 2004). Early teachers of hypnosis such as Abb e Faria (Carrer, 2004), often proted from using public demonstrations of hypnosis as a way of drawing attention to their ideas about the true nature of hypnotic phenomena while addressing the publics misconceptions of what is happening in the hypnotic relationship. More recently there has been great progress on establishing standards of training for hypnosis (Elkins & Hammond, 1998 that have even been merged with excellent pedagogical perspectives such as the spiral curriculum model (Wark & Kohen, 2002). This chapter has concluded with a brief look at how we can utilize and integrate all these pedagogical methods and insights to create hypnosis training programs within graduate school settings.
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About the Editor and Contributors
THE EDITOR
Deirdre Barrett, PhD, is a psychologist on the faculty of Harvard Medical Schools Behavioral Medicine Program. She is the past president of both the International Association for the Study of Dreams and the American Psychological Associations Division 30: Society of Psychological Hypnosis. Dr. Barrett has written four books: The Committee of Sleep (Random House, 2001); The Pregnant Man and Other Cases from a Hypnotherapists Couch (Random House, 1998); Waistland (Norton, 2007); and Supernormal Stimuli (Norton, 2010). She is an editor of two additional books, The New Science of Dreaming (Praeger/Greenwood, 2007) and Trauma and Dreams (Harvard University Press, 1996), and has published dozens of academic articles and chapters on health, hypnosis, and dreams. She is editor-in-chief of DREAMING: The Journal of the Association for the Study of Dreams. Dr. Barretts commentary on psychological issues has been featured on Good Morning America, The Today Show, CNN, Fox, and the Discovery Channel. She has been interviewed for dream articles in the Washington Post, the New York Times, Life, Time, and Newsweek. Her own articles have appeared in Psychology Today and Invention and Technology. Dr. Barrett has lectured at Esalen, the Smithsonian, and universities around the world.
THE CONTRIBUTORS
Steve K. D. Eichel, PhD, ABPP, is a licensed and board-certied psychologist in Newark, Delaware, with training in clinical counseling and forensic psychology. He became interested in hypnosis while still in college and began his formal training in clinical hypnosis in 1982. Dr. Eichel is an ASCH-approved consultant in clinical hypnosis; he is also a former president of the Greater Philadelphia Society of Clinical Hypnosis and served on its board of governors for ten years. Most of his hypnosis-related research and writing has focused on deceptive, unethical, and coercive persuasion and the manipulation of states
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of consciousness, especially by destructive religious, political, and therapy cults. He has also presented national and regional workshops on integrating hypnosis and hypnotic techniques in the treatment of trauma and addictions. Dr. Eichel currently divides his time between a broad clinical practice, serving on the Delaware State Board of Examiners of Psychologists, the Board of Trustees of the American Board of Professional Psychology, the Professional Advisory Board of the International Cultic Studies Association, and the executive committees of several other professional associations. Melvin A. Gravitz, PhD, is Clinical Professor of Psychiatry and Behavioral Sciences at George Washington University School of Medicine and Behavioral Sciences in Washington, DC. He is certied in clinical and in forensic psychology by the American Board of Professional Psychology and in clinical and in experimental hypnosis by the American Board of Psychological Hypnosis. He is past president of the American Society of Clinical Hypnosis and APA Division 30: Society of Psychological Hypnosis. With a special interest in the history of hypnosis and its forensic applications, he has a personal library of some 2,500 volumes in that eld and is a frequent contributor to hypnosis literature. J urgen W. Kremer, PhD, Dipl.-Psych., received his education at the University of Hamburg in Germany and is the editor of ReVision A Journal of Consciousness and Transformation. His past positions include: dean of faculty and vice president of academic affairs at Saybrook University in San Francisco; academic dean and program director of the Integral Studies Program and the East-West Psychology Program, as well as codirector of the PhD program for traditional knowledge at the California Institute of Integral Studies. He continues to teach at Saybrook University, CIIS, and Sonoma State University and holds a full-time position at Santa Rosa Junior College. He has cowritten several books, including Towards a Person-Centered Resolution of Intercultural Conicts (1980), and contributed extensively to journals, handbooks, readers, and more popular venues. After receiving his doctorate in clinical psychology at the University of Hamburg, Germany, and working for some years in private practice, Dr. Kremer relocated to San Francisco to teach at Saybrook. He has edited special ReVision issues on Peace and Identity; Paradigmatic Challenges; Culture and Ways of Knowing; Indigenous Science; and Transformative Learning. He has done extensive eldwork on the use of indigenous hypnotic-like procedures, especially in S apmi (arctic Europe) and the Southwestern United States; he has applied his ndings in clinical and nonclinical settings. Stanley Krippner, PhD, is professor of psychology at Saybrook University, San Francisco, California. In 2002, he received the Division 30 Award for Distinguished Contributions to Professional Hypnosis from the Society of Psychological Hypnosis of the American Psychological Association. During the same
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year, he received the American Psychological Association Award for Distinguished Contributions to the International Advancement of Psychology. He is a Fellow of APA Division 30, of the Society for Clinical and Experimental Hypnosis, and the American Society of Clinical Hypnosis. He has lectured and conducted workshops in psychological hypnosis in Brazil, Cuba, India, Italy, Mexico, Russia, Sweden, and the United States, and is a member of the Swedish Society of Clinical Hypnosis. He is a fellow of the Association for Psychological Sciences, the Society for the Scientic Study of Religion, and the Society for the Scientic Study of Sexuality. He is the coeditor of Varieties of Anomalous Experience: Examining the Scientic Evidence; Broken Images, Broken Selves: Dissociative Narratives in Clinical Practice; and The Psychological Impact of War Trauma on Civilians: An International Perspective. He has coauthored Personal Mythology, Extraordinary Dreams, and Haunted by Combat: Understanding PTSD in Combat Veterans. Robert G. Kunzendorf, PhD, is professor of psychology at the University of Massachusetts, Lowell, and is coeditor of the journal Imagination, Cognition, and Personality: Consciousness in Theory, Research, Clinical Practice. He has published over 100 articles concerned primarily with visual imagination, consciousness (including hypnotic phenomena that are conscious, but not selfconscious), and existential issues. In addition, he has coedited four books: The Psychophysiology of Mental Imagery, Mental Imagery, Hypnosis and Imagination, and Individual Differences in Conscious Experience. He is currently working on two more books: a monograph on The Evolution of Consciousness and SelfConsciousness and a coauthored work on Envisioning the Dream through Art and Science. David Spiegel, MD, is the Jack, Lulu, & Sam Willson professor in the School of Medicine, associate chair of Psychiatry & Behavioral Sciences, director of the Center on Stress and Health, and medical director of the Center for Integrative Medicine at Stanford University School of Medicine, where he has been a member of the academic faculty since 1975. He is past president of the American College of Psychiatrists and is past president of the Society for Clinical and Experimental Hypnosis. He has published 10 books, 349 scientic journal articles, and 148 chapters on hypnosis, psychosocial oncology, stress physiology, trauma, and psychotherapy. His research has been supported by the National Institute of Mental Health, the National Cancer Institute, the National Institute on Aging, the John D. and Catherine T. MacArthur Foundation, the Fetzer Institute, the Dana Foundation for Brain Sciences, and the Nathan S. Cummings Foundation, among others. He is winner of 22 awards, including the 2004 Judd Marmor Award from the American Psychiatric Association for biopsychosocial research and the Hilgard Award from the International Society of Hypnosis. His research on cancer patients was featured in Bill Moyerss Emmy award-winning PBS series, Healing and the Mind, and recently on the Jane Pauley Show and Good Morning America.
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Lynn C. Waelde, PhD, is a professor at the Pacic Graduate School of Psychology, Palo Alto University, California, and a consulting associate professor at Stanford University School of Medicine. Her clinical and research interests focus on stress disorders and therapeutic applications of meditation and mindfulness. Her trauma research has addressed diversity issues such as race-related stress and ethnic identity, dissociation, and responses to natural disasters. She has also investigated applications of meditation and mindfulness to diverse health and mental health issues. She is founder and director of the Inner Resources Center of the Kurt and Barbara Gronowski Psychology Clinic. The center conducts psychoeducational programs, clinical interventions, professional training, and research concerning the applications of mind-body therapies, especially meditation, for mental, emotional, physical, and spiritual well-being. Waelde has a bachelors degree in psychology and a masters degree in anthropology from Louisiana State University. She received her masters and doctoral degrees in developmental child clinical psychology from the University of Colorado at Boulder. She completed her predoctoral internship at the VA Medical Center in New Orleans, where she completed training as a PTSD specialist. Matthew White, MD, MS, did his undergraduate work at Stanford University and earned his MD and MS from the UC Berkeley / UC San Francisco Joint Medical Program. After residencies in Internal Medicine at UC San Francisco and in Psychiatry at Stanford University he is currently completing an NIMHsponsored post-doctoral fellowship. His research focuses on using functional MRI to study hypnosis as well as various psychiatric disorders, including depression, obsessive-compulsive disorder, and trichotillomania. Ian E. Wickramasekera II, PsyD, is on the faculty of the University of Illinois Medical School, Chicago. He previously directed the hypnosis training program at the Adler School of Professional Psychology from 2004 to 2008. In his research and clinical work, he draws upon his background in B on-Buddhism, humanistic/transpersonal psychology, hypnosis, and mind/body medicine. His major research interests in hypnosis revolve around the topic of empathy in its relationship to hypnotic phenomena. He is also fascinated with the transformation of suffering into happiness that occurs within therapeutic relationships and through developing the inner disciplines of mind/body medicine such as hypnosis, meditation, and relaxation. He is a past president of APA Division 30: Society of Psychological Hypnosis. His research and writings have appeared in journals such as American Journal of Clinical Hypnosis, Dissociation, International Journal of Clinical and Experimental Hypnosis, and the Journal of Humanistic Psychology. He received the award for early career contributions from the American Society of Clinical Hypnosis in January 2007. In August 2007 he also was honored with the award for early career contributions from the Society of Psychological Hypnosis.
Index
absorption in imaginative activity, 16 Adler School of Professional Psychology in Chicago, 153 African-Brazilian mediumship, 100, 115119 agency, hypnotic inversion of, 4547 age regression, 65 alerting, 41 alterations in consciousness, 99, 100 altruistic trance states, 112, 113 Alzheimers disease, 43 American Association of Marriage and Family Therapists, 142 American Board of Examiners in Clinical Social Work, 138 American Board of Hypnosis in Dentistry, 132 American Board of Hypnotherapists/ Hypnotherapy (ABH), 126, 131 American Board of Medical Hypnosis, 63, 132 American Board of Professional Psychology (ABPP), 132, 138 American Board of Psychological Hypnosis, 63, 132 American Boards of Hypnosis (now American Boards of Clinical Hypnosis), 132 American College of Forensic Examiners (ACFE), 129 American Council of Hypnotist Examiners (ACHE), 131
American Hypnosis Board for Clinical Social Work, 132 American Medical Association, 56 American Psychological Association, 132 American Psychotherapy Association, 127, 133 American Society of Clinical Hypnosis (ASCH), 125, 132, 133, 142, 147, 150, 152 amnesia, 28; hypnotic deactivation of self-conscious source monitoring associated with, 79 amygdala, 46 anterior cingulate gyrus, 41 Approved Consultant in Clinical Hypnosis, 133 Arons, Harry, 131 Association to Advance Ethical Hypnosis (AAEH), 125, 131; AAEH Code of Ethics, 142 attention systems, hypnotic changes in, 4142 autobiographical memory, 46 automaticity, hypnotic effects on, 4445 automatic writing, 65 awareness, 99 Bali, hypnotic-like procedures in, 111113 Balinese folk customs, 100
166
Index
basket drum ceremony, 109 Bernheim, Hippolyte, 130 blood oxygen level-dependent (BOLD) signal uctuations, 41 body painting, hypnotic-like procedures, 104 B on-Buddhism, 147, 148, 149, 154 Braid, James, 97, 147, 150 Braidism, 97 Breuer, Joseph, 130 British Medical Association, 131 Buddhists, 147, 148, 149, 154 California Board of Hypnotherapy, 131 canonical brain networks, connectivity analysis during mindful mediation, 4344 chanting, hypnotic-like procedures, 98, 103 Charcot, Jean-Martin, 130 cleansing, hypnotic-like procedures, 103 clinical hypnotists, 141n1; hypnosis as distinct profession, 134135, versus lay hypnotists, conicting paradigms, commitment to science, 134 consciousness, 99 Consumer Fraud Reporting Organization, 131 contextual positioning, 64 control instruction, 5 Council of Professional Hypnosis Organizations (COPHO), 135136 Coyote Way, 106107 credentialing, meaning of, 136138. See also hypnosis credentialing culpability, 69 cultural context, hypnotic-like procedures, 102 dACC, 39, 41, 43, 44 dancing, 112 daydreams, 17 default-mode network (DMN), 41, 44 dietary practices, hypnotic-like procedures, 103
dissociated memories, hypnotic recovery of, 1011 dissociated perceiving with or without a hidden observer: hypnotic deactivation of self-conscious source monitoring during, 56 dissociaters: comparison with dissociaters, 2832, Dissociative Disorder, 3132, hidden observers, 29, nightmares, 29, 3031, PostTraumatic Stress Disorder, 3132, trauma histories, 29, 31, waking imagery hypnotic characteristics of, 18 dissociation group, 2528; early memories of fantasies and parental discipline, 2527; experience of hypnosis, 2728 Dissociative Disorder, 3132 Dissociative Experiences Scale, 11 DLPFC, 39, 41, 44 DPPFC, 39 drama, hypnotic-like procedures, 104 dreams, 17; fantasizers versus dissociaters, 29, 3031 early memories of fantasizers: in dissociation group, 2527 parental discipline and, 2123, egoistic trance states, 113 Elkins, Gary, 152 EMDR International Association, 142 environment, distraction in, 68 Erickson, Milton, 132 ethical considerations, for forensic hypnosis, 7273 executive attention, 41 false memories, hypnotic creation of, 1011 fantasizers, 17, 1825; comparison with dissociaters, 2832, Dissociative Disorder, 3132, hidden observers, 29, nightmares, 29, 3031, PostTraumatic Stress Disorder, 3132, trauma histories, 29, 31, waking imagery hypnotic characteristics of,
Index
167
18; earliest memories of, and parental discipline, 2123; experience of hypnosis, 2325; vividness of imagery, 1921 fantasy-proneness scale, 16 Faria, Abb e, 147, 151 fear, 68 Federal Model, 62 lm: featuring hypnosis, 8591; inductions of hypnosis in, 7980 re ceremony, 108109. See also realistic cinema hypnosis fMRI, connectivity analysis during mindful mediation, 4243 forensic hypnosis, 5374; ethical considerations, 7273; illustrative cases, 6972; interview for, 6264; laboratory experiments, 57; legal issues, 5862; mechanisms of memory and, 5557; real-life studies, 5758; resistance, 6769; techniques, 6466; therapeutic serendipity, 6667; varieties of, 5455 Freud, Sigmund, 130 frontoinsular cortex, 39, 40, 42, 43, 44 Gnosticism, 148 graduate schools: training program for teaching hypnosis within, demonstrations, providing, 155, personal practice and mentorship opportunities, 154155, spiral curriculum method, 156, three-class model, 153154 Greater Philadelphia Society of Clinical Hypnosis, 125, 133 gustatory stimulation, hypnotic-like procedures, 103 hallucination: during hypnotic deactivation of self-conscious source monitoring, 35 Hammond, Corydon, 152 Harvard Group Scale of Hypnotic Susceptibility (HGSHS), 17, 156 healing ceremonies, 38
health benets, of mindfulness meditation, 3940 HGSHS-A, 24 hidden observer, 5 Hilgard, Ernest, 156 hippocampus, 43, 44 homovanillic acid (HVA), 41 Hurd Rules, 62 hypnosis: dissociaters experience of, 2728; as distinct profession, 134135; effects on automaticity, 4445; fantasizers experience of, 2325; forensic (see forensic hypnosis); inductions in lm, 7980; lay versus professional, 133134; in media, 7792; in musical theater, 8283; neuroimaging of, 3839; public demonstration of, 150151; realistic cinema, 8391, 8591; in song, 8283; stereotypes of, 80; teaching (see teaching hypnosis); as technology, 138141; in television, 8182. See also individual entries Hypnosis Consultants, 131 hypnosis credentialing, 125143; brief history of, 130131; lay, 131; problems of, 135136; professional, 131133 hypnotic analgesia, 5 hypnotic blindness, 5 hypnotic creation, of false memories, 1011 hypnotic deactivation, of selfconscious source monitoring, 111; associated with posthypnotic amnesia, 79; dissociated memories, recovery of, 1011; dissociation with or without a hidden observer, 56; false memories, hypnotic creation of, 1011; hallucination during, 35, 4; hypermnesia for, 910 hypnotic deafness, 5 hypnotic hypermnesia: for selfconscious source monitoring, 910 hypnotic-like practices, 100; ancient pedagogical perspectives on
168
Index
teaching, 147150; in graduate schools, teaching, 155 hypnotic-like procedures, 97121; African-Brazilian mediumship procedures, 115119; in Bali, 111113; historical and crosscultural issues, 100102; multidimensionality, in Din e (Navajo) chantways, 106111; multi-sensual perspectives on, 102104; in S apmi, 113115; shamanic consciousness during, 104106 hypnotisme, 97 hypothalamus, 44 ideomotor signals, 65 image-vividness, 45 imaginative suggestibility, 125 inappropriate methods of induction, 68 indigenous, 100 integrative theory, 1 intentionality, 45 International Medical & Dental Hypnosis Association (IMDHA), 126, 139 International Society of Hypnosis (ISH), 132 interstimulus interval (ISI), 44 interview: for forensic hypnosis, 6264 Janet, Pierre, 130 kami, 101 Krasner, A. M., 131 languages, 99 lay hypnosis credentialing, 131. See also hypnosis credentialing lay hypnosis versus professional hypnosis, 133134 lay hypnotists versus clinical hypnotists, conicting paradigms: commitment to science, 134; hypnosis as distinct profession, 134135 legal issues, forensic hypnosis, 5862
long-term memory (LTM), 5556. See also memory Los Angeles Police Department, 57 McGill, Ormond, 130 media, hypnosis in, 7792, 8591; implications, 9192; inductions in lm, 7980; musical theater, 8283; realistic cinema, 8391, 8591; song, 8283; television, 8182 medial prefrontal cortex, 41 Medical Hypnosis Association, 133 memories, 66; long-term, 5556; shortterm, 5556; static phenomenon, 66 Mesmer, Franz, 97, 147 mesmerism, 97 metaphors, 66 mind/body techniques, 38 mindfulness-based stress reduction (MBSR), 3940 mindfulness meditation: canonical brain networks, functional connectivity analysis of 4344; fMRI, functional connectivity analysis of, 4243; health benets of, 3940; hypnotic changes in attention systems, 4142; hypnotic trance and, resting state networks connectivity analysis during, 42; neuroimaging and, 4041 misconceptions about hypnosis, 68 monoeidism, 97 motor activity, 46 motor cortex, 45 movement, hypnotic-like procedures, 104 musical theater: hypnosis in, 8283 National Board for Certied Clinical Hypnotherapists, 133 National Guild of Hypnotists (NGH), 126, 131, 132, 133, 138, 140 negative transference, 68 neo-dissociation theory, 25, 156 neuroimaging: of hypnosis, 3839; and mindfulness meditation, 4041 nightmare, 17, 30
Index
169
North, Rexford, 131 North American shamanism, 100 Obsessive personality traits, 68 occipital cortex, 46 olfaction, hypnotic-like procedures, 103 Oregon Department of Education, 131 orienting, 41 parental discipline: and early memories of fantasizers, 2123, in dissociation group, 2527 percussion, hypnotic-like procedures, 103 Phenomenology of Consciousness Inventory-Hypnotic Assessment Procedure (PCI-HAP), 156 possibly imagined, 11 posterior cingulate cortex (PCC), 44 post-traumatic source amnesia, 11 Post-Traumatic Stress Disorder, 3132 professional hypnosis credentialing, 131133. See also hypnosis credentialing pseudo-hallucinations, 3 psychogenic amnesia, 10 public demonstration, of hypnosis, 150151 Quaballah, 148 rapport, 138 realistic cinema hypnosis, 8391. See also lm region-of-interest (ROI) analysis, 41 religious belief, 6869 resistance, forensic hypnosis, 6769 resting-state connectivity, 43 resting-state networks (RSNs), 43; connectivity analysis during mindful mediation, 42 revivication, 65 ritual implements, hypnotic-like procedures, 103 sacred geography, hypnotic-like procedures, 102
S ami traditions, 100 sand painting ceremony, 109111 S apmi: contemporary shamanic practices in, 113115 self-consciousness, 3, 9 self-conscious source monitoring: associated with posthypnotic amnesia, 79, dissociated memories, recovery of, 1011, dissociation with or without a hidden observer, 56, false memories, hallucination during, 35, hypnotic creation of, 1011, hypnotic deactivation of, 1 11; during sleep, 2, hypermnesia for, 910 sexual fantasies, 27 shamanic consciousness, during hypnotic-like procedures, 104106, 105; Din a (Navajo) chantways, hypnotic-like procedures in, 106111, basket drum ceremony, 109, re ceremony, 108109, sand painting ceremony, 109111, unraveling ceremony, 108 shamanism, 100 shame and embarrassment, 68 short-term memory (STM), 5556. See also memory singing, hypnotic-like procedures, 103 sleep; somnambulistic phenomena during, 2 Society for Clinical and Experimental Hypnosis (SCEH), 131, 132, 147, 150; Frye Rule, 58 Society of Harmony, 151152 Society of Psychological Hypnosis, 146, 150, 97 somnambulistic phenomena, 2 song; hypnosis in, 8283 source-monitoring theory, 10 spiral curricula method, 153, 156 standards of training, teaching hypnosis, 151153 Standards of Training in Clinical Hypnosis (SOTCH), 152154
170
Index
Stanford Hypnotic Clinical Scale, 5 Stanford Hypnotic Susceptibility Scale: Form C (SHSS: C), 154, 156 Stanford Scale of Hypnotic Susceptibility, 17 static concept of memory, 66 stereotypes, of hypnosis, 80 storytelling, hypnotic-like procedures, 102 striatum, 41 Stroop interference paradigm, 4445, 47 subliminal stimuli, 910 Susm, 148 suggestibility, 37 Susto, 100 tactile stimulation, hypnotic-like procedures, 104 Tantra, 148 tape recorder model, 66 teaching hypnosis, 145147; historical perspectives, 147153, public demonstration, 150151, spiral curricula method, 153, standards of training, 151153, teaching hypnotic-like practices, ancient pedagogical perspectives on, 147150; within graduate schools, training program for, demonstrations, providing, 155, personal practice and mentorship
opportunities, 154155, spiral curriculum method, 156, three-class model, 153154; television; hypnosis in, 8182 Tellegans Absorption Scale, 17 Tellegen and Atkinsons Absorption Scale, 16, 19 therapeutic serendipity, 6667 three class model, 153154 Tibetan Buddhism, 147, 148, 149 Time regression, 65 trance, 45 trauma histories; fantasizers versus dissociaters, 29, 31 Trust Imagination instruction, 5 Try Hard instruction, 5 unraveling ceremony, 108 verbal instructions, hypnotic-like procedures, 103 vivid imagery and fantasies, 1921 voxel-based morphometry (VBM), 40 wagamama, 100 waking-sleeping cycles, hypnotic-like procedures, 104 within-subject correlation, 4 Women in Transition, 139 Women Organized against Rape, 139

Volume 2: Applications in Psychotherapy and Medicine
Deirdre Barrett, Editor
Copyright 2010 by Deirdre Barrett All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, except for the inclusion of brief quotations in a review, without prior permission in writing from the publisher. Library of Congress Cataloging-in-Publication Data Hypnosis and hypnotherapy / Deirdre Barrett, editor. p. ; cm. Includes bibliographical references and index. ISBN 978-0-313-35632-2 (hard copy : alk. paper) ISBN 978-0-31335633-9 (ebook) ISBN 978-0-313-35634-6 (vol. 1 hard copy : alk. paper) ISBN 978-0-313-35635-3 (vol. 1 ebook) ISBN 978-0-31335636-0 (vol. 2 hard copy : alk. paper) ISBN 978-0-313-35637-7 (vol. 2 ebook) 1. Hypnotism. 2. HypnotismTherapeutic use. I. Barrett, Deirdre. [DNLM: 1. Hypnosismethods. 2. Mental Disorderstherapy. WM 415 H9961 2010] RC495.H963 2010 2010015824 615.80 512dc22 ISBN: 978-0-313-35632-2 EISBN: 978-0-313-35633-9 14 13 12 11 10 1 2 3 4 5
This book is also available on the World Wide Web as an eBook. Visit www.abc-clio.com for details. Praeger An Imprint of ABC-CLIO, LLC ABC-CLIO, LLC 130 Cremona Drive, P.O. Box 1911 Santa Barbara, California 93116-1911 This book is printed on acid-free paper Manufactured in the United States of America
Contents
Acknowledgments Introduction Deirdre Barrett Chapter 1 Ericksonian Approaches to Hypnosis and Therapy Stephen R. Lankton Chapter 2 Ego Psychology Techniques in Hypnotherapy Arreed Franz Barabasz Chapter 3 Hypnotic Dreams Deirdre Barrett Chapter 4 The Merits of Applying Hypnosis in the Treatment of Depression Michael D. Yapko Chapter 5 Hypnosis in Interventional Radiology and Outpatient Procedure Settings Nicole Flory and Elvira Lang Chapter 6 Hypnosis in the Treatment of Smoking, Alcohol, and Substance Abuse: The Nature of Scientic Evidence Kent Cadegan and V. Krishna Kumar
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Chapter 7 Hypnosis and Medicine: In from the Margins Nicholas A. Covino, Jessica Wexler, and Kevin Miller About the Editor and Contributors Index
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Acknowledgments
I would like to thank Debbie Carvalko from Praeger Publishers for her advocacy of this project, and for her advice, organization, and review of these volumes. I would also like to thank the books advisory board: Arreed Barabasz, PhD, EdD; Elvira Lang, MD; Steve Lynn, PhD; and David Spiegel, MD, for their help in identifying topics to be covered and advice on the best authors to cover them. Finally, I want to acknowledge the professional hypnosis societies that introduced me to the members of the advisory board and to most of the chapter authors. These organizations taught me much of the hypnosis Ive learned since my basic graduate school training, as they have for many of the chapter authors. They provide forums in which advances in hypnosis are shared in a timely manner among practitioners. The rst two societies listed here publish academic journals in which much of the research and clinical techniques summarized in these volumes has appeared. All ve conduct stimulating conferences with research presentations and workshopsfor students as well as practicing professionals. All maintain referral lists from which potential clients can locate skilled hypnotherapists in their geographic area. They constitute a rich resource for readers wishing to pursue more learning about hypnosis. The Society for Clinical and Experimental Hypnosis SCEH Executive Ofce P.O. Box 252 Southborough, MA 01772 Tel: 508-598-5553 Fax: 866-397-1839 Email: info@sceh.us Publishes International Journal of Clinical and Experimental Hypnosis
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American Society of Clinical Hypnosis 140 N. Bloomingdale Rd. Bloomingdale, IL 60108 Telephone: 630-980-4740 Fax: 630-351-8490 Email: info@asch.net Publishes American Journal of Clinical Hypnosis Society of Psychological Hypnosis Division 30American Psychological Association APA Division 30 Membership 1400 N. La Salle, Unit 3-S Chicago, IL 60610 http://www.apa.org/divisions/div30/homepage.html European Society for Hypnosis ESH Central Ofce Inspiration House Redbrook Grove Shefeld, S20 6RR United Kingdom Telephone : 44 11 4248 8917 Fax : 44 11 4247 4627 E-mail : mail@esh-hypnosis.eu http://www.esh-hypnosis.eu/index.php?folder_id14&le_id0 International Society for Hypnosis http://www.ish-web.org/page.php
Introduction
Deirdre Barrett
Hypnosis is named for the Greek god of sleep though, even in ancient times, few thought of it as literal sleepthis was simply the best analogy for an altered state so far from waking cognition and behavior. Western medicine rst called the phenomena mesmerism after Franz Mesmer, who conducted group trance inductions in eighteenth-century Europe. Mesmer attracted attention for his amboyant style and his cures of hysteria that eluded other physicians of the time. Of course, Mesmer did not invent hypnosis, he merely rediscovered techniques that had been practiced around the world since the dawn of history. A fourth-century BCE Egyptian demotic papyrus from Thebes describes a boy being induced into a healing trance by eye xation on a lighted lamp.1 Third-century BCE Greek temples in Epidaurus and Kos, dedicated to the god Asclepius whose snake-entwined staff is now our modern medical symbol, the caduceusused hypnotic-like incubation rituals to produce their dramatic cures.2 Mesmers contribution was that he reminded the Western world of this marvelous therapy. Young doctors ocked to him to study, but the medical establishment was no friendlier to alternative medicine then than now. Mesmer was exiled from medical practice, but therapists and the general public have remained fascinated with hypnosis ever since. In recent years, we have been able to understand hypnosis much better than Mesmer did with his eighteenth-century versions of magnetic and electrical elds of the body. Indeed we are able to see what real changes in brain activity occur during the process, but also a wealth of modern cognitive, linguistic, and personality research help explain it. Hypnosis and Hypnotherapy brings together the latest research on the nature of hypnosis and studies of what it can accomplish in treatment. Volume 1 addresses the question of what hypnosis is: the cognitions, brain activity, and personality traits that characterize it, as well as cultural beliefs about hypnosis. In Chapter 1, Robert Kunzendorf describes how cognitive processing differs
Introduction
during hypnosis from usual waking modes. He characterizes the core change as the deactivation of self-conscious source monitoring. This lack of awareness of the self as the origin of many perceptions during hypnosis leads to experiencing imagery as hallucinations and to alterations of memory processing including dissociation, amnesia, and hypermnesia. Kunzendorf explains how these changes can sometimes enable hypnosis to recover repressed memories but also increase the possibility of creating false ones. The most common misconception in hypnosis lore is the notion that trance, hallucinatory imagery, the will to carry out suggestionsindeed all the phenomena of hypnosisemanate from the hypnotist. In fact, it is the subject who produces these. In Chapter 2, I examine personality traits associated with the ability to enter hypnotic trance. Very few people are totally unhypnotizable, but the number able to experience the deepest hypnotic phenomenaeyes open hallucinations, negative hallucinations (failing to perceive something that is right in front of one), suggested amnesia and analgesia sufcient for surgeryis similarly small. Hypnotizability is not a present/absent dichotomy but a continuum. Many traits were historically hypothesized to determine hypnotizability such as hysteric personality, passivity, weak will, and need to please, but these actually bear little or no correlation when subjected to modern research analyses. This chapter summarizes the cluster of traits that do predict response to hypnotic induction. All of the interview and test questions that correlate highly concern hypnotic-like experiences of everyday life vividness of imagery, propensity to daydream, and the ability to block out real sensory stimuli. I also present a distinction between two types of high hypnotizablesone of whom has more of a propensity toward vivid, hallucinatory imagery, and the other toward dissociative, amnestic separation of memory. The rst group fantasizers tend to have a history of parents who read them much ction and encouraged fantasy play, while the second group dissociaters have a history of trauma or isolation during which they learned amnestic defenses. In Chapter 3, David Spiegel, Matthew White, and Lynn Waelde review the effects of hypnosis on physiologic functions. Past studies have found that induction of the hypnotic state reduces sympathetic nervous system activity and increases parasympathetic activity, as measured by the low frequency/high frequency ratio in spectral analysis of heart rate, and by increases in vagal tone. Both of these changes are associated with the ability to self-soothe. Hypnosis has also been found to affect the secretion of cortisol and prolactin and to modulate other neural and endocrine components of the stress response. The authors then describe recent brain imaging of hypnosis at their lab and other research facilities. The most consistent changes are found in the frontal attentional systems. Spiegel, White, and Waelde explain why these often track with the alterations of autonomic tone noted in the peripheral studies of hypnosis. They describe
Introduction
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how hypnosis is associated with changes in the executive attention function of the anterior cingulate gyrus and involves activation rather than arousal in neurological termsand dopaminergic rather than noradrenergic in biochemical ones. This type of activation promotes chunking, or reducing the number of parallel systems, and indicates an inner rather than outer focus. Spiegel, White, and Waelde compare brain imaging ndings in hypnosis with those associated with mindfulness meditation and discuss the physiological similarity of states produced by the two techniques. Finally, they discuss shifts in brain activity associated with particular hypnotic phenomena such as alterations of pain perception and with the lessened sense of self-agency during hypnosis that was characterized as essential in Chapter 1. In Chapter 4, Melvin Gravitz describes forensic hypnosisthe role it has played in police investigation and the court system. Views of hypnosis have swung from touting hypnosis as a truth serum to seeing it as inherently invalidating witness testimony. Gravitz reviews the precedents and opinions at all levels, up to and including the U.S. Supreme Court, and offers his own balanced view of appropriate uses and safeguards. He discusses how the hypnotic alterations of memory discussed in Chapters 1 and 3, and the hypnotic-associated personality traits dealt with in Chapter 2, manifest specically during criminal witness proceedings. Next, in Chapter 5, I discuss the depiction of hypnosis in art and medialm, television, theater, music, and cartoons. These depictions emphasize behavioral control rather than rich alterations of subjective experience. Most lms cast hypnosis in a dark lightas a tool for seduction or murder. When hypnosis is portrayed positively, it is often either as a truth serumsimilar to the overly optimistic court opinions discussed in Chapter 4 (in fact, these often appear in courtroom dramas) or as endowing subjects with impossible psychological, mental, or athletic abilities. The chapter concludes with a discussion of how more realistic depictions of hypnosis in media might be encouraged. In Chapter 6, Stanley Krippner and J urgen Kremer discuss hypnoticlike practices in shamanism and folk medium traditions with illustrative examples from various North American tribes, Balinese folk customs, contemporary S ami (indigenous Scandinavian) practices and AfricanBrazilian mediumship. They describe the many similarities in these societies inductions and Western hypnosis, including verbal inductions and suggestion, sleep analogies, and heavy reliance on imagery and storytelling (the latter being characteristic mostly of Ericksonian hypnosis to be described in Volume 2, Chapter 1, rather than of all Western hypnosis). Krippner and Kremer also contrast trance-induction practices that are common in the indigenous cultures but not in Western hypnosis including chanting, percussion, dance or other ritualistic movement, and the burning of incense. They note a fundamental difference in the two types of indigenous practices of shamanism versus mediumship. Shamans are usually
xii
Introduction
aware of everything that occurs while they converse with spirits, even when a spirit speaks through them, whereas mediums claim to lose awareness once they incorporate a spirit, and purport to remember little about the experience once the spirit departs. This distinction is similar to the two types of high hypnotizablesfantasizers and dissociaters described in Chapter 2. Krippner and Kremer describe how these cultures foster fantasy proneness and train dissociation to some degree, but that there also seem to be signicant demand characteristics to produce the culturally sanctioned behavior. Krippner has also researched individual variables of subjects within these cultures, nding some of the same characteristics associated with improvement by Western psychotherapy such as willingness to change ones behavior predict benecial outcome to treatment with shaman or medium. In Chapter 7, Steve Eichel describes the responses of the main lay hypnosis credentialing groups (those not associated with the mental health professionals, dentistry or medicine, but purporting to represent the profession of hypnosis) to applications for credentialing from a distinctly unqualied practitioner . . . his pet cat Zoe. Eichel uses the humorous ploy of getting Zoe certied with applications listing study at ImaCat U and hefty licensing fees to point out whats wrong with the concept of commercial credentialing groups unafliated with state licensing or university certication. Eichel goes on to describe why it is important to have clinicians trained in the underlying disorders that they are treating before applying hypnosis to them. Finally, in Chapter 8, Ian Wickramasekera describes in more detail how this training should be conducted. He reviews the history of how hypnosis has been taughtin Western psychotherapy and medicine, but also in the indigenous cultures covered in Chapter 6, ending with a description of the modern training guidelines established by the American Society of Clinical Hypnosis. Wickramasekera discusses how it is possible to draw together the best elements of each of these different pedagogical traditions into a training program for teaching hypnosis either within a university setting or a postgraduate certicate program. Volume 2 addresses the clinical applications of hypnosis in psychotherapy and medicine. In the term hypnotherapy, the second half of the term is as important as the rst. Except for some generalized effects on relaxation and stress reduction, it is not the state of hypnosis itself that affects change, but rather the images and suggestions that are utilized while in the hypnotic state. Because hypnosis bypasses the conscious minds habits and resistances, it is often quicker than other forms of therapy, and its benets may appear more dramatically. However, the reputed dangers of hypnotherapy are really those of all therapy: rst, that an overzealous therapist may push the patient to face what has been walled off for good reason before new strengths are in place; and second, that the therapist will abuse his or her position of
Introduction
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persuasion. People come to hypnotherapy with similar complaints and hopes to those they bring to any treatment for physical or psychological problems. Despite the added role of hypnotizability, most of the same factors determine the outcome: the skill of the therapist, the patients motivation to drop old patterns, the rapport between patient and therapist, and how supportive family and friends are of change. Volume 2 begins by introducing the different branches of hypnotic psychotherapy. In Chapter 1, Stephen Lankton describes Ericksonian hypnotherapy the approach derived from the body of writing, training, and lectures of the late Milton Erickson. Ericksonian techniques include designing individualized inductions in the clients distinctive language, incorporating the clients metaphors for their disorders into the suggestions for change and using indirect suggestionwhich is ambiguous, vague, and more permissive to avoid provoking resistance. In Chapter 2, Arreed Barabasz traces the history of psychodynamic and ego psychology applications to hypnosis and then describes in more detail modern ego state hypnotherapy. Ego state theory posits that peoples personalities are separated into various segments. Unique entities serve different purposes. Ego states often start as defensive coping mechanisms and develop into compartmentalized sections of the personality, but they may also be created by a single incident of trauma. Ego states maintain their own memories and communicate with other ego states to a greater or lesser degree. Unlike alters in multiple personalities, ego states are a part of normal personalities. Conicts among states take up considerable energy, often forcing the individual into withdrawn, defensive postures. Hypnosis can facilitate communication between ego states, allow memories associated with one to become available to the whole person, and teach people to shift states more consciously and adaptively. Chapter 3 continues the discussion of psychodynamic uses of hypnosis, with my summary of the research and clinical work on hypnotic dreams and the variety of ways of combining hypnosis and dreamwork for the mutual enhancement of each. One can use hypnotic suggestions that a person will experience a dream in the trance stateeither as an open-ended suggestion or with the suggestion that they dream about a certain topicand these hypnotic dreams have been found to be similar enough to nocturnal dreams to be worked with using many of the same techniques usually applied to nocturnal dreams. One can also work with previous nocturnal dreams during a hypnotic trance in ways parallel to Jungs active imagination techniques to continue, elaborate on, or explore the meaning of the dream. Research has also found that hypnotic suggestions can be used to inuence future nocturnal dream content, and that hypnotic suggestions can increase the frequency of laboratory-veried lucid dreams. Hypnotic suggestion can also be used simply to increase nocturnal dream recall. In Chapter 4, Michael Yapko discusses the newest branch of hypnotherapy cognitive behavioraland especially its use in treating depression. He describes
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Introduction
how the classic conceptualization of hypnosis as believed-in imagination is consistent with modern cognitive behavioral theory. Hypnosis can serve as a means of absorbing people in new ways of thinking about their subjective experience and as a method of replacing automatic negative thoughts with positive beliefs and expectancies. It can foster skill acquisition, breaking old associations and instilling new ones. Yapko reviews the growing body of research on the effectiveness of such techniques. Finally, because insomnia is such a common symptom of depression, he describes in detail how hypnosis can resolve insomnia by inducing relaxation and interrupting the ruminations that interfere with sleep. The remainder of the volume addresses applications of hypnosis to medical problems. In Chapter 5, Nicole Flory and Elvira Lang review the use of hypnosis for analgesia from nineteenth-century surgery prior to the discovery of ether up to modern times. The authors describe how surgery has evolved from more traditional large-incision techniques toward the insertion of surgical instruments through tiny skin openings under the guidance of X-rays, ultrasound, magnet resonance imaging (MRI), and endoscopes. They then review in detail their own carefully controlled research on utilizing hypnosis to alleviate pain, anxiety, and other distress associated with surgery in the new interventional radiological settings. Despite previous speculation by others that it would add excessive costs or time to the procedures, the authors found that teaching hypnosis-naive patients techniques on the operating table shortened procedures by decreasing patient interference and decreased costs by lowering subsequent complication rates. In addition to reducing the main target symptoms of pain and anxiety, hypnotic interventions kept patients blood pressure and heart rate more stable. Flory and Lang conclude that hypnotic techniques can be safely and effectively integrated into high-tech medical environments. In Chapter 6, Kent Cadegan and Krishna Kumar review studies on using hypnosis to treat smoking, alcoholism, and drug abuse. There is much more research on its use for smoking cessation than for any other addictive disorder. They report that results are encouraging even for two-session hypnotic smoking cessation treatment, but that there is no evidence for the efcacy of the one-session approach, though clinically, this is frequently practiced. Efcacy of hypnotherapy is less rigorously documented for other addictions, though there is growing interest in its use. Research on hypnosis to aid sobriety in alcoholics has found positive effects, but with small sample sizes and only short-term follow-up. There is less data yet on hypnotic interventions in drug addiction. In one recent study, veterans at an outpatient substance abuse treatment center benetted from training in self-hypnosis, with a very strong main effect for practicethe more regularly they practiced their self-hypnotic suggestions, the likelier they were to remain abstinent. Cadegan and Kumar predict that, with more research like this, it will eventually become possible to say to a potential client that hypnosis can help
Introduction
xv
them control their addiction if they have certain characteristics (e.g., hypnotizability, motivation to quit, and availability of social support), and if they are willing to practice (with specication about the nature and amount of practice). Finally, in Chapter 7, Nicholas A. Covino, Jessica Wexler, and Kevin Miller briey review the research on hypnotic pain control, already described in Chapter 6 as establishing a clear efcacy for hypnosis in that area. They then review the research on hypnosis in other health related areas, such as insomnia, asthma, bulimia, and a number of more function gastrointestinal disorders such as hypermotility (leading to cramps and chronic diarrhea) and hyperemesis (uncontrolled vomiting, usually due either to cancer chemotherapy or as a complication of pregnancy). They conclude that results on all these disorders are clearly positive but need more research. They emphasize the pointwhich is true of both application of hypnosis to psychotherapy discussed earlier in this volume and to its role in medicinethat there is great promise for its use with many illnesses and conditions. However, for hypnosis to be better accepted, it is imperative that researchers in the eld update older studies with ones that pay more attention to current norms of empirically validated treatments and integrate promising strategies from related research such as the mindfulness meditation discussed in Volume 1, Chapter 3. Then this powerful technique will begin to be applied to many disorders in a way that it is currently only utilized routinely for pain control, anxiety, and smoking cessation.
NOTES
1. Grifth, F. I. & Herbert Thompson (Eds.) (1974) The Leyden Papyrus: An Egyptian Magical Book. New York: Dover Publications. 2. Hart, Gerald (2000) Asclepius: The God of Medicine. London: Royal Society of Medicine Press.
Chapter 1
Ericksonian Approaches to Hypnosis and Therapy

Stephen R. Lankton
INTRODUCTION
The focus for this chapter is an approach to change based upon the life work of Milton Erickson, MD. This is often referred to as the Ericksonian Approach to hypnosis and therapy. It represents a distinctive and effective approach to psychotherapy and the use of hypnosis as an adjunct to psychotherapy (Zeig, 1982). Dr. Ericksons approach can be distinguished by differences between his selection and use of therapeutic content and in handling of the process of change in psychotherapy. Ironically, process and content distinctions are themselves sometimes blurred in Ericksonian approaches, and these points will be discussed.
HISTORY AND BACKGROUND

The Ericksonian Approach has been derived from the body of work, training, and lectures provided by Milton Erickson, MD (19011980). Erickson was generally acknowledged to be the worlds leading practitioner of medical or clinical hypnosis. His name and his ideas have been used by many professionals to denote some aspect of their work. However, it is often unclear what specic aspect of their work merits that distinction. This presents a difculty I will address later. Similarly, with the rise of a rash of nonprofessionals who refer to themselves as certied hypnotherapists, even greater reference is made to their so-called Ericksonian Hypnotherapy. As with other approaches to change, such as Gestalt therapy and cognitive behavior therapy, there is no formal body of control over the use of Ericksons name. There is no universally accepted and established standard on how one interprets Ericksons practices or how one applies his approach in treatment. While this situation may lead to much misinformation, there are several
scholarly works written by Erickson and about his work that preserve an accurate record of his approach, concepts, techniques, and philosophy (Erickson & Rossi 1979; Erickson, 1980g, h, i, & j; Fisch, 1990; Haley, 1973; Lankton & Lankton, 2008/1983, 2007; Lankton, 2004; Rossi, Ryan, & Sharp, 1983; Zeig, 1980; Zeig & Lankton, 1988). I will return to the delineating features of Ericksons approach shortly. First, for the record, I will briey discuss Milton Erickson, the man. At the time of his death on Tuesday, March 25, 1980, Erickson was said to have written over 300 professional papers and hypnotized over 30,000 subjects. He was born in Aurum, Nevada, on December 5, 1901. Many readers will probably be familiar with the major accomplishments during his later life: his family of eight children; his many grandchildren; and his worldwide professional impact. For those who are not familiar with his early development and his early professional life, I will provide a brief summary. It was at age eight that Erickson decided to become a doctor when he grew up, after a family doctor pulled his tooth and gave him a nickel. Around the age of 12 he and some friends learned about hypnosis for the rst time from a cheap pamphlet that one of them purchased. Later, he learned techniques of deep introspection that would come to serve him well in his professional life. He developed infantile paralysis of polio in August 1919, at age 17. He recalled hearing the physicians explain to his mother that her son would not live to see another sunset (personal communication, August, 1974). He indicated that he felt great anger that a mother should be told such a thing about her son. When his family members came into his room after meeting with the doctors, he instructed them to arrange the furniture in a particular way. The rearranged furniture allowed him to see out the west window. Erickson said that he would be damned if I would die without seeing one more sunset (personal communication, August, 1974; Rossi, Ryan, & Sharp, 1983, p. 10). Of course, he lived. This experience was powerful in forming Ericksons worldview. His pre-college years were lled with hours and days of concentration and contemplation. Having survived the predicted death, Erickson was told he would never walk again. He had no sensation or control below his neck. Yet, not being of the mind to accept such speculation without challenge, he spent hours learning to discover feelings and sensations in those muscles not completely destroyed by polio. Erickson learned to revivify and retrieve experiential memories of shoveling, hoeing, and so on. Within a year, he had regained the use of his upper torso and was up on crutches. His later success resulted in having completely regained the use of his legs and his ability to walk and pedal a bicycle around his undergraduate campus. He explained all of these successes to the act of discovering the experiential resources and doing so by appealing to simple,
previously learned skills such as using a shovel or a hand hoe. Sufciently revivifying his use of such tools gradually gave him the access to his motor skills. These episodes of willful intention and the lessons he took from them shaped his professional approach in many ways. He crystallized for himself a path of overcoming ones real or perceived limitations no matter how serious. In time, Erickson began a premed curriculum at the University of Wisconsin. He actually began ofcially practicing hypnosis as an undergraduate and was considerably capable by the time he graduated in 1928 with his medical degree. He met and studied hypnosis with Clark Hull who later sponsored him in his internship. As he studied hypnosis in a class taught by Hull, Erickson rst began to recognize the difference in the existing view of hypnosis and how it works and what he learned from his own life experience. He did not think, as he was being taught, that the key to hypnosis was suggestion (planted in the unconscious), but rather that the key was developing the experiential resources needed in each particular context. Erickson interned at Colorado Psychopathic Hospital in child psychiatry and then began working as a senior psychiatrist at Rhode Island State Hospital. In the spring of 1934, he began as the head of psychiatric research at Wayne County General hospital in Eloise, Michigan. Eloise was home to 40,000 psychiatric patients! At that time he began openly practicing and writing about hypnosis. In 1939 he became an associate professor at the Wayne University College of Medicine. He held the position of full professor in Wayne Universitys Social Service Department and Michigan State Colleges clinical psychology program. Dr. Erickson moved to Phoenix in the summer of 1948 in order to nd a climate that would reduce his sensitivity to allergens. He worked in the Arizona State Hospital for a period and then went into private practice. Erickson contracted a second type of polio or post-polio syndrome, in 1953. At this time he lost the use of muscles in his back, diaphragm, abdomen, left leg, right arm, mouth, and tongue. In that state, however, he still continued to work with patients and professionals from around the world. Some were ongoing students and some only visited briey. Among them were such luminaries as Aldous Huxley, Margaret Mead, and Gregory Bateson. Hundreds of well-known psychiatrists, psychologists, and therapists worked with him or visited him including Herbert Speigel, Lawrence Kubie, Seymour Hershman, Irving Secter, Lynn Cooper, Theodore Sarbin, Theodore X. Barber, Andre Weitzenhoffer, Martin Orne, Ernest Hilgard, Jay Haley, Daniel Goleman, Ernest Rossi, Robert Pearson, Sid Rosen, Moshe Feldenkrais, Jeffrey Zeig, myself, and many others. Erickson once remarked that these physical limitations had also made him more observant. The skills he developed for his own survival he utilized in his observation of others. He became vigilant of the minute muscle movements people employ and found them to be revealing of information
that had bearing on clinical issues (Haley, 1967). Erickson said, My tone deafness has forced me to pay attention to inections in the voice. This means Im less distracted by the content of what people say. Many patterns of behavior are reected in the way a person says something rather than in what he says (Haley, 1967, p. 2). This keen sense of observation of meaningful patterns of behavior is yet another hallmark that distinguishes Ericksons approach to therapy and hypnosis from most other therapies. There are several in-depth biographical works on Erickson; this discussion is not intended to summarize or replace them (Haley, 1993; Erickson & Keeney, 2006; Rossie & Ryan, 1985). To explain an Ericksonian approach to therapy and the use of hypnosis and therapy, it is important to establish the absolute necessity of retrieving experiential resources by means of the hypnotic experience. His early recovery from polio, in retrospect, had become the acid test of those concepts. While such a perspective may seem reasonable to many therapists of today, this notion was at odds with traditional psychiatry during much of Ericksons professional life. This approach calls for an active, that is, strategic, and participatory therapista far cry from an analyst who attempted to be invisible behind a couch.
RATIONALE AND PHILOSOPHY

Ericksons work spanned 50 years and 30,000 clients (Lankton & Lankton, 2008/1983, p. xiii) who came from a broad background: rich, poor; single, married; adults, children; neurotic, psychotic; inpatient, outpatient; urban, rural; and educated, illiterate. Derived from and used with this rich diversity, there are several tenets that affect the practice of therapy as well as the way in which problems and people are viewed.
Assessment and Treatment Planning

It is not surprising to nd at the heart of Ericksons work a diagnostic framework that beats to the rhythm of todays systems and communication theories (Lankton & Lankton, 2008/1983, p. 28). Erickson formulated and used a relationship and family approach to treating individuals long before it was fashionable. His approach is apparently rooted in the awareness that people operate from internal maps of the world and that these have been learned. These internal guidelines contain rules for interaction, experience, and perception, and these constitute internal experiential resources. In addition, our internal maps will contain learned limitations regarding how we each interact, perceive, and experience the world. It is perhaps only of minor signicance that Dr. Erickson was a pioneer in applying this sort of diagnostic framework. His early writings indicate that he was also well versed in psychodynamic theory. It will be shown later that he occasionally discussed matters such as defense mechanisms
and other analytic-dynamic concepts. However, he was reluctant to codify his model of the human mind or human conduct. He would frequently tell students that he made up a new approach for each client. To some degree, this must certainly have been an exaggeration. However, he was sensitive to the unique needs of each individual and did tailor his communication and interventions to that person. Nevertheless, we can see at a higher level of analysis repeated patterns in his behavior. Before examining these, it is important to mention that Dr. Ericksons work must be considered more than a collection of techniques and patterns. He was a very careful observer, diagnostician, and was a consummate professional who kept careful notes. While it is somewhat easy to understand the interventions that he used, it is more difcult to recognize the diagnostic mindset that he held while using these interventions. As any trained health care professional should do, Erickson kept detailed case les that recorded his observations, assessments, diagnosis, interventions, and the clients responses to those interventions. He referred to his case les before each session and entered progress notes as soon as possible after each session. While his diagnostic histories were not obtained from a chronology of psychosocial events, they were obtained by careful observation and a selective history of the clients current life context and relationships (personal communication, August, 1975).
Utilization of Client Behavior

Utilization was one of the hallmarks of Ericksons work. Utilization is a process of using the clients energy, point of view, skills, and potentials. Whatever the patient presents to you in the ofce, you really ought to use (Erickson & Rossi, 1981, p. 16). Utilization is a term that Erickson used to depict his approach in two important areas. One is the here-and-now use of material presented from the client. If a client demonstrates relaxation, tension, talkativeness, silence, questioning, passivity, movement, stillness, fear, condence, and so forth, it is to be accepted and used (that is, the client would be directed to continue it) to further the therapeutic movement in a natural way. Tension and resistance are not seen as or labeled as such, but rather, are accepted and in some manner used to facilitate a context for change. If a mother, father, and child cling closely to one another, rather than attempting to spatially separate them and calling their resultant hesitation or anxiety resistance, the therapist may ask them to let the child hold them even closer together with each arm as the interview takes place. This is using the here-and-now behavior to increase the joining and the comfort of the client as well as to reduce the discomfort or anxiety that any other intervention would create. The second manner in which utilization is intended to be understood applies to using the potential abilities each client brings to the session
(Erickson, 1981, p. 17). Using the latent resources each person brings to a session will allow for a rich diversity in a typical therapy session. Each person, for instance, can fantasize, recall, regress, anticipate, relax, forget, imagine, alter consciousness, and so forth, and, using these natural abilities, the client and therapist can cooperate in developing a wide range of helpful contexts for change.
Speak the Clients Own Experiential Language

It follows from the utilization approach that therapists must speak the clients own experiential language and meet them at their model of the world (Lankton & Lankton, 2008/1983, p. 5). He states, therefore, you ought to start simply and let the patients elaborate in accord with their own personality needsnot in accord with your concepts of what is useful to them (Erickson, 1981, p. 12). Communicating in this manner requires that the therapist be exible in his or her manner. This behavioral exibility is to be used in the service of matching the clients type of language, conceptual and family orientation, cultural background, and even the clients speed of speaking, bodily posture in movement, and breathing rate, when possible. Dr. Erickson himself had difculty in moving his limbs, however, rst-hand observation of his behavior revealed that he would change other nonverbal behavior to be in rhythm with his clients (Lankton, 2003/1980).
Reduction of Resistance
Several aspects of Ericksons approach can be viewed as components that reduce resistance. These include his attempt to speak the clients language, utilization of the material given rather than confront or block the material given, introduce ambiguity, allow the clients personal interpretation of the ambiguity to temporarily prevail, avoid labels, initially seek very small changes in the therapeutic direction, interpret and reframe client behavior in such a way as to make it appear positive, and so on. By blending therapeutic intervention and guidance with the clients own predisposition for movement, emotion, and thought, Ericksonian therapy can provide very little for clients to resist. A good analogy to help understand this type of interaction with clients is to compare it to the martial arts. Some aspects of conventional therapy might be compared to the confrontation in the martial art of karate, while Ericksonian therapy could be compared to approaches such as in tai chi or aikido (Ueshiba, 1991). In karate, the practitioner learns to block and punch in order to defend against the aggression of the opponent. In tai chi or aikido, the practitioner learns to use the forward movement and energy of the opponent to reduce conict without aggression. Compare Ericksons view to that of the founder of aikido: Regarding technique, it is necessary to develop a strategy that utilizes all the physical conditions and
elements that are directly at hand. . . . When your opponent wants to pull you must learn to anticipate and direct such a pull (Ueshiba, 1991, p. 35).
Flexibility and Direct Communication

Its important to note that not all clients bring resistance to therapy. Some clients are highly motivated and cooperative and simply seek the tools they need for change. Other clients commonly seen present a great deal of defensiveness and poor communication or cooperation skills. A hallmark of doing therapy in a fashion that was representative of Ericksons work is the skill of being exiblethat is, the ability to effect change in the most rapid manner despite adapting to the type of client who arrives in the ofce. When a client arrives who is cooperative, communicates well, and is motivated for change, it is most appropriate to use direct communication, direct hypnotic suggestion, and decisive non-evasive behavior. Dr. Erickson was an expert at this sort of communication. In fact, it can be shown that he used that type of communication for the longest period of his professional career. The principle of utilization alone dictates that if a congruent client comes requesting information and ideas, the therapist ought to take the direct and non-evasive posture that will help fulll the clients learning needs as soon as possible. For such a client, using indirect, ambiguous, or metaphoric techniques for anything other than illustrating a point with greater clarity would conceivably be an injustice. In this type of direct communication, Erickson was well equipped. In other words, when initially working with a client who arrives in the ofce presenting a good deal of motivation, a history of rich personal and interpersonal resources, and is a good communicator, the use of indirect suggestion or metaphor would be less efcient than the use of direct suggestion and non-ambiguous communication. Once again the Ericksonian therapist should be exible enough to respond by matching these communication signals with similar communication. Similarly, referring to the principle of utilization, when a client comes to the ofce who is argumentative, condescending, and competitive, the model provided by Erickson prescribes that therapy should allow the client to win the argument, be one up, and win the competition. An approach of direct communication may provide the best target against which such clients can argue, criticize, and compete. For these clients, the introduction of ambiguity and indirect suggestion could conceivably be inappropriate because it would provide no solid content for the continuance of that clients skill set (regardless of how self-defeating it might be). However, beyond the context of interview management and after such a client was in trance, then the use of indirect techniques might be most appropriate. This is in part due to the fact that such clients are often not
able to easily bring forth the necessary positive experiences to promote change. In these circumstances, indirect techniques become valuable because of the role they play in stimulating thought. To use a colorful analogy, one might say that the mental search that is necessary to personalize and make sense of the ambiguity of indirect techniques is analogous to the active stirring around inside a junk drawer to locate a lost object. Rearranging the items of random junk often reveals treasures that have been overlooked. In that same way, the listeners of indirect suggestion, binds, anecdote, and metaphor turns over various ideas in their mind in order to discover the best meaning to give the ambiguity. This act of examining and re-examining ideas often yields ideas, methods, and avenues for retrieving desired therapeutic experiences. Finally, a fourth example would be the case of a client who enters therapy with the customary ambivalence, relatively more impoverished background of resource experiences, moderate communication skills, but encumbered by various learned limitations. Such clients are not particularly compliant nor do they fully understand how to locate and reassociate various experiential resources. Such clients perhaps represent the majority of customary outpatient mental health patients. With these clients a mixture of both direct and indirect suggestion is the most logical way to proceed. Indirect suggestions, anecdotes, binds, and metaphor help listeners create a conditional mental search and tentative understanding. This creates expectancy in the mind of the listener that helps them bring a solid understanding to any subsequent direct communication that follows. This pattern of using indirection followed by direct suggestion, for most clients, will usually prove to be the most efcient both prior to and during trance experiences. It has been three decades since the death of Dr. Erickson. Yet, some individuals in the therapeutic community may be under the impression that Ericksons most distinctive feature was his use of indirect communication. This would be an incorrect assumption. The most distinctive feature about Ericksons work would likely be best stated in the terms exibility and utilization. While other features are also predominately important in his worksuch as taking a nonpathological approach, trying to get the client moving as soon as possible, being active and strategic in the therapy, and emphasizing the present and future development of the client rather than the historical pastexibility and utilization were the hallmarks of Dr. Ericksons work throughout the course of his career.
Indirection and Ambiguity

Indirection is an orientation to offering ideas that Erickson developed in the last few decades of his career. It became a well-known principle of his approach (Erickson & Rossi, 1980a; Haley, 1963, 1973, 1967; Watzlawick, Weakland, & Fisch, 1974; Fisch, Weakland, & Segal, 1982; Lankton &
Lankton, 2008/1983) in the last half decade before his death. One aspect of indirection is the latitude it provides for each clients own experience and thinking. The use of ambiguity can sometimes instill a certain curiosity that can give rise to a degree of pleasant mental excitement toward change. Rather than detracting from communication, ambiguity often enhances it. This applies not only to hypnosis but also to normal communication conducted with families in waking state conversation. Perhaps the vast majority of clients that are seen in outpatient psychotherapy are neither highly motivated nor good communicatorsnor are they extremely rigid poor communicators. Instead, it might be fair to say that the vast majority of clients for many therapists, especially those in outpatient settings, are only moderately good communicators who are ambivalent about changing and somewhat defensive about their lack of experiential resources. For these individuals, therapy often results in defensiveness and an inability for them to identify and retrieve the needed resources for change. In situations such as these, indirect techniques are often most helpful. Their helpfulness lies in the manner in which they engage the client. They facilitate a mental search process while reducing defensiveness by disguising the desired goal. When clients identify a t between what the suggestion has hinted and their own personal history, the experiential options are expanded. Since they have not had to comply with the therapists directions, clients who respond to indirection have developed their own answer or their own resource actions from, so to speak, within themselves (Lankton & Lankton, 2008/1983). It is important that the reader bear in mind that indirection does not constitute a dening feature of Ericksons approach. It constitutes one of the pillars that he relied upon in his career, having perfected it in his later years. However, there is a danger in promoting the use of indirect techniques among inexperienced therapists or professionals using hypnosis. The danger is found not in the technique itself, but rather in an attitude that is occasionally inferred by would-be practitioners who have not thoroughly learned the clinical logic behind indirect techniques. Using indirect techniques correctly and effectively takes a great deal of work and study. It is unfortunately too common that I hear students of an indirect approach state that a therapist only needs to simply trust their unconscious and tell clients content that is spontaneously delivered. The model displayed by Erickson was anything but a y-by-the-seat-ofyour-pants or spontaneous approach. Erickson worked out the wording of his inductions and his early stories over a period of dozens of drafts. He would write out, for example, a 20-page induction and edit it down to 12 pages. Then he would edit his 12-page induction down to 7 pages. Eventually he would continue the edit until what remained was a page and a half of a wellcrafted induction (Haley, 1967). While he was a keen observer, he did not interpret meaning to his observations ippantly. He was a strong critic of
10
people who claim to be mind readers (personal communication, August, 1978). He developed his understanding and observational skills over the period of many years and built those understandings on a foundation that originated from a deeply personal insight into his own motor behavior. Therapists who believe they can replicate that sort of observational talent are likely to be grossly mistaken. Being aware that one will not be as perceptive as Erickson means that those professionals who wish to apply his work in their therapy will need to augment their face-to-face communication with clients. There will be a need for more verbal conrmation from clients. And too, there may be a need for the use of other assessment tools. Even simple tools like the Interpersonal Check List (Leary, 1957) can provide valuable insight about the range of behavior a client is capable of producing for those of us who are not as perceptive as Erickson. The use of tools of indirection includes metaphor, indirect suggestion, therapeutic binds, anecdote, and ambiguous function assignments (Lankton & Lankton, 2008/1983, 1986). In contrast to direct techniques and direct suggestion, indirect techniques are difcult to learn, understand, and use. Therefore, I have often written about and taught these techniques in my professional publications and workshops. It is my intention to provide a sufcient articulation of these ambiguous techniques so as to make possible to construct well-conceived empirical research studies about them and to help therapists use them wisely. Lacking such careful articulation, these techniques will simply be lost to history. Therefore, I will provide further details and an illustration about these lesser understood and practiced techniques of Ericksons work.
Hypnotic Language
Hypnotic language refers to verbal and nonverbal communication that elicits unconscious responses in a single listener or in multiple listeners. Traditionally, when one speaks of hypnotic language, it means direct suggestion, and means that the hypnotist makes a clear and direct request for a certain response. For example, Close your eyes. Listen to everything I say. Follow my suggestions completely. In addition, however, when one speaks of hypnotic language, it may mean a form of indirect suggestion where the relationship between the operators suggestion and the subjects response is less obvious. Indirect language can also include forms of confusion, anecdote, and metaphor. For example, Your conscious mind may not immediately realize how much your unconscious mind will learn. You might enjoy how much you learn sooner or later. Direct suggestion can be dened as the language that elicits an unconscious response to a stated goal. Direct suggestion gets best results when the operators prestige and authority is high and the principles of repetition,
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along with the evocation of ideosensory and ideomotor processes are used (Weitzenhoffer, 1957). Sometimes these are enhanced by goal-directed fantasy that is often recognized as the basis of direct suggestion (Barber, Spanos, & Chaves, 1974). Erickson states that much of hypnotic psychotherapy can be accomplished indirectly (Erickson & Rossi, 1981, p. 13). Indirect suggestion is hypnotic language that is recognized for being ambiguous, vague, and more permissive in nature. Responses to indirect suggestion are recognized as being a function of the subjects personal need, and, perhaps because of this, they may be more effective, or at least experienced as being more relevant, than direct suggestion at an individual level. The rationale for using indirect suggestion is also characterized by a number of basic features that are of particular interest: Indirect suggestion permits the subjects individuality, previous experience, and unique potentials to become manifest; The classical psychodynamics of learning with processes like association, contiguity, similarity, contrast checking, and so forth, are all involved on a unconscious level; Indirect suggestion tends to bypass conscious criticism and learned limitations. Because of this it can be more effective and long lasting than direct suggestion. Indirect suggestion may be successfully used with subjects who are awake; in waking state its suggestive inuence is much greater than that of a direct suggestion. It frequently exerts an effective inuence on people who do not yield to direct suggestion, as was pointed out by V. Bekhterev and colleagues (Bekhterev, 1998). It could be said that the stronger suggestion is the one that is more concealed. Language can be direct, indirect, confusing, anecdotal, logical, rational, poetic, and metaphoric. Let me say that again, all language is hypnotic language and it varies by degree of effectiveness. If we classify communication by degrees of effective hypnotic response that it produces, we would be able to place all communication into a continuum of hypnotic languagefrom minimally effective to powerfully effective. We can measure this effectiveness in several ways by answering some simple questions of both low and highly hypnotizable subjects: How soon does the person respond to the language? How long does the effect last? How resistant to change is the response? How much energy, effort, or repetition must be used to obtain the response? In any event, the goal in using hypnotic language is to elicit experience in the listener. The goal is not, as some uninformed people might think, to place an idea in the subconscious. Again, the goal of language is to elicit experience: cognitive, perceptual, emotional, and behavioral experience.
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Depathologizing
Since problems are not thought to be inside a persons head, there is a depathologizing of people (Fisch, 1990). Problems are thought to be the result of trying to move toward a more normal state in an unfolding life cycle (Haley, 1973, p. 150). Ericksonian therapy attempts to avoid labels and redene any possible stigma attached to a clients presenting problem. In a dramatic example of this, Erickson once had a young withdrawn woman with a previously embarrassing gap in her teeth. He encouraged her to learn to propel water through that gap. He eventually convinced her to shoot water at a young man who had shown some interest in her and whom she had avoided. The results of this interaction eventually led to the courtship between these two young people (Haley, 1973). By allowing this girl to continue to avoid contact with others, and by redening the gap in her teeth as something enjoyable rather than a deformity, he was able to avoid the obvious resistances that could have been created by an approach to therapy that wished to teach her to become assertive and proud despite her problem. Ironically, she did become assertive and proud but was able to do so without having to rst consider her problems as a negative liability she was going to have to overcome in the course of therapy (Haley, 1973). Therapy is directed toward helping clients contribute to a creative rearrangement in their relationships so that developmental growth is maximized. Accompanying the reduction of the pathology oriented assessment is a corresponding reduction in so-called resistance.
Creating a Context for Change

Additionally, in Ericksonian therapy, the therapist is active and shares responsibility for initiating therapeutic movement and creating a context in which change can take place (Dammann, 1982). This is often facilitated by introducing material into the therapy session and by the use of suggestion, metaphor, and even extramural assignments. That is, a therapist may not wait until clients spontaneously bring up material but rather may invite or challenge clients to grow and change by creating a context in which it can occur. It would probably be most accurate to say that an Ericksonian therapist does not consider himself or herself an expert on the client who appears in the ofce, but rather tries to be an expert for creating a context for that client to change. That context can be didactic outpatient psychotherapy, psychotherapy done in hypnosis, family therapy, couples therapy, homework assignments, or combinations of all of the above. But it is working with the unique client to develop a context that works for them that constitutes another aspect of the exibility that is a hallmark of Ericksonian therapy.
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Getting the Client Moving as Soon as Possible

Ericksonian therapy is interested in getting clients active and moving (Zeig, 1980). This movement can begin with very small incremental changes inside the ofce and later be magnied into greater behavioral changes in their lives outside the ofce. Hypnotherapy and the use of direct suggestion, anecdotes, therapeutic metaphors, and indirect suggestions are ways of conversing with clients to help create the impetus during sessions to carry out new relational behaviors or congruently engage in the homework assignments. Its conceivable, for example, that a client would be taught during a session to begin moving a nger when he hears his wife speak. This simple behavior could then be leveraged to having him turn his head to make eye contact with his wife when she speaks outside the session. Assignments are often given in order to have clients carry out agreedupon behaviors between the sessions. It is from the learning brought by new actions and not from insight or understanding that change develops. It may be, in fact, that change leads to insight (Dammann, 1982, p. 195). Consequently, clients understanding or insight about a problem is not of central importance. The matters of central importance are the clients participation in new experiences and transactions in which they congeal developmentally appropriate relational patterns.
Present and Future Orientation

Ericksonian therapy is future oriented and is centered upon an integration of family therapy and individual hypnotherapy, though these areas are often seen as extremes with very little convergence. The inuence of Ericksons approach grew in these two areas independently as it provided examples for the philosophical work of Bateson and other epistemological thinkers who emphasized the need to depart from a model of linear causality associated with the medical model of therapy (Fisch, 1990). The Ericksonian-strategic approach is a method of working with clients emphasizing common, even unconscious, natural abilities and talents. This is in distinct contrast to conventional psychotherapy approaches that place an emphasis upon dysfunctional aspects of clients an attempt to analyze, interpret, or develop insight for them during therapy sessions. Instead, it works to frame change in ways that reduce resistance, reduce dependence upon therapy, bypass the need for insight, and expand creative adjustment to developmental demands, while removing the presenting problem and allowing individuals to take full credit for changes achieved in therapy. In the development of most approaches to psychotherapy, there has been considerable effort to elaborate a theory that will guide clinical procedure. While practice needs to be informed by theory and research, the
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clinical interventions developed from theory or research often are restrictive in the range of behaviors prescribed for the therapist. This appears particularly true for psychoanalytically oriented therapies that until very recently have continued to hold a position of dominance in the medical and psychological communities. Erickson and Rossi (2008) identied the limitations of these therapies as arising from three general assumptions: Therapy based on observable behavior and related to the present and future circumstances of the client is often viewed as supercial and lacking depth when compared to therapies that seek to restructure clients understandings of the distant past. The same approach to therapy (e.g., classical analysis, gestalt, Transactional Analysis, or non-directive therapy) is not appropriate for all clients in all circumstances. Effective therapy occurs through an interpretation and explanation of a clients inner life based on the assumptions of the given theory. Change, from this perspective, occurs mainly through insight by a client into his or her behavior. These assumptions deny the context of the problem, the unique learnings, experiences, and resources of clients, and the type of symptom presented. Most therapies require, if only inadvertently, that clients adapt to the therapists worldview when it may not be in their best interests to do so. From early in his life, Erickson began to challenge traditional notions, expectations, and limitations placed on him. We can see examples of this difference even in the initial contact that Erickson has with clients. Erickson felt that focusing on childhood psychosocial history, to the exclusion of the clients daily life, contradicts basic experience. Events in daily life can have a profound inuence in the development of character or personality. As Erickson & Rossi (2008) correctly point out, these events do not need to be considered extensions of earlier unresolved infantile traumas in order to be understood. While people have memories, perceptions, feelings, and so forth regarding their past, current realities impinge on them that affect their daily and future interactions in the world. Preoccupation with the past and a disregard of present and future needs unnecessarily prolong and complicate the process of therapy. In fact, the phenomenon of selective recall may provide the client with a great deal of apparent facts about the past that parallel the present problem. While Erickson himself never said so, one might go so far as to speculate whether or not memories of the past constitute a sort of metaphor for the clients present experiences. In any event, a hallmark of an Ericksonian approach is an emphasis on current interpersonal relationships and their inuence on the development
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and resolution of problems. While an individual may have developed a symptomatic behavior in the distant past, the Ericksonian view focuses on how the problem is maintained in the present. Thus, in this approach, the unique interpersonal interactions in the clients present life are of primary importance, rather than a reliance on the application of a rigid theory and technique.
CHANGES IN TREATMENT APPROACH OVER TIME

When considering this emphasis on interpersonal focus, its important to note the difference between Ericksons early career practices and his later career developments. The eld of psychotherapy in hypnosis has witnessed controversy about Ericksons approach. Some individuals would claim that Ericksons later students misunderstood his approach (Hammond, 1988). Because some individuals emphasized techniques of indirection and ignored Ericksons use of techniques that were more direct, a schism developed. It was clear to individuals who studied directly with Erickson, rather than those who simply learned about him through his writings, that the schism did not need to exist. Individuals who studied with Erickson early in his career witnessed a man who was highly inuenced by the prevailing psychoanalytic theory and the style of authoritarian-directed hypnosis that existed. At that point in his career, Erickson used a great deal of repetition, redundancy, and direct suggestion. Later in his career, Erickson evolved from this authoritarian approach and changed to a more ambitious style of therapy. The more permissive and ambiguous approach to hypnosis and psychotherapy that Erickson demonstrated in his later years was not the result of Erickson mentally and physically deteriorating, as some have intimated (Hammond, 1984). Erickson specically addresses the issue of his change and the rationale for his change in his writings. He had a well-thought out and logical reason for including more forms of interaction and permissiveness in his psychotherapy and hypnosis. He felt that it was important to good therapy to allow clients a greater latitude of understanding. He believed that indirect techniques facilitated the client developing their own experience rather than complying to the demands of the therapist (Erickson and Rossi, 1980c). Perhaps the professional who studied with Erickson for the longest period of continuous time was Jay Haley. Haley was witness to Ericksons earlier approach to change as well as his later approach to change. This distinguishes him from those who experienced Erickson either in the earlier or in the later decades of his career. Haley did not consider Ericksons later emphasis upon indirection in hypnosis and therapy a result of his physical deterioration (incidentally, there was certainly no evidence of mental deterioration in Erickson). If he did, in fact, develop the indirect
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approach because he was physically ailing in his later years, readers might take a lighthearted humor in the recognition that a reliance upon indirect techniques may very well reduce stress on the therapist but it appears to increase the therapists effectiveness with many clients! What could be better? In any case, we can see the articulation of this evolution, from a reliance upon direct communication to a more indirect approach to therapy and an evolution from a strongly authoritarian to a more permissive interpersonal posture in Ericksons own words if we study the entire body of his written work.
CHANGES IN TREATMENT DURATION

In the early 1950s, we see several cases during which Erickson took months and years. The case of the man with a fat lip took upwards of 11 months (Erickson and Rossi, 1979, p. 224) and the case of the February Man from Michigan took far longerup to two years (Erickson, 1980a, pp. 525542). While it is true that Erickson made himself available to clients for an indenite period of time while he lived in Phoenix, his published cases became shorter in duration. In 1973 we nd the case of the eight-year-old stomper that took two hours (Haley, 1973, p. 219). Various cases of his shock technique in 1973 entailed one- to two-hour long sessions (Erickson & Rossi, 1980a, p. 447). In general, the movement to brief therapy progressed continually and became prominent in his practice in the late 1960s and beyond.
Changes in Ericksons Conceptualization of Symptoms

Lets consider some changes in the view of symptoms from a psychoanalytic view to an interactional view. From his earliest years as a psychiatrist at least until 1954, Erickson took a traditional analytic view of neurosis and various symptoms. He said the development of neurotic symptoms constitutes behavior of a defensive, protective character (Erickson, 1980c, p. 149). At this early point in his career, he had not fully developed a theory that was opposed to the prevailing traditional understanding of behavior. By the mid-1960s, his view had become much more interactional. Perhaps this was a result of his collaboration with Jay Haley, Gregory Bateson, John Weakland, and the Palo Alto Communication Project. In any case, Erickson writes, in 1966, Mental disease is the breaking down of communication between people (Erickson, 1980d, p. 75). However, by the end of his career, he had moved even further from the analytic and the communications or systems theory of disease. He states, Symptoms are forms of communication and cues of developmental problems that are in the process of becoming conscious (Erickson & Rossi, 1979, p. 143). His evolution of thought about problems became less and less focused on them as pathological artifacts until,
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in the end, symptoms could be seen as communication signals of desired directions of growth. Erickson even went so far as to take such signals to be a request for change, albeit unconscious contracts for therapeutic engagement. However, in todays world, Erickson would have been restricted by requirements and considerations of informed consent, of course.
Cure Accomplished by Reassociation of Experience

A focus on the psychosocial past can often reveal moments of learned limitation. For example, a historical event may reveal the most intense example of a time when a patient learned to avoid expressing a certain emotion that is still lacking in the present. Exploring the past events and traumas can be the basis for some types of psychotherapy, but that should not be therapys exclusive focus. Ericksonian therapy is based on identifying client strengths and increasing the possibility of new learnings and experiences that can be used for solving problems in the clients present life. The retrieval or building of that missing emotional experience would be central in the Ericksonian approach. In addition, his approach focuses on orienting clients to solutions necessary for future developmental changes. At least one area in which Erickson never wavered in the course of his career was his view of what constituted cure. I suspect this was a result of his personal experience overcoming paralysis. He learned as a young adult that experiential resources created change. As early as 1948 Erickson recognized that cure was not the result of suggestion but rather resulted from the reassociation of experiences (Erickson, 1980e, p. 38). In the later years of his career, we nd this theme repeated again and again (Erickson & Rossi, 1979; Erickson & Rossi, 1980b, p. 464; Erickson & Rossi, 1981).
Changes in Use of Hypnotic Suggestion

As mentioned, professionals who studied with Erickson early in his career purport a different orientation to therapy than those who studied with him during his later years. In a 1957 transcript of induction, we nd Ericksons redundant use of words like sleep as in the following quote, Now I want you to go deeper and deeper asleep (Haley, 1967, p. 54). In addition, his authoritative approach can be found in this same transcript represented with the statement, I can put you in any level of trance [italics mine] (Haley, 1967, p. 64). However, by 1976 Erickson believed indirection to be a signicant factor (Erickson, Rossi, & Rossi, 1976, p. 452) in his work. Furthermore, by 1981 Erickson clearly states that he offers ideas and suggestions (Erickson & Rossi, 1981, pp. 12) and explicitly adds, I dont like this matter of telling a patient I want you to get tired and sleepy (Erickson & Rossi 1981, p. 4). With regard to his use of indirection, this appears to be clear evidence that it evolved to occupy a
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prominent place in his practice to a point in the late 1970s when Erickson had all but abandoned his earlier techniques of redundancy and authoritarianism during induction.
BASICS INTERVENTIONS OF THE APPROACH

It is difcult to categorize Ericksons customary approach to therapy that is, the approach that he most commonly used. There are a wide range of case examples where the technique used was never repeated. On the other hand, there are some interventions that were clearly used repeatedly such as the February Man story and commands delivered within that story. Others include the use of reframing, the use of indirect suggestion to induce trance and retrieve experiences, the use of confusion technique, structured amnesia, and the use of rehearsals done through visual imagination and trance.
Speaking the Clients Language and Matching Behavior

Ericksons own explanations were often frustrating to many of his students, as he insisted upon sharing wisdom in a rather folksy manner. For instance, asked what the most important thing was in therapy, he would comment, Speak the clients own experiential language. When asked for the next most important thing to do, he commented, Put one foot in the clients world and leave one foot in your own (personal communication, August, 1975). Such comments seemed to side step conventional scientic language and left one wondering if he would eventually come to add more. He never would. The topic of matching the behavior of the client is a logical extension of speaking the clients language. Certainly speaking clients language is matching their verbal behavior and way of expressing themselves. There has also been a good bit of discussion in the last three decades about matching the clients physical behavior. It is not accurate however to say that Erickson would nd it appropriate in his practice to mirror the behavior of all of the clients he saw. There are many examples of cases that have been published about Ericksons work in which he clearly took an interpersonal posture that was dissimilar than that of his clients (Haley, 1973). For example, there is a case of a woman who had very low selfesteem and was overweightin this case, Erickson initially took a role that would be described as hostile and dominant. In another case, a man who was a ute player saw Erickson because of his enlarged and swollen lower lip. This client was extremely hostile and critical of Ericksonin this case, Erickson took a role that would be described as submissive and self-critical. In other cases he played a role that could be described as bossy and told parents they were to allow him to make all of the decisions
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about their son. In still another case, Erickson played a very critical role when he turned and stomped on the feet of a young girl who felt obsessed about the size of her growing feet. Each of these cases and more can be found in the Uncommon Therapy casebook (Haley, 1973). So what are we to make of the allegation that Erickson matched the behavior of his clients in a symmetrical fashion when so many cases illustrate that he did not? The answer is quite simple. Once again, the key is that Erickson demonstrated exibility in his approach. However, there are guidelines for matching that may not be quite so evident at rst glance. In each of the cases I cited before, Erickson took a complementary role rather than a symmetrical role in his interpersonal posture with these clients. Id like to illustrate this with the following explanation. Assume a simple bell curve that describes the range of client behavior from, on the left side, extremely exible or loose behavior through relatively normal behavior in the middle and all the way to extremely rigid behavior on the far right side of the curve. That is to say, behavior that tends to match the cultural norm is in the middle of the bell curve. Each standard deviation to the left-hand side describes increasingly more chaotic behavior that would include, for example, moderate to high anxiety, histrionic behavior, hysterical behavior, borderline behavior, and eventually psychotic behavior. Each standard deviation to the right-hand side from the norm would contain examples of increasingly rigid behavior such as, depression, obsession, compulsion, narcissism, and paranoia, until nally one reached a paranoid personality type behavior. I am not concerned about the exact ordering of these diagnostic labels. Rather, I am concerned with the notion that behavior can be extremely chaotic or extremely rigid and that we could look at this on a continuum in which we nd culturally normative behavior located in the middle of the bell curve. Once we have constructed this mental map, we have a good way to better understand the logic of using the concept of matching in Ericksonian approaches to therapy and hypnosis. Using Ericksons successful behavior with clients as a model, the following conclusion could be drawn. Those clients that fall, loosely, within a standard deviation both sides of normative behavior would be met with a symmetrical matching. That is, the body posture of the therapist would match the body posture of the client. This behavioral matching could be done with extreme attention to detail so the therapist matches the clients movement of limbs, legs, breathing, eye movements, and so forth. However, once the presentation of the clients behavior exceeds a certain limit beyond the normative and, by comparison, is overly rigid or overly chaotic, the therapist may be well advised to use complementary matching instead of symmetrical. For example, if an extremely hostile and rigid prosecuting attorney seeks therapy, matching the clients behavior in a symmetrical fashion may be ill advised. Its extremely possible or likely
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that such an interpersonal posture would result in a symmetrical escalation of hostilities. Instead, taking a complementary matching position would probably make for a better joining maneuver. The exibility to allow oneself to initially be in a position of receiving criticism from such a client could be seen as an implementation of the utilization principle. The conclusion that should be drawn from this discussion is that the initial joining behavior frequently referred to as matching has to be considered as a subset to the utilization principle of Ericksonian therapy. There are instances of matching that will establish a symmetrical relationship and cases of matching that will establish a complementary relationship. Finally, the therapeutic indicators that help determine which type of matching will provide the best initial therapeutic union have to do with the degree of rigidity or chaotic behavior exhibited by the client. In addition, the experience of the therapist in dealing with individuals who exhibit a broad range of behavior, and the unique characteristic of any particular client, are the nal determinants of when the selection of complementary versus symmetrical matching should take place.
Hypnosis
Hypnosis was part of Ericksons therapy at least as early as 1934 (Haley, 1967, p. 2) and he is probably most recognized as a pioneer and proponent of clinical hypnosis. Erickson stated that hypnosis was primarily a state in which there is an increased responsiveness to ideas of all sorts (Erickson & Rossi, 1981, p. 4). However, it should be noted that not all of the Ericksonian therapy models that developed from Ericksons inuence have included or emphasized hypnosis. Some practitioners of an Ericksonian approach to therapy (or who borrowed heavily from Ericksons work) emphasize strategic assignments, therapeutic ordeals, or family therapy using paradoxical directives, behavior rehearsal, structured interactions, and direct suggestion, to the exclusion of hypnotherapy and hypnotic indirection (Haley, 1984, 1985a, 1985b, & 1985c; de Shazer, 1985; Lankton, S., 2001). It is certainly possible to simply have therapeutic conversations that do not at rst glance resemble formal trance (Matthews, 1985b). However, hypnosis is a useful tool to accomplish certain interview management, continue diagnostic assessment, and stimulate novel thinking, feeling, and resource retrieval within the session. There are a variety of opportunities to introduce hypnosis in Ericksonian therapy and one of these is simply to notice and encourage naturally occurring altered states of consciousness that clients will automatically experience. Whether or not to formally label the experience trance is sometimes a debatable issue. Indeed, one of Ericksons primary contributions was an emphasis on the naturally occurring elements of common everyday trance and demystication about trance being an unusual or vulnerable state of consciousness (Erickson &
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Rossi, 1976, 1979, 1980b). It always utilizes such naturalistic modes of functioning; it never imposes anything alien on the patient (Erickson & Rossi, 1981, p. 5). His work blurred the boundaries between formal trance and waking state (Erickson, 1980f). I am not very greatly concerned about the depth of the trance the patient is in . . . (Erickson & Rossi, 1981, p. 3). Experiences of searching for meaning in response to an ambiguous or cryptic suggestion can lead to therapeutic receptivitythat condition in which clients can discover relevant experiences and facilitate the answers for which they are searching (Lankton & Lankton, 2008/1983). While hypnosis is listed here as an intervention or technique, it is more accurate to think of hypnosis as a modality for exchanging ideas and stimulating thinking with a client and concentration on their own experience. The essential point is that they pay attention, not necessarily to me, but to their own thoughtsespecially the thoughts that ash through their mind (Erickson, 1981, p. 5). As a modality or context for communication, less emphasis is placed on hypnosis itself and instead attention is focused on that which is relevant. Too often, people think of hypnosis as something that the expert practitioner will do to them and that it will, in and of itself, cure them or simply remove the troublesome symptom. This is a view of hypnosis Ericksonian practitioners work to dispel in favor of asking clients what resource experiences they need to retrieve while relying upon hypnosis as an aid.
Using Hypnosis with Families

It has been mentioned that not all practitioners of an Ericksonian approach use hypnosis. However, it should be noted that many of the family therapists who embrace an Ericksonian approach to therapy also use hypnosis in their family therapy (Ritterman, 1983; Parsons-Fein, 2004). While that is not the major emphasis of this writing, I offer the following guidelines that have been observed and developed for introducing and using hypnosis in a family session (Lankton & Lankton, 2007/1986). Try to initially avoid using hypnosis with the identied patient in a family. This is because family therapists do not wish to reinforce the possible myth that this family member contains the problem in the family. Protect the identied patient from further exposure to discrimination. Since hypnosis is largely misunderstood by the general public, it is important to be certain that he or she is not seen as so sick as to require a formidable intervention like hypnosis. Avoid playing the role that a rigid family might be assigningfor example, x the problem in the sick member. Do, however, introduce hypnosis for the purpose of facilitating relief to the person currently experiencing or communicating the most pain.
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If the identied patient also happens to be the client member who is in the most pain, make an exception to the rst guideline by offering hypnosis to both the identied patient and the most healthy family member or members. Hypnosis with two or more individuals at the same time provides a context for building rapport between them (this is especially useful if they are struggling and failing to build a relationship for various reasons). Hypnotize all adults in the family. This can be done for the purpose of a stated shared goal or, alternatively, for individual goals that are unique to each individual. This latter type of approach requires greater effort, concentration, and training on the part of the therapists.
Induction of Hypnosis
With regard to introducing trance, it is possible to simply notice the naturally occurring inwardly focused attention of a client and suggest that this experience be intensied. This is not very much different from the often routine suggestion to someone experiencing a particular emotion to go with that feeling. Though that therapeutic directive is not usually associated with the development of hypnotic trance, per se, formal hypnotic induction need not consist of a break in the normal ow of communication. This type of conversational induction is usually not considered to be an unusual disruption in the therapeutic process. It often includes additional suggestions for focusing inward and deepening absorption. Suggestions such as, you can close your eyes as you allow yourself to go deeper with that feeling and that experience and perhaps notice that things outside you can seem irrelevant for the moment and so on. However, the word trance or hypnosis need not be used at all. Conversational induction underscores the idea that hypnosis is simply a modality for exchanging ideas as are other more familiar interventions. Therapists use different methods of introducing hypnosis, but the two most common approaches are methods of naturalistic induction (often accompanying an internal xation) and methods of formal induction (often accompanying an external xation). The naturalistic induction method involves an elicitation of the unconscious material that accompanies the conscious contract developed and shared with the therapist and usually related to the clients initial request for treatment. Often clients are prepared to become absorbed in a contemplation of their possible gains from therapeutic work. When that occurs, therapists can ask the subject to close their eyes and experience some aspect of this internal resource. That is, the client might mention that he or she would like to overcome depression and feel as lighthearted as he or she once did. When the therapist recognizes
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the slightest indicator that the client has a memory of feeling lighthearted, it is an opportunity to ask the client to close their eyes and began to recover both the memory and experience of feeling lighthearted. With this very slight alteration of consciousness, hypnosis can be initiated and developed from that conversational beginning. In this case, the induction and subsequent hypnosis represents the immediate therapeutic attempt to perform a naturalistic induction. As clients increase their internal concentration, they will of course respond in ways that signal their degree of success. In addition to head nodding and head shaking (and the meaning attributed to each), search phenomena are of a broader category. Behaviors in this category range from slight to extreme changes in various reexes, muscle tone, and skin color. Easily recognized search phenomena indicators include slowed swallow, blink, and breathing reex, increased skin pallor, and increased muscle lassitude in the cheeks and forehead. This behavior is taken to indicate that clients are experiencing some degree of a sense of tness between the suggestions and their own personal frame of reference (Lankton & Lankton, 2008/1983, 2007/1986). However, it further demonstrates that clients are not altogether certain that the resources they need are available. Hence, they are searching for further connections between the goals they value and the tools they know they have. In other words, the search phenomena indicate the clients willingness and perceived need to move in the implied direction at the present time. The nonverbal dialogue with therapists at this subtle level constitutes a sort of unconscious contract development. Again, it occurs by means of ideomotor response to ideas conveyed by therapists who imply successful developmental gains. Clients can also be asked to answer verbally, of course. In so doing, they will often indicate a further elaboration of the presenting conscious contract. This form of gentle induction of hypnosis illustrates that hypnosis is a natural response to communication and problem solving. It tends to demystify hypnosis and promote the notion that it has a rightful place in the realm of natural and ordinary interventions from which therapists can choose. Once again, trance maintenance suggestions and suggestions of deepening are often necessary to facilitate greater internal absorption and the appearance of phenomena usually associated with various trance depths. Although naturalist and conversational inductions often require more skill from the therapist, they require less compliance from the client. The procedure for a formal induction with external xation is similar to that used in a traditional ritualistic induction. The subjects are asked to set their attention on some close external object so they might become more absorbed in the process of concentration. As they do, the therapist proceeds with any one of a variety of instructions most suited for the particular client before them: conscious-unconscious dissociation induction,
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systematic relaxation and deepening, naturalistic, traditional, guided imagery, and so forth. While traditional ritualistic inductions are often contrasted to the conversational or naturalistic induction, it should be noted the selection of suggestions formed with permissive language, indirect suggestions, and therapeutic binds make this sort of formalized inductions distinctly different than those created with direct suggestions. The timesstructuring of a formal trance induction separates the trance from what followed and that demarcation can serve to provide security and familiarity to those clients who come to therapy with more rigid expectations of what hypnosis ought to be like. Often, a formal induction of hypnosis proceeds by asking clients to be seated with their arms and legs uncrossed and their attention focused to a progressive relaxation throughout the body. As the relaxation is deepened, the therapist may even use counting to help the client develop an expectation that their internal focus is also going deeper. This sort of formal induction is perfectly acceptable; however, the aforementioned methods of conversational and naturalistic inductions may be much more consistent with an approach that utilizes the clients immediate presentations and concerns. In a permissive approach, clients should be offered suggestions with an understanding that they can follow those that are relevant, modify those that can be modied to become relevant, and ignore those suggestions that seem to be irrelevant. All clients, through this type of participation, are responding to their own meaning that they place on the words from the therapist, or in a way, hypnotizing themselves. They are in control of engaging or disengaging from the therapists inuence as a result. It stands to reason, then, that clients will stay in trance as long as the material provided is relevant or appears relevant to their growth concerns.
Formal Induction Sequence Outline

1. Orient the client to trance. This step involves making certain that the clients are physically, cognitively, and psychologically prepared for the trance. 2. Fixate attention and rapport. Most frequently clients attention is xated on a visual object, story, or body sensation such as relaxation. 3. Establish a consciousunconscious dissociation (Lankton & Lankton, 2008/ 1983, 2007/1986). Therapists use conscious-unconscious dissociation language (Lankton & Lankton, 2008/1983, p. 141), including the possible use of anecdote and education about unconscious processes to assist clients in the development of dissociated and polarized attention.
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4. Ratify and deepen the trance. Ratication of the clients process of unconscious search is easily accomplished by helping focus client awareness on the many alterations that occur in their face muscles, reexes, respiration, and skin coloration. Deepening may be facilitated by several means including confusion, offering small incremental steps, or indirect suggestions, therapeutic binds, and controlled ambiguity. 5. Utilize trance to elicit experiences and subsequently associate experiences. Therapeutic use of trance includes using those unconscious processes stimulated by induction. The experiences needed are determined by the diagnostic assessment and contracted therapy goals. Experience may be facilitated by the use of indirect suggestion and anecdotes, therapeutic binds, metaphor, guided imagery, direct suggestion, and so forth. Finally, therapists help clients arrange elicited experiences into a network of associations that will help them form a perceptually and behaviorally based map of conduct. 6. Reorient the client to waking state. Reorientation may be rapid or gradual. At this stage, the therapist has a nal opportunity to assist clients in developing amnesia, posthypnotic behavior, and/or other trance phenomena that are part of the treatment plan. Therapists trained in the Ericksonian approaches are most likely to use a conscious-unconscious dissociation or a conversational induction (Erickson & Rossi, 1979). Such an induction produces the groundwork for further elaboration with ambiguity of indirect suggestion, therapeutic binds, and therapeutic metaphor. A degree of increased dissociation begins to occur in response to comments about unconscious experience. Language such as the following may be used to facilitate that dissociation with the client: Your conscious mind can listen to the things that I say while your unconscious begins to identify those ideas that are relevant for you. Your conscious mind may be listening and sorting through your experiences while your unconscious relates in a global fashion to the experiences that you need. And, your conscious mind may be following a certain train of thought while your unconscious reacts symbolically or follows an entirely different train of thought thats useful for you. In this manner, therapists direct the conscious mind to experiences that are easily validated and basically true for the client at that time. Thus, the induction is individualized and relevant. Comments regarding the unconscious mind of a client are generally more global, contain a great deal more ambiguity, and will involve an amount of vagueness. This sort of vagueness can easily be elaborated and controlled by the use of therapeutic stories or indirect suggestion.
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Hypnotherapeutic interventions strictly aimed toward the verbally shared contract will be understood as relevant by most clients. A clear contract reduces clients surprise or possible sense of having been deceived. With many clients, this is of concern and ought to be given serious attention. While, with other clients, this is less of a concern due to their understanding that they are seeking the therapists professional skill, regardless of the specic form it takes. No matter which of the chosen method of induction, what happens before and after the trance also needs to be considered carefully. After the trance experience is terminated, it may be useful to once again ask clients to engage in the problem-solving communications that had preceded the trance. In this way, resources retrieved during the trance will be further associated to immediately relevant concerns and increase the likelihood that the course of problem solving will be enhanced. Additionally, the entire trance experience is logically embedded in the middle of a structured interaction that is designed to bolster changing individual personality structure and transactional patterns.
The Use of Metaphor as Indirect Intervention

In 1944, Erickson reluctantly published The Method Employed to Formulate a Complex Story for the Induction of the Experimental Neurosis (Erickson, 1980b, p. 336). His understanding at that point was that a complex story that paralleled a clients problem could actually heighten the clients discomfort and bring the neurosis closer to the surface. Within a decade, in 1954, he was using fabricated case histories of eeting symptomatology (Erickson, 1980c, p. 152) indicating that at least some of the stories he told had been confabulated. Still, almost two decades later in 1973, we see that Erickson provides several examples of case stories for making a therapeutic point (Haley, 1963) and by 1979 he actually used the heading of metaphor as a class of interventions (Erickson & Rossi, 1979, p. 49). Again, this movement corresponds to his movement from direct and authoritarian therapy to indirect and permissive therapy.
Uses of Metaphoric Stories

A therapeutic metaphor is a story with dramatic devices that captures attention and provides an altered framework through which clients can entertain novel experience (Lankton, 2003/1980; Lankton & Lankton, 2008/1983, 1989, 2007). Metaphor is a form of two-level communication that uses words with multiple connotations and associations so that a clients conscious mind receives communication at one level while his or her unconscious mind processes other patterns of meaning from the words and develops
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related experiences (Erickson & Rossi, 1979). The therapeutic intention is to occupy, xate, or disrupt the clients conscious frame of reference while generating an unconscious search for new or previously blocked meanings or solutions. Using metaphor, the therapist can: decrease the conscious resistance of the client; make or illustrate a point to the client; suggest solutions not previously considered by the client; seed ideas to which the therapist can later return; and reframe or redene a problem for the client so the problem is placed in a different context with a different meaning (Zieg, 1980; Lankton, 2003/1980).
As a listener becomes increasingly engaged or absorbed in a story, there is a reduction in defensive mechanisms that customarily constrain the listener to sets of common (for them) experience. That is, listening to a story that symbolizes tenderness can lead a person who normally defends against sadness to weep. The concept of a novel experience may need slight elaboration. It pertains to experiences that are commonly excluded from the experiential set of the listener. While listening to an absorbing story, a client may, with relative ease, temporarily experience one or several specic experiences that, if therapeutically managed, can assist the listener in creating personal change. The assistance in creating personal change comes about as clients reexamine perceptions or cognitions, emotions, or potential behaviors in light of a recognition that these new experiences, perceptions, or cognitions once thought to be alien actually are or can be a part of their own personality and experience. In general, it could be said that the usefulness of metaphor in therapy comes into play at any point in therapy where it is advisable or useful for clients to recognize that experiential resources lie within themselves rather than having to introject or incorporate them from an outside authority (including the therapist). The outcome of metaphors is determined by the experiences that are elicited during the telling of the story. It can be assumed that the conscious mind of the listener will be engaged in the actual plot and development and of course conclusion of the story (if it is compelling). However, the unconscious outcome will be the result of elicited experiences evoked by the story. This is an important distinction to remember. The story is a vehicle for eliciting experiences, and that is often done with tangents taken from the storyline itself. If one thinks of the point of the story itself as the major therapeutic intervention, the client will only gain a cognitive understanding. The cognitive understanding is much like insightand we know that insight does not change a persons behavior as much as a behavior change will lead to insight.
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Simple Isomorphic Metaphors

Metaphors that can be described as isomorphic, and therefore parallel to the problem, are simple metaphors. They take the information from the clients life and match it one-for-one with the constructed story. That is, every signicant noun in the original problem is matched with a noun in the story, and every signicant verb in the problem is matched with a verb in the story. The relationship between the verbs and nouns is relatively obvious in that it is parallel to their relationship in the story. The relationship between the problem and the story can be illustrated in the following example. Here we see that Joseph, who had a son named Paul, was in a car accident. The result of the accident was a serious injury of his son that took months to heal. As a result, Joseph feels a great deal of guilt. And as a result of the guilt, he remains jobless. He sought psychotherapy for assistance. A metaphor that could be built in an isomorphic fashion would be, for example, the one that follows. A building engineer who was in charge of construction crews was working on a building. Unexpectedly, the building collapsed and there were a great deal of injuries. One of the things that was damaged was the condence of investors. All the investors abandoned the project. As a result, the building engineer felt helpless. As it turns out, his ability to seek and obtain employment was severely hampered by his feeling of helplessness, and he could not get any new investor contacts. In graphic summary, would look like the following:
TABLE 1.1 Problem characteristics
Joseph Son Paul Car Auto accident Serious injury Guild Joblessness
Metaphor content
Building engineer Construction crew Building Collapse of building Investments lost Helplessness Cant secure a contract
This simple form of matching the problem to elements in the story can have a therapeutic usefulness as well as therapeutic limitations. Generally, it is easy to match the client situation with an imaginary or real story. However, the ending ought to be designed to be both reasonable with the story and retrieve useful therapeutic resources. It is most benecial to formulate the ending that is the therapeutic goal before telling a story. These simple metaphors are also a useful form for delivering information to the client in a relative state of anonymity. That is, by the use of embedded quotes, or embedded commands, the therapist can illustrate dialogue within a simple metaphor. And, within that dialogue messages can be delivered to
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the client. For example, the therapist might say, I had a client come see me this morning. And while he was on the elevator coming to my ofce, a total stranger looked at him and said, Get a job now and then you will start to feel better. Now, even without a sophisticated ending to this story, that client has gotten the instructional material that says something useful for the direction of therapy. It becomes thought provoking, to say the least. A more sophisticated way to end isomorphic metaphors is to create a context in which the protagonist of the story retrieves useful resources to solve his problem. These resources will of course be parallel to the resources of the client. Clinical observation suggests that clients make sense of the content of the metaphor because they apply their personal experience to the ambiguity in the story. Since this is the case, a metaphor that is parallel to the problem simply heightens their awareness of the problem. It is important for the therapist, therefore, to place emphasis upon the construction of the solution. Since the important aspect of a metaphor is the construction of the solution, the entire metaphor can become parallel to the solution from the onset. Metaphors that are constructed in this manner are comparatively more sophisticated. These advanced metaphors are called complex goaldirected metaphors. The following brief outlines illustrate the major architecture of four different goal-directed metaphor protocols (Lankton & Lankton, 2007/1986).
Complex Goal-Directed Metaphor Protocols

A. Attitude change protocol 1. Describe a protagonists behavior or perception so it exemplies the maladaptive attitude. Bias the discussion of this belief to appear positive or desirable. 2. Describe another protagonists behavior or perception so it exemplies the adaptive attitude (the goal). Bias the discussion of this belief to appear negative or undesirable. 3. Reveal the unexpected outcome achieved by both protagonists that resulted from the beliefs they held and their related actions. Be sure the payoff received by the second protagonist is of value to the client listener. B. Affect and emotion protocol 1. Establish a relationship between the protagonist and a person, place, or thing that involves emotion or affect (e.g., tenderness, anxiety, mastery, confusion, love, longing, etc.). 2. Detail movement in the relationship (e.g., moving with, moving toward, moving away, orbiting, etc.). 3. Focus on some of the physiological changes that coincide with the protagonists emotion (be sure to overlap with the clients facial behavior and other identiable bodily changes).
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C. Behavior change protocol 1. Illustrate the protagonists observable behavior similar to the desired behavior to be acquired by the client. There is no need to mention motives. List about six specic observable behaviors. 2. Detail the protagonists internal attention or non-observable behavior that shows the protagonist to be congruent with his or her observable behavior. 3. Change the setting within the story so as to provide an opportunity for repeating all the behavioral descriptions several (e.g., three) times. D. Self-image thinking protocol 1. Central self-image (CSI) construction a. Describe a protagonist who is seeing a reection or picturing himself or herself accurately. b. Explain how the protagonist recalls and experiences several desired qualities (which may be resources retrieved earlier in the session). c. Describe how the original visual image of the self is altered in behaviorally specic ways consistent with each quality being experienced. 2. Self-image scenarios process a. Using the story of the protagonist imaging his or her CSI as a device, describe imagined background details as follows. b. Introduce a positive, non-anxiety producing scene and people and describe the protagonist experiencing and thinking through behaviors in that scene (keeping the desired resources constant). c. Introduce other backgrounds and people in gradual successive approximations from the previous scenes to, eventually, the most difcult and contracted therapeutic goal.
The Ambiguous Aspect of Metaphor

Unlike directive and manipulative therapies that, through implication or connotation, tell clients how to perceive, think, feel, or behave, techniques of indirection allow clients to modify verbal input from the therapist and t it to their own situation with a greater degree of relevance and with an element of ego-syntonic meaning. If clients are instructed to conduct themselves in a certain manner or say certain sentences to their spouse in directive couples therapy, these things may be ego-dystonic since they come from outside as implied or denoted by the therapist as something clients should or must do. However, when clients have determined for themselves a relevant meaning to a more ambiguous input from a therapist, they are acting upon perceptions, behaviors, or feelings that truly belong to them as a part of them. Lets examine this ambiguous element more closely. The degree of ambiguity in a therapeutic story can be regulated by the teller so the story is
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more or less vague to the listener. Regardless of the degree of vagueness, listeners create their own relevant meaning in order to understand the story. This accounts for the ego-syntonic nature of the understanding and the lack of mere compliance by listeners. However, as the degree of vagueness increases, there is an exponential increase in the number of possible meanings that listeners can give to the story. It is assumed that listeners sorting through several possibilities at what has been determined to be thirty items per second (Erickson and Rossi, 1979, p. 18) become increasingly absorbed in weighing the best t for these possible meanings. This ongoing process of weighing meaning has a number of therapeutic benets: there is an increase in participation by listeners there is a heightened valuation in any meaning that is found by listeners as it has been made a deeper part of their own experience there is a depotentiation of normal, rigid ego controls while seeking a best t there is an increase in the duration of time given to examining possible meanings This last element, in fact, accounts for a therapeutic effect upon the client long after the therapy session has ended. Indeed, for a highly meaningful and yet extremely vague metaphoric story, listeners may continue to turn it over in their mind (from time to time) for years after the therapy session and do so for events that even years later parallel the original therapeutic learning incident. For this reason, the use of metaphor can be summarized as follows. It increases the relevance of therapy for clients and involves clients more highly in their own change process. It expands the usual limiting experience that has led to a stabilization of the presenting problem or dynamic and brought the person to therapy. It offers an engaging element of ambiguity that may continue to alert listeners to their therapeutic learnings for years after a therapy session. And it offers a wide range of potentially correct responses within the therapeutic limits. Since indirect hypnotic language offers listeners the ability to apply a wide range or spectrum of potential understandings to what the therapist has said, there is a corresponding reduction in listener resistance. Any therapeutic modality that nds clients to be resistive, possibly due to the nature of the modality itself, will be able to take advantage of metaphoric stories providing those stories are constructed and shared in a manner that employs the necessary components of therapeutic change. Erickson once said: I do certain things when I interview a family group, or a husband and wife, or a mother and son. People come for help, but they also come to be substantiated in their attitudes and they come to have face
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saved. I pay attention to this, and Im on their side. Then I digress on a tangent that they can accept, but it leaves them teetering on the edge of expectation. They have to admit that my digression is all right, its perfectly correct, but they didnt expect me to do it that way. Its an uncomfortable position to be teetering, and they want some solution of the matter that I had just brought to the edge of settlement. Since they want that solution, they are more likely to accept what I say. They are very eager for a decisive statement. If you gave the directive right away, they could take issue with it. But if you digress, they hope you will get back and they welcome a decisive statement from you. (Erickson, in Haley, 1973, p. 206)
ILLUSTRATION OF INDIRECT SUGGESTION LANGUAGE

Some of the most intriguing use of hypnotic language and perhaps the origins of indirect hypnotic language came from Ericksons work. It appears that ambiguity and relevance are the key factors to powerful therapeutic language. Clinically, it appears that the value of long-lasting hypnotic suggestion corresponds to the amount of ambiguity it conveyswhile at the same time it appears to be personally relevant. The more ambiguity that can accompany an apparently relevant suggestion that creates a desired response, the longer and stronger that response will be. There is a limit to the amount of ambiguity each person can tolerate before a sense of relevance is impossible to maintain. Erickson appears to have learned this in his clinical work and supported it in the latter decades of his career. Indeed, ambiguity often allows language to seem more relevant. Consider the following examples. Relaxation [direct suggestion]: Let yourself relax. Let go of the tensions that you experience in your arms, allowing those muscles to become more and more relaxed . . . and let go of the tensions that you experience in your shoulders, allowing those muscles in your shoulders and back to become more and more relaxed . . . and let go of the tensions that you experience in your chest and belly and lower back . . . allowing those muscles to become more and more relaxed . . . and allow the muscles in your legs . . . to become more and more relaxed . . . your entire body . . . relaxing . . . until you feel limp and relaxed like an old rag doll. Relaxation [indirect suggestion]: I wonder if you know how it can feel . . . after a long day of physical activity when youve had a lot of things to do and you managed to accomplish everything and you get to the end of the day and you can nally let everything go and get some sleep? . . . everyones had that experience . . . the conscious mind cant really appreciate how the unconscious can bring about an alteration that slows down the body . . . and the body for comfort maybe slowed it down for rejuvenation or for some other reason . . . and when a person gets ready for bed, slips between the sheets and
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feels those initial feelings . . . how cool and clean the sheets feel . . . whats the best word to describe that? . . . every child knows the feeling of comfort. Suggesting eye closure [direct authoritarian suggestion]: Now . . . your eyelids will become heavier . . . your eyelids are becoming heavier and heavier . . . so heavy that you cannot keep your eyes open . . . close them now. Suggesting eye closure [indirect suggestion]: Under what circumstances do the muscles of the face seem to support the eyelids? . . . they might become more and more relaxed or maybe just stop looking . . . I wonder which it will be in the case of each patient or each client . . . your conscious mind may wonder if your unconscious mind will actually close your eyes, or will it be the conscious mind that chooses to close your eyes so that you can let your unconscious mind wonder about a lot of things.
Creating Forms of Indirect Suggestion

The various forms of indirect suggestion and therapeutic binds might be seen as different specic vehicles for introducing ambiguity. That is to say, the different forms of indirect language are like specic different doorways into the mind. Ironically, the manner in which one can construct ambiguous indirect hypnotic language provides a great deal of therapeutic accountability. Using indirect language, the therapist can: introduce or illustrate a point to the client suggest solutions not previously considered by the client seed ideas to which the therapist can later return decrease the conscious mind resistance of the client reframe or redene a problem for the client so the problem is placed in a different context with a different meaning retrieve and associate experience such as emotion, thought, perception, behavior, and expression. In each case, just as in the case of metaphor, the ambiguity of the suggestion requires that the client create personal meaning out of the words. It is this act of creating personal meaning that gives indirect suggestion greater power and longer-lasting effect. The client actually will get the answer within their own experience and not comply to demands of the therapist. Indirect suggestion can be an important part of accomplishing both the internal absorption and dissociation. The following section will give a brief glimpse as to what some of those forms of suggestion are and how they are formed. Six common forms of indirect suggestion and four common forms of therapeutic binds are representative of the large number of ways in which indirection can be codied. Before beginning the illustrations of several forms of indirect suggestion and therapeutic binds, it is important to emphasize the following. These
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statements are intended to be formulated around a chosen therapeutic goal. In each case that chosen goal will be related to the next desired movement in the therapy. That is to say, if the client is seated and relaxed, the next desired goal might be to accomplish an induction with eye closure. On the other hand, if that has already been accomplished, the next desired therapeutic goal might be to help the client facilitate a sense of security or an intense memory of a desired experience. Regardless of the specic goal, the sentence structures that will be the vehicle for expressing that goal can be dened and delineated. This is not only useful for articulating the means by which hypnosis and therapy can be accomplished and taught, but also for carefully dening the procedures for the sake of future empirical research. The more carefully interpersonal communication can be specied, the more accurately empirical research can be carried out. Irrespective of these concerns, however, professional scholarship calls for a careful development and an earnest attempt to increase accountability of the therapeutic process. These forms of indirect suggestions and therapeutic binds, and more, were used by Erickson for both the induction of hypnosis and the process of psychotherapy during hypnosis and family therapy (Erickson & Rossi, 1980a, 1980b, & 1980c; Haley, 1963; Lankton & Lankton, 2008/1983; & Erickson 1980f).
Open-Ended Suggestions
Open-ended suggestions take the form of increasing the degree of ambiguity for any element in a sentence that would otherwise be a direct suggestion. In common social communication, its usually an open-ended suggestion that introduces a topic. For example, an open-ended suggestion such as, Everyone can nd a way to record information thats important, could have been formed from the direct suggestion Write this down. Since its an open-ended suggestion, the degree of compliance from the client is irrelevant. Instead of telling the client what to do, it initiates the clients own search process for a discovery of whats relevantif that happens to be writing down whats been said, then an exact t between the otherwise unstated goal and what the client decides will have been made. But thats unusual. Open-ended suggestions are a prime example of how indirection is designed to be client centered and to facilitate helping clients discover their own understanding of whats relevant and useful to them, with the therapist still retaining an element of control, yet avoiding an authoritarian relationship.
Implication and Presupposition

The form of suggestion called presupposition is a simple type of implication. It can be a simple or complex presupposition, which then also states
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a desired goal. For example, a simple presupposition is, After you write this down, well continue. This example uses a presupposition syntax (the word after), followed by the goal of taking notes by writing. Other simple presuppositions are: Since this is the rst time youve been in trance, close your eyes and After your trance is over, well do some talking about it or One of the rst things youll want to do in trance may be formulating a sense of comfort. In simple presupposition, the stated goal follows immediately after the presupposition syntax. It should be noted also that these suggestions are kept quite short. The reason for that is further speaking will begin to focus the clients attention elsewhere and become another form of suggestion I will discuss in a moment. In each of those examples, simple presupposition was followed by a statement of the goal. The complex version involves the form called an implication. An implication requires that the speaker link two concepts together such that one relates to (e.g., causes) the other. And in addition, the concepts must have exact oppositesthat is, the concept of eyes open has the opposite of eyes closed. The concept of tense has the opposite of relaxed. So an implication that links eyes open and tension would be: Keeping your eyes open can help you stay tense. Obviously the implication is that the listener will become relaxed when they close their eyes.
Questions or Statements That Focus Awareness

Indirect language suggestions that focus awareness can take the form of questions or statements. Statements such as, I wonder if youll be going into trance soon or I dont know if youve discovered how comfortable you are have the effect of helping clients notice the portion of the sentence that highlights the goal and yet offers the sentence in a manner that seems to be rhetorical rather than strongly exclamatory. This form can also occur in questions such as, Have you noticed how relaxed you are yet? or Do you think youll begin thinking about the goal that we spoke of? While these questions seem rhetorical, in order to consider them, the client must focus awareness as prescribed in the suggestion. In each of these examples a statement of the goal is presented following the question or observation.
Truism
Truisms state something that is essentially undeniable. Such sentences usually begin with phrases like, All children or all people or in all cultures. For example, All people have their own way of going into trance, Every child uses imagination to think about ideas, In every culture, people problem solve in various ways. In each of these examples, a truism is followed by statement of the desired goal.
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All Possible Alternatives

Suggestions stating all possible alternatives can take several different forms, but have the common aspect of listing many different ways or times in which a stated goal can be reached or experienced. For example, Your eyes may close suddenly or they may close slowly or you may close them and open them repeatedly, maybe youll squint for some time, or its possible that youll have your eyes closed without realizing it and in some cases even have your eyes open and think that theyre closed. Another example pertaining to relaxation could be, You may relax systematically from your head to your feet or you may relax from your feet to your head, perhaps youll discover some portions already relaxed and relax adjacent parts of your body, or its possible that there will be a gradual relaxation all over your entire body at once, or possibly random limbs and muscle groups will relax in a more spontaneous manner or perhaps it will happen differently. In all possible alternative suggestions, it is advisable to have one of the alternatives state that the client will not do any of those on the list. This is because, in fact, you are trying to list all possible alternatives including the alternative that nothing of that nature will occur. In this form of suggestion, the therapists list helps clients recognize that there are many ways the goal can be achieved and that they have a choice in how they personally express themselves. Therapists continue to establish an egalitarian relationship or client-centered relationship with the client rather than forcing an authoritarian and heightened compliant relationship.
Apposition of Opposites
This form of suggestion emphasizes that the occurrence of a desired goal may proceed paradoxically against some behavior that is generally seen as an opposite. For example, The greater a degree of tension you have in your muscles, the more profoundly you may relax, The longer you have been confused about the issue, the more rapidly an idea may come, or The greater your uncertainty has been, the stronger your conviction may be. Clients can redirect and use energy previously devoted to avoiding or resisting to drive an equally strong, willful experience or behavior in the direction of their change. No reason or logic should be given for this paradox but rather clients should be allowed to discover for themselves how it becomes true for them. With indirect suggestion, the goal is not to make people behave in a particular way but rather to help stimulate their own thinking and experience in such a manner that they determine for themselves exactly whats relevant and how its relevant for them.
Binds of Comparable Alternatives

The rst of the four therapeutic binds is binds of comparable alternatives. In this type, two alternatives are provided so clients may choose
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which is best for them. In the process of making either choice, the actual desired goal is accomplished because it was presupposed by both choices. For example, You may want to try these ideas in your family before you go to work; however, it may be best for you to try them after work. In this case, the act of trying the therapeutic material with the family exists for the client whether or not an attempt is made before or after work to implement the behavior. You may go into trance by closing your eyes or you may wish to keep your eyes open also facilitates going into trance regardless of the condition of the eyes.
Conscious/Unconscious Therapeutic Binds

The conscious/unconscious therapeutic bind takes a form that is somewhat like an algebra expression with an x and y variable, one for the conscious and one for the unconscious. The form of the sentence is: The conscious mind may do x as the unconscious mind does y. There are three things to consider about such a sentence. The rst is what goes in place of the x. It is a good idea to place a word that refers to something that clients can verify with their conscious mind. Also some verb of mental activity such as wonder, discover, know, investigate, or nd works very well in the position of x. This is especially true when there is only one specic therapeutic goal at that moment. What goes in place of the y in the formula is exactly what the goal is or some sub-portion of the goal at that moment. For example, if the goal happens to be to feel more comfortable spending time around ones new employer, the suggestion may state: Your conscious mind may be surprised to discover how your unconscious will bring a feeling of relaxation around your new employer. If the goal is to relax in trance and recover a memory, the sentence could be formed as, Your conscious mind may be relaxed while your unconscious investigates that memory. The third thing to consider with conscious/unconscious therapeutic binds is how the conscious and unconscious parts of the sentence are connected. There are a variety of causal links such as and, as, since, while, and because that can connect the two events. In general it is best to use a conjunction to link the two events together and avoid strong causal relationships.
Double Dissociative Conscious/Unconscious Therapeutic Binds

This form of bind is exactly the same as the previous one except that it accommodates two goals by duplicating and reversing variables on the conscious and unconscious as that phrase is repeated. An example of the formula is, Your conscious mind may do x as your unconscious mind does y or, your conscious mind may do y as your unconscious mind does x. When x and y represent two different goals, they can or may become inexorably linked together by this type of verbal production. For example, if
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the goal is to feel comfortable and relaxed as you visualize interacting in a job interview, the sentence becomes, Your conscious mind may be comfortable and relaxed as your unconscious rehearses how you will conduct yourself at the job interview or perhaps your conscious mind will rehearse how you will conduct yourself at the job interview while your unconscious mind is comfortable and relaxed. Therapeutic bind is especially apparent in this sort of sentence. The client in trying to determine whether or not the rst part or the second part of the sentence is the most true has, in fact, associated comfort and relaxation and visualizing the job interview. The only way to escape making the bind become true is to simply pay no attention to the actual content of the indirect suggestion used by the therapisthence the understanding that these are therapeutic binds.
Pseudo Non-Sequitur Binds

The fourth form of bind is a pseudo-non-sequitur bind. I refer to them as rephrasing binds because a goal is stated and then renamed. A true non-sequitur question such as Do you walk to school or carry your lunch? may at rst appear to be appropriately well formed as a question but actually bears no connection between the elements provided for choice and is therefore a non sequitur. In a pseudo-non-sequitur bind, two apparently different choices are provided for the client; however, the choices are simply the same optionspoken once and then reworded. This form differs from the bind of comparable alternatives because either choice is exactly the same choice. For example, Do you think youd like to go into a trance or would it be better to simply achieve an altered state appropriate for your learning today? Another example is, You could let all the muscles in your body go limp, or, if you prefer, to just relax completely.
USING INDIRECT SUGGESTIONS IN THE CONTEXT OF INDUCTION

No goal is likely to be reached by the utterance of a single suggestion but each goal can be addressed by using many of the different types of suggestion. This probably facilitates listeners processing the data with varying and different kinds of mental mechanisms. For example, presupposition, comparison, contrast, generalization, checking for tness, choice, and so on. The differing forms of suggestions and binds require ferrying types of thought process. Therefore, by using various forms of suggestions and binds to restate therapeutic goals, the therapist enhances the possibility that clients will respond in a way that is meaningful to them. A brief example of an induction using these suggestions follows. The suggestions in the left column are labeled by the names of the suggestion appearing in the right column.
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The suggestions in this brief induction are given as examples to facilitate an understanding of how trance induction might be developed using, primarily, indirection in a client-centered fashion in the clinical setting. It
TABLE 1.2
I dont know whether or not youve been in trance. After you reorient from trance we can discuss it. You can go into trance in your own way. Everyone goes into trance in a way thats unique for them. Just uncross your legs, put your arms at your side and begin. You might develop an altered state thats appropriate for learning today or maybe develop a deep clinical trance. And you can do that rapidly, or suddenly, or you can go into trance and come out and go back in again, or you might simply gradually drift into a deep trance, or perhaps a medium trance, or nothing at all. You can go into trance with your eyes open or closed. But, go ahead and close them now. And let your conscious mind really wonder what the rst thing your unconscious will do as you turn your attention inward. Did you wonder when you would go more deeply? You may nd that your conscious mind is able to make some sense of things that your unconscious mind focuses on as you turn your attention inward or maybe your conscious mind, in turning your attention inward, will allow your unconscious mind to nd some things that it can focus upon. Because, every human being has the ability to orient their experience toward that which is relevant. And the longer time youve spent in confusion wondering what to do, the more rapidly you may embrace the direction that seems right for you. Take your time to select memory of a time you felt most condent. And feel it now. The human mind has an amazing capability of applying previously learned experiences in new and useful ways. statement to focus awareness presupposition truism truism direct suggestion ending with deletion pseudo-non-sequitur bind suggestion covering all possible alternatives
bind of comparable alternatives direct suggestion conscious/unconscious bind
question to focus awareness with an embedded command double dissociative conscious/ unconscious bind
open-ended suggestion
acquisition of opposites
direct suggestion
direct suggestion open-ended suggestion
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also illustrates how direct suggestion can be interspersed with indirect suggestion to facilitate the desired outcome. Greater detail and study and supervised training are always necessary for the appropriate and ethical use of suggestion in hypnosis and therapy. Erickson believed that the depth of trance is less important than the relevance of the trance. He stated, I nd that one can do extensive and deep psychotherapy in the light trance as well as in the deeper medium trance. One merely needs to know how to talk to a patient in order to secure therapeutic results (Erickson and Rossi, 1981, p. 3). The relevance of the trance will increase the degree of internal concentration and therefore increase the depth of trance. Each trance is individualized to the client, and scripted inductions should be avoided as much as possible. The state of internal absorption, the presence of some degree of ambiguity, and dissociation of the conscious mind establish a situation of communication with the client that is most conducive to helping that client focus upon and amplify various experiences.
RESEARCH
Overall, the Ericksonian tradition has been a lineage of living wisdom (like the passing on of martial arts skills) rather than a science. Most therapists realize the greatest amount of Ericksonian concepts and approaches when they are explained and demonstrated rather than from a critical examination of data supporting the theories and perspectives on hypnosis, the unconscious, and the nature of human experience. However, it is clear that much scientically based research needs to be conducted to establish an empirically based Ericksonian body of knowledge. The majority of articles appearing in refereed professional journals are publications of anecdotal case reports addressing many therapeutic venues and type of problems. These include brief therapy (Battino, 2007), utilization (Thomas, 2007; Akiyama, 2006), anxiety (Camino, Gibernau, & Araoz, 1999), depression (Young, 2006), post-natal well-being (Guse, Wissing, & Hartman, 2006), Candida (Edwards, 1999), family therapy (Crago, 1998), child therapy (Tennessen & Strand, 1998), solution focused (Santa, 1998), indirect suggestion (Fourie, 1997), and geriatric therapy (Gafner, 1997). However, there is a paucity of empirical research showing what constitutes the effectiveness of an Ericksonian approach. Representative of what little exists ranges from therapeutic storytelling (Parker & Wampler, 2006), tailored and scripted inductions (Barabasz & Christensen, 2006), and visual recall in trance (Tamalonis & Mitchell, 1997) to research conducted on the effectiveness and subjective experience of hypnotic language and comparisons of direct and indirect suggestion (Alman & Carney, 1980). The following is a brief, but certainly not comprehensive, overview of some of that early research of indirect language in hypnosis.
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Alman and Carney (1980), using audio-taped inductions of direct and indirect suggestions, compared male and female subjects on their responsiveness to posthypnotic suggestions. They reported that indirect suggestions were more successful in producing posthypnotic behavior than were direct suggestions. McConkey (1984) used direct and indirect suggestions with real and simulated hypnotic subjects. Although all of the simulated subjects recognized the expectation for a positive hallucination, half of the real subjects responded to the indirect suggestions and half did not. He concluded that indirection may not be the clinically important notion as much as the creation or existence of motivation where the overall suggestion is acceptable such as making the ideas congruent with the other aims and hopes of a patient (p. 312). Van Gorp, Meyer, and Dunbar (1985), in comparing direct and indirect suggestions for analgesia in the reduction of experimentally induced pain, found direct suggestion to be more effective reducing pain as measured by verbal self-reports and physiological measures. Stone and Lundy (1985) investigated the effectiveness of indirect and direct suggestions in eliciting body movements following suggestions. They reported that indirect suggestions were slightly more effective than direct suggestions in eliciting the target behaviors. Mosher and Matthews (1985) investigated the claim by Lankton and Lankton (1983) that indirect hypnotic language created by embedding a series of metaphors will create a natural structure for amnesia for content presented in the middle of the metaphoric material. The authors compared treatment groups who received multiple embedded stories with indirect suggestion for amnesia with control groups who received multiple embedded metaphors without indirect suggestions for amnesia. They found support for the structural effect of embedding metaphors on amnesia. Matthews, Bennett, Bean, and Gallagher (1985) compared subjects responses on the Stanford Hypnotic Clinical Scale (Morgan & Hilgard, 1978) to subjects responses on the same scale rewritten to include only indirect suggestions. They found no signicant behavioral differences between the two scales. However, they did report that individuals who received the indirect suggestions perceived themselves to be more hypnotized than those who received the original Stanford Hypnotic Clinical Scale. Nugent (1989a) attempted to show a causal connection between symptomatic improvement and the notion of unconscious thinking without conscious awareness. In a series of seven independent case studies with a range of presenting problems (e.g., fear of injections, performance anxiety, claustrophobia), he used the same methodological procedure and treatment intervention of indirect suggestion language for change. A pretreatment baseline response and therapeutic change relative to the intervention were all systematically assessed. In all seven cases, each client reported a clear, sustained
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positive change with respect to the presenting problem using indirect language. Although the individual case study has certain methodological limitations, Nugents use of seven independent cases with a carefully followed treatment protocol makes his conclusion of causality more convincing. This brief overview of research results would appear to be mixed in support of an indirect approach using suggestion, binds, and metaphor as compared with direct suggestion for many tasks. Direct hypnotic language was found more effective in treating pain in one study. However, indirect hypnotic language was seen as most effective in eliciting movement behavior, producing trance depth, subjective experience of relevance, amnesia, and posthypnotic behaviors in other studies. And, when motivation was present, indirect suggestion was also seen as most effective for more difcult trance phenomena such as positive hallucination. However, the reader should remember that for most of this research the tests were done with audio taping to standardize the intervention and that it was therefore not possible to tailor the suggestions (whether direct or indirect) and stories to the individual. A study by Barabasz and Christensen (2006) found that tailored inductions performed better than scripted inductions. As a result, the majority of these studies do not emphasize the importance of adapting and using the unique responses of the individual throughout hypnosis. Similarly, and perhaps more important, many of these tests were not designed in a context that attempted to address the relevant (growth) goals of individual subjects involved. Therefore, while the research gives us some idea, it does not represent a fully accurate picture of how a clinical client would experience the interventions when the hypnotic language is shaped and chosen for each individual. Finally, these bits and pieces do not adequately address the entire course of treatment that would be considered Ericksonian in style. It is perhaps easier to discuss techniques than to discuss the subtle but more important contributions of this overall approach. With an over-emphasis on technique, therapists have frequently been guilty of applying a technique without an adequate sense of how hypnotic language can develop within a natural interaction with clients.
CONCLUSION
As Haley notes, . . . Dr. Erickson has a unique approach to psychotherapy which represents a major innovation in therapeutic technique (Haley, 1967, p. 1). The therapeutic goal of an Ericksonian approach to hypnosis and therapy is to help clients concentrate upon and increase the use of desired experiential resources. This, in turn, is done to lead clients to change their relational patterns and bring a cessation to various presenting problems so they can live fuller and happier lives. Trance is a means of developing a state of heightened internal concentration for appropriate experiential
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resources that can be elicited and linked together. In turn, these gains must be conditioned to occur in specic life situations and during certain problem situations. Once that happens, a cure has been established. Both of these aspects of heightened concentration and increased control of experience can be readily available when therapists use appropriate hypnotic language. An appropriate hypnotic language involves verbal and nonverbal communication that is understood as relevant and ambiguous to a certain degree. This controlled elaboration of ambiguity can be accomplished with utilization, reframing, indirect suggestions, therapeutic binds, simple and complex metaphor, and direct suggestion techniques. Ericksons inuence has grown from a seed to a forest over the last few decades. This is in large part due to his own tireless work and, after his death, the many dedicated faculty members who teach at professional training events sponsored by the Milton H. Erickson Foundation, Inc., the American Society of Clinical Hypnosis, the Society of Clinical and Experimental Hypnosis, the International Society of Hypnosis, and their subordinate events worldwide. Further, his work is advanced by the many books and professional papers written by these individuals. At the time of this writing, a search of Amazon.com for Ericksons name lists 132 books. A search on the Internet today reveals 272,000 entries for Milton Erickson and 215,000 for Milton H. Erickson. There are currently 118 Erickson Institutes established worldwide for the further study and practice of Ericksons contributions to hypnosis, brief therapy, family therapy, and psychotherapy. Nevertheless, as with any talented innovator, the skill, perception, and capability of the originator seems to be a high-water mark in the eld that is seldom achieved by subsequent generations of trainees. His clinically proven skill sets, like those of a complicated martial art, require careful study and practice, and time to replicate. His documented accomplishments with the skill sets will provide the motivation for years of material for future empirical research, evidence-based outcome studies, and the formulation of creative clinical applications. Finally, I want to caution readers, as did Jay Haley (Haley, 1993), on the care with which these powerful techniques should be exercised.
REFERENCES
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Bandler, R., & Grinder, R. (1975). Patterns of the hypnotic techniques of Milton H. Erickson, M.D. Cupertino, CA: Meta Publications. Bandler, R., & Grinder, J. (1979). Frogs into princes. Moab, UT: Real People Press. Barabasz, A., & Christensen, C. (2006). Age regression: Tailored versus scripted inductions. American Journal of Clinical Hypnosis, 48(4, Apr. 2006), 251261. Barber, T., Spanos, N., & Chaves, J. (1974). Hypnotism, imagination and human potentialities. New York: Pergamon. Battino, R. (2007). Expectation: Principles and practice of very brief therapy. Contemporary Hypnosis, 24(1, Mar. 2007), 1929. Bekhterev, V. M. (1998). Suggestion and its role in social life. L. H. Strickland (Ed.) T. Dobreva-Martinova (Trans.). New Brunswick, NJ: Transaction Publishers. Berne, E. (1972). What do you say after you say hello? New York: Grove. Bowers, K. S. (1966). Hypnotic behavior: The differentiation of trance and demand characteristic variables. Journal of Abnormal Psychology, 71, 4251. Camino, A., Gibernau, M., & Araoz, D. (Trans). (1999). Ericksonian hypnosis: Applications in psychotherapy. Australian Journal of Clinical Hypnotherapy and Hypnosis, 20(1, Mar. 1999), 2338. Coe, W., & Scharcoff, J. (1985). An empirical evaluation of the neurolinguistic progamming model. International Journal of Clinical and Experimental Hypnosis, 23, 310319. Crago, H. (1998). The unconscious of the individual and the unconscious of the system. Australian and New Zealand Journal of Family Therapy, 19(2, Jun. 1998), iiiiv. Dammann, C. (1982). Family therapy: Ericksons contribution, in Zeig, J. (Ed.), Ericksonian approaches to hypnosis and psychotherapy (pp. 193200). New York: Brunner/Mazel Publishers. De Shazer, S. (1985). Keys to solutions in brief therapy. New York: W. W. Norton. Dowd, E. T., & Hingst, A. G. (1983). Matching therapists predicates: An in vivo test of effectiveness. Perceptual Motor Skills, 57, 207210. Dowd, E. T., & Pety, J. (1982). Effect of counselor predicate matching on perceived social inuence and client satisfaction. Journal of Counseling Psychology, 29, 206209. Edwards, L. (1999). Self-hypnosis and psychological interventions for symptoms attributed to Candida and food intolerance. Australian Journal of Clinical Hypnotherapy and Hypnosis, 20(1, Mar. 1999), 112. Erickson, B., & Keeney, B. (Eds.) (2006). Milton H. Erickson, M.D.: An American healer. Sedona, AZ: Ringing Rocks Press. Erickson, M. (1980a). February man: Facilitating new identity in hypnotherapy. In E. L. Rossi (Ed.), The collected papers of Milton H. Erickson on hypnosis: Vol. 4. Innovative hypnotherapy (pp. 525542). New York: Irvington. Erickson, M. (1980b). Method employed to formulate a complex story for the induction of an experimental neurosis in a hypnotic subject. In E. L. Rossi (Ed.), The collected papers of Milton H. Erickson on hypnosis: Vol. 3. Hypnotic investigation of psychodynamic processes (pp, 33655). New York: Irvington. Erickson, M. (1980c). Special techniques of brief hypnotherapy. In E. L. Rossi (Ed.), The collected papers of Milton H. Erickson on hypnosis: Vol. 4. Innovative hypnotherapy (pp. 14987). New York: Irvington.
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Erickson, M. (1980d). Hypnosis: Its renaissance as a treatment modality. In E. L. Rossi (Ed.), The collected papers of Milton H. Erickson on hypnosis: Vol. 4. Innovative hypnotherapy (pp. 375). New York: Irvington. Erickson, M. (1980e). Hypnotic Psychotherapy. In E. L. Rossi (Ed.), The collected papers of Milton H. Erickson on hypnosis: Vol. 4. Innovative hypnotherapy (pp. 3548). New York: Irvington. Erickson, M. (1980f). The confusion technique in hypnosis. In E. L. Rossi (Ed.), The collected papers of Milton H. Erickson on hypnosis: Vol. 1. The nature of hypnosis and suggestion (pp. 25891). New York: Irvington. Erickson, M. H. (1980g). The collected papers of Milton H. Erickson on hypnosis: Vol. 1. The nature of hypnosis and suggestion. E. L. Rossi (Ed.). New York: Irvington. Erickson, M. H. (1980h). The collected papers of Milton H. Erickson on hypnosis: Vol. 2. Hypnotic alteration of sensory, perceptual and psychophysical processes. E. L. Rossi (Ed.). New York: Irvington. Erickson, M. H. (1980i). The collected papers of Milton H. Erickson on hypnosis: Vol. 3. Hypnotic investigation of psychodynamic processes. E. L. Rossi (Ed.). New York: Irvington. Erickson, M. H. (1980j). The collected papers of Milton H. Erickson on hypnosis: Vol. 4. Innovative hypnotherapy. E. L. Rossi (Ed.). New York: Irvington. Erickson, M. H., & Rossi, E. (1979). Hypnotherapy: An exploratory casebook. New York: Irvington. Erickson, M., & Rossi, E. (1980a). Varieties of double bind. In E. L. Rossi (Ed.), The collected papers of Milton H. Erickson on hypnosis: Vol. 1. The nature of hypnosis and suggestion (pp. 41229). New York: Irvington. Erickson, M., & Rossi, E. (1980b). Two level communication and the micro dynamics of trance and suggestion. In E. L. Rossi (Ed.), The collected papers of Milton H. Erickson on hypnosis: Vol. 1. The nature of hypnosis and suggestion (pp. 430451). New York: Irvington. Erickson, M., & Rossi, E. (1980c). Indirect forms of suggestion. In E. L. Rossi (Ed.), The collected papers of Milton H. Erickson on hypnosis: Vol. 1. The nature of hypnosis and suggestion (pp. 452477). New York: Irvington. Erickson, M., & Rossi, E. (1981). Experiencing hypnosis: Therapeutic approaches to altered state. New York: Irvington. Erickson, M., & Rossi, E. (1989). The February Man: Evolving consciousness and identity in hypnotherapy. New York: Brunner/Mazel. Erickson, M. & Rossi, E. (2008). An introduction to therapeutic hypnosis and suggestion. In Rossi, E., Erickson-Klein, R., & Rossi, K. (Eds.), The collected works of Milton H. Erickson, Vol. 2, Basic hypnotic induction and suggestion (pp. 18). Phoenix, AZ: The Milton H. Erickson Foundation Press. Erickson, M. H., Rossi, E, & Rossi, S. (1976). Hypnotic realities: The induction of clinical hypnosis and forms of indirect suggestion. New York: Irvington. Falzett, W. C. (1981). Matched vs. unmatched primary representational system and their relationship to perceived trustworthiness in a counseling analogue. Journal of Counseling Psychology, 28, 305308. Fisch, R. (1990). The broader implications of Milton H. Ericksons work. In Lankton, S. (Ed.), Ericksonian monographs, Number 7 (pp. 16). New York: Brunner/Mazel.
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Fisch, R., Weakland, J., & Segal, L. (1982). The tactics of change: Doing therapy briey. San Francisco: Jossey-Bass. Fourie, D. (1997). Indirect suggestion in hypnosis: Theoretical and experimental issues. Psychological Reports, 80(3, Pt 2, June 1997), 12551266. Gafner, G. (1997). Hypnotherapy with older adults. Contemporary Hypnosis, 14(1), 6879. Gill, M. M., & Brenman, M. (1959). Hypnosis and related states: Psychoanalytic studies in regression. New York: International Universities Press. Gumm, W. B., Walder, M. K., & Day, H. D. (1982). Neurolinguistic programming: Method or myth? Journal of Counseling Psychology, 29, 327330. Guse, T., Wissing, M., & Hartman, W. (2006). A prenatal hypnotherapeutic program to enhance postnatal psychological wellbeing. Australian Journal of Clinical & Experimental Hypnosis, 34(1, May 2006), 2740. Haley, J. (1963). Strategies of psychotherapy. New York: Grune & Stratton. Haley, J. (Ed.) (1967). Advanced techniques of hypnosis and therapy: Selected papers of Milton H. Erickson, M.D. New York: Grune & Stratton. Haley, J. (1984). Ordeal therapy. New York: Jossey-Bass. Haley, J. (Ed.) (1985a). Conversations with Milton H. Erickson, M.D.: Volume 1, changing individuals. New York: Triangle Press. Haley, J. (Ed.) (1985b). Conversations with Milton H. Erickson, M.D.: Volume 2, changing couples. New York: Triangle Press. Haley, J. (Ed.) (1985c). Conversations with Milton H. Erickson, M.D.: Volume 3, changing families. New York: Triangle Press. Haley, J. (1973). Uncommon therapy: The psychiatric techniques of Milton H. Erickson, M.D. New York, Norton. Haley, J. (1993). Jay Haley on Milton H. Erickson. New York: Brunner/Routledge. Hammond, D. C. (1984). Myths about Erickson and Ericksonian hypnosis. American Journal of Clinical Hypnosis, 26, 236245. Hammond, D. C. (1988) Will the real Milton Erickson please stand up? International Journal of Clinical and Experimental Hypnosis, XXXVI(3), 173181. Henry, D. (1984). The neurolinguistic programming construct of the primary representational system: A multitrait multi-method validational study. University of Connecticut: Unpublished master thesis. Hilgard, E. R. (1965) Hypnotic susceptibility. New York: Harcourt, Brace & World. Hilgard, E. R. (1975) Hypnosis. Annual Review of Psychology, 26, 1944. Hilgard, E. R. (1966) Posthypnotic amnesia: Experiments and theory. International Journal of Clinical and Experimental Hypnosis, 14, 104111. Hilgard, E. R., Weitzenhoffer, A., Landes, J., & Moore, R. (1961). The distribution of susceptibility to hypnosis in student population: A study using the Stanford Hypnotic Susceptibility Scale. Psychology Monographs, 75(8), 122. Kirsch, I. (1985). Response expectancy as a determinant of experience and behavior. American Psychologist, 40(11), 11891202. Kirsch, I. (1990). Changing expectations: A key to effective psychotherapy. Pacic Grove, CA: Brooks Cole. Laing, R. (1972). Politics of the family and other essays. New York: Vintage Books. Laing, R. D. (1967). The politics of experience. New York: Ballantine Press. Lankton, S. (1989). Motivating action with hypnotherapy for a client with a history of early family violence. In Lankton, S. and Zeig, J. (Eds.), Ericksonian monographs, Number 6 (pp. 4361). New York: Brunner/Mazel.
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Lankton, S. (2001). Ericksonian therapy. In R. Corsini (Ed.), Handbook of innovative therapy (pp. 194205). New York: Wiley. Lankton, S. (2003/1980). Practical magic: The application of basic neurolinguistic programming to clinical psychotherapy. New York: Crown Publishers. Lankton, S. (2004). Assembling Ericksonian therapy: The collected papers of Stephen Lankton. Phoenix, AZ: Zeig/Tucker. Lankton, C., & Lankton, S. (1989). Tales of enchantment: Goal-oriented metaphors for adults and children in therapy. New York: Brunner/Mazel. Lankton, S., & Lankton, C. (1983). The answer within: A clinical framework of Ericksonian hypnotherapy. New York: Brunner/Mazel Publishers. Lankton, S. & Lankton, C. (2007/1986). Enchantment and intervention in family therapy: Using metaphors in family therapy. New York: Crown Publishers. Lankton, S., Lankton, C., & Matthews, W. (1991). Ericksonian family therapy. In Gurman, A. & Kniskern, D. (Eds.), Handbook of family therapy. New York: Brunner/Mazel. Leary, T. (1957). Interpersonal diagnosis of personality: A functional theory and methodology for personality evaluation. New York: The Ronald Press. Matthews, W. (1985) Ericksonian and Milan therapy: An intersection between circular questioning and therapeutic metaphor. Journal of Strategic and Systemic Therapy, 3, 1626. Matthews, W. (1985). A cybernetic model of Ericksonian hypnotherapy: One hand draws the other. In Lankton, S. (Ed.), Ericksonian monographs, Number 1 (pp. 4260). New York: Brunner/Mazel. Matthews, W., Bennett, H., Bean, W., & Gallagher, M. (1985). Indirect versus direct hypnotic suggestionsan initial investigation: A brief communication. International Journal of Clinical and Experimental Hypnosis, XXXIII(3), 219223. Matthews, W., & Dardeck, K. (1985). The use and construction of therapeutic metaphor. American Mental Health Counselors Association Journal, 7, 1124. Matthews, W., Kirsch, I., & Mosher, D. (1985). Double hypnotic induction: An initial empirical test. Journal of Abnormal Psychology, 94(1), 9295. Matthews, W., & Mosher, D. (1988). Direct and indirect hypnotic suggestion in a laboratory setting. British Journal of Experimental and Clinical Hypnosis, 5(2), 6371. Matthews, W., Lankton, S., & Lankton, C. (1996). The use of Ericksonian hypnotherapy in the case of Ellen. In S. J. Lynn, I. R. Kirsch, and J. W. Rhue (Eds.), Casebook of clinical hypnosis (pp. 36591). Washington, DC: American Psychological Association. McConkey, K. (1984). The impact of indirect suggestion. International Journal of Clinical and Experimental Hypnosis, 32, 307314. Morgan, A., & Hilgard, J. (1978). The Stanford hypnotic susceptibility scale for adults. American Journal of Clinical Hypnosis, 21, 148169. Mosher, D., & Matthews, W. (1985). Multiple embedded metaphor and structured amnesia. Paper presented at the American Psychological Association meeting, San Diego, CA. Nugent, W. (1989a). Evidence concerning the causal effect of an Ericksonian hypnotic intervention. In Lankton, S. (Ed.), Ericksonian monographs, Number 5 (pp. 6885). New York: Brunner/Mazel. Nugent, W. (1989b). In Lankton, S. (Ed.), A multiple baseline investigation of an Ericksonian hypnotic approach. Ericksonian monographs, Number 5 (pp. 69 85). New York: Brunner/Mazel.
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OHanlon, W. (1987). Taproots. New York: Norton Publishers. Orne, M. (1959). The nature of hypnosis: Artifact and essence. Journal of Abnormal and Social Psychology, 58, 277299. Parker, T., & Wampler, K. (2006). The use of therapeutic storytelling. Journal of Marital & Family Therapy, 2(Apr. 2006), 155166. Parsons-Fein, J. (2004). Loving in the here and now. New York: Penguin. Ritterman, M. (1983). Using hypnosis in family therapy. San Francisco: Jossey-Bass. Rossi, E., & Ryan, M. (Eds.) (1985). Life reframing in hypnosis. New York: Irvington. Rossi, E., Ryan, M., & Sharp, F. (Eds.) (1983). Healing in hypnosis by Milton H. Erickson. New York: Irvington. Santa, R., Jr. (1998). What do you do after asking the miracle question in solution-focused therapy? Family Therapy, 25(3), 189195. Stone, J. A., & Lundy, R. M. (1985). Behavioral compliance with direct and indirect body movement suggestions. Journal of Abnormal Psychology, 3, 256263. Tamalonis, A., & Mitchell, J. (1997). Empirical comparison of Ericksonian and traditional hypnotic procedures. Australian Journal of Clinical Hypnotherapy and Hypnosis, 18(1, Mar. 1997), 516. Tennessen, J., & Strand, D. (1998). A comparative analysis of directed sandplay therapy and principles of Ericksonian psychology. The Arts in Psychotherapy, 25(2), 109114. Thomas, F. (2007). Scouts honor. Journal of Family Psychotherapy, 18(3), 2007, 8589. Ueshiba, M. (1991). Budo. Tokyo: Kodansha International. Van Gorp, W. G., Meyer, R. G., & Dunbar, K. D. (1985) The efcacy of direct versus indirect hypnotic induction techniques on reduction of experimental pain. International Journal of Clinical and Experimental Hypnosis, 4, 319328. Watts, A. (1957). The way of zen. New York: Vintage Press. Watzlawick, P., Weakland, J., & Fisch R. (1974). Change. New York: W. W. Norton & Co. Weakland, J., Fisch, R., Watzlawick, P., & Bodin, A. (1974). Brief therapy: Focused problem resolution. Family Process, 13, 141168. Weeks, J. R., & Lynn, S. J. (1990). Hypnosis, suggestion type and subjective experience: The order effects hypothesis revisited. International Journal of Clinical and Experimental Hypnosis, 38, 95101. Weitzenhoffer, A. M. (1957). General techniques of hypnotism. New York: Grune & Stratton. Weitzenhoffer, A. M., & Hilgard, E. R. (1963) Stanford hypnotic susceptibility scale, Form C. Palo Alto, CA: Consulting Psychologists Press. Yapko, M. D. (1982). The effect of matching primary representational system predicates on hypnotic relaxation. American Journal of Clinical Hypnosis, 23, 169175. Young, G. (2006). Hypnotically-facilitated eclectic psychotherapeutic treatment of depression: A case study. Australian Journal of Clinical Hypnotherapy and Hypnosis, 27(1, Fall 2006), 113. Zeig, J. (Ed. with commentary). (1980). A teaching seminar with Milton H. Erickson. New York: Brunner/Mazel. Zeig, J. (Ed.). (1982). Ericksonian approaches to hypnosis and psychotherapy. New York: Brunner/Mazel. Zeig, J., & Lankton, S. (1988). Developing the Ericksonian therapy: state of the art. New York: Brunner/Mazel.
Chapter 2
Ego Psychology Techniques in Hypnotherapy

Arreed Franz Barabasz
To paste a coping skill on the surface of an injured person is to further remove that person emotionally from the self. (Watkins & Barabasz, 2008; Watkins & Watkins, 1997) The human personality is not a unity, although it is usually experienced as such. Our personalities are separated into various segments. Unique entities serve different purposes. This is the central premise of ego state therapy. The state that is overt and conscious at a particular time is the executive state. Those states that are not executive may or may not be aware of what is going on at a conscious level. Conicts among states take up considerable energy, often forcing the individual into withdrawn, defensive postures. A person, such as in the case of Mathew below, will not be at peace with himself until the conicts are resolved. (Watkins & Barabasz, 2008) Mathew is in a new relationship with Emma. He sees Emma playing with a child. He feels and believes, This is the woman for me. I love her and I want to spend the rest of my life with her. Later in the same day she criticizes him about his job as a plumber. He feels defensive and thinks, What did I ever see in this woman? How can I get out of this relationship? These responses may sound extreme, but they are not unusual, and it is not unusual for a person to bounce among several ego states in the process of making a major decision (one state may be in favor, one may be against, and another indifferent). In one moment on one day Mathew may know he wants Emma as his partner, and in another moment he may know he does not. In this example, Mathew
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has an ego state that loves and dreams of a family. It is a soft, caring part of him, and when he sees the woman he cares about playing with a child his loving/caring ego state becomes executive. While in this state, Mathew is capable of feeling very positive and interested in Emma. These are honest feelings. It is Mathew who is feeling them. It is Mathews loving/caring part. Later, when Emma criticized his job, another part of Mathew is energized to become executive (comes out). Mathews defensive, dont pick on me ego state becomes executive. This is not a loving, caring part of Mathew, and probably cant even feel love. Its role is to protect, by creating a shell and withdrawing from the attacker. While in this state, Mathew cannot imagine life with Emma. This too is a part of Mathew, just as valid and needed as the other. (Emmerson, 2003, p. 2) As shown by Mathew, in the previous case, an ego state is an organized system of behavior and experience whose elements are bound together by a common principle. However, each state is separated from other states by a boundary that is more or less permeable (Watkins & Watkins, 1997, p. 25). Each is distinguished by a particular role, mood, and mental function, which when conscious [executive] assumes the persons identity. Ego states start as defensive coping mechanisms and when repeated develop into compartmentalized sections of the personality (Emmerson, 2003, p. 3). They may also be created by a single incident of trauma such as an auto accident, rape, or even the rst day of kindergarten. Ego states maintain their own memories and communicate with other ego states to a greater or lesser degree. Unlike alters in multiple personalities in those with dissociative identity disorder (DID), ego states are a part of normal personalities.
THE EVOLUTION OF EGO STATE THERAPY

Hypnosis pioneer Pierre Janet (1907) seems to have been the rst to describe those covert personality segments with which we will concern ourselves within ego state theory and therapy. Janets focus was on the study of true multiple personalities (dissociative identity disorder) and was probably the rst to use the term dissociation to describe systems of ideas that were split off, thus not in association with other ideas within the personality. He also implied that these personality patterns can exist subconsciously in normal functioning individuals even though not overt and available to conscious observation and experience. As one of the rst psychoanalysts to deviate from pure Freudian doctrine, Carl Jung (1969) also recognized well-established covert structures within the collective or unconscious. These were termed archetypes. More transient groups of unconscious ideas clustered together were referred to as a complex. Although the terminology varies from that of Janet as
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well as our own, both Jungs concepts of a personality complex as well as the more structured archetypes he is best known for refer to personality segments that are organized into unconscious patterns. Paul Federn (1952a) was the rst to systematically apply the concept of ego states to provide a psychodynamic understanding of human behaviors. His disciple Eduardo Weiss (1960) translated his papers, published them, and extended many of their implications. Neither Federn nor Weiss ever seemed to fully realize the great signicance of ego states in their treatment procedures, nor did they seem to understand that an alternative theoretical formulation was needed to comprehend its potential as a new sophisticated form of hypnoanalysis. This endeavor became one of John G. Watkinss greatest contributions to the science and practice of psychotherapy (AFB). John G. Watkins was the rst to recognize that Federns theory was entirely limited to only ego-energized items. Watkins modied the conceptualization and developed the theory of ego states with his wife Helen Huth Watkins. This new theory includes ego-energized and object-energized elements. Thus, when they have become organized together in a coherent pattern, the ego state may represent an age of a relationship in the individuals life, which may have been developed to cope with a certain situation (Barabasz & Watkins, 2005; Watkins, 1978; Watkins & Watkins, 1979, 1981, 1982, 1986, 1997). Lets say your patient was severely punished as a ve year old. Becoming quiet, saying little, and withdrawing passive aggressively was a way of handling the situation. Such coping patterns seemed to also work in later life. So when in trouble with an authority gure the adult now nds the veyear-old ego state returning no matter how short sighted, present oriented, and ultimately self-defeating it may be. As Marlene Hunter (2004, p. 88) points out, those with borderline personality disorder still cope the way they did when they were 5 years old. Thus, our conceptualization of an ego state is one that includes both ego and object energized elements that are encompassed within a common principle, a collection of subject and object items that belong together in some way and that are included within a common boundary that is more or less permeable. By permeable we mean that it is accessible by the conscious and sometimes, but not always, in subconscious communication with other co-existing ego states. When one of these states is invested with a substantial quantity of ego energy it becomes the self in the here and now. We say that it is executive and it experiences the other states, if it is aware of them all, as he, she, or it since they are primarily invested with object energy. As ego and object energies ow from one state to another, the behaviors and experiences of the individual change, and we may assign the diagnosis of Dissociative Identity Disorder (DID; Multiple Personality Disorder). Dened in this way, ego states subsume what we call multiple personalities but also
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include other clusters of mental functions, which may or may not reach consciousness and directly change behavior.
THE MOST SIGNIFICANT HUMAN EXPERIENCE: SUBJECT-OBJECT

My leg is me. My arm is me. My thought is me, or is it, if I am hallucinating? Subject-object, what is within my self, and what is not, is perhaps the most signicant area of human experience. Perceptions refer to mental images and sensations, which are normally elicited by objects outside the body. But a stone in the stomach and infection in the blood are also objects. An arm is normally considered as subject, part of me. But if it is paralyzed and devoid of feeling and movement, then it, too, becomes an object. An idea, a concept is normally subjectit is my thought. But a hallucination is an idea, which is perceived as coming from the outside. The hallucination is not perceived as part of me, therefore, it is perceived as object. Clearly then, the body cannot be the criterion for distinguishing between object and subject. The entity which does so discriminate is our essence, the self. That which is perceived as outside myself whether it is within the body or not is object. That which is experienced, as within my self, hence, part of the me, is subject. The self and not the body is the distinguishing agent, and the difference is judged by our feeling of selfness when we are aware of it.
THE SELF
The self and what constitutes it has been the subject of numerous theories as well as scientic controversies. Freud (1933) postulated a state of primary narcissism, an inherent condition in the original child. Later, he viewed the ego as a structure within the mind, which was equated with the self. This was apparent in his topographic conceptualization of the mind when one looks at it as originally written in German. The ego structure was represented as the selbst, literally translated into English as the self. Hartmann (1958) regarded the ego, hence the self, as not only an inherent structure, but partially determined by the impact of the veridical world on the developing infant. Other object-relations analysts, such as Winnicott (1965) saw the self and its feeling of self-existence as coming about as the mother, who acts like a mirror, reects back to the child his or her own experience and gestures. The child then believes that when I look, I am seen, so I exist. When the mother resonates to the childs needs, the latter becomes aware of them. This awareness then slowly evolves into this sense of self. It is the me inside, sometimes working and serious, sometimes at play, sometimes in pleasure and others in pain. Mahler (1972) emphasized
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the maternal role in developing the childs self through a separationindividuation process by which he or she comes to know himself or herself. As the child interacts with mother, the child separates himself or herself to develop a unique identity and sense of selfness. Similarly, Hartmann (1958) considered the self as an object representation or experiential construct, but Kernberg (1976) extended this formulation to reserve the term self to the sum-total of self-representations. By this he apparently meant that certain experiences, feelings, and images were endowed with self-feeling that interacted with other images and sensations that were felt as not me, but were also represented within the mind. This interaction is embedded within the ego and constitutes the self. I (J.G.W.) proposed a similar view (Watkins, 1978, ch. 6) that existence occurred only when an object, a not-me, impacted a subject, a me. This is consistent with Fairbairns conceptualization (see Guntrip, 1961) that ego and object are inseparable. An object is not signicant (e.g., does not exist to its perceiver) unless it has some ego energy in contact with it. The classical theory developed by Freud in its original form posited that the individual was born with innate drives, sexual and aggressive, and that it was in the satisfaction or frustration of these that personality structure and neurotic conicts developed. Analysts operating from this basic assumption became known as the drive model analysts. These theorists and psychotherapists were considered the original members of the relational school who increasingly emphasized the role of interpersonal relationships as a basis for shaping all human development. As the relational branch of object relations theory developed, opposition to the drive/libido theory grew. Harry Stack Sullivan (1968) highlighted the interpersonal dimension arguing that Freuds theory could be better understood on the basis of interpersonal processes. Sullivans elaborate conceptualization of psychopathology emphasized a persons behaviors that are intended to minimize or avoid anxiety that was rooted in dreaded thoughts of rejection and derogation by parents, others, and eventually oneself. Sullivan explained that particular aspects of the child, such as crying or whining, result in parental rejection or ridicule (e.g., telling a boy to stop acting like a girl). Integrating that these parts represent an anxiety arousing bad self, these aspects are split off or disowned. What Sullivan overlooked is that although they may be split off they are not killed off; disowning by repression assures they remain as covert ego states that continue to affect behavior in less-than-ideal ways given that their overt expression has been denied. Our ego state conceptualization suggests such split-off unexpressed child xed ego states are likely to become malevolent. However, Sullivan did recognize that the child develops coping mechanisms to preclude being subjected to anxiety-arousing rejection again (Teyber, 2000, p. 6). Unfortunately, in adulthood these responses become characterological as the child
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now grown to adult size anticipates that new experiences with others will repeat the relational patterns of the past. Eventually, patients childlike attempts to contain their bad aspects will lead to frustration. The self-effacing patient will not win approval of everyone they need, the aloof patient will be forced by situational demands to compete with others, and the expansive (histrionic) patient will not always succeed at manipulating others to defer to their demands. When such a student receives anything less than 100 percent approval from an instructor or mentor, they will feel completely defeated and overreact with great drama toward a signicant person and may engage in storytelling in an effort to seek attention from others. Therapists who fail to recognize this expression of an often repressed ego state (the narcissistic wound in Kohuts [1977] interpersonal process terms) will question this overreaction and provide a rational appraisal of the situation. This attempt at reality grounding might well result in a transference reaction toward the therapist who has missed entirely the deeper meaning to the client coming from the frustrated childish ego state. The therapist must grasp the patients point of view that this seemingly minor rejection indicates once again for the patient that no matter how great their efforts they cannot get it right. Rather than reject the ego state that is expressing such desperation, the therapist should reect compassion for the burden of perfectionism that the client has suffered from since childhood. This resonant understanding will strengthen the therapeutic alliance and create, especially with the aid of hypnosis, a safe place for the patient to explore collaboration of their ego states. Kohut (1971, 1977) departed most from drive theory. In his Psychology of the Self (1977), Kohut assigned the classical functions of ego, super-ego, and id to the self. He hypothesized that this entity was developed by the infants internalization of self-objects, meaning the signicant people in the childs world, usually his or her parents. Through their empathic responses to his or her needs, they provided the experiences necessary for the development of the childs self. This is an extension of Mahlers concepts, but unlike her, Kohut broke more denitely with the drive theory approach since he perceived the self as almost entirely a product of interpersonal relations. Kohut felt that the self expresses a need for contact with others as its basic motivational apparatus rather than sexual or aggressive drives. Because of loyalty to Freud, and their own wish to be identied with the body of classical psychoanalysis, the object-relation theorists and to a lesser extent the interpersonal process theorists kept trying to reconcile their new concepts, derived from clinical experience with classical drive theory (Greenberg & Mitchell, 1983). All of these practitioners were inhibited, at least to some degree, in proposing concepts of personality development, which departed too widely from accepted theories. Innovative psychological theories that deviated too radically from Freuds, such as Alfred Adlers
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(1948), Carl Jungs (1916), and Otto Ranks (1952) had all resulted in the past with their author being rejected from membership within classic psychoanalysis. Kohuts views, which were probably the most progressive of the object relation theorists, were most likely more closely aligned than the other three to the earlier views of Paul Federn, who was a friend and close associate of Sigmund Freud.
PAUL FEDERNS EGO PSYCHOLOGY

Federn was one of the rst to join Freuds group and developed innovative techniques for treating psychosis. As early as 1927, Paul Federn had proposed many of the concepts advocated later by the object relations and interpersonal process theorists. His work was almost completely ignored in the controversies between drive model and relations model theorists as he remained all but unreferenced by those credited with the development of object relations theory. One gets the impression that they never read Federn, and it remained to Eduardo Weiss (who was analyzed by Federn and trained by Freud) to publish an English compilation of Federns papers. The ignorance of Federns contributions may stem from three primary problems. First, Federn wrote in what almost any upper-level graduate student would view as complex, long-winded, German sentences. Weiss, who was John G. Watkinss analyst, once said to J. G. W., Federn is very difcult to understand. That is why I had to write an introduction to his book to explain him. At that time, J. G. W. was in analysis with Weiss. J. G. W. noted, I had not acquired the courage to say, But Dr. Weiss your writings are also hard to understand (Watkins & Barabasz, 2008). Another reason may have been that Federn used alternative terminology to refer to psychoanalytic structures and processes that were then currently in normal usage. Federn himself was not fully aware of the extent to which his view departed from Freuds. At any rate, his theories have not been widely read nor understood by the few that have attempted their reading. Federns theories, however, provide a foundation for Ego-State Therapy as a unied theory, which integrated the use of hypnosis to dramatically speed psychoanalytic processes and its extensions. After more than a quarter century of development by John and Helen Watkins as the primary formulators of the theory and therapy, Ego State Therapy is now considered established. The rst World Congress of Ego State Therapy was held March 2023, 2003, in Bad Orb, Germany, with the recognition and sponsorship of both the German and European Hypnosis Societies. Ego State Theory was again a central focus of the European Society of Hypnosis Congress held in Gozo, Malta, September 1823, 2005, and most recently at the International Tagung Ego State Therapy: Hypnosis, Trauma and Psychotherapy, Kathmandu, Nepal, May 48, 2008, and in Pokhara, Nepal, May 1214, 2008.
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EGO STATE THEORY

As is well known, Freud based much of his theory on the displacements of a single energy, libido, which originated in the id. He later hypothesized the need for two variants of libido: narcissistic libido and object libido. Yet this still represented only two different allocations of the same energy source rather than two different kinds of energy. Hartmann originally (1955) referred to a primary ego energy, which was not derived from instinctual libidinal energy. Later, Jacobsen (1964) supported an initial state of undifferentiated energy, which then acquires libidinal or aggressive qualities. Kohut (1971), while attempting to appear loyal to Freuds drive theory, proposed that libidinal energy could be divided into two separate and independent realms, including narcissistic libido and object libido. All of the psychodynamic object-relations and interpersonal process theorists recognized that Freuds single energy theory, libido, was not adequate to account for the phenomena, which they observed in their patients. Their tortured writings show numerous efforts to force these phenomena into a single energy (libido) mold. Federn had broken with that position much earlier and had clearly formulated a two-energy theory that resolved many of the conicts in understanding psychodynamic processes and thus provided a rationale for more effective therapeutic interventions (see Federn, 1952a). It also provided a rationale for hypnotherapy and hypnoanalysis, a consequence not envisioned by either Federn or Weiss.
EGO AND OBJECT ENERGY

Federn hypothesized different energies: ego energy and object energy. The term libido, as formulated by Freud, meant an instinctual sexual energy emanating from the id. It was also an object energy, since it could be displaced to various objects such as the patients mother, who then became an object of erotic interest further extended by Jung (1966), who regarded it as life energy to differentiate it from that of purely sexual energy. To avoid the confusion, let us follow both Federns and Weisss later terminology and use only ego energy and object energy. Energy can be dened as an investment of a quantum of energy to activate a process. A motor is energized with electricity and then runs. Ego energy is the energy that cathects or activates the ego. It is the energy of the self. In fact, it is the self. Ego energy is what you are, it is the you in you. Self is an energy, an organic, life energy, not a compilation of feelings, thoughts behaviors, and so forth. Ego energy has but one basic quality, the feeling of selfness, of me-ness. If an arm is invested or energized with this ego energy, then I experience it as my arm. If a thought is invested or activated with ego energy, then I experience it as my thought. It has
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become part of the me, and, therefore, I regard it as within myself. By calling it ego energy and not ego libido, we will no longer confuse it with the instinctual, sexual, and object energy. Federns second energy was object energy. It is qualitatively very different, being a nonorganic energy, much like electricity, radiation, and so on. It has but one basic quality. Like ego energy, it can activate or make a process go, but any process or body part object energized is not experienced as me. It is sensed or perceived as an object, hence, outside my self. Patients suffering from borderline personality disorder (BPD) ascribe only such object energy to other humans in their life space. To them, people serve a purpose but do not have selfness. Kohut and other object relationsinterpersonal process theorists were apparently unaware of Federns work and did not seem prepared to challenge Freuds drive theory to the point of recognizing that the concept of a single kind of energy called libido had to be eliminated to bring the theoretical structure to fruition in the treatment of patients. Instead, Kohut and the others continued to modify the concept of the manner of cathecting by a single energy, which determined whether a representation became a true object or a self object. It seemed that at some level Kohut recognized the need for a two-energy approach but could never bring himself to such a conceptualization. Federns concept of two different kinds of energy directly challenged Freuds basic views regarding a single, unitary libido. As such, it was ignored by many psychoanalysts until the advent of Ego State Therapy. Neither ego energy nor object energy should be equated in any way with consciousness. If my arm has been hypnotically anesthetized, paralyzed that is, and removed from my self-control, its ego energy has been removed (dissociated). The arm is now experienced by me as an it, an external object and entirely outside of myself. If the paralysis is hypnotically removed and the feeling of selfness restored, that is because we have invested it again with ego energy. From this perspective, hypnosis is clearly the modality of choice for directing the various displacements of ego energies and object energies. Existence is impact between object and subject, so consciousness in ego state theory is an economic matter. When the impact of an object-energized element on an ego-energized boundary exceeds a certain magnitude, we become aware, hence, conscious of it. This depends both on how highly energized the object is and how highly energized the ego boundary is. We can become aware of strongly energized (energized objects) even if the ego boundary is lightly energized and the impact of a low-energized object may become conscious if the receiving ego boundary is highly energized. If you stroke my hand lightly, I may not feel anything. If you slap it strongly, I become aware of the touch. As you develop a highly tuned listening, ego boundary, hence, a sensitive third ear (Reik, 1948), you may become quite
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aware of an unconscious and symbolic communication from your patient, which the more obtuse practitioner will completely miss. Introjection and identication depend on the allocation of object or ego energies. When I introject an outside personperhaps my fatherI have erected a mental image, a replica or representation of my father based on my perceptions of him. This introject is an object because at this time it is invested with object energy. If my father was a critical person, at the time that I introjected him, I will feel (perhaps unconsciously) the lash of his criticism within which I may simply experience as depression. It, a notme, is critically and harmfully impacting the me. There may also be an introject of a partner, or friend. These are always persons who are, or least have been, meaningful at some time in your patients life. The patient is frequently astounded at the emotions they experience while an introject is executive, yet by such experiencing in the rst person the patient develops a better understanding of that introject and their limitations. Introjects are not ego states. They are not part of the patients personality, yet, they can be treated in much the same way as an ego state is and perhaps most importantly they can change to bring greater health to the patients adaptability and functioning in life. Introjects can be scary, abusive, and threatening, or kind and helpful. As Emmerson (2003, p. 12) points out, when the signicant person in the persons life was benevolent, an introject will then also be benevolent. However, an introject that had been internalized as cold and scary may, through ego state negotiation, become warm and caring. Thus, as we will discuss later, it is frequently helpful for ego states to be encouraged in therapy to express themselves as introjects. The hypnotized client can express feelings toward the malevolent introject by being encouraged to speak to those interjected emotions and told, What you did to me was wrong! No doubt you will have at one time heard the phrase, If you cant beat em, join em. Psychodynamically, we call it identication with the aggressor. For example, let us say you are employing ego state therapy to treat a borderline personality disorder. You know the disorder was developed in your patient due to abandonment of a signicant other, usually a parent. The child xates at the age at which the abandonment occurred and internalizes the concept that they deserve to be abandoned as they must have been bad. Accordingly, to escape from the internal criticism, which as in the previous case may have been expressed as depression, I may identify with my father. Hence, a common choice in borderlines is in choosing a series of psychologically or physically abusive, controlling signicant others. What happens here is that I remove the object from this representation and invest it instead with ego energy. I infuse the representation with the feeling of selfness. The introject is no longer a not-me object but instead has become part of the me. I experience it within myself. I am no longer depressed by my fathers introjected criticisms; but I am now critical of my own children.
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The content of the introject has not been changed. It has now become an identofact, a part of my self. I have become like my father, and the neighbors say, He is just like his father. In so identifying with such a signicant other, your patient becomes sicker and less able to adapt in any overall sense, thus, mature functioning and healthy adaptation is precluded. In object relations terminology we might note that what had been an object representation has now become a self representation. (At rst, the patient sees the serious problems in the individual and then becomes just like that individual.) This same maneuver is possible with hypnotic intervention through hypnotic suggestion. Ego and object energies can be manipulated therapeutically to the benet of the patient (subject-object techniques are reviewed in Barabasz and Watkins, 2005, pp. 49 and 177, and elsewhere in that volume). The object relations and interpersonal process theorists are sometimes difcult to understand because they often confuse introjects and identications. Kohut (1977), for example, appears to dene the term of what earlier analysts called introjects of signicant others, which at rst are objects but later are changed into identications. He believed that such entities are necessary even in adaptive mature adults. In Federns Ego Psychology, the term self-object is contradictory. A representation of a signicant other constructed within the individual will either be activated by object energy, like an introject, as previously discussed, or energized by ego energy, like an identication. The childs merger with such self-objects may be gradual; a representation cannot be both self and object at the same time since this is determined by the quality or nature of the activating energy. It cannot be experienced as me and as not me at the same time.
HYPNOSIS AND ENERGIES

Hypnosis emerges as the key modality for moving and changing of energies when formulating treatment plans for your patients on the basis of object and subject energies. One hypnotically suggests to a patient that he or she is now able to move a hysterically paralyzed limbthis may happen because ego energy has now been invested in it, changing it from object to subject, hence, bringing it within the self and back to the patients voluntary control. Similarly, by hypnotically moving more object energies into a circumscribed repressed memory, it becomes strong enough to impact the ego boundary so as to render it conscious. Energies can also move into an object or process whenever we simply pay attention to it. Federn did not employ hypnosis in his treatment, yet he foreshadowed its use in Ego State Therapy. Eduardo Weiss, in his introduction to Federns book (Federn, 1952a, p. 15), wrote, Ego states of earlier ages do not disappear, but
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are only repressed. In hypnosis, a former ego state containing the corresponding emotional dispositions, memories, and urges can be re-awakened in the individual. This was a rather profound statement for that era. If a hypnotized participants hand is made to wag up and down (Barabasz & Watkins, 2005) without conscious control, we have simply removed its ego energy. It is anesthetized and apparently not within the control of the amused subject. Its movement is now object energized. The wagging can become voluntary only if it is ego energized. Hypnosis thus becomes a very powerful therapeutic modality for altering ego and object energy changes within our patients.
PSYCHOSES AND EGO ENERGIES

Federns most signicant contribution stemming from his two-energy theory was in the understanding of psychotic symptoms and the psychotherapeutic treatment of the psychoses (see Federn, 1952a, chs. 612). Federn characterized a hallucination as a pseudoperception. The schizophrenic actually sees, hears, or otherwise senses something that does not really exist in the outer world. To the psychologically ill patient these perceptions appear to be quite real, as can be well veried by the clinician who tries to persuade the client otherwise. Yet, the stimuli from these pseudoperceptions arise from within the patientthat is, the patients own inner cognitions. They represent ideas that are normally experienced as subjectthat is, as stemming from ones self. The psychotic, however, experiences them as object and similar to other outside objects that he or she sees, hears, or otherwise senses. How can thoughts be turned into perceptions? Federn hypothesized that psychotic patients sense the contents of their delusions and hallucinations as real because they originate from repressed mental stimuli that entered consciousness without obtaining ego energy, not because of faulty reality testing as graduate students are frequently taught and many in our eld assume. The problem is in the weakness of the ego boundary. Like a geographical boundary, such as that between two countries that is inadequately patrolled by border guards, citizens can be mistaken for aliens and vice versa. In the psychotic, the inability to test reality adequately results from an energy deciencya lack of sufcient ego energy to patrol the ego boundaries, where the differentiation must be made for normal adaptation to the outside world. Federns approach was intended to help the patient build more ego energy. That, of course, is precisely what we do with relationships, supportive therapy, exercise, and so forth. In the implementation of such an approach, Federn often (please consider the era of the mid1900s) used a nurse, a mother-surrogate, who could provide the nurturing relationship normally received from ones mother (Schwing, 1954). The mother gure is critically important because her nurturing in developing self-identity and stable object representations, which Federn and Schwing
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had been emphasizing, has currently begun to receive more attention. The signicance of mothers as transitional objects in the development of self structures in infants has been increasingly recognized (Baker, 1981; Barabasz & Christensen; 2006 Christensen, Barabasz, & Barabasz, 2009). Baker (1981), Copeland (1986), and Murray-Jobsis (1984) have employed many of these same concepts in treating psychotics within the hypnotic modality with remarkable positive and lasting outcomes.
REALITY A REALITY B
Now what was happening here is that Federn, and especially his disciple Weiss (1960), stressed the distinction between reality testing and the sensing of reality. We sense reality as something outside our self whenever an objectenergized item impacts an ego boundary. However, to test reality we need to use our eyes, ears, and body and note that the sensed object moves its relative position accordingly. The schizophrenic, for example, fails to take this action, relying instead entirely on his or her weakened ego boundary in a desperate attempt to distinguish real from unreal, thoughts from perceptions. Federn reported that there is a felt difference between an impact of an object on the inside of the egos boundary and its outside, that which interacts with the external world. If this is also true, there would have to be a change in the magnitude of the impact. The psychotic then would be able to experience this reality of his or her reported experience when it is explained to the patient that there are in actuality two kinds of reality, reality A and reality B. The idea here is to enlist the patients cooperation rather than the patients antagonism when being confronted with reality as if they were being accused of lying. What might said to the patient is, When you see me here I want you to label that reality A. When you see or hear those people who are persecuting you, I want you to please call that reality B. Now reality A is a kind of experience you can share with others around you because they, too, are aware of reality A. However, reality B is a private reality, which they cannot share. If you talk to them about reality B they will think you are crazy! Please do this, when you describe to me any experience, tell me, at least for now, whether it is reality A or reality B. Testing this remarkable intervention with numerous psychotic patients, Federn concluded that psychotic patients could, indeed, distinguish between reality A and reality B even though both were experienced as real. By teaching these patients to make this discrimination, he was exercising, strengthening, and re-energizing their ego boundaries. In time, these patients made this distinction. By not reinforcing reality B, the hallucinated reality was deenergized. Reality B was then returned to the world of nocturnal dreams, wherein lie the consciously inactive hallucinations of normal people. By reducing the energy in reality B, its impact with self-boundaries became lower than the threshold necessary to become conscious.
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By positing a two-energy system, Federn provided a new rationale to explain many psychological processes that cannot be satisfactorily accounted for by Freuds one-energy (libido) system. For example, if a thought of my dead mother crosses my mind and reaches consciousness, but is activated with object energy, I will experience it as a perception of my dead mother. I will see her. And, if I report this perception as real, others will say I am psychotic and hallucinating. Years ago, John G. Watkins was trying to explain the mechanism of projection to a paranoid patient. As we all know, that is usually a futile task. Much to his surprise, the patient smiled and said, Well doctor, if you are trying to tell me that those men who persecuted me were a product of my own imagination, you don t have to. I arrived at that conclusion my self over the weekend. In utter amazement, Watkins spent some time evaluating him before accepting that his delusions and hallucinations had disappeared. The patients own unconscious hatreds externalized into a perception of men out there who were persecuting him, had been deenergized of object energy, and were now energized with ego-energy. He experienced them as his thoughts and not his perceptions. The critical point I am trying to make here is that a one-energy system would not give us an adequate explanatory rationale even though psychodynamically we are still unaware of just what caused this energy shift. Psychologists and psychoanalysts frequently confuse subject and object. Thus, an introject is supposed to be an internal object. Yet, analytic writers portray a patient as introjecting another person when they describe that individual as acting and talking like the other person. The image of the other, when internalized, is at rst invested with object energy. That is why it is an internal object. An introject is like that submarine sandwich you ate one late evening that lies in the stomach ready to resurface at midnight. It is within the self but not part of it, ingested but not digested. For the individual to act and talk spontaneously like any other, the object energy must be withdrawn and ego energized. In object-relations theories, we would simply say that the object representation has changed into a self-representation. Then we no longer have an introject; we have an identofact. The internalized has become part of the me. For example, a teenage girl in love imitates the behavior of her boyfriend, eating what he eats and regressing to earlier behaviors by acting as immaturely as he does. This action is at rst an introject of that same-age immature boyfriends behaviors. Eating like him, behaving like him, and taking on his views are simply internal representations of the boyfriend, copied but not part of her own self. However, in the course of time, it may become automatic. The behaviors have become egotizedthat is, invested with ego energy. It is now part of her own self. Her same-aged but now more mature girlfriends watch her behaving like her boyfriend does and are amazed. If he lacks future goal directed plans, she too loses focus; if he is
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opinionated, bitter, or selsh, she is too. She has identied with her boyfriend. An identication with a previously introjected other may be minimal or signicant, depending on how much of the others physical attributes and or psychological behavior, as in the present example, is taken over. As Watkins (1978a) points out, an introject is the result of the process of introjection, and a new term is needed to distinguish between the process of identication and the result of that process. Consider our use of the word identication when referring to the process, and the term identofact to indicate the internal, ego-energized image that has been created by identication. The girl described herein has changed the introject, and object representation, of her boyfriend into an identofact, a self-representation. This distinction between what is subject (ego-energized) and what is not self (object-energized) in physical and psychological processes is crucial. The movement from one to the other is fundamental to the practice of ego state therapy, as well as many other treatment approaches.
PERSONALITY DEVELOPMENT: INTEGRATION AND DIFFERENTIATION

Personality develops through two basic processes, integration and differentiation. By integration, a child learns to put concepts together, such as cow and horse to build more complex units called animals. By differentiation, he or she separates general concepts into more specic meanings, such as discriminating between a cat and a rabbit. Both processes are normal and adaptive. Normal differentiation permits us to experience one set of behaviors at a party Saturday night and another at the ofce Monday morning. When this separating or differentiating process becomes excessive and maladaptive, we call it dissociative identity disorder. When we differentiate two items, both of which are consciously in mind, we can compare them and note their differences. In dissociation, the two items are so separated from each other that comparison is not possible, since only one is within consciousness at any given time. Both differentiation and dissociation involve the psychological separating of two entities, but differentiation is lesser in degree, generally adaptive, and considered to be normal. Dissociation, on the other hand, is considered to be pathological. It may be more immediately adaptive to cope with the stress of a specic situation, but often at the future expense of greater maladaptiveness. Differentiation and dissociation may be considered as simply resulting from different degrees of the separating process.
EGO STATES
To understand the nature of ego states one must consider their origin. Most frequently, they were rst created when the individual was quite
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young. They think concretely like a child. Because of the emergence of primary process thinking as produced by hypnotic age regression (Barabasz & Christensen, 2006; Christensen, Barabasz & Barabasz, 2008), adult logic, therefore, may not reach them, even though they often talk in an adult voice. It is as if they were frozen in time. Covert ego states, unlike the alters in a true multiple personality (DID), require hypnosis for their activation. But, if they rst originated when the patient was a child, then one should think of them like a small girl who is dressed up in her mothers clothes and pretending to be an adult. The ability to think concretely like a child has been lost by the majority of adults, and thus we are at a disadvantage in dealing with child ego states, especially when they are not so clearly differentiated as true multiple-personality-like alters. States that were created during the patients teens will still think like a teenager, rejecting and suspicious of grown-ups and very defensive of their own (pseudo) independence; they do not want to be told what is right or what they ought to do. This characteristic is illustrated in the case excerpts (see Watkins & Barabasz, 2008). When working therapeutically with child and adolescent states, one should conceptualize to whom one is talking and conduct the interaction accordingly. The clinician or counselor who resonates well will have the greatest probability of success. Be mindful that a child ego state was developed to adapt to the conditions of days gone by, not today. Its attempts to function today result in maladaptive behaviors (short-sighted present rather than future-oriented actions). As one inquires and secures information about the time and circumstances when an ego state rst appeared, ones approach can be modied accordingly, even though one is confronted ostensibly with a full-grown adult. This modication can be done, without embarrassment, by the use of hypnosis. The psychotherapist interacts as one would with a child when the patient is hypnotized. Bear in mind that an ego state was most likely developed to enhance the individuals ability to adapt and cope with a specic problem or situation in the past. Thus, one ego state may have taken over the overt, executive position when dealing with parents, another on the playground, another when dealing with a signicant other, and yet another when participating in a sporting event, and so on. In the case of dissociative identity disorder, which is manifested by the presence of true multiple personality alters, the specic situation is usually some very severe trauma such as child abuse or traumatic abandonment. The ego state forms to help in dissociating the pain from the primary alter or to make it easier for the major personality to deal with an abuser (controller) without inviting retaliation. It is to be expected that these specic ego states will be reactivated in the transferences of the present, such as to teachers, employers, supervisors, mentors, colleagues, and, of course, therapists (Watkins & Barabasz, 2008).
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A common trait is that once created, ego states are highly motivated to protect and continue their existence. The clinician who tries to eliminate (kill off) a maladaptive state will nd to his or her dismay that the entity probably does not want to disappear, but that ones intervention has now created an internal enemy who resists therapeutic intervention. Part-persons seek to protect their existence, as do whole-persons. This tendency also has important implications in the treatment of dissociative identitydisordered patients. Perhaps the most important point to remember is that it is much easier to modify the motivations of malevolent and maladaptive ego states and their behavior constructively than to attempt to eliminate them. Persistence in existence is to understand that the original ego state came into being to protect and facilitate the adaptation of the primary person. It remained because it had a certain amount of success. It was positively reinforced, rst for coming into existence, and then for continuing its presence. It makes no difference whatsoever that now its efforts may be contra productive to the person. The earlier adaptations, which are now maladaptive, will hold precedence. First, we must familiarize ourselves with the differences in the environment of the patients past and that of the present. We cannot generally induce a state to change into an adaptive stance toward current adult problems when the treating counselor or clinician does not understand its earlier struggles. Recognition of these traits is essential in the planning and conduct of effective therapeutic maneuvers such as abreactions (Barabasz, 2008a,b,c). When working with ego states, the internal equilibrium of the patient will change in such a way that a new ego state, or one that has been long dormant, will be energized and make itself known. This state may rst manifest itself by slight changes in posture, mannerism, or voice pitch. Using the explanatory value of Federns two-energy theory makes it easier to understand. The nature of the past problems helps us to determine the creation and energies of the various states. The adaptational needs of the present must be met with the appropriate dispositions of object and ego energies assisted by an understanding and accepting therapist. Hypnosis is the key modality that facilitates this allocation of subject and object energies. This treatment goal can be reached from a variety of orientations according to the clinicians primary training including behavioral, psychoanalytic, cognitive-behavioral, Rogersian, and existential therapies. Any such approach constitutes ego state therapy when the goal is appropriate dispositions of object and ego energies. Ego states that are cognitively dissonant or have contradictory goals often develop conicts with each other. When they are energized and have rigid, impermeable boundaries, multiple personalities (DID) may result. However, many such conicts appear between ego states only covertly, and these are often manifested by anxiety, depression, or any number of neurotic, maladaptive, and childlike behaviors.
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Ego states may be large, encompassing broad areas of behavior and experience, or they may be small including very specic and limited reactions. They may also overlap. For example, a six-year-old child ego state and a reaction to father ego state both speak the English language. They can range from minor mood shifts to true overt multiple personalities, the difference being the permeability of their separating boundaries.
EGO STATE BOUNDARIES: THE DIFFERENTIATIONDISSOCIATION CONTINUUM

Psychological processes do not exist on an either-or basis. Anxiety, depression, immaturity, and so forth all lie on a continuum with lesser or greater degrees of intensity. So it is with differentiation-dissociation. On one end of the continuum, the boundaries are so permeable that they are almost nonexistent. The individuals behavior is very much the same from time to time. The difference that does occur is generally adaptive, and we call it normal differentiation. As the ego state boundaries become increasingly rigid, intrapersonal communication is impeded so that behavior becomes less and less adaptive. When we approach the end of the continuum, the boundaries are very rigid and impermeable, the behavior is maladaptive, and we call it dissociation. At this extreme end of the continuum, the various ego states no longer interact or communicate with one another and the individual suffers from a true multiple personality (dissociative identity disorder) if more than one becomes energized enough to assume the overt executive position temporarily. In between these extremes lies a body of ego states that may act like covert multiple personalities, but which do not spontaneously become overt. However, they can be activated hypnotically. The various states are conscious of the existence of one another but refer to the others as he, she or it, and not as me. This position on the differentiation-dissociation continuum represents a bordering (almost true) multiple personality and is not to be confused with the diagnosis of borderline personality disorder. The in-between ego states, because of the lesser degree of rigidity in the semipermeable boundaries, retain partial communication, interaction, and sharing of content. In general, they remain covert and do not spontaneously appear overtly, but they can be activated into the executive position by hypnosis. In this region, a conict between the states may be manifested by headaches, anxiety, withdrawal, passive aggressive, and other maladaptive behaviors, such as are found in the neuroses and in the psychophysiologic disorders. It is in this area where the most productive contributions of ego state concepts to psychotherapy have occurred. We are, therefore, concerned with a general principle of personality formation in which the dispositions of the activating energies
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and the impermeability of the boundaries separating the organized egostate patterns have resulted in relatively discreet personality segments that may alternate in assuming the executive position, experienced as the self in the here and now. The extreme form of this separating process, as noted before, can result in true dissociative identity disorders. For some time, true multiples were considered to be extremely rare. However, as recognized in the Diagnostic and Statistical Manual of Mental DisordersIV (APA, 1994) and in the more recent text revised (TR) edition, many reports of cases meeting full diagnostic criteria are now being presented. The disorder is still uncommon but it can no longer be considered rare. For example, borderline multiples are frequently misdiagnosed as borderline personality disorders. This is fairly common and particularly prevalent among females, and may be due to the higher frequency of abuse of females as children as well as gender-specic maladaptations to abandonment.
CHARACTERISTICS OF EGO STATES AND DISSOCIATIVE IDENTITY DISORDER

Ego states should be regarded as part-persons. Except in the case of true multiple personality (DID), they do not normally appear overtly unless hypnotically activated. There is far too much evidence to the contrary to impute to them simply as therapist-created artifacts since they often differ widely from therapist expectations. Some act like complete persons. Others appear to be very limited personality fragments, perhaps created for a specic defensive purpose. They may have quite differing interests, purposes, and values, even as do the various alters in a true dissociative identitydisordered personality. Obviously then it is not surprising to nd them often in intra-personal conict with one another, creating tension, anxiety, psychosomatic symptoms, the desire for ight, and other maladaptive behaviors. As one ego state put it, I make her eat because if she is over-weight men (who are dangerous) will not be attracted to her. Covert ego state conicts may create headaches just like the quarreling of multiple personality alters who struggle to emerge and take over executive control of the body.
EGO STATE THERAPY

Ego state therapy is the utilization of individual, family, and group therapy techniques for the resolution of conicts between the different ego states that constitute a family of self within a single individual (Watkins & Watkins, 1997, p. 35). Therapy involves a kind of internal diplomacy that may employ any of the cognitive-behavioral, psychoanalytic, Rogersian, or humanistic techniques of treatment but almost always uses hypnosis. These techniques are directed toward the part-persons represented by the ego states and not toward the whole individual. While it is possible to practice
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ego state therapy in the conscious condition (Emmerson, 2006), the use of hypnosis is the method of choice for most practitioners. This is because ego states, unlike true dissociative identity disorder (DID) alters, do not usually become overt spontaneously. Most of the time they require hypnotic activation. Through hypnosis we can focus on one segment of personality and temporarily ablate or dissociate away other parts. In fact, since hypnosis is itself a form of dissociation, it is not surprising to nd that good hypnotic participants often manifest covert ego state segments in their personalities even though they are not mentally ill. Hypnosis offers access to levels of personality that in classical psychoanalysis require much, much longer periods of time to contact. Since ego state therapy is an approach involving inter-part communication and diplomacy, hypnosis generally becomes an essential for practicing it when the states are covert. At times an ego state may be exerting an inuence as object on the primary individualin which case we might say, I would like to talk to that part (we dont use the term ego state with the patient) of Mary Anne who has been compelling her to overeat (or who knows about her overeating). A communication back from such a part commonly is the result. The content of this part is often at considerable variance with the therapists expectations, contradicting the notion that ego states are only artifacts created to please the therapist (a common argument posed by those who incompletely understand ego state therapy). Only being part-persons, ego states often think concretely like a child and must be communicated with accordingly. Sometimes ego states appear during sleep or in hypnosis-like dream gures. The same general strategies and tactics used in treating DID patients apply when working with the more covert ego states except that they must be preceded by a hypnotic induction.
EFFICACY RESEARCH
Much of the recognition of the efcacy of ego state therapy has been based on clinical experience rather than controlled research as evidenced by the acceptance of this approach at the First World Congress on Ego State Therapy held in Bad Orb, Germany, in 2003, and most recently in Kathmandu, Nepal, in 2008. Nonetheless, controlled research, although still in its infancy (Frederick, 2005), thus far indicates that ego state therapy is effective in assisting clients with both psychological and somatic symptoms. Using a time series analysis as the experimental procedure, Emmerson and Farmer (1996) found that women with menstrual migraines were able to experience not only a signicant reduction in headaches, but also a reduction in depression and anger. This occurred following a fourweek treatment with ego state therapy. The monthly average number of days with migraine went from 12.2 to only 2.5. Consistent with this
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decline in headaches was a statistically signicant decline in levels of depression and anger. The ego states text (Watkins & Watkins, 1997) reports on 42 clients who had received ego state therapy for a median of only 11 hours total treatment and those who had received other types of therapy with a median of 145 hours. Twenty-four clients said ego state therapy met their expectations, while only seven clients said the other therapies met their expectations. Gainer (1993) also reported very positive effects of ego state therapy. When trauma held by a child ego state was processed, there was complete remission of Reex Sympathetic Dystrophy (Ginandes, in press).
EGO STATES AND HIDDEN OBSERVERS

Little more than a quarter of a century ago, Ernest R. Hilgard was demonstrating hypnotic deafness before a class of students at Stanford University. As Barabasz and Watkins (2005) explain, to dissociate something one must rst be aware of it at some level, or as Martin Ornes trance logic conceptualization would dictate, you have to hear it or see it before its presence can be negatively hallucinated away. Given that understanding, let us get back to Hilgards fascinating demonstration. As he was about to invoke hypnotic deafness, a student in his class asked whether some part of the apparently deaf subject might be aware of what was going on. Hilgard then said to the hypnotized subject, although you are hypnotically deaf, perhaps there is some part of you that is hearing my voice and processing the information. If there is I should like the index nger to rise as a sign that this is the case. Much to Hilgards surprise, the nger lifted! Later, he discovered that individuals similarly reported being aware of pain (but without its sensation) in a hypnotically anesthetized hand. Hilgard ascribed this phenomenon to a cognitive structural system, which he called the hidden observer. Watkins and Watkins (19791980) conducted a set of experiments in which they activated hidden observers in former ego state therapy patients using the same procedures and verbalizations employed by Hilgard in his studies, repeating with both hypnotic deafness and hypnotic analgesia. What emerged were various ego states with which they had dealt in treatment over a year earlier. They hypothesized that hidden observers and ego states are, therefore, the same class of phenomena. To conclude this discussion, let us note the differences between Federns original conception of ego states and Watkinss view of them. To Federn, the ego remained a constant. Different contents could pass in and out if it by being ego-energized, which were then organized by the ego into the ego states. When an ego state was de-energized of self-energy, it retained its organization and continuous existence as an object representation. An ego state consisted only of self-energized items. In our view (Watkins &
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Barabasz, 2008), the self consists of pure ego-energy, not contents, such as motivations, affects, ideas, and so forth. This energy is not the energy of the self, it is the self. When this ego energy passes into contents, these are then experienced as part of the self; in other words, they are experienced as me. The movement is on the part of the self energy as it passes into and out of various organized behavior and experience patterns we call ego states. Such a state may contain both object and self representations, which on repression, removed from consciousness, still retain their respective and relative structures. Thus, this ego state, whether self or object-energized, is the unit to be dealt with in therapy. It takes on the character of the major amount of energy within it, ego or object, and is experienced by the individual as such, the me or less frequently as the it. Looking once again at the gure showing the differentiation-dissociation continuum, it is worth noting that hidden observers and other partially separated personality segments exist as ego states within the middle range.
EGO STATE THERAPY TREATMENT

The ego state therapy session typically resembles family therapy in that one member speaks, another is asked to respond, and an exchange of communications begins. Sometimes it is necessary to call on specic states to come out and speak. At other times they will emerge spontaneously so long as the hypnotic state has been adequately established. Sometimes no one will abdicate if pressed too hard, and another will appear. The important point is that the therapist thinks of it as talking to a multiplicity and not a unity. There is a single body in view but you are dealing with a family. What one says to one ego state may well be heard by others who can take offense and oppose ones treatment efforts. The counselor or clinician operates like a group therapist. Any therapeutic maneuver, such as reection, ventilation, desensitization, abreaction, free association, interpretation, reinforcement (approval), clarication, and so forth that is part of your armamentarium may be employed. These can be used within the basic theoretical orientation that you have been trained in. However, they are to be applied with the use of hypnosis and to the various personality segments rather than to the patient viewed as a unity. Sometimes the awareness of what has been done with an ego state may be brought to the attention of the conscious person. At other times, efforts will be made to strengthen some of the more constructive ego states. Occasionally, an ego state can be found that may serve as an assistant therapist, consulting with the clinician about strategy, advising of the effects of earlier maneuvers, and helping in planning future steps. We (Watkins & Barabasz, 2008) have taught ego states, who at rst were destructive, to become constructive. It is our job to try at all times to discover and meet the needs
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of each ego state. Where they are conicting, negotiation and compromise are indicated. Your role as a psychotherapist is frequently that of a communicator and a mediator between the clashing states. For example, George (a teenager ego state) was asked, Would you be willing to do your homework during the week if father (a parental ego state) doesnt bug you about playing on the weekends? Remember that ego states, like dissociative identity disorder alters, originated for defensive adaptive purposes during the persons critical developmental years and/or in response to trauma such as faced by soldiers in the Iraq wars, so they may no longer now be adaptive for the individual. As they were developed when the individual was a child and/or for immediate survival defense mechanisms, they do not serve well for normal functioning adults. It is, therefore, unwise to eliminate bad ego states. Rather, one can avoid much resistance if you treat all the ego states with the utmost courtesy and respect, secure their cooperation, try to meet their needs, and play the role of a good friend to each. Attempts to eliminate a state mobilizes much resistance that can sabotage treatment.
SUMMARY
Ego state therapy was derived from the study of multiple personalities and experiments with normal, hypnotized subjects within the general theoretical structure of hypnoanalysis. Hilgards hidden observers and the theories of Paul Federn served as an origin for its conceptual structure. However, we (Barabasz & Watkins, 2008) have elaborated on its original formulations and altered them in certain signicant areas based on our experimental studies and clinical experiences. It is essential to recognize that the separating function in the formation of personality structure, like almost all psychological processes, exists on a continuum ranging from normal, adaptive differentiations through defensive operations to maladaptive dissociation as exemplied in true dissociative identity disorder. Ego state therapy may use any of the directive, cognitive-behavioral, analytic, or humanistic approaches in treatment. But it applies these to personality segments, that is, part-persons, and not to the entire individual. Generally, it does so with the use of hypnosis since covert ego states do not typically appear spontaneously without having been hypnotically activated. The orientation here is hypnoanalytic ego state therapy. However, a therapist with a different theoretical orientation might prefer to practice a hypnocognitive ego state therapy, applying his or her interventions to part-persons (ego states) rather than to the entire individual. Ego state therapy is a very potent treatment procedure because it focuses on the specic areas of the personality that are most relevant to the presenting problem. This tactical advantage is valuable not only in dealing
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with the occasional true multiple personality, but extending to the vast array of neurotic, psychosomatic, and behavioral disorders ranging from simple stop smoking and weight reduction problems to severe phobic and anxiety cases. When used with skill, ego state therapy can provide approaches for handling borderline conditions in ways well beyond the scope of other therapies currently available or, for that matter, in any case where some measure of dissociation, mild or severe, is found.
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Chapter 3
Hypnotic Dreams
Deirdre Barrett
Hypnosis and dreams have much in common, as is reected in our language about them: Hypnosis is named for the god of sleep, phrases such as dream-like are scattered through hypnotic inductions and dream actions are sometimes described with words such as trance. Most references to non-pathological hallucinations refer to one or the other of these two states (Barrett, 1995). What they have in common is the coming together of the two major human modes of cognition: 1. The emotional, visual, irrational, hallucinatory, and intuitive mode of thought that Freud called primary process, recently termed right brain thought in popular literature (with only the loosest relationship to actual hemispheric specialization). 2. Logical, verbal, linear reasoning that Freud called secondary process, now popularized as left brain thinking. In deep hypnosis and lucid dreams (dreams in which the dreamer knows he or she is dreaming), these two processes are strongly manifested and integrated with each other. In deep hypnotic trance, the coexistence is achieved by starting in the logical waking state and introducing hallucinatory imagery; in a lucid dream it is achieved by starting in the primary process/hallucinatory mode and introducing secondary process logic. Although lighter hypnotic trances and normal dreams are characterized by more secondary process and more primary process respectively, they still involve a degree of coexistence of both modes not seen in most other states of consciousnessnormal waking is mostly secondary process, psychosis is mostly primary process, and non-dreaming sleep shows very little of either. So hypnosis and dreaming already share much in common, but there is one area of interaction that is especially rich for these overlapping of modes of thought.
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THE HYPNOTIC DREAM

A variety of hypnosis-related phenomena are sometimes referred to as hypnotic dreams including nighttime dreams inuenced by posthypnotic suggestions and fantasies occurring spontaneously under hypnosis. This chapter will reserve the term for its most common usagethe result of an explicit direction to have a dream while in a hypnotic state. However, Ill return to some of these other potential relationships between dreaming and hypnosis in the last section. The hypnotic dream was advocated as a therapy technique by many early psychodynamic hypnotherapists such as Milton Erickson, Jerome Schneck, Merton Gill, Margaret Brenman, and Erika Fromm. Erickson (1958) described a procedure he called the rehearsal technique in which he had a patient repeat over and over again a dream with the implied freedom of redreaming it in different ways. He believed that this served the dual purpose of progressively deepening the trance and of gaining insight into, and working through of, unconscious conicts as the dream is reissued in less and less censored versions. For example, Erickson cites the case of a patient who had reported a dream in which he was in a pleasant meadow among comfortable warm hills. At the same time, the patient experienced a strong desire for something unknown and a paralyzing feat. On further elaborations, the locale changed to a valley with a little stream of water owing under a horrible poisonous bush. Again the dreamer continued to look for something, while feeling terribly frightened, and getting smaller and smaller, as he was terrorized by the unknown that was pushing closer. In the next repetition, the dreamer was a lumberjack picking up logs owing down the river, and every time he obtained a log, it turned out to be just a skimpy little rotten stick compared to the big logs of other lumberjacks. In the next dream, he was shing, and while everybody else caught big sh he only succeeded in obtaining a little sickly looking one that he was nally forced to keep. Further repetitions eventually resulted in the disappearance of extensive amnesias and conscious blocking, and thus enabled the patient to reveal without further symbolism his inferiority feelings connected with stunted genital development and to discuss strong homosexual inclinations. Sacerdote (1967a) describes a similar use of hypnotic dreams for rapid therapy, but stresses the experience of the dream as inherently therapeutic aside from any interpretation or insights gained from it. Some of his examples are very analytic and similar to Ericksons usage, while others involve an interpretation or breaking down of defenses. In the case of an obese elderly woman, she was told during the rst and only hour of treatment under hypnosis: The dream will now start; you will be telling me all about that dream. In the dream you will see yourself having some very pleasant experiences, nice and slim as you want to be. What the dream will really be all about, it will be your own affair.
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She reported the following dream: I am in Paris, and then on the Riviera, and I am dancing and dancing; and then I went shopping, and ho! It is so wonderful; to get into clothes, size 10, and I had such a wonderful time. A second dream the same hour ran: Oh, it is so wonderful, so wonderful; to be thin! Now I am on the beach and people are saying, What happened? Who are you? I dont recognize you. I am just walking up and down on the beach and it is such fun; it is wonderful! Oh, I love the bathing suits!! I never could wear a bathing suit! Oh, that man! I do so want to go dancing tonight (Sacerdote, 1967a, pp. 116117). While the therapy was not quite limited to this one hypnotic session, it was after this one hour that she began to lose weight, becoming and remaining slim. In a further article, Sacerdote (1972) reported the successful treatment of a long-standing case of insomnia that was apparently due to a fear of having nightmares by carefully inducing controlled dreams that let conicts be expressed more gradually than in a full-blown nightmare. Gill and Brenman (1959) described the use of hypnosis both for the production of original dreams and for the continuation of night dreams. In their technique the patients are told that they will continue a dream where it left off and that its meaning will become clearer. They gave the example of a young soldier discharged from the army in a state of depression and anxiety. He reported a dream of walking up a mountain path leading to a cave and trying to look inside, but waking up before he could see in. Under hypnosis, the patient looked in the cave and saw a witch who then becomes his mother, someone who was still somewhat frightening. Eventually, he was able to climb up on her lap and rest there like a young child. He then got up and walked away as a grown man. This dream was accompanied by great emotional expression and seemed to relieve his depression and anxiety greatly, the authors seeing the abreactive effect of the dream in this instance being the main component. Berheim (1947) also stressed the abreactive effect of hypnotic dreams and offered an example in which he obtained good results by having a veteran go through a hypnotic dream about a real past traumatic memory of a battle and being wounded. He spoke out loud for himself and everyone else present as he reenacted the scene cathartically. Lecron and Bordeaux (1947) described how hypnotic subjects could be instructed to dream on any specic topic. In a therapy setting, they believed that two of the most useful specics were to have a person have a dream about their attitude toward a signicant person or to have a dream about why resistance had appeared in an analysis. They report that an interpretable dream usually results from these suggestions that frequently speed up the progression of therapy. Crasilneck and Hall (1975) reported helping a woman to nd a lost locket by suggesting she would have a dream under hypnosis that would reveal its location. She had a dream in which she was looking at rows of
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books. Upon awakening, she remembered she had been reading a specic book the night the locket was lost, went to her bookcase, and found the locket marking her place. Sacerdote (1968) described a group dream induction technique that he found helpful with patients who had trouble developing hypnotic dreams at rst. He hypnotized a group and began with the people who easily produced dreams and they reported them out loud. He found that those who have had more difculty dreaming can then, after hearing other dreams, begin their own dreams, which at the outset incorporate elements of the other patients reports but go on to represent the dreamers own unique material.
COMPARISONS OF HYPNOTIC AND NOCTURNAL DREAMS

These linear descriptions of the use of hypnotic dreams illustrate that it can be both an illuminating projective device for discovering conicts and a helpful mode for working through these conicts. How much the hypnotic dream resembles a more common therapy toolthe nocturnal dreamis a more difcult question. An early review of the hypnotic dream literature (Tart, 1965) observed, at that time, that there was a lack of research concerning the equivalence or differences of hypnotic dreams from nocturnal dreams. Tarts review covered 34 publications in the area, only 10 of which he characterized as recognizing a need for some comparison of hypnotic dreams to nocturnal dreams. Of 14 studies drawing conclusions about this issue based on either anecdotal observation or theoretical assumptions, 10 asserted that hypnotic and nocturnal dreams are the same and 4 indicated differences. It is quite clear that hypnosis is physiologically a waking state of consciousness rather than true sleep, although S. Kratochvil and H. MacDonald (1969) did nd that posthypnotic suggestions could be carried out during sleep, suggesting that hypnosis can be superimposed with physiological sleep if explicit suggestions are given for this. Chapter 4 of this volume reviews neurological correlates of hypnosis in detail. However, there are several physiological ndings specic to the hypnotic dream rather than characteristic of hypnosis in general. Two studies (Schiff, Bunney, & Freedman, 1961; Barrett, 1979) have reported that in highly hypnotizable subjects, hypnotic dreams are accompanied by movements that look indistinguishable from the Rapid Eye Movements (REMs) that accompany dreams during sleep. This raises the question of whether hypnotic dreams share any physiology with REM sleep. There is one physiological study comparing hypnotic dreams with other periods of hypnosis. De Pascalis (1993) reported Fast-Fourier spectral analyses of EEG readings from frontal, middle, and posterior electrodes placed on each side of subjects scalps during hypnotic dream suggestions and during a resting trance state. With posterior scalp
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recordings, during hypnotic dreams, high hypnotizables displayed, as compared with the rest-hypnosis condition, a decrease in alpha 1 and alpha 2 amplitudes. This effect was absent for low hypnotizables. High hypnotizables during the hypnotic dream also displayed in the right hemisphere a greater 40-Hz EEG amplitude as compared with the left hemisphere; this effect was also absent in low susceptibles. The majority of clinical writings on the use of hypnotic dreams are much more concerned with the degree of similarity of content and the psychological signicance of hypnotic and nocturnal dreams than with their physiological correlates. Sacerdote (1968), the leading proponent of the use of the hypnotic dream stated: I have accepted on the basis of my experience that dreams hypnotically or post-hypnotically induced are psychodynamically equivalent and at times physiologically identical to natural dreams and therefore therapeutically valuable (p. 168). Most of the clinicians dealing with this issue tended to agree on this equivalence; some state the assumption perfunctorily while others made elaborate arguments. Several theorists saw the equivalence as logically following from their theoretical concept of hypnosis. Fromm (1965) described their equivalence as resulting from both being primary process thought productions; she began her article Dreams are the Royal Road to the Unconscious. Freud was referring to ordinary nocturnal dreams but the same is true for the fantasies and dreams produced by hypnosis (p 119). Gill and Brenman (1959), while not arguing for an exact equivalence between hypnotic and nocturnal dreams, stated that since both hypnosis and dreaming are regressive states, this would facilitate switching easily from one to the other. They believed a person would be able to state unconscious conicts more sharply via hypnotic dreams than in a waking state. Schneck (1959) detailed his observations on the points of similarity between hypnotic and nocturnal dreams, stressing that all the same primary process mechanisms are employed: Hypnotic dreams may bear such close structural resemblance to nocturnal dreams as to be essentially indistinguishable from them. They may be simple or complex in concordance with the manner in which the patient tends to express himself in this fashion and in keeping often with the form and content of his spontaneous nocturnal dreams. The variety of dream mechanisms employed in the latter are evident in the former and the analysis of hypnotic dreams are often therapeutically benecial. . . . Symbolizations, condensations, displacements and substitutions, representations by the opposite and a broader array of mechanisms are readily discernible. (pp. 156157) In another article, Schneck (1966) discussed the frequent arguement that hypnotic dreams are short, simple, and non-symbolic compared to the stereotype of intricate nocturnal dreamwork. He pointed out that in
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actuality, real nocturnal dreams also show this wide range of complexity. Schneck (1974) gave examples of the same individuals hypnotic nightmares (which occurred merely at the request for a dream under hypnosis) together with his nocturnal nightmares. Schneck concluded that both were structurally and dynamically equivalent, and that both dealt primarily with oedipal conicts the patient was working through in an analysis with the author at that time. Both types of nightmares seemed to yield an equal number of associations and interpretations by the patient. In two other studies, Schneck compared hypnotic dreams and nocturnal dreams with yet another category, the self-hypnotic dream, in which the subject would put himself into autohypnosis and suggest to himself that he would dream. Schneck found all three types of dreams were indistinguishable with respect to degree of activity, extent of embellishment, and nature of symbolizations. Furthermore, he found that all categories include sudden changes in locus, cast of actors, and types of action (Schneck, 1953). In another article, however, Schneck (1954) did allude to a difference he observed between hypnotic and self-hypnotic versus nocturnal dreams. He reported that in contrast to the nocturnal dreams, the two types of hypnotic dreams for one specic patient typically included lengthy conversational situations during which the patient spoke for herself or projected onto other various characters different points of view about immediate problems. Sweetland and Quay (1952) found that initial attempts at hypnotic dreams sometimes differed from nocturnal dreams but that after some practice, all subjects were able to produce dreams that they, the subjects, could not distinguish in any way from their night dreams. Mazer (1951) experimented with 26 subjects, giving them suggestions to dream while in hypnosis that specied that the dream would be symbolic, with a disguised meaning. He concluded that while all hypnotic dreams were not exact duplications of nocturnal dreams, differences were minimal. Mazer gave examples not only of the hypnotic dream but also of extensive associations and interpretations by the patients. He also reported a relationship between depth of the hypnotic trance and dream quality, nding that the more deep hypnotized the subject, the more symbolic and the more exactly like night dream was the hypnotic dream. Domhoff (1964) reviewed studies near the same time as Tart (1964) pointed out that all empirical studies up to that time had looked only at hypnotic dreams, making unsupported assumptions about nocturnal dream content. He argued that not all nighttime dream content t the stereotype. Domhoff suggested that hypnotic dreams likely differ no more from that stereotype than a representative group of nocturnal dreams from the same subjects might, and that the two categories could be equivalent.
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Shortly after that, Moss (1967) conducted a survey that shows a narrow majority of diplomates in Clinical and Experimental Hypnosis (created by the American Board of Examiners in Psychology) equated hypnotic and nocturnal dreams. He received 46 replies from 52 diplomates canvassed in response to the question of whether they viewed hypnotic dreams as similar in essential respects to nocturnal dream. The disagreement and uncertainty of these experts on the question is illustrated in the following distribution of his answers despite the majority agreement: Some authors did propose specic differences between hypnotic and nocturnal dreams on theoretical grounds. Kanzer (1953), on a theoretical basis, argued that the setting of the hypnotic dream is bound to make it different from a spontaneous night dream. He stated: On such induced dreams, the voice of the hypnotist takes the place of the days residues, his ideas shape the latent thoughts, his comments give rise to the dream wish (p. 231). Kanzer observed that dreams induced under hypnosis showed greater censorship than did spontaneous dreams. He also found that the form and imagery of the hypnotic dream were more typical of preconscious than unconscious mental activity. Brenman (1949) also assumed that the context of hypnosis must have a signicant effect on the dream. She stated: In spite of the many similarities to night dreams in the formal structure of the hypnotic dreams, it must not be forgotten that while the primary function of the night dream is to guard sleep, the motive power for the hypnotic dream derives from the need to comply, in so far as possible, with the expressed wishes of the hypnotist; thus to guard an interpersonal relationship (p. 458). She belittled the assumption that hypnotic instructions to dream will result in a real dream, saying this employed the same logic as assuming that a hypnotic instruction to y will result in real ight. She examined responses to the suggestion You will now have a dream and observed: By and large, these productions employ primary processes more than does normal conscious, waking thought but less than does the typical night dream described by Freud. It might be said that often the hypnotic dream is a kind of second-rate poetry compared to this tight, complex outcome of the dreamwork. Thus, although a wide range of phenomena appears, it may be said, for the point of view of the formal qualities, that the average hypnotic dream takes a position which is intermediate between the conscious waking day-dream and the night dream (p. 457). Barber (1962) and Walker (1974) took a more extreme positionthat the hypnotic dream is exactly the equivalent of a conscious waking daydream. Barber asserted: the hypnotic dream: is typically an unembellished imaginative product containing very little evidence of dreamwork. In some instances it consists of straightforward previous happenings or of
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former night dreams; in the majority of instances, it consists of banal verbal or marginal associations to the suggested dream topic (p. 218). While Baber admitted he had occasionally seen hypnotic dream accounts that appeared to resemble nocturnal dreams, he offered the following three explanations for this resemblance: 1. They came from sophisticated subjects having great familiarity with Freudian dream theory who were likely to apply this to conscious productions. 2. Hypnotic dreams published in the literature were a few atypical ones selected from a large sample of failures. 3. The experimenters either implicitly, or explicitly, have given the expectation that they want their subjects to come up with elaborate symbolization. Barber concluded by saying: even with dreams suggested to deeply hypnotized subjects, it is difcult if not impossible to differentiate these from the imaginative productions of non-hypnotized controls who are instructed to imagine scenes vividly or to make up dreamlike material (p. 219). Walker (1974) wrote: A more useful way of conceptualizing the hypnotic dream may be to see it as qualitatively no different from the response a person gives when simply asked to have a fantasy. . . . It is time that the knowledge about the hypnotic dream be integrated into the broader area of fantasy. Walker did not believe the hypnotic dream can be appropriately used in therapy in the manner a night dream would be interpreted. Instead, she suggests it be employed more in the manner of Desoilles (1965) Directed Daydreaming, that is, as a kind of guided fantasy with systematic relaxation. Tart (1964) found a difference in how easily nocturnal and hypnotic dreams could be inuenced by topic. He had good hypnotic subjects listen to a tape-recorded narrative and told them to dream about it upon falling asleep that night and to have a dream about it immediately under hypnosis. Hypnotic dreams were found to conform much more closely to the narrative, although sleep dreams were also inuenced. Several researchers enumerated different types of hypnotic dreams of which only one type resembled the night dream. Tart (1966) and Gill and Brenman (1959) both suggested four such divisions. Tart categorized responses to suggestions as: (1) simply thinking about something, (2) daydreaming, (3) vivid hallucinations like watching a lm, and (4) feeling bodily located in a dream world. He gave dream suggestions to both waking subjects and to those who had been through a hypnotic induction routine and then had them rate their own dreams as falling into one of these categories. A minority of
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subjects rated their experiences as feeling bodily located in a dream world even with hypnotic induction. There was also a positive correlation of dream vividness to depth of hypnosis as measured by response to other hypnotic suggestions. However, there was no correlation between dream vividness and having gone through the induction routine. Tart criticized other studies on hypnotic dreams for dening hypnosis as having gone through hypnotic induction procedures; he believed it was more rightfully judged by the subjects state of consciousness. Gil and Brenman (1959) distinguished four different types of productions issuing from the hypnotic instruction to dream. They were: 1. The embellished reminiscence. 2. The static pictorial image. 3. The quasi-allegory (which they described as resembling a conscious daydream but including in a rather obvious and primitive fashion some elements of unconscious symbolism). 4. The quasi-dream (which they said taken out of context is often indistinguishable from a night dream). They found that analyzing all categories of productions was helpful in therapy, but did not conclude that even the fourth category is the exact psychodynamic equivalent of a night dream. Spanos and Ham (1975) studied the characteristics of hypnotic dreams, working largely from a Barber-style theoretical orientation. They used 49 female student nurses at Medeld State Hospital (where Barber taught) as their subjects. All subjects were administered the Barber Suggestibility Scale (Barber, 1969) in a group setting. Their hypnotic dream reports, one per subject, were transcriptions of their verbal responses in an individual hypnotic session. Following the dream session, all subjects rated the extent to which they (1) became involved in their imaginings, and (2) experienced their imaginings as an involuntary process. Furthermore, two judges independently rated the transcribed dream protocol of each subject for imaginative involvement. Judges also rated the dream protocols of 30 subjects for implausibility, fearfulness, and fragmentation. (The remaining 19 subjects had reported that nothing happened in response to the suggestion to dream.) Subjects self-ratings of dream protocols for involvement correlated highly with one another. Both involvement measures also correlated with self-ratings of involuntariness of imaginings and with Barber Suggestibility Scale scores. The main emphasis, however, was upon how little dreamlike quality was involved in the hypnotic dream reports. Nineteen subjects experienced nothing, and of the remaining 30, the authors noted that: for the overwhelming majority of these subjects a hypnotic dream consisted of a
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plausible, non-fragmented, non-fearful, imaginary story (Spanos and Ham, 1975, p. 47). The authors did mention that a few subjects reported imaginings that were implausible, fearful, and/or fragmentedanother experimenter might have said more like nocturnal dreams, although they did not put it in those terms. Spanos and Ham concluded by stressing a signicant point: the often overlooked vast individual differences in response to the same instruction to dream. They also concluded that hypnotic dreams were much like waking thought processes, without taking into account the brevity of the induction and instruction procedures or the biases of the people involved. The experimenters, and quite possibly the nurse-subjects, were already rm believers in Barbers idea that hypnotic phenomena should not viewed as something different from waking consciousnessthe opposite bias of most researchers in other studies. The one study that did in some way compare hypnotic and night dreams empirically was one by Hilgard and Nowlis (1972), however, they used different groups of subjects for the two categories of report. They collected hypnotic dreams in the course of administering the Stanford Hypnotic Susceptibility Scale, Form C (Weitzenhoffer and Hilgard, 1962). One step on this scale is an instruction to have a dream about the meaning of hypnosis specically. Once the dreams were collected, Hilgard and Nowlis had subjects rate their own dreams on a three-point scale of vividness, counted the number of words in the dream accounts, and using Hall and Van de Castles (1966) system, scored the number and categories of human characters in the dreams. They found 63 percent of their subjects rated their dreams as vivid as night dreams, 33 percent rated them like watching a movie, and 4 percent rated them like thinking or daydreaming. In order to compare these results to night dreams, Hilgard and Nowlis used the data of Hall and Van de Castle (1966) who had collected nocturnal dreams from a variety of subjects, including university undergraduates and prisoners. They were not well matched with Hilgard and Nowliss subjects on age, geographic region, hypnotic susceptibility (on this potentially crucial variable, Hilgard and Nowliss subjects were selected to score higher than the general population), or most other variables. The specication of the dream topic of the hypnotic dream only also negatively affected comparability. Hilgard and Nowlis acknowledged this as a rather unsatisfactory procedure, but characterized it as a pilot study that might indicate any gross differences among hypnotic and nocturnal dreams. Hilgard and Nowlis did report several marked differences. Their hypnotic dreams were much shortera range of 13 to 238 words as compared to 50300 for nocturnal dreams (though they failed to note that Hall and Van de Castle had tossed out dream reports under 50 words as too short to meaningfully score). The hypnotic dreams averaged 1.3 characters instead of the 2.6 Hall and Van de Castle reported for nocturnal, and the hypnotic
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dreams had fewer relatives as characters. The hypnotic dreams were also characterized by the authors as having more Alice-in-Wonderland, psychedelictype distortions. They did feel they were quite similar to nocturnal dreams in many ways and concluded that they are best considered as projective products falling somewhere between the Thematic Apperception Test (TAT) stories and night dreams. A comparative study by Mixer (1961) reported no differences on reality orientation of deep trance subjects hypnotic dreams versus night dreams. In his study, experienced clinicians independently rated the degree of reality orientation expressed in each dream as impossible, improbable, or probable. Mixer interpreted the lack of signicant differences in the two sets of data as indicating that there is not difference in the degree of realism shown in hypnotic and nocturnal dreams of the same subjects, when their hypnotic dreams occur in a deep trance under conditions which duplicate night dreaming as closely as possible. Mixer did not use a medium trance group or draw any conclusions about whether hypnotic and nocturnal dreams would show the same reality orientation for them.
CONTENT OF HYPNOTIC, NOCTURNAL, AND DAY DREAMS FROM THE SAME SUBJECTS
This author undertook a study to explore how the content of hypnotic dreams, nocturnal dreams, and daydreams from the same subjects resembled or differed from one another and what depth of trance might play in this (Barrett, 1979). Sixteen university undergraduates, equally divided by both gender and capacity to achieve a medium versus deep trance by Davis and Husband (1931) criteria, were selected. No light trance group was included, as Hilgard (1965) has determined that a successful response to a suggestion to have a hypnotic dream falls near the beginning of the medium trance ranking. Subjects ages ranged from 18 to 26 years. During a six-week period, subjects were asked to write down the rst three nocturnal dreams they remembered each week and their rst three fantasies of daydreams in as much detail as they remembered. Once a week, the subjects were hypnotized and instructed three times during the session to have a hypnotic dream. After theses sessions, they were asked to write down everything they remembered of the hypnotic dreams. A few subjects failed to remember some of their dreams, so the total collected was 285 hypnotic dreams, 285 daydreams, and 277 nocturnal dreams. All types of dream accounts were rated on scales from the Hall and Van de Castle rating system developed for nocturnal dreams. These included a three-point scale for settingpredominantly indoor, approximately equal, more of dream outdoorsand two-point scales for presence of certain types of charactersmales, females, family, acquaintances, and strangers. Characters were recorded only for categories on which they were scorable.
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For instance, someone appeared only in the total, not by gender and acquaintanceship categories. A relative would appear in the family category but not in the gender categories. Other Hall and Van de Castle categories scored were two-point scales for hostility and friendliness on the part of other characters, and themes of anger, fright, sadness, happiness, or sexuality on the part of the dreamer. Reports could be scored as having none, any, or all of these characteristics present. For example, the following hypnotic dream report was rated by both raters as containing anger, fright, and sadness on the part of the subject: I was in a boat alone on the lake. I was mad about something and was trying to drive away from it. I drove the boat until I saw an old man on the shore. I stopped and we went into his cottage and ate. We laughed until I was no longer mad. When I left it was dark. I couldnt see my way home so I stopped the boat. I looked straight up. The boat began to spin one way and I spun the other way. What little light there was closed in to a tiny circle and shot over to the left and disappeared (Barrett, 1979a). Other variables in addition to the Hall and Van de Castle system were used. Since the distinction of logic versus primary process thinking was often written about in the hypnotic dream literature, all categories of accounts were rated on a three-point scale of distortion and illogical sequence versus coherence of story line. The following hypnotic dream was rated at the distortion end of the scale by both raters: I am standing on a beach or an island in the South Pacic. I turn around and notice that a group of people are chasing me. They chase me all over the island until I am trapped at the edge of a cliff which faces the ocean. I know that if I jump I will not be killed but still there is some fear of dying. Finally I jump off the cliff and into the water. Upon hitting the water I slowly oat to the bottom of the ocean. When I get to the bottom I see a big orange sh which asks me what I am doing there. I tell the sh that I have come to learn. The sh then tells me that I am not ready and that I should go back. I then begin to oat back up to the surface. [The dream ends.] The following hypnotic dream was rated by both raters at the straight story line end: I was somewhere with my girlfriend and we were talking about her going away to that school. I was mentioning that I didnt want her to go away to that school. But I told her that I understood that she had to go where shed be happy. And she turned all emotional and started crying and told me she was glad I was so understanding. And then she kissed me on the cheek and left to go inside. (My girlfriend was, in fact, up looking at this school the weekend I had the dream.)
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Dream reports were rated on a three-point scale of activity versus passivity on the part of the dreamer. Passivity sometimes involved the dreamer being present in the dream but inactive, as in the following hypnotic dream scored passive by both raters: Im at a striptease show. The main attraction comes out, and my friends and I cheer. She comes out dancing and wiggling about. Suddenly she pulled out a gun and began shooting people in the audience, yelling about male pigs and getting revenge. We are all in a daze under chairs, but then she lays down her gun and nishes the dance. Also rated as passive were dreams with the subject absent such at this nocturnal dream: There were some horses running in a eld. They were being led by a white stallion. This Stallion was very big and powerful. He kept running faster and faster. Until he began to y. Then all of them were ying. They ew to the north till I couldnt see them. As an example of a dream rated as very active by both raters was the following nighttime dream: Im lying in my bedand hear sudden screams outside on the dimly little street. Being on the second oor, I jumped up and looked out and saw a woman being raped by a gorilla. Thinking I was awake, I ran outside and threw a paper cup at him and he fell over dead. I then jumped back up into my window and went back to bed. The presence or absence of two other characteristics, unembellished memory and realistic planning, were rated on a two-point scale. An example of a report scored as unembellished memory by both raters was this hypnotic dream: Images from a more recent event, spring break. Flying with my uncle in his Cessna Cardinal, four-seater aircraft. Vivid image of him, some feel of the place, interesting, exciting. Could look out the window and see the ground below clearly. Farms, wooden, white farm houses, roads, woods, ponds, elds, fences. An example of a daydream report scored as realistic planning by both raters was: The thought of getting a new stereo system has loomed across my mind quite often. Since I had never owned one, I was excited about getting one. It would be a Marantz or Pioneer cassette player-receiver. I seldom think of any other kind. These ratings were done by two raters who did not know what type of dream a given report was. One rater did all 847 dream reports; the second rated one-third of the dream reports, equally distributed over subjects, style of dream, and week of experiment. Rater reliability was calculated for these 285 reports. High reliability was obtained, with rater agreement ranging from 92 to 100 percent for the different characteristics. The rst raters scores were then used for the statistical analyses. In addition, length in words was counted for all types of accounts by rater 1. In two pre-experimental sessions, consistency of trance depth and rater agreement on visual observation of REM were checked. Subjects were found to be consistent in depth of trance reached, and raters agreed
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100 percent on whether rapid eye movements were present for these 96 hypnotic dream periods (16 subjects 2 sessions 3 dreams). During the experimental period, the presence or absence of REM accompaniment during hypnotic dreams was noted by the experimenter only. The ratings of each type of dream were averaged for every subject. Wilcoxon matched pairs signed ranks tests were done for all characteristics between the three types of dreams. In accordance with standard procedures for less than 25 pairs, Wilcoxon T scores were converted to Z scores for purposes of assessing statistical signicance levels. Table 3.1 presents mean ratings on each variable for the total group of subjects. Tables 3.2 and 3.3 report the mean ratings for deep and medium trance subjects, respectively. The categories of characters found in night dreams and hypnotic dreams were quite similar, and both differed from the characters found in daydreams. Table 3.4 presents Wilcoxon scores transformed to Z scores for these differences, which shows them to be significant. The greatest difference was that there were many more family members found in hypnotic and nocturnal dreams. There were also more strangers in them than in daydreams. There was a tendency for daydreams to average more acquaintances and fewer total characters, but neither of these trends achieved high statistical signicance. In terms of the total number of dreams that had any characters, the only signicant difference was that daydreams were slightly more likely to be totally without characters than were night dreams. Emotional themes were similar between nocturnal and hypnotic dreams and different for daydreams (see Table 3.5). In the medium trance group, there were some differences between nocturnal and hypnotic dreams too. Hypnotic and nocturnal dreams got signicantly higher ratings on anger, fright, and sadnesswhereas daydreams were higher on happiness. Night dreams received somewhat higher ratings on fright and sadness than did hypnotic dreams. However, this trend on the total scores reected only the medium trance subjects; the deep trance subjects fear and sadness scores did not differ signicantly between hypnotic and night dreams. There were no signicant differences for the sexuality theme; it occurred about equally in hypnotic, night, and daydreams. Attitudes of other characters showed similar trends to the subjects emotions (see Table 3.6). Hostility of other characters was more common in nocturnal and hypnotic dreams than in daydreams. For medium trance subjects only, hostility was more common in nocturnal than in hypnotic dreams. Friendliness of other characters showed no signicant differences among types of dreams. The only signicant difference in settings of dreams was that hypnotic dreams were more likely to be set outdoors than were nocturnal dreams. Distortion was much more common in hypnotic and nocturnal dreams than in daydreams (see Table 3.7). Action ratings were signicantly higher for hypnotic and nocturnal dreams than for daydreams. For medium trance
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TABLE 3.1 Means of Variable Ratings for Total Subjects Dream Type Variable
Female family Male family Female acquaintances Male acquaintances Female strangers Male strangers Distortion Anger Fright Sadness Happiness Sexuality Hostility Friendliness Setting (1 indoors, 3 outdoors) Any people present? Length in words Unembellished memory Planning Activity 1, Passivity 3
Hypnotic
.16 .22 .44 .54 .39 .30 1.49 .14 .24 .10 .41 .04 .30 .36 2.22 .69 78.05 .21 .24 1.72
Day
.04 .03 .43 .46 .34 .23 1.07 .04 .04 .09 .68 .12 .13 .43 2.01 .56 62.60 .35 .49 1.51
Night
.21 .13 .30 42 .50 .51 1.48 .17 .38 .23 .26 .11 .40 .30 1.85 .78 98.72 .12 .11 2.20
subjects only, nocturnal dreams had a higher action rating than did hypnotic dreams. Planning and memory were both more common in daydreams than in nocturnal or hypnotic dreams. For the medium trance subjects only, they were both more common in hypnotic than in nocturnal dreams. Length in words for the total group was greater for hypnotic and nocturnal dream reports than for daydreams and greater for nocturnal than hypnotic dreams. There were not signicant differences by gender in any of these trends. REM was completely consistent for a given subject: it was observed as either 0 percent or 100 percent of their hypnotic dreams. All eight deep trance subjects and one medium trance subject exhibited REM accompaniment to dreams. The other seven medium trance subjects did not. Thus, the clearest nding was the relation between depth of trance and the characteristics of hypnotic dreams. It is certainly possible that some characteristic not included in this study would show some differences between deep trance subjects hypnotic and nocturnal dreams. However, it is clear the two categories have very much in common for this population. In psychotherapy, symbolic interpretation of deep subjects hypnotic dreams just as one would use on nighttime dreams is appropriate. Hypnotic dreams have the obvious advantages of ability to direct the topic of the dream and recall in patients who seldom remember nocturnal dreams. For medium trance
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TABLE 3.2 Means of Variable Ratings for Deep Trance Subjects Dream Type Variable
Hypnotic
.17 .24 .44 .45 .28 .25 1.56 .14 .32 .11 .32 .06 .35 .37 2.22 .68 77.64 .17 .16 2.15
Day
.04 .03 .65 .58 .18 .12 1.04 .01 .07 .04 .72 .04 .16 .41 1.98 .50 58.82 .38 .46 1.63
Night
.24 .09 .27 .36 .64 .53 1.49 .21 .36 .27 .22 .11 .43 .31 1.98 .71 83.88 .12 .14 2.16
subjects, the content differences between hypnotic and nocturnal dreams found in this study were great enough to indicate that hypnotic dreams cannot be used interchangeably in techniques designed for nocturnal dreams. The distortion versus straight story line continuum in the present study bears a rough similarity to the psychoanalytic distinction between unconscious, primary process material versus conscious, secondary process thought. On the basis of the distortion scores, the medium trance hypnotic dreams can be viewed as having less primary process content than either nocturnal dreams or deep trance hypnotic dreams. The lower scores on negative themes of fright, sadness, and anger also support a conceptualization of the medium trance dreams as more closely aligned with normal waking consciousness than ones nocturnal dreams, although not as much as daydreams. These medium trance hypnotic dreams should not be used with the presumption that they are yielding predominantly unconscious material. This awareness that hypnotic dreams are not really night dreams is implicit in many clinical hypnotic dream articles, though alternate suggestions, such as Walkers (1974) that hypnotic dreams be used more like guided fantasies are not completely appropriate either, as even the medium trance dreams still differ signicantly in context from daydreams. The approach most indicated by the present studys ndings on medium trance
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TABLE 3.3 Means of Variable Ratings for Medium Trance Subjects Dream Type Variable
Hypnotic
.16 .21 .45 .63 .50 .34 1.42 .13 .17 .10 .49 .02 .25 .34 2.22 .70 78.46 .25 .32 1.30
Day
.03 .04 .22 .34 .49 .34 1.10 .08 .02 .14 .66 .20 .10 .42 2.04 .63 66.36 .32 .52 1.40
Night
.18 .18 .33 .49 .35 .48 1.48 .13 .36 .19 .31 .10 .40 .30 1.72 .85 113.55 .11 .08 2.24
subjects would be to use their hypnotic dreams in a therapeutic medium designed specically for them. In fact, this is what many clinicians seem to do. Approaches from Sacerdotes 1967a book onward advocate gaining insight from the projective qualities of hypnotic dreams in a manner that is not predicated on the basis of their being exactly like nocturnal dreams. This makes much use of the unique potential to request that the hypnotic dream be on a specic topicwhich is possible with much more reliability than when using pre-sleep suggestions to inuence nocturnal dreams. These techniques also use suggested repetitions and elaborations of hypnotic dreams that would not be possible with nighttime dreams. For medium trance subjects who do show major differences between night dream content and that in hypnotic trance, this type of technique would seem most useful. The one nding of my study that is inconsistent with the Hilgard and Nowlis (1972) study is in terms of comparing amounts of distortion between hypnotic and nocturnal dreams. I used a scale of distortion in terms of a break in logical sequence similar to the characteristics discussed as primary process. Hilgard and Nowlis had an Alice-in-Wonderland, psychedelic distortion scale that consisted largely of things changing size unexpectedly. I had assumed they would overlap, but on closer thought, this is not much like any characteristics of real nighttime dreams. It is
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TABLE 3.4 Z Scores Between Average Frequencies of Types of Characters in Dream Reports Type of character
Total Hypnotic with day Day with night Hypnotic with night Family Hypnotic with day Day with night Hypnotic with night Acquaintances Hypnotic with day Day with night Hypnotic with night Strangers Hypnotic with day Day with night Hypnotic with night Males Hypnotic with day Day with night Hypnotic with night Females Hypnotic with day Day with night Hypnotic with night Any characters present Hypnotic with day Day with night Hypnotic with night
Total Subjects
1.86 1.14 .05 3.18** 2.82** .71 .11 .62 1.66 2.02* 2.43* 1.58 1.81 1.29 .21 1.19 1.34 .21 1.62 2.35* 1.56
Deep trance Subjects

.70 .28 .84 2.37* 1.57 1.15 1.26 1.26 1.36 1.40 12.24* 1.54 .70 .42 .28 .14 .70 .70 1.44 1.40 1.12
Medium trance Subjects

.98 1.12 1.18 2.20* 2.20* .41 2.03* 1.26 .84 1.40 1.40 .07 1.54 1.54 .56 1.12 .98 1.12 1.54 2.03* .56
* p<.05, two-tailed. ** p<.005, two-tailed.
more characteristic of lms and hallucinogenic drug experiences. So it makes sense that there is more from the otherwise-less-like-nocturnal-dreams medium trance subjects hypnotic dreams. Since the deep trance dreams were so similar in all measured content to nocturnal dreamsincluding amount of irrational distortion and unpleasant affect intrudingit might seem reasonable to utilize more of the techniques developed for nocturnal dream while remaining aware that physiologically theyre not from the same state. A nal note of interest in the content of the three categories of dream reports is that the group averages do not give any sense of the range of content; standard deviations offer a rough outline, but individual reports make clearer. As already discussed in this chapters, not all nighttime dreams t the stereotype of distortion and primary process. But this was true for differences in daydreams. A few examples were extremely full of
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TABLE 3.5 Z Scores Between Average Frequencies of Types of Emotional Themes in Dream Reports Emotional theme
Anger Hypnotic with day Day with night Hypnotic with night Fright Hypnotic with day Day with night Hypnotic with night Sadness Hypnotic with day Day with night Hypnotic with night Happiness Hypnotic with day Day with night Hypnotic with night Sexuality Hypnotic with day Day with night Hypnotic with night
Total Subjects
3.06 2.54 .21 3.41** 3.41** 3.08** .97 2.61* 3.08** 2.02* 2.43* 1.58 .92 .51 1.84

2.52* 2.37* .63 2.52* 2.37* .67 1.05 2.52* 2.11* 2.52* 2.52* .61 1.28 1.46 .91

1.83 1.18 .17 2.37* 2.52* 2.37* .25 1.18 2.37* 1.12 2.52* 1.86 1.78 .84 1.48
primary processor other rare categories like fear and sadness. These differences are best illustrated with examples of the atypical dreams, so rst, this is a nocturnal dream from one deep trance subject: Our fraternity was having a basketball game at Alumni Gym, and I was in the team. I was sitting on the end of the bench, and when one of our players was hurt, Steve decided to put me in. It took me awhile to get going, but nally I began moving pretty good. I wanted to score badly, so when I got the ball I shot and made it. The next time down court, I put a great move on my man and scored easily. Then when the opponent came down the court, and I dived after the ball, someone else dived after it too. He landed on my legs. His legs and mine became intertwined and he twisted my ankle. I had to be carried off the court. In contrast to this narrative, which could pretty much describe a waking basketball game, the following daydream was reported by another deep trance subjectthe rst two sentences identifying type of account were stripped off for the raters but are printed here for relevance: This daydream occurred in Special Ed. Class. I wasnt actually asleep, but I was denitely in another world. I dreamed that I was in my
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TABLE 3.6 Z Scores for Attitudes of Other Characters and Settings of Dream Reports Variable
Hostile Characters Hypnotic with day Day with night Hypnotic with night Friendly Characters Hypnotic with day Day with night Hypnotic with night Setting Hypnotic with day Day with night Hypnotic with night
Total Subjects
3.01** 3.35** 1.36 .83 1.29 .67 1.29 1.29 3.01**

2.03* 2.37* .00 .56 .91 1.79 1.12 .28 1.52

2.52* 2.38* 2.24* .70 .98 .17 .84 2.10* 2.52*
house, upstairs, getting ready to go somewhere. My sister came to get me and bring me downstairs. I seemed to recognize the two visitors waiting downstairs. All I can remember is their big oppy hats covered most of their faces and their owing dresses. I think that I was excited over their visit and I was about to go and greet them, but my instructor spoke to me. REMs during hypnotic dreams also had a clear relationship to dream content. However, they corresponded so closely to whether the subject was from the medium or deep trance group that presence or absence of REM during hypnotic dreams was virtually synonymous with trance depth. Therefore, its hardly a useful measure in research where experimenters are already assessing formal hypnotic depth by established scales. However, it may be very useful to observe REMs or lack thereof in clinical settings, where formal trance depth is rarely assessed, as this may indicate how deeply hypnotized the patient is and give a sense of how primary process the dream content is.
OTHER UTILIZATION OF HYPNOSIS WITH DREAMING

There are two other major ways in which hypnosis has been employed in combination with dreaming. The rstcontinuing or interpretation of a nocturnal dream in the hypnotic stateis much like the hypnotic dream. Hypnosis has been employed much like Jungs technique of active imagination to return to, continue, or elaborate on parts of a previous nocturnal dream. Hypnosis, as compared to doing these exercises in a usual
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TABLE 3.7 Z Scores for Distortion, Action, Planning, Memory, and Length in Words of Dream Reports Variable
Distortion Hypnotic with day Day with night Hypnotic with night Action Hypnotic with day Day with night Hypnotic with night Planning Hypnotic with day Day with night Hypnotic with night Memory Hypnotic with day Day with night Hypnotic with night Length in words Hypnotic with day Day with night Hypnotic with night
Total Subjects
3.52** 3.41** .27 1.98 3.52** 2.67** 3.30** 3.30* 1.73 2.56* 3.30** 2.17* 2.33* 3.52** 2.53*

2.52* 2.36* .83 2.38* 2.52 .11 2.52* 2.37* .21* 2.52* 2.52 .31 1.68 2.52* 1.40

2.52* 2.52* .67 .21 2.52* 2.52* 2.20* 2.37* 2.20* 1.18 2.20* 2.37* 1.68 2.52* 2.24*
waking state, may heighten the experiential vividness of such experiences. With hypnosis, therapists sometimes give clients suggestions to reenter the dream and replay parts of it that are vague or forgotten. Some assume this is the actual nocturnal dream being recalled, but of course others suggest that new material might as easily be substituted. However, most agree that it provides interesting material for therapy whichever may be the case. One can also take a dream that seemed to terminate prematurely and suggest that it continue. This will result in an experience much like the hypnotic dream except that it begins with a topic determined by the dreaming mind the night before rather than by the waking ego of the dreamer or hypnotherapist. Hypnosis can also be employed for even more direct interpretation of nocturnal dreams. Upon hypnotically reentering the dream scene, the dreamer can ask characters, Who are you? What do you represent? and What are you trying to tell me? They can look around a scene and ask: What is this place or What real-life setting does this resemble? Often quite unexpected yet crystal-clear answers come more directly than when pondering these questions from the more usual conscious left-brain/secondary process mode.
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An example drawn from a woman in a brief workshop that I conducted illustrates some of these processes. Marge chose to work in this manner with a brief nightmare about her husband who had died six months previously. In the dream, Marge was in her house doing minor domestic tasks when the doorbell rang. She went to the door and opened it; there stood her dead husband. At this point she awakened in terror. Marge suffered both fright and intensication of grief for some time after this dream. Many bereaved people dream of lost loved ones, but usually these dreams are anywhere from bittersweet to deeply comforting to the dreamer (Barrett, 1991). The few frightening dreams about someone who has been much loved often contain some obvious element of the deceased beckoning the dreamer to join them in death. Marges nightmare did not seem to have this element, and she did not immediately know what it was about the dream image or her feelings about her husband that had made it so terrifying. In trance, I directed Marge to reenter the dream and instead of waking up at the crucial point, to ask the dream character who he was. Despite the obvious identication as her husband (characters usually give a rich array of answers that augment rather than replace the obvious identity), Marges husband said, I am joy. She was then instructed to ask what he had come to tell or show her and he said, You can be joy, too. I then suggested she could interact with him or continue the dream in another way until it felt concluded. She proceeded to dance with him and then, bidding him goodbye, to go on dancing by herself before the dream ended. Marge woke up smiling and began to relate a group of associations to the dream content to do with having always thought of her husband as the carefree, easy-going one in the marriage who knew how to enjoy himself and brought joy into her life. She realized that, in addition to the immense loss of him, she had been feeling that her own capacity to have fun had gone with him. She felt that the dreams image had given her the ability to have fun for herself in the future. The other way in which hypnosis has been utilized in working with dreams is to use it to inuence the content or recall of nocturnal dreams. Research by Charles Tart (1964) has found that hypnotic suggestions can inuence future dream content. Hypnosis can be used to augment the same type of dream incubation procedures that are used without trance to shape dreaming toward solving a specic problem or for creative inspiration, however, the probability of achieving the desired content on a given night seems to be higher with hypnotic suggestion (Barrett, 1995). For example, a painter in one of my hypnosis and dream workshops found that with selfhypnotic suggestions to herself at bedtime, she could reliably produce dreams of paintings that she then replicated awakephenomena that had occurred spontaneously but rarely for her previously. Joe Dane (1985) demonstrated that hypnotic suggestions can increase the frequency of laboratory-veried lucid dreams. Zadra (1996) applied this
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to inducing lucidity to alter the content of recurring nightmares or help the dreamer wake from them. I have found that it is easier to help someone alter recurring nightmare content toward other forms of mastery via hypnosis than it is to induce lucidity. With trauma patients who have nightmares that replay, at least partially, real events, rehearsal of changes in the dream during hypnosis can be very effective. In trance they practice a different ending to the dream in which they thwart a violent attack, tell off an abuser, remind themselves this is not my fault at some crucial moment, or say this doesnt have to happen any more, and wake up. This hypnotic visualization, combined with the suggestion that at night the dream will happen much as it was dreamed in hypnosis, is often effective in altering even long-standing nightmares. Many people have also utilized hypnotic and self-hypnotic suggestions for increased dream recall. Hypnotherapists often use this process with patients who begin as low dream recallers, using hypnosis both for direct verbal suggestions, such as, You will nd yourself remembering dreams easily and clearly when you wake up in the morning, and for imagery picturing oneself nishing a dream, waking up with it clearly in mind as one reaches for a notebook, and watching oneself writing it down, and perhaps sketching images from it also. My patients and students have also had good results with learning self-hypnosis and using it for such suggestions to themselves at bedtime.
CONCLUSIONS
Combining hypnosis and dreamworkespecially for the majority of people who do not come by either lucid dreams or deepest trances easily may more completely realize the interaction of primary and secondary process thought. I believe the potential therapeutic effect of this is not that primary process/right brain, intuitive thinking is inherently wiser (although I realize there are psychology theories, especially dream theories, that do espouse exactly this idea). Rather, I believe that it is a function of how completely this mode is usually ignored, whereas logical thinking is employed ad nauseum in attempts to solve the problems of an individuals life. The primary process made need only become equally valuable in order to contribute signicantly to what the rational mode has not yet achieved. And when they are working together, there is a feedback loop where the intuitive images are then evaluated by the rational process. There may also be limited specic ways in which primary-process imagery can be uniquely benecial by itself and for which secondary process has no equivalent: vivid emotionally connected imagery, as opposed to other forms of suggestion or ways of thinking about problems, seems to have special ability to instigate change, training waking behavior and even the bodys physiological processes to follow what has just been imagined.
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Hypnosis and dreams both supply this powerful rehearsal of alternative ways of being. The combination of both yields the most exibility for directing this imagery in the direction of desired change.
REFERENCES
Albert, I., & Boone, D. (1965). Dream deprivation and facilitation with hypnosis. Journal of Abnormal Psychology, 5, 267271. Baker, E. (1983). The use of hypnotic dreaming in the treatment of the borderline patient: Some thoughts on resistance and transitional phenomena. International Journal of Clinical and Experimental Hypnosis, 31, 1, 1927. Barber, T. X. (1962). Toward a theory of hypnotic behavior: The hypnotically induced dream. Journal of Nervous and Mental Disease, 135, 206221. Barber, T. X. (1969). Hypnosis: A scientic approach. New York: Van Nostrand Reinhold. Barrett, D. L. (1979a). The hypnotic dream: A content comparison to nocturnal dreams and waking fantasy. Unpublished Doctoral dissertation, University of Tennesee-Knoxville. Barrett, D. L. (1979b). The hypnotic dream: Its content in comparison to nocturnal dreams and waking fantasy. Journal of Abnormal Psychology, 88, 584591. Barrett, D. L. (1991). Through a glass darkly: The dead appear in dreams. OMEGA: The Journal of Death and Dying, 24, 97108. Barrett, D. L. (1995). Using hypnosis to work with dreams. Self and Society: A Journal of Humanistic Psychology, 23(4), 2528. Berheim, H. (1947). Suggestive therapeutics: A treatise on the nature and uses of hypnotism. Translated from the French edition by C. A. Herter. New York: London Book Company. Brady, J. P., & Rosner, B.S. (1966). Rapid eye movements in hypnotically induced dreams. Journal of Nervous and Mental Disease, 143, 2835. Brenman, M. (1949). Dreams and hypnosis. Psychoanalytic Quarterly, 18, 455465. Crasilneck, H. B., & Hall, J. A. (1975). Clinical hypnosis: Principles and applications. New York: Grune and Stratton, 229230. Dane, Joe. (1985). Comparison of waking instructions and post-hypnotic suggestions for lucid dream induction, Dissertation, Georgia State University. Davis, L. W., & Husband, R. W. (1931). A study of hypnotic susceptibility in relation to personality traits. Journal of Abnormal and Social Psychology, 26, 175182. De Pascalis V. (1993). EEG spectral analysis during hypnotic induction, hypnotic dream and age regression. International Journal of Psychophysiology,15(2), 153166. Desoille, R. (1965). The directed daydream. Monograph. New York: The Psychosynthesis Research Foundation. Domhoff, B. (1964). Night dreams and hypnotic dreams: Is there evidence that they are different? International Journal of clinical and Experimental Hypnosis, 12, 159168. Erickson, M. H. (1958). Deep hypnosis and its induction. In L. M. LeCron (Ed.), Experimental hypnosis. New York: The Macmillan Company.
Hypnotic Dreams
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Fisher, C. (1953). Studies on the nature of suggestion: Part I. Journal of the American Psychoanalytic Association, 1, 222255. Fromm, Erika. (1965). Spontaneous autohypnotic age regression in a nocturnal dream. International Journal of Clinical and Experimental Hypnosis, 13, 119131. Gill, M., & Brenman, M. (1959). Hypnosis and related states. New York: International Universities Press. Hall, C. S., & Van de Castle, R. L. (1966). The content analysis of dreams. New York: Appleton-Century-Crofts. Hilgard, E. R. (1965). Hypnotic susceptibility. New York: Harcourt, Brace, & World. Hilgard, E. R., & Nowlis, D. P. (1972). The contents of hypnotic dreams and night dreams: An exercise in methodology. In E. Fromm and R. E. Shor (Eds.), Hypnosis: Research developments and perspectives (pp. 85, 113). Chicago: Aldine Atherton. Kanzer, M. (1953) The metapsychology of the hypnotic dream. International Journal of Psychoanalysis, 34, 228231. Kratochvil, S., & MacDonald, H. (1972). Sleep in hypnosis: A pilot EEG study. American Journal of Clinical Hypnosis, 15, 2937. LeCron, L. M., & Bordeaux, J. (1947). Hypnotism today. New York: H. Wolff, 213214. Mazer, M. An experimental study of the hypnotic dream. Psychiatry, 14, 265277. Mixer, B. (1961). A comparison of hypnotic and nocturnal dreams. Unpublished masters thesis, University of Missouri. Moss, C. Scott. (1967). The hypnotic investigation of dreams. New York: John Wiley and Sons. Nie, N. H. (1975). SPSS: Statistical Package for the Social Sciences (2nd ed.) New York: McGraw-Hill. Sacerdote, P. (1967a). Induced dreams. New York: Vintage Press. Sacerdote, P. (1967b). Therapeutic use of induced dreams. American Journal of Clinical Hypnosis, 10, 19. Sacerdote, P. (1967b). Induced dreams: Further application. American Journal of Clinical Hypnosis, 10, 167173. Sacerdote, P. (1972). Some individualized hypnotheraputic techniques. International Journal of Clinical and Experimental Hypnosis, 20, 114. Schiff, S., Bunney, W., & Freedman, D. (1961) A study of ocular movements in hypnotically induced dreams. Journal of Nervous and Mental Disease, 133, 5967. Schneck, J. M. (1963). Clinical and experimental aspects of hypnotic dreams. In Kline, M. V. (Ed.), Clinical correlates of experimental hypnosis. Springeld, IL: Thomas. Schneck, Jerome M. (1947). The role of a dream in treatment with hypnosis. Psychoanalytic Review, 34, 485491. Schneck, J. M. (1954). Dreams in self-hypnosis. Psychoanalytic Review, 41, 18. Schneck, J. M. (1960) Observations on the hypnotic nightmare. American Journal of Clinical Hypnosis, 2, 122137. Schneck, J. M. (1959). Self-hypnotic dreams in hypnoanalysis. Journal of Clinical and Experimental Hypnosis, 1, 4453. Schneck, J. M. (1961). The structure and function of hypnotic dreams. Perceptual and Motor Skills, 23, 490497.
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Schneck, J. (1974). Observations on the hypnotic nightmare. American Journal of Clinical Hypnosis, 16, 240245. Solovey, G., & Milechin, A. (1960). Hypnosis, suggestion, and oneiric activity. American Journal of Clinical Hypnosis, 2, 122137. Spanos, N. P., & Ham, M. W. (1976). Involvement in suggestion-related imaginings and the hypnotic dream. American Journal of Clinical Hypnosis, 18, 4351. Spanos, N. P., & McPeake, J. D.(1975). Involvement in everyday imaginative activities, attitudes toward hypnosis, and hypnotic suggestibility. Journal of Personality and Social Psychology, 31, 594598. Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York: W. W. Norton & Company. Sweetland, A., & Quay, H. (1952). An experimental investigation of the hypnotic dream. Journal of Abnormal and Social Psychology, 47, 658682. Tart, C. T. (1962). A comparison of suggested dreams occurring in hypnosis and sleep. International Journal of Clinical and Experimental Hypnosis, 12, 263289. Tart, C. T. (1965). The hypnotic dream: Methodological problems and a review of the literature. Psychological Bulletin, 63, 8799. Tart, C. T. (1966). Types of hypnotic dreams and their relation to hypnotic depth. Journal of Abnormal Psychology, 71, 377382. Torda, C. (1975). Dream content and anxiety and anger. American Journal of Clinical Hypnosis, 17, 253259. Walker, P. (1974). The hypnotic dream: A reconceptualization. American Journal of Clinical Hypnosis, 16, 246255. Weitzenhoffer, A. M., & Hilgard, E. R. (1962). Stanford Hypnotic Susceptibility Scale, Form C. Palo Alto, CA: Consulting Psychologists Press. Zadra, A. (1996). Recurrent dreams: Their relation to life events and well-being. In D. Barrett (Ed.), Trauma and dreams. Boston: Harvard University Press. Zamore, N., & Barrett, D. L. (1989) Hypnotic susceptibility and dream characteristics. Psychiatric Journal of The University of Ottawa, 14, 572574.
Chapter 4
The Merits of Applying Hypnosis in the Treatment of Depression

Michael D. Yapko
OVERVIEW
Depression is a serious and already widespread problem warranting the substantial attention it receives from the mental health profession. Currently, nearly 20 million Americans are known to be suffering with the disorder, and the rate of depression in the United States is on the rise in every age group (National Institute of Mental Health, 2002). Each depressed individual directly affects many others (family, friends, co-workers), multiplying the number of people touched by depression to many tens of millions. Ultimately, we are all affected by depression, even if only indirectly, by having to share in the hurtful consequences of the many negative behaviors (such as drug abuse, poor parenting, and diminished productivity) that often have their origin in badly managed depression (Weissbourd, 1996). The primary purposes of this chapter are twofold: First, to highlight some of what we already know about the nature of major depression (i.e., Major Depressive Disorder) and what seems to be effective in its treatment, and second, to draw attention to ways clinical hypnosis can further enhance aspects of the treatment process. This chapter considers the merits of hypnosis as part of a greater psychotherapy regimen for major depression only. It does not address either antidepressant medication issues or other forms of depression (such as bipolar disorder, depressed phase). When psychotherapy is clinically indicated, whether in combination with antidepressant medications or as a sole intervention, hypnosis may sensibly be employed as a means for helping facilitate the therapeutic goals. The treatment literature makes it quite clear that treatment for depression is best thought of as an active, skill-building process (Martell, Jacobson, & Addis, 2001). Hypnosis can provide a strong foundation for motivating people and empowering them with structured processes of experiential
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learning (Yapko, 2001, 2003, 2006). Given the reach of depression into our pockets, our personal relationships, our communities, and our very lives, addressing this complex disorder in a variety of timely and effective ways is an especially urgent challenge we as health care professionals face. Hypnosis is not meant to be a magical means of suggesting that symptoms simply disappear. Rather, hypnosis is a means of absorbing people in new ways of thinking about their subjective experience, thereby potentially altering it in meaningful ways. Since the most common symptom of depression that people complain about is a sleep disturbance, after rst describing general aspects of depression as a problem and hypnosis as a solution, I will focus specically on the use of hypnosis in addressing insomnia associated with depression.
SOME OF WHAT WE KNOW ABOUT MAJOR DEPRESSION

Depression has been and continues to be heavily researched. The amount of data generated by clinicians and researchers thus far has been impressive by any standard, and has led to some rm conclusions: Major depression has many contributing factors, not a single cause. The three primary domains of the contributing factors are biological, psychological, and social. Hence, the so-called biopsychosocial model predominates (Cronkite & Moos, 1995; Thase & Glick, 1995). Depression has many underlying risk factors and a variety of comorbid conditions likely to be associated with it (Stevens, Merikangas, & Merikangas, 1995). In fact, numerous medical (e.g., cancer, heart disease) and psychological conditions (e.g., anxiety disorders, substance abuse disorders) are found to commonly coexist with depression, requiring sharp differential diagnosis and multifaceted treatment planning (American Psychiatric Association, 2000). Depression can be successfully managed in the majority of sufferers with medication and/or psychotherapy (Schulberg, Katon, Simon, & Rush, 1998). While no one antidepressant has denitively been shown to be superior in rates of effectiveness to another, therapeutic efcacy studies show some psychotherapies (specied later) outperform others in treating depression (Barlow, 2004). Medication has some treatment advantages, such as a generally faster rate of symptom remission and greater effectiveness in treating the vegetative symptoms, for example, sleep and appetite disturbances (DeBattista & Schatzberg, 1995). Medication also has some disadvantages, including uncertain dosing and effectiveness, potentially negative side effects, habituation and poop-out (i.e., the drug may eventually stop working), and higher initial rates of relapse (Altamura & Percudani, 1993; Dubovsky, 1997).
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Psychotherapy also has some treatment advantages and disadvantages. The therapies that enjoy the greatest empirical support are cognitive, behavioral, and interpersonal approaches (Depression Guideline Panel, 1993). The advantages include therapys focus on skill building and the associated reduced relapse rate, the value of the therapeutic relationship, the greater degree of personal empowerment, and the potential to not just perform a mop up of preexisting problems but to instead teach the skills of prevention (Seligman, 1990; Yapko, 1999). The disadvantages of psychotherapy include the greater reliance on the level of clinician competence (i.e., experience and judgment), the greater time lag between the initiation of treatment and the remission of symptoms compared to medications, the lesser effect in reducing vegetative symptoms, and the potential detrimental side effects of client exposure to a clinicians particular theoretical or philosophical stance (Mondimore,1993; Thase & Howland, 1995). The extraordinary ongoing success of the Human Genome Project has highlighted the complex relationship between genetics, environment, and specic disorders. Genetic vulnerabilities or predispositions exist, but they operate in association with environmental variables that may increase or decrease their likelihood of expression (Siever, 1997). In the specic case of (unipolar) major depression, the genetic contribution has been shown to be signicant, with environmental factors (both social and psychological) appearing to also have signicant inuence in its onset (Kaelber, Moul, & Farmer, 1995). (In contrast, the genetic component of bipolar disorder has been shown to be a strong one; Dubovsky, 1997.) The relationship between neurochemicals and experience is bidirectional, meaning environmental triggers inuence neurochemistry at least as much as neurochemistry inuences experience (Azar, 1997; Dubovsky, 1997; Siever, 1997). There is evidence to suggest that psychotherapy may be a means for directly and/or indirectly affecting neurotransmitter levels in the brain, perhaps in some a parallel to the effects of medication (Schwartz & Begley, 2002). Research has yielded many other insights about depression, of course, but the previous statements reect a high level of general consensus among depression experts.
Some of What We Know about Treating Depression with Psychotherapy

Depression isnt just suggested away with hypnotic suggestions. Hypnosis has to be employed realistically by aiming at and modifying appropriate targets in treatment. Thus, this section will discuss some of what seems to matter most in clinical intervention.
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A number of important insights about major depression and suggestions for its treatment were articulated in the depression treatment guidelines developed by the United States Agency for Health Care Policy and Research (AHCPR), now the Agency for Healthcare Quality and Research (AHQR; Depression Guideline Panel, 1993): (1) Three psychotherapies were shown to have the greatest amount of empirical supportcognitive, behavioral, and interpersonal psychotherapies. These are identied as the psychotherapies of choice, and any or all can be applied according to the clients symptom prole (not the clinicians preferred orientation); (2) Psychotherapy should be an active process in the way it is conducted, involving active exchanges between clinician and client that would typically involve providing psychoeducation, the development of skill-building strategies, the use of homework assignments, and the use of the therapy relationship as both a foundation and a vehicle for exploring relevant ideas and perspectives; (3) Therapy should not only focus on problem solving, but the teaching of problem-solving skills, especially as they relate to symptom resolution, the guidelines suggested focus of treatment; (4) Effective therapy need not have an historical focus. According to the treatment guidelines, the most effective therapies are goal-oriented, skill-building approaches. None of them focus on attaining extensive historical data to explain the origins of depression. Rather, they focus on developing solutions to problems and coping skills for managing symptoms. Hypnosis is especially amenable to each of these psychotherapeutic applications, since it, too, is an active and directive means of intervention. The same indications and contraindications as articulated in the treatment guidelines (Depression Guideline Panel, 1993) prevail when applying hypnosis, particularly the recommendation that clinicians adapt their approach according to the patients symptom prole rather than a specic theoretical allegiance. In performing an extensive review of clinical and research literature in order to prepare the depression treatment guidelines, the panel formed the conclusion that trying to nd a specic origin for an individuals depression was unnecessary in promoting recovery. This sharply distinguishes what might be termed an event-driven perspective (the view that depression has its origin in specic historical events that must be identied and worked through) from what could be called a process-driven perspective (the view that depression has its roots in ongoing ways of erroneously or negatively interpreting or managing various life experiences). Recognizing that depression arises for many reasons of a process-driven nature accentuates the realization that by the time depression strikes most individuals, one or more risk factors (such as perceptual style, cognitive style, and level of social and problem-solving skills) had already been well in place (Seligman, 1989). The research makes it abundantly clear that depression is much more than a biologically based problem (Joiner, Coyne, & Blalock, 1999; Yapko, 2006). Thus, helping people recognize that depression arises, in part, because of social and psychological factors can help them to avail themselves of the
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benets psychotherapy can provide. After all, no amount of medication (or brain stimulation or brainwave reeducation) can provide people with better problem-solving skills, coping skills, cognitive skills, relationship skills, or a supportive network of friends. Of the various approaches to treating depression that have been evaluated scientically, there is unequivocal evidence that the therapies that actively encourage people to develop specic life-enhancing skills perform better than other therapies that do not (Martell et al., 2001). As our understandings of both hypnosis and depression have deepened in recent years, the antiquated concerns that hypnosis would hurt rather than help the depressed client have markedly diminished. We have learned, for example, that suicidality isnt about inadequate ego defenses, and that depression isnt really about anger turned inward. Instead, we have learned that there are specic risk factors evident in ones thinking, behaving, relating, and perceiving that can, under certain stressful conditions, give rise to depressive episodes. As a result, there are many more immediate and welldened targets for hypnotic intervention than previously realized. It has been amply demonstrated that psychotherapy can succeed, and succeed well, when people who suffer depression are taught key life skills that empower them to live more personally satisfying lives. One can describe the term depression as a global shorthand, a convenient label for a wide range of symptoms and patterns of experience. Effective treatment must rst involve identifying the salient patterns that regulate the experience of depression in a given individual. We also know that therapy, any therapy, will necessarily have to interrupt ongoing patterns of experience in some way and generate some new patterns of experience that prove benecial to the clients mood, outlook, and behavior. The task for the clinician is to absorb the client in new patterns, whether patterns of thought as in cognitive therapy, patterns of physiology as in somatic-based interventions, or whatever patterns are addressed in a specic style of intervention. Hypnosis is multidimensional in its ability to focus anywhere and catalyze the merits of the intervention, whatever form it might take. As stated earlier, depression is the product of many contributing variables. Can hypnosis be used in ways that address risk factors and the process underlying the formation of some forms of depression? This chapter offers both evidence and clinical experience in using hypnosis in just such a manner.
THE EMPIRICAL BASIS FOR EMPLOYING HYPNOSIS IN THE TREATMENT OF DEPRESSION

The body of literature describing the relationship between the quality of ones beliefs and ones mood is substantial. It is well established that the positive, optimistic person is less likely to suffer depression. Likewise, such a person will also benet: (1) physically by likely suffering less serious illness and higher rates of recovery; (2) in terms of productivity, having higher levels
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of focus, persistence, and frustration tolerance; and, (3) in terms of greater sociability and likeability, enjoying the many health and mood benets associated with having more close and positive relationships (Peterson, 2000; Seligman, 1989, 1990, 2000; Yapko, 1997, 1999, 2001). The overlap between depression as a problem and hypnosis as a means for addressing it centers on the believed-in imaginations of the depressed client. Believing life is unfair, or Im no good, or Ill never be able to do that are just a very few of the many self-limiting and even self-injurious beliefs that depressed individuals may form and come to hold as true. Thus, it is no coincidence that cognitive-behavioral therapies, which challenge depressed individuals to learn how to identify and self-correct their cognitive distortions and behave more effectively, have been shown to be highly effective approaches (Clarkin, Pilkonis, & Magrude,1996; Greenberger & Padesky, 1995). It is terribly unfortunate that the scientic literature about the use of hypnosis specically with depressed populations is sparse because of how long hypnosis was discouraged as a treatment tool based on misinformation discussed earlier. However, that is beginning to change; in a recent book edited by the author of this chapter (Yapko, 2006), many well-known clinicians and hypnosis experts described their applications of hypnosis in a variety of clinical populations all sharing an underlying depression. A variety of therapeutic efcacy studies have been published attesting to the added value of hypnosis to established treatments, especially cognitivebehavioral approaches (Lynn, Kirsch, Barabasz, Cardena, & Patterson, 2000; Kirsch, Montgomery, & Sapirstein, 1995; Schoenberger, 2000.) In one recent study of hypnosis applied specically to a depressed population (Alladin & Alibhai, 2007), the group receiving hypnosis treatments in combination with cognitive behavioral therapy (CBT) showed greater reduction in depression, anxiety, and hopelessness than the group receiving CBT alone. Depression is a global term, however. In fact, depression is comprised of many different components, including cognitive patterns (such as attributional style), behavioral patterns (such as avoidant coping styles), and relational patterns (such as hypercriticalness). Many of these components have been addressed successfully with hypnosis (Kirsch, 1996; Schoenberger, 2000; Schoenberger, Kirsch, Gearan, Montgomery, & Pastyrnak, 1997). Employing these treatments with depressed populations for whom these cognitive and behavioral issues would be relevant would undoubtedly improve their condition. In fact, much of what is presented in this chapter could be characterized as cognitivebehavioral therapy performed within a hypnotic and strategic framework (Yapko, 1988, 1992, 1993, 2006).
WHAT IS POSSIBLE IN HYPNOSIS?

The fact that people can manifest a variety of normally hidden capacities in hypnosis is the reason why hypnosis offers so much as a treatment
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tool. If one were to do even a cursory review of the scientic literature attesting to the value of hypnosis in a variety of medical, dental, psychotherapeutic, and educational settings, one would nd an enormous array of highquality research that supports its use. More recently, newer technologies for conducting brain scans (i.e., fMRI, CAT, PET, and SPECT) have spawned new insights into the working relationship between the mind and brain. Similarly, using advanced diagnostic tools to afrm measurable changes in physiology in response to mere suggestions (such as inuencing blood ow, muscular tension, immunological responses, and perceptions of pain) has led to a virtual explosion of applications of hypnosis in behavioral medicine. In hypnosis, people are able to manifest a variety of talents that are collectively termed hypnotic phenomena. These include: (1) age regression (dened as the intense and experiential absorption in memory such that memories can be recalled in vivid detail and perhaps even relived as if occurring in the now, allowing for the reframing of memories, for example); (2) age progression (dened as the intense and experiential absorption in expectations, a vehicle for establishing positive self-fullling prophecies, for example); (3) analgesia and anesthesia (the ability to reduce or even eliminate sensation, exceptionally valuable in the treatment of all kinds of pain); and (4) dissociation (the ability to break global experiences into component parts and selectively amplify or de-amplify a part depending on therapeutic objective, such as encouraging a controlled detachment from overwhelming emotions). There are many other hypnotic phenomena that become accessible in hypnosis that are also benecial to employ in the course of psychotherapy, and the interested reader may choose to learn more than this brief chapter can address. Sufce it to say that as one considers what is possible in hypnosis, wherever one can inuence mental or physical processes it quickly becomes apparent that, the limits of which have not been anywhere even close to dened yet, hypnosis will be valuable.
WAYS TO USE HYPNOSIS IN PSYCHOTHERAPY

A clinician has to be deliberate about choosing focal points for his or her interventions. Focusing on someones cognitions, for example, shouldnt be a standard procedure as a self-identied cognitive therapist. Rather, it should be a choice one makes to focus on the clients thoughts because there is a powerful depressogenic pattern operating on that dimension. But, for someone else, the focus will need to be on his or her relationships, and for someone else on his or her sleep difculties. What a clinician will focus on and amplify with hypnosis will, hopefully, differ according to the unique prole of each individual client. This is one of the great strengths of being knowledgeable about hypnosis: the ability to make good therapeutic choices based on client need outweighs loyalty to a particular theory of intervention. There are many different ways to apply hypnosis in psychotherapy. Since hypnosis is not generally considered a therapy in its own right, hypnosis
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is typically integrated with other psychotherapeutic treatments, such as cognitive-behavioral therapy (CBT) or interpersonal therapy (IPT). Thus, how one applies hypnosis will be entirely consistent with however one thinks about the nature of peoples symptoms and the nature of therapeutic intervention. Hypnosis essentially amplies experience. So, if one wants to focus the client on his or her cognitive dimension of experience, perhaps to teach a client to recognize and correct so-called cognitive distortions, one might use hypnosis to help make such identication and correction a more natural and even more automatic process. (Aaron Beck, a founding father of modern cognitive therapy, may not talk about the unconscious the way a hypnosis practitioner might, but he speaks readily of automatic thoughts. What about hypnosis to instill positive automatic thoughts?) Hypnosis can be used to help manage symptoms. This is a more supercial, yet meaningful, application of hypnosis. Using hypnosis to reduce anxiety or rumination so an anxious or depressed client can enhance his or her sleep, for example, is not a deep intervention, yet clinically it is an enormously valuable one (Yapko, 2006). Teaching someone to manage pain is not psychologically deep, but can literally save peoples lives (Phillips, 2006). Hypnosis can be used to foster skill acquisition. As alluded to before, teaching clients specic skills (e.g., social skills or problem-solving skills) is a standard part of almost any therapy. It is well established that experiential learning is the most powerful form of learning. Hypnosis is a vehicle of experiential learning. Its not just something to consider or distantly imagine. Its something to be absorbed on many different levels. There is plenty of evidence that hypnosis generally enhances psychotherapy for this very reason. Thus, when comparing CBT without hypnosis versus CBT with hypnosis, the addition of the hypnosis enhances therapeutic efcacy. (Note that the salient research question is not how hypnosis compares to CBT, but how CBT without compares to CBT with hypnosis.) Hypnosis can be used to establish associations and dissociations. What aspect(s) of experience do we want the client more connected or associated to? What aspect(s) of experience do we want the client disconnected or dissociated from? Someone who is lacking emotional awareness (what might be termed affective dissociation in hypnotic terms) can benet from an emotionally focused (associative) intervention, while someone who is hyperemotional (emotionally associative) might benet from a more cognitively based (emotionally dissociative) intervention. Hypnosis allows one to structure interventions according to whatever aspects of experience might best serve the client to associate to or dissociate from (or to amplify or deamplify). And, if one thinks in these terms, it is easy to see how any therapy similarly focuses on or away from specic dimensions of experience, though predictably less effectively by not using the amplied experience of the hypnotic condition.
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Hypnosis is regarded as a tool, a vehicle for dispensing information, building perspective, enhancing skill acquisition, and creating a context for therapeutic change to take place. Thus, one can use hypnosis to highlight to a patient his or her cognitive distortions, offering suggestions for more automatically recognizing and refuting them. Thus, if one wishes to make use of cognitive therapy techniques, hypnosis can be used to help establish therapeutic associations in the patient for more readily identifying and clarifying his or her distorted thoughts and attributions (Yapko, 1992, 2003). Similarly, if one chooses to focus on the relational dimension, using an interpersonal model as a conceptual and practical framework, hypnosis is also applicable. Identifying and relating skillfully to other peoples needs and values, establishing and consistently enforcing ones limits in ones dealings with others, and developing greater awareness of ones own needs and how they might best be met are all examples of skills one might wish to help the patient build using hypnotic suggestions. In short, the ability of hypnosis, applied either formally or informally, to build a strong link between the troublesome context and the skilled response desired in that context is the primary reason why hypnosis can be so easily integrated into virtually any model of treatment. There are many other ways to use hypnosisto build positive expectations, to amplify and work with emotion-laden memories, to enhance cognitive exibility, to instill better coping skills, and to increase self-efcacy are just a few applications immediately relevant to a sophisticated therapy practice, regardless of ones preferred theoretical orientation.
WHAT MAKES HYPNOSIS VALUABLE IN THE TREATMENT OF DEPRESSION?

Hypnosis may be valuable in treatment because of its relationship to subjective states like depression. Upon deeper reection, the overlaps between the separate yet related domains of hypnosis and depression become more evident. Ill describe just a few of these: (1) Both come about and increase in intensity the more narrow your focus; (2) Both are ultimately social processes, greatly inuenced by your relationships with others, whether the other is a clinical authority describing the therapeutic merits of exposing you to an induction procedure, or the other is a parent or spouse describing the aws in your character; (3) Both are a product of expectancy, whether the expectation is one of getting the benevolent corrective message into your unconscious through suggestions received in a dissociated state, or whether the expectation is that no amount of your effort will result in a success, thereby giving rise to the apathy so typical of depression; and (4) Both involve what hypnosis pioneers Theodore Sarbin and, later, Ernest Hilgard, described when they suggested hypnosis is, in part, a believed-in imagination, an experience based on the recognition that people can and do get deeply absorbed in
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highly subjective beliefs and perceptions that quite literally regulate the quality of their lives (Sarbin, 1997; Hilgard, personal communication, 1988). These beliefs and perceptions can be altered and amplied during the experience of hypnosis, well illustrating the point how idiosyncratic each persons sense of reality really is, especially in response to mere suggestions. The notion of an individuals personal reality essentially being a believedin imagination preceded the origin and development of cognitive therapy by decades, even centuries, and rmly established the relevance of hypnosis in treatment. Cognitive-behavioral therapy is, at this time, probably the most well-researched method of therapeutic intervention. It is founded on the premise that people in general, and depressed people in particular, regularly make identiable errors in information processing, thinking and genuinely believing in their mistaken notions of what trulyand depressinglyseems like reality to them (Beck, 1997; Beck, Rush, Shaw, & Emery, 1979). This process of becoming absorbed in ones (depressing) imaginings is, indeed, an instructive parallel to what occurs in hypnosis, where a clinician performs an induction and attempts to absorb the individual in alternative ways of experiencing him or herself. Through procedures employing hypnosis, the clinician creates a context where the individual can change the direction and quality of his or her focus. Perhaps the suggested focus is on engaging in some new life-enhancing behavior, or perhaps on exciting and motivating glimpses of future possibilities, or possibly on rewriting some of the negative internal dialogue, or somehow altering for the better any of literally scores of depressing focal points (e.g., cognitive styles, coping styles, relational styles). What the clinician suggests during hypnosis may not be any more true in an objective sense than what the person previously believedit may just feel much better and serve the person better. Hypnosis as a means of teaching people, a vehicle for getting new possibilities for thinking, feeling, behaving, and relating integrated more quickly and deeply is precisely why knowledgeable clinicians do hypnosis in the rst place.
HYPNOSIS AND POSITIVE PSYCHOLOGY

With an increasing emphasis within the psychotherapy profession to pay more attention to whats right with people rather than whats wrong with them (Seligman, 2000), the very rst lesson one learns when studying hypnosis takes on a new signicance: What you focus on you amplify. Do we as mental health professionals want to focus on pathology or wellness? Is the goal of treatment to decrease pathology or weakness, or to expand strength? These are not merely semantic issues. On the contrary, how one responds to a clients distress and organizes therapeutic intervention is broadly based on whether one strives to identify and address client weaknesses or strengths.
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In this sense, hypnosis can be thought of as the original positive psychology. Indeed, well before the term positive psychology was coined in just the last decade, pioneering psychiatrist Milton H. Erickson, MD, as early as the 1940s, was writing about the need to pay more attention to and thereby amplify peoples strengths. Erickson is often described as the most creative and inuential clinician (as opposed to theorist) of the twentieth century, and it is hardly a coincidence that so many of his innovative contributions directly involved insightful applications of clinical hypnosis (Haley, 1973; Zeig, 1980). Anyone who practices clinical hypnosis does so with the rmly entrenched and therapeutically invaluable belief that people have many more abilities than they consciously realize. Hypnosis engenders an entirely optimistic appraisal of people such that therapy gets organized around the belief that people can discover and develop the very resources within themselves they need to improve. Hypnosis creates an amplied, energized, high-powered context for people to explore, discover, and use more of their innate abilities. Hypnosis isnt the therapy, and hypnosis itself cures nothing. Rather, hypnosis is the vehicle for empowering people with the abilities and realizations that ultimately serve to help them. It isnt the experience of hypnosis itself thats therapeutic, its what happens during hypnosis in terms of developing new and helpful associations. The study of hypnosis, then, involves a process of discovering what latent capacities are accessible in the experience of hypnosis, and how to bring them forth at the times and places they will best serve the client. It truly is a positive psychology in practice.
HYPNOSIS AND BUILDING REALISTIC EXPECTANCY

One of the strongest factors contributing to the viability of hypnosis as an intervention tool is termed expectancy (Coe, 1993; Kirsch, 2000). Expectancy refers to that quality of the clients belief system that leads him or her to believe that the procedure implemented by the clinician will produce a therapeutic result. Positive expectancy for treatment involves multiple perceptions: The clinician is seen as credible and benevolent, the procedure seems to have a plausible perhaps even compelling rationale, and the therapy context itself seems to support its application. Thus, by the client being instructed in the value and the methods of hypnosis, whether directly or indirectly, an expectation is established that the associated procedures will have some potentially therapeutic benet, increasing the likelihood of them actually doing so (Barber, 1991; Zeig, 1980). Expectancy is an especially critical issue in the treatment of major depression. Cognitive theory in particular has viewed depression as existing on a three-point foundation of negative expectations, negative interpretation of events, and negative self-evaluation (Beck, Rush, Shaw, & Emery, 1979). An
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individuals negative expectancy for life experience is a cognitive pattern and risk factor that has been associated with difculties not only in the realm of mood, but also in poorer physical health, poorer social adjustment, and diminished productivity. Furthermore, negative expectancy has been associated to lowered treatment success rates (Seligman, 1989, 1990). At the extreme, negative expectancy in the form of a pervasive sense of hopelessness can be associated with suicidality (Beck, Brown, Berchick, Stewart, & Steer, 1990). Establishing positive expectancy in a variety of specic contexts may be a necessary ingredient in effective treatment (Yapko, 1988, 1992, 1993, 2001). Age progression in hypnosis as a vehicle for concretely establishing a positive and motivating view of the future may be helpful in this regard (Torem, 1987, 1992, 2006; Yapko, 1988, 1992, 2001, 2003, 2006). Important as it may be, however, a focus on expectancy to the exclusion of other factors of potential therapeutic effectiveness can also be limiting. Someone can have positive expectations yet generate no meaningful therapeutic results for a variety of reasons. For every client who began therapy with high hopes that went unfullled, the point is clear that positive expectations are not enough. They must be realistic and they must occur within a larger therapeutic framework that is able to convert the promise of expectancy into the reality of a goal accomplished. Expectancy matters, but even positive, well-dened expectations can become a source of problems rather than a source of solutions if they are unrealistic. Thus, a clinician must be able to educate the client in the process of distinguishing realistic from unrealistic expectations, whether positive or negative. Hypnosis can help in this therapeutic endeavor.
TARGETING THE MOST COMMON SYMPTOM OF DEPRESSION: HYPNOSIS AND PSYCHOTHERAPY FOR INSOMNIA
The time hypnosis may be of greatest benet in psychotherapy is when it is used as a means of teaching skills that can empower the therapy client (Yapko, 2001, 2003). Regarding insomnia in particular, the most common symptom of depression, there are a number of specic skills that someone suffering insomnia can learn that will make a positive difference, such as relaxation and good sleep hygiene. However, there is another specic skill that is an amenable target for a well-crafted hypnotic intervention. That target is called rumination. Rumination is the cognitive process of spinning around the same thoughts over and over again. It is considered an enduring style of coping with ongoing problems and stressors, a coping style that can both lead to and exacerbate depression. Ones coping style is a signicant factor in ones overall mental health and is an especially important factor in depression. Although coping
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responses may be classied in many ways, most approaches distinguish between strategies oriented toward confronting the problem and strategies oriented toward reducing tension by avoiding dealing with the problem directly (Holahan, Moos, & Bonin, 1999). Rumination can be thought of as a pattern of avoidance that actually increases anxiety and agitation. Ruminative responses include repeatedly expressing to others how badly one feels, pondering to excess why one feels bad, and catastrophizing the negative effects of feeling bad (Nolen-Hoeksema, 1991.) By ruminating, the person avoids having to take decisive and timely action, further compounding a personal sense of inadequacy. Rumination leads to more negative interpretations of life events, greater recall of negative autobiographical memories and events, impaired problem solving, and a reduced willingness to participate in pleasant c & Alloy, 2001). As Just & Alloy (1997) stated, correlaactivities (Spasojev tional, eld, longitudinal, and experimental studies all provide evidence that ruminative behavior is not only highly associated with depression, but serves to increase both the severity and duration of episodes of depression. The common term analysis paralysis describes the hazard of ruminating at the expense of taking effective action. It is especially signicant that rumination not only features in the quality of ones depression, but it actually predicts depression. Susan NolenHoeksema of Yale University published enormously valuable research that establishes the link clearly: A ruminative coping style that precedes depressive symptoms predicts higher levels of depressive symptoms over time (after accounting for baseline levels), onset of new depressive disorders, greater chronicity of depressive disorders, and higher levels of anxiety symptoms (Nolen-Hoeksema, 2000, 2003). Thus, rumination is an especially high-priority target at which to aim ones interventions, hypnotic or otherwise. Rumination generates both somatic and cognitive arousal, both of which can exacerbate insomnia, but the evidence suggests cognitive arousal is the greater problem. As Harvey (2000) reported in her research on the relationship between cognitive arousal and insomnia, insomniacs were ten times more likely to cite cognitive arousal as central to their sleep difculties, compared with somatic arousal. Harvey went on to say that the need to aim for minimal cognitive processing and effort toward sleep are key treatment goals.
HYPNOSIS, TARGETING RUMINATION AND ENHANCING SLEEP

Having asked literally hundreds of individuals who declare themselves good sleepers what they tend to think about when they go to sleep, their common and consistent answer is some variation of the reply, nothing. That doesnt mean literally that they think of nothing and have an empty
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mind. Rather, it means that the content of what they think about is so simple and nonthreatening that it generates no signicant somatic or cognitive arousal to interfere with sleep. Conversely, when I ask people who say they sleep poorly what they think about when going to sleep, they typically say some variation of, everything. They think of worrisome problems, unresolved situations needing to be addressed, obligations to be met, tasks still needing to be done, and on and on. The levels of cognitive and somatic arousal are raised to the point of interfering with sleep. The use of hypnosis to teach the ability to direct ones own thoughts rather than merely react to them is a well-established dynamic and a principal reason for employing hypnosis in any context (Lynn & Kirsch, 2006; Yapko, 2003). Reducing the stressful wanderings of an agitated mind and also relaxing the body while simultaneously helping people create and follow a line of pleasant thoughts and images that can soothe and calm the person are valuable goals in the service of enhancing sleep. In order to achieve these aims, there are a number of important components to include in ones treatment plan. These include: (1) Teaching the client how to efciently distinguish between useful analysis and useless ruminations. The distinction features variations in factors such as the amount of research, if any, to be done and the timing of a decision to act (i.e., how much information to gather and how long to contemplate what to do), but the single most important distinguishing characteristic is the conversion from analysis to action; (2) Enhancing skills in compartmentalization in order to better separate bedtime from problem-solving time with the welldened goal in place of keeping them separate; (3) Establishing better coping skills that involve more direct and effective problem-solving strategies. For the client that avoids making decisions and implementing them out of the fear of making the wrong one, such as perfectionist individuals, who are also at higher risk for depression as a result of their perfectionism (Basco, 1999), he or she will need additional help learning to make sensible and effective, albeit sometimes imperfect, problem-solving decisions; (4) Helping the client develop effective strategies for choosing among a range of alternatives. There is evidence that having more options, an oft-stated goal for clinicians, actually increases the anxiety and depression of those who dont have a good strategy for choosing among many alternatives (Schwartz, 2004); (5) addressing issues of sleep hygiene and attitudes toward sleep in order to make sure the persons behavior and attitudes are consistent with good sleep; and (6) Teaching mind-clearing or mind-focusing strategies, especially self-hypnosis strategies of one type or another that help the person direct their thinking in utterly benign directions. Each of the rst ve components listed here support the potential value of the sixth, the actual hypnosis strategy one employs to help calm the person to sleep.
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HYPNOTIC APPROACHES
Hypnosis can be used as a vehicle for teaching the client effective ways to make distinctions between useful analysis and useless ruminations, compartmentalize various aspects of experience, develop better coping skills, develop more effective decision-making strategies, and develop good behavioral and thought habits regarding sleep. Such hypnosis sessions are quite different in their structure than is a session designed specically for the purpose of enhancing the ability to fall and stay asleep. The primary difference between a sleep session and a regular therapy session employing hypnosis is that hypnosis for sleep enhancement is designed to actually lead the client to fall asleep. In standard therapy sessions involving hypnosis, the opposite is truethe clinician takes active steps to prevent the client from falling asleep during the session. It has been well established that hypnosis isnt a sleep state, and that sleep learning is a myth. Thus, clinicians employing hypnosis encourage the client to become focused, relaxed, yet maintain a sufcient degree of alertness to be capable of participating in the session by listening and actively adapting the clinicians suggestions to his or her particular needs. Another key difference between a hypnosis session for enhancing sleep and a standard therapy session is the role of the client during the process. In therapy, the client is dened as an active participantactively involved in the search for relevance for the clinicians suggestions, actively involved in absorbing and integrating the suggestions, and actively nding ways to apply them in the service of self-help. Relaxation may or may not be a part of the process. In fact, some suggestions a clinician offers during hypnosis might even be anxiety provoking or challenging to the clients sense of comfort. After all, personal growth often means stepping outside ones comfort zone. In the sleep session, however, cognitive and somatic arousal are to be minimized, and so challenges to the clients beliefs (or expectations, role denition, or any other aspect a clinician might appropriately challenge) are precluded. The content of the strategy (e.g., progressive relaxation, imagery from a favorite place, recollection of a happy memory, creation of fantasy stories, counting sheep, etc.) is a secondary consideration. Thus, what specic hypnotic approach one uses is relatively unimportant. The primary consideration is that whatever the person focuses on, it needs to be something that reduces both somatic and cognitive arousal. Approaches can be direct or indirect according to what the client nds easiest to respond to. Likewise, they can be content or process oriented, again depending on what the client nds easiest to relate to. Since sleep isnt something that can be commanded, an authoritarian style is generally counterproductive. A permissive style is both gentler and more consistent with an attitude of allowing sleep to occur instead of trying to force it to occur.
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The use of recorded hypnotic approaches (i.e., tape recordings or compact disc recordings) can be a useful means of helping the client to develop the skills in focusing on calming suggestions. Generally, these should be considered a temporary help in the process so that the person is eventually able to fall and stay asleep independently using self-hypnosis. However, recordings pose no major or even minor hazards that warrant concern they will be abused in some way, so there seems to be no good reason to push clients to stop using the recordings for as long as they nd them helpful. Helping people learn to slow down, curtail their ruminations, establish stronger boundaries between their work and personal lives, and better separate problem-solving time from sleep time are all worthwhile goals to address in treatment. These are life skills that may be learned with clinicians serving as teachers or guides. Hypnosis can be an effective vehicle for teaching such skills, even if just teaching basic relaxation skills, perhaps even outperforming sleep medications. As one prominent sleep and depression researcher wrote, using deep muscle relaxation and other forms of progressive relaxation strategies may help individuals to fall asleep more quickly . . . controlled studies suggest effects as strong as, and with greater durability than, those observed with sedative hypnotics (Thase, 2000, pp. 4950). The quality of the symptoms a client presents can point the clinician in the direction he or she might go if the client is to be sufciently empowered to get some control back and reduce or eliminate symptoms. For as long as a client feels victimized by his or her symptoms, recovery from depression is extremely unlikely (Cohen, 1994). The goals of therapy include not only reducing or eliminating symptoms, but also reducing or eliminating associated risk factors for further episodes. Depression is often described in the literature as a recurrent disease, and relapse statistics conrm an ever-higher probability of later episodes the more episodes one has (Glass, 1999). Using the previous example of insomnia as a target, insomnia is the symptom. But, unless the individuals ruminative coping style is altered, and unless the persons global cognitive style is addressed by teaching better compartmentalization (boundary) skills (e.g., to separate problem-solving time from sleep time), the mere teaching of relaxation skills is unlikely to be of enough help to the person to overcome depression.
A SAMPLE TRANSCRIPT OF HYPNOTIC SUGGESTIONS TO ENHANCE SLEEP

The following abbreviated hypnosis transcript can illustrate what kinds of suggestions might be given to someone who tends to ruminate at bedtime. The goal is to provide a comfortable, relaxed experience in which the person discovers he or she can clear his or her mind of the clutter that interferes with sleep.
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Id like to invite you to arrange yourself in a position that is comfortable. Id encourage you to listen to the recording of this session while you are lying in bed so you can drift off to sleep and then sleep comfortably through the night. Unlike other kinds of sessions weve done involving hypnosis or relaxation processes, with this particular hypnosis session it is appropriate for you to listen to it while youre in bed as youre going to sleep. After all, the purpose of this particular session is to make your sleep easier, more satisfying, and more restful. So, with that in mind, Id like you to let your eyes close . . . and notice the differences instantly as soon as you let your eyes close . . . It means you are no longer focusing on things around you. . it means that you have closed your eyes to the outside world . . . for now . . . And in a way . . . you might think of that . . . simple action of closing your eyes . . . as starting to close out . . . the world out there . . . Now, certainly youll hear . . . the sounds . . . the routine sounds . . . of your environment . . . and because they are so routine . . . whether it is a dog barking or crickets chirping . . . or trafc . . . it doesnt matter what it is . . . its routine . . . And that frees your mind . . . to be very present in this moment which precedes your sleep . . . you get to let your mind . . . grow ever quieter . . . ever more comfortable . . . and notice how good that feels . . . Its really quite soothing to now recognize that you can . . . slowly turn down . . . the rate and volume of your thoughts . . . until you nd yourself . . . thinking in a slow, quiet whisper . . . that is barely audible . . . and what matters is that you have the ability . . . to focus your thoughts on whatever soothes you . . . and relaxes you . . . and makes you feel good . . . theres so much freedom in just relaxing and not having to think . . . you can feel the freedom . . . of being able to . . . drift off . . . to sleep . . . slowly . . . deliberately . . . And, little by little . . . you may become aware . . . that you really arent thinking about anything in particular . . . and how your attention stays ever more focused on . . . the wonderfully . . . comfortable . . . immediacy . . . of the safety and warmth . . . the deeply comfortable warmth . . . of your bed . . . And then you can notice the subtle sensations . . . associated with falling asleep . . . Which parts of your body . . . seem to drift off . . . rst? . . . Which parts are heaviest . . . as if it would take just massive effort to move them? . . . And which parts are lightest . . . and free . . . And with your breathing slowing . . . and your mind . . . growing ever quieter . . . it can feel wonderful . . . to be drifting off . . . so easily . . . and effortlessly . . . and theres no need to drift off to sleep just yet . . . unless you really want to . . . but you can allow yourself . . . the luxury . . . of being in this . . . state of mind . . . and body . . . for a long restful time . . . And when you wake up after this deep, restful sleep . . . many hours from now . . . youll naturally feel rested . . . and energized . . . its a powerful experience . . . of rediscovering . . . quite
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naturally . . . that you can sleep . . . you can sleep . . . deeply . . . And so you can . . . just enjoy . . . the comfort . . . the sense of peacefulness . . . that you can carry with you into your dreams . . . and sleep . . . sleep . . . So now . . . you can drift off . . . drift off . . . and sleep well . . . Good night.
CONCLUSION
It is no coincidence that of the therapies with the greatest level of empirical support for their effectiveness in treating depression (cognitivebehavioral and interpersonal), none of them focus on the past and all of them focus on helping depression sufferers build the skills that can empower them. In this chapter, I have emphasized the merits of hypnosis as a vehicle for teaching new skills, encouraging active experimentation with them in everyday contexts, and using the feedback from life experience to continually adapt oneself to changing demands. Such teachings directly counter the popular psychologies that emphasize non-discriminately trusting your guts or living in the present or thinking you can have it all and countless other such global phrases that set people up to get hurt when they discover the hard way these principles dont apply in all (or perhaps even most) life situations. Hypnosis can reasonably be considered the original positive psychology. Anyone who applies hypnosis does so with the rm belief that people have more resources than they consciously realize, and that hypnosis can help bring these resources to the fore. Empowering people in this way is a natural component of an effective treatment for depression, for no one can overcome depression while feeling or behaving in a disempowered manner. Hopefully, as we continue to learn more about the many pathways into depression, we will learn more about the many pathways out as well, including those involving skillful applications of hypnosis.
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Yapko, M. (2003). Trancework: An introduction to the practice of clinical hypnosis (3rd ed.). New York: Brunner/Routledge. Yapko, M. (Ed.) (2006). Hypnosis and treating depression: Applications in clinical practice. New York: Brunner/Routledge. Zeig, J. (Ed.) (1980). A teaching seminar with Milton H. Erickson, M.D. New York: Brunner/Mazel.
Chapter 5
Hypnosis in Interventional Radiology and Outpatient Procedure Settings

Nicole Flory and Elvira Lang
OVERVIEW
Over the past decades, surgery has evolved from the traditional largeincision technique to minimally invasive approaches, fueled by a revolution in medical imaging and device design. Skilled specialists can now insert surgical instruments through tiny skin openings under the guidance of X-rays, ultrasound, magnet resonance imaging (MRI), or endoscopes. The eld of interventional radiology has blossomed from these advancements, and other specialties have adopted the minimally invasive approaches pioneered in radiology. Many surgeries that previously required general anesthesia and prolonged hospital stays are now outpatient procedures. While patients greatly benet from these developments, high-tech procedures still involve considerable physical and psychological risks for patients who can now remain alert and conscious on the operating table. In addition, indications for interventions have expanded to include more fragile patients, who in the past would have been excluded from more traditional treatment, and these patients require an even greater degree of care. Managing procedural distress in the interventional radiology suite and other outpatient procedure settings remains a challenge for clinicians and patients. Treatment teams typically rely on local anesthetics and drugs to counteract pain and anxiety. Although generally safe, these can have limited effectiveness and serious side effects. With the publics increasing interest in more holistic approaches, that is, a combination of high tech and high touch, and mounting scientic evidence for alterative approaches, use of hypnosis in the procedural setting shows great promise. This chapter will touch on the specics of the setting, and the premise, attractiveness and challenges of using hypnosis during surgery in conscious patients.
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HYPNOSIS IN THE EVOLUTION OF SURGICAL AND ANESTHETIC APPROACHES

In the evolution of surgery, development of instrumentation, anesthesia, and infection-free healing have been intimately intertwined. Progress in one of these domains fuels progress in the others, and conversely, without progress of all three, the eld cannot progress effectively. In the nineteenth century, the Scottish surgeon James Esdaile started to use hypnotic techniques in India mainly out of desperation for lack of other means of pain control (Esdaile, 1946/1957). He had heard of Franz Mesmer in Vienna who had gained fame curing mainly psychosomatic illnesses through hypnotic and trance-like states. Esdaile had never seen a mesmeric session, but read about its use for medical procedures. He successfully used these techniques during major surgery. He not only found that patients experienced less pain, but also noticed that the rate of infection was greatly reduced. However, with the discovery of the clinical use of ether and shortly thereafter chloroform, clinicians gave preference to the use of pharmaceuticals for pain control and the initial excitement about hypnosis in the operating room diminished. In 1846, Morton rst gave ether to patients for dental procedures and then demonstrated its use to the public in an amphitheater later known as Ether Dome at the Massachusetts General Hospital (Skolnick, 1996). In 1847, Simpson rst used chloroform on women during child birth (Simpson, 1847), which caused much controversy and contempt among certain religious groups (Mander, 1998). The initial enthusiasm for ether and chloroform, however, was damped by serious side effects and deaths following surgery (Duffy, 1964). This was mainly due to poor safety considerations, over sedation, and the spread of infectionin particular, during labor and delivery involving physicians (Mander, 1998). In 1847, Semmelweiss contributed a milestone to the evolution of surgery (Grant, Grant, & Lockwood, 2005). By promoting hand washing with 4 percent chlorinated lime solution for doctors and their trainees assisting in childbirth, he was able to reduce maternal mortality from 1330 percent to 1.2 percent (Nuland, 2003). Thus, he brought about one of the most important steps in reducing wound infection and mortality. Unfortunately, Semmelweiss efforts were met with much hostility and hand washing was accepted only years later, after his death, as a principle of antisepsis in surgery (Grant et al., 2005). His experience may serve as an example that simple measures with obvious positive patient outcomes still can face great opposition from members of the medical community who adhere to ingrained but unproven customs. With the progress made in the nineteenth century, surgeons of the twentieth century were ready to expand to an extensive array of open surgeries including large abdominal incisions and chest operations with heart lung machines. In the last decades, technical evolution has permitted
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less-invasive methods to address the same plumbing needs with speedier recovery. Specially trained physicians can now insert miniature high-tech devices through the patients skin under the guidance of various imaging techniques. These imaging techniques include X-rays, ultrasound, computer tomography, MRI, or endoscopes. For example, pus, kidney stones, gall bladders, and tumors can now be removed without cutting patients open. Interventionalists can now open blocked arteries, veins, or bile ducts from the inside through image-guided surgical interventions. The new subspecialty of radiology, called interventional radiology, and subsequently, interventional pulmonary, gastroenterology, cardiology, vascular, and general surgery have all proted tremendously from advances in minimally invasive surgery. In conjunction with the evolution of surgical techniques, the modes of chemical anesthesia have also expanded. Local anesthetics with varying times of actions have been devised, and drugs that counteract pain and anxiety are continuously evolving. For minimally invasive surgery, general anesthesia is no longer necessary. Interventionalists usually administer injections of local anesthetic medication (such as lidocaine) in conjunction with analgesic agents and intravenous (IV) conscious or moderate sedation (Lang, Chen, Fick, & Berbaum, 1998; Martin & Lennox, 2003). While these drug regimens generally are well tolerated during procedures, they are not always effective and can have side effects including cardiovascular problems, cessation of breathing (apnea), shortage of oxygen (hypoxia), unconsciousness (coma), and very rarely death (Martin & Lennox, 2003). While serious complications during minimally invasive procedures are rare, even a very low incidence of adverse events has larger-scale consequences. For example, millions of routine endoscopies are performed. Experts estimate that 313 percent of patients will face complications or other adverse outcome following their endoscopy (Mahnke et al., 2006). About 750 per 100,000 individuals undergo endoscopies for upper gastrointestinal problems annually (British National Institute for Health and Clinical Excellence; Web page 12/11/2006). In the United States, experts suspect that endoscopies result in more than 70,000 serious complications each year. Therefore, any medical intervention should be used judiciously to provide the best care to patients (Martin, Lennox, & Buckley, 2005). The occurrence of adverse effects not only depends on the type of procedure performed, but also on the amount and properties of each medication as well as the patients susceptibility to certain medical problems (Hatsiopoulou, Cohen, & Lang, 2003). Research ndings document that the amount of medication for the same medical procedure differs signicantly between patients, health care providers, and hospital settings (Gracely, McGrath, Heft, & Dubner, 1977; Lang et al., 1998). The risk associated with the use of monitored anesthesia during minimally invasive procedures can be comparable to that seen in general anesthesia. It is thus
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not surprising to see a rekindling of interest in hypnosis for the management of procedural distress. In the nineteenth century, the development of pharmacologic anesthesia greatly reduced the use of hypnosis during surgery (D. Spiegel, 2006; Wain, 2004), but a small group of dedicated physicians continued using hypnotic techniques solely or as an adjunct throughout the century. Hypnosis was then mainly used for individuals who had a contraindication to chemical anesthesia or purposefully requested a hypnotic intervention (Blankeld, 1991). While use of general anesthesia permitted development of extensive open surgery, it also opened the way to minimally invasive techniques that now no longer require general anesthesia. In the twenty-rst century, we may well have reached the point where the greatest procedural risks are those related to the patients pain, anxiety, and the management of these symptoms. Greater requests for transparency in medicine and the requirements of hospitals to share complication rates with the public make nonpharmacologic methods, with their high safety prole and the potential for high patient satisfaction, once again a very attractive alternative.
PROCEDURAL ENVIRONMENT
Despite the minimally invasive label, procedures in interventional radiology or other outpatient settings are not free of pain and possible distress. During outpatient surgery or minimally invasive procedures, patients typically remain conscious and immobilized on a table, sometimes for several hours, and in cases where image guidance is necessary, the room is darkened to permit viewing of the monitors. Instruments such as wires, catheters, and endoscopes that can measure several feet in length are inserted into various openings. If one were to design a psychological experiment to create feelings of anxiety and despair, one would likely choose most of the elements present in the procedure room: fear for life or health, loss of control, uncertainty of outcome, presence of masked strangers, darkness, immobilization, exposure and vulnerability (Flory, Salazar, & Lang, 2007). Even for generally healthy and well-adjusted individuals, a visit to the operating room can be a stressful experience. Patients often experience worry and concern, such as fear about being in pain, giving up control, loss of body image or physical attractiveness, surgical complications, adverse reactions to anesthesia, and death (Anderson & Masur, 1983). Optimal patient care involving heavy reliance on technology-based interventions like radiology procedures should expand to include much needed emotional support for patients (Peteet et al., 1992). Reducing anticipatory anxiety is not only desirable in itself but also has considerable implications for the upcoming procedure. In a study with patients undergoing interventional radiological procedures, pre-procedure anxiety signicantly correlated with anxiety, pain, and medication use and overall procedure length (Schupp,
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Berbaum, Berbaum, & Lang, 2005). Highly anxious patients ask for and are offered more medication during surgery, therefore exposing them to a greater likelihood of adverse events. Pain and distress can also result in a longer stay in the recovery room, additional medication use, delayed discharge, and hospital readmission (Chung, Ritchie, & Su, 1997). Recovery from surgery is of vital importance since all the mentioned adverse events put additional strain on the patients and at the same time inate health care costs (Montgomery et al., 2007).
BASES OF PROCEDURAL PAIN MANAGEMENT WITH HYPNOSIS

The experience of pain is a complex and highly subjective phenomenon (Price, Harkins, & Baker, 1987). The same physical stimuli that may be barely noticed as painful could be experienced as excruciating in a different setting, or as David Spiegel once described the phenomenon, the strain in the pain is in the brain. Focused attention and awareness are key elements in changing perceptions of pain (Spiegel & Spiegel, 1978). For example, intense attention toward an imagined warm and tingling sensation may modify the brains response to the painful signal (Spiegel & Bloom, 1983). Pain is usually perceived in different dimensions according to its sensory, cognitive, and affective-emotional aspects (Melzack, 1999). Hypnosis can reduce both the sensory and affective dimensions of pain, thereby reducing overall pain perception (Wright & Drummond, 2000). Magnetic resonance imaging studies have demonstrated that the wording of hypnotic suggestions can systematically alter the brains processing of the same painful stimulus. Suggestions targeting the sensory dimensions of pain resulted in a modulation of activity in the primary sensatory cortex, while suggestions targeting the affective components of pain resulted in changes in the anterior cingulated cortex (Rainville, Bao, & Chretien, 2005; Rainville, Carrier, Hofbauer, Bushnell, & Duncan, 1999; Rainville, Duncan, Price, Carrier, & Bushnell, 1997). Pain and anxiety are interrelated (Schupp et al., 2005), and reduction of one is likely to benecially affect the other. Hypnotic techniques can be considered brief therapeutic interventions changing cognitions, emotions, and behaviors of individuals. Hypnotic analgesia lets patients explore their own capacity to interact with a painful or uncomfortable situation (Spiegel et al., 1989). Its benets have been documented for patients in various settings with no or little side effects (Faymonville et al., 1995; Huth, Broome, & Good, 2004; Lang et al., 2000). This is in contradiction to the purely pharmacologic approach. While pharmacologic treatments for pain and anxiety may seem like a quick x, clinical experience shows that the adrenergic activation of very anxious patients can override even large amounts of sedatives and narcotics. This adrenergic activation does not only render chemical drugs ineffective, but is
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also dangerous once the procedure is over and the full drug effect suddenly emerges. In this context it seems much more efcient to engage in a quick hypnotic anxiety conversion up front. On the other hand, one should not be opposed to judicious use of drugs or place performance pressure on patients and their hypnosis providers. It is important to offer patients the choice of hypnosis, drugs, both, or none in what they perceive as their needs within the realm of safety. Earlier concerns of some, that sedatives and analgesics may adversely affect a patients ability to engage with hypnosis on the procedure table, have not been proven in a series of clinical studies. These have shown that procedural pain and anxiety can be well managed through a combination of relatively small amounts of medication and hypnosis in a wide range of medical procedures (Baglini et al., 2004; Butler, Symons, Henderson, Shortliffe, & Spiegel, 2005; Lang et al., 2000; Lang et al., 2006; Stewart, 2005).
HYPNOTIC TECHNIQUES
Since this book describes hypnotic techniques and general principles, we will explain approaches that are more specic to interventional radiology and other outpatient medical settings. The interventional procedure suite can be noisy, sabotage prone, and buzzing with different activities. This environment is very different from the practice of a therapist or psychologist with a couch in a tranquil ofce setting. While an ofce setting allows 40-minute inductions, the generation of patient-specic tapes, and possibly subsequent patient practice at home, the procedure environment requires quick action. In the ideal case, hypnosis in the procedure room should be provided by a person who is already part of the team (Blankeld, 1991). This person would have had the opportunity to meet the patient on a prior visit and used the opportunity to learn the patients individual responses to stressful situations. In our experience this is highly unlikely in the current cost- and time-conscious culture of medicine. Often, the needs and provisions for each individual patient can only be established once the patient has arrived in the procedure room. Rapid attention to such needs and brief interventions are essential. Emphasis should be placed on building rapid rapport, positive wording of suggestions, openness to discussion, and use of patientcentered imagery. On the other hand, patients are highly suggestible in the health care setting and, in particular, the acute care area (H. Spiegel, 1997), so that lengthy inductions are not necessary. Also, the approach should not interfere with patient preparation for the surgery and surgery itself. Although hypnosis is still highly cost effective even if it adds procedure time (Lang & Rosen, 2002; Montgomery et al., 2007), it has been very difcult in our experience to convey to procedure personnel that halting their activityeven for a little while and contrary to the evidencecould
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bring any good at all. We have learned over the years that it is very well possible to start the hypnotic process while a patient is being prepped (e.g., cleansed with antimicrobial solution), hooked up to equipment, or even when being positioned in a mammography unit. To guide patients into self-hypnotic relaxation, we typically use scripts; yet these are structured such that exibility, openness, and patient-centered imagery are all key elements. The overpowering aspect of technology in the procedure room is well offset by a highly permissive, responsive, and interactive approach that conveys a greater sense of control for the patient (Flory et al., 2007). It therefore mirrors some of the key aspects of Ericksonian hypnosis. Some argue that a deeper explorative non-scripted approach could produce even better results (Barabasz & Christensen, 2006), but such requires very highly skilled hypnotists, which typically are not available on a daily basis in the clinical setting. Seeing a hypnosis provider sit down to read a script can reduce misperceptions of hypnosis, overcome resistance, and provide comfort for both patients and health care professionals. A script can be a safety blanket that conveys how important the wording is when the patient lies on the operating table. It permits the whole treatment team to learn and reinforce hypnotic vocabulary. In addition, the use of scripts enables a greater standardization of treatment that is essential for documentation and reproducibility. It also permits the exchange of personnel during procedures and allows patients to drift in and out of hypnosis as they wish. All hypnosis should be considered self-hypnosis as patients explore their own abilities to deal with painful or distressing stimuli. A semantic shift from hypnosis to self-hypnosis emphasizes the patients active participation. Patients often feel out of control, passive, exposed, and vulnerable. Imagery that patients used to describe this state ranged from a piece of red meat with a butcher knife all the way through, to a little mouse being chase by huge barn cats, or surrounded by knights in silver armors ready to pierce me. In the same way that these patients can produce distressing imagery, they can also envision more resourceful scenarios if guided appropriately. It is best to teach patients to help themselves, and patients take pride and fulllment in being able to produce such scenarios. Their choices are highly individualanother reason why we do not believe one-size-ts-all hypnosis tapes. What pleases some patients may be disturbing to others as in the following examples: camping on the Mississippi, oating on the clouds with ones deceased relatives, ying a plane in the dark night sky, gambling in Las Vegas, or even canning vegetables while watching TV (Fick, Lang, Benotsch, Lutgendorf, & Logan, 1999). There are many ways to structure the hypnotic process in the procedure room; based on our experience, we describe what we found most useful in our setting. The approach contains two elements. The rst is a set of structured attentive behaviors that the hypnosis provider displays in the
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rst seconds of the patient encounter. The second element is the reading of the script in the next section. We have reported that hypnosis in the operating room should also include other techniques in addition to hypnosis such as structured attentive behaviors, establishing rapport, correct use of language and suggestions, patient-initiated imagery, relaxation training, and provisions to address patients worries as early as possible (Lang et al., 1999). Structured attentive behavior consists of several behaviors, most importantly listening. Attentive listening is the key to instant rapport buildingthe listener seeks to understand and uses patient-generated images for the hypnosis. A second element is matching the patients verbal and nonverbal behavior pattern; examples include sitting at eye level with the patient and the removal of barriers between the patient and the hypnosis provider in the operating room. Other elements of attentive behaviors include provision for increasing the patients perception of control by prompt responses to patient requests. Last, but not least, encouragement presented in statements like thank you for your cooperation will empower the patient to take a more active role during his or her medical treatment (Lang et al., 1999). The correct use of language and suggestions is important since patients generally present to the operating room with heightened suggestibility (H. Spiegel, 1997). Negatively loaded suggestions such has sharp pain and pressure now or this will hurt a bit can reinforce anxiety and magnify attention to pain (Lang et al., 2005). Emotionally neutral descriptions are preferable and may include feeling of warmth and fullness or focus on the sensation of your breath. Positive suggestions foster relaxation, and patient-centered imagery around successful coping will enhance the patients well-being (Erickson, 1994). It is best to tap into the already existing coping strategies by using the patients words and descriptions.
SCRIPT
There are many options for hypnosis scripts. After having worked with several scripts and learned from our pitfalls, Dr. D. Spiegel helped us develop the following script, which was tested for efcacy in several randomizedcontrolled trials (Lang et al., 1999; Lang et al., 2006). Over the years we made small changes based on feedback from the hypnosis community. For individuals who wish to develop their own scripts, we recommend that the following elements be included: a short explanation about what is going to happen, use of an induction that can be repeated should other personnel or events sabotage the process and inadvertently re-alert the patient, an immunization against the noise and interruptions in the room as well as unhelpful suggestions, a simple way to engage in resourceful imagery, elements of anxiety and pain conversion if needed, and a reorientation that acknowledges the patients contribution.
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We want you to help us to help you to learn a concentration exercise to help you get through the procedure more comfortably. It can be a way to help your body be more comfortable through the procedure and also deal with any discomfort that may come up during the procedure. It is just a form of concentration, like getting so caught up in a movie or a good book that you forget you are watching a movie or reading a book. Now you may be interested to learn how you can use your imagination to enter a state of focused attention and physical relaxation. If you hear sounds or noises in the room, just use these to deepen your experience. And use only the suggestions that are helpful for you. There are a lot of ways to relax, but here is one simple way: On one, you can do one thinglook up. On two, two things, slowly close your eyes and take a deep breath. On three, three things, breath out, relax your eyes, and let your body oat. Thats good, just imagine your whole body oating, oating through the table, each breath deeper and easier. Right now you might imagine that you are oating somewhere safe and comfortable, in a bath, a lake, a hot tub, or just oating in space, each breath deeper and easier. Just notice how with each breath you let a little more tension out of your body as you let your whole body oat, safe and comfortable, each breath deeper and easier. Good, now with your eyes closed and remaining in this state of concentration, please describe for me how your body is feeling right now. Where do you imagine yourself being? What is it like? Can you smell the air? Can you see what is around you? Good, now this is your safe and pleasant place to be and you can use it in a sense to play a trick on the doctors. Your body has to be here, but you dont. So just spend your time being somewhere you would rather be. Now, if there is some discomfort, and there may be some with the procedure as they prepare you and insert the line, or as you feel the dye entering your body, there is no point in ghting it. You can admit it, but then transform that sensation. If you feel some discomfort, you might nd it helpful to make that part of your body to feel warmer, as if you were in a bath. Or cooler, if that is more comfortable, as if you had ice or snow on that part of your body. This warmth and coolness becomes a protective lter between you and the pain. If you have any discomfort right now imagine that you are applying a hot pack or you are putting snow or ice on it and see what it feels like. Develop the sense of warm or cool tingling numbness to lter the hurt out of the pain. With each breath, breathe deeper and easier, your body is oating, lter the hurt out of the pain. Now again with your eyes closed and remaining in the state of concentration, describe what you are feeling right now.
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(1) If they are at their safe and comfortable placereinforce it. What is it like now? What do you see around you? What are you doing? (2) If they are in painThe pain is there but see if you can add coolness, more warmth, or make it lighter or heavier. If no longer in painGood, continue to focus on those sensations. If still in painTry to focus on sensations in another part of your body. Now rub your ngertips together and notice all of the delicate sensations in your ngertips and see how much you can observe about what it feels like to rub your thumb and forengers together. How do you feel now? If not in painGood, continue to focus on these sensations. If still in painNow imagine yourself being at ________ (patients safe place) where you said you felt relaxed and comfortable. What is it like now? What is the temperature? What do you see around you? (3) If they state that they are worriedOkay, your main job right now is to help your body feel comfortable, so we will talk about what is worrying you. But rst, no matter what we discuss, concentrate on your body oating. So lets get the oating back into your body. Imagine that you are in this favorite spot and when you are ready let me know by nodding your head and then we will talk about what is worrying you. But remember no matter what we discuss concentrate on your body oating, and feel safe and comfortable. So what is worrying you? (Discuss) How do you feel now? If not worried: Good, now continue to concentrate on body oating, and feel safe and comfortable in your favorite place. If after discussing patient has persistent worry, thenOkay you might picture in your mind a screen like a movie screen, TV screen, or a piece of clear blue sky. First you might see a pleasant scene on it. Now you may picture a large piece of blue screen divided in half. All right, now on the left half, picture what you are worrying about on the screen. Now on the right half, picture what you will do about it, or what you would recommend someone else to do about it. Keep your body oating, and if you are worrying about the outcome, okay admit it to yourself, but your body does not have to get uptight about it. You may, but your body does not have to. Good, you know that whatever happens there is always something you can do. But for now just concentrate on keeping your body oating and feeling safe and comfortable. Sometimes throughout the procedure sayIf you feel any sense of discomfort you are welcome to let me know about it. You may use the lter to lter the hurt out of the pain, but by all means let me know and I will do what I can to help you with it as well. Whatever you do just keep your body oating and concentrate on being in the place where you feel safe and comfortable. When nished, sayOkay the procedure is over now. We are going to leave formally this state of concentration by counting backwards from three to one. On three get ready, on two with your eyes closed roll up your eyes, and on one let your eyes open and take a deep breath and let it out.
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That will be the end of the formal exercise, but when you come out of it you will still have the feeling of comfort that you felt during it. Ready, three, two, one. If necessary: Threeget ready. Twowith your eyes closed roll up your eyes. Onelet your eyes open and take a deep breath, and feel refreshed and proud about having helped yourself through this procedure.
SCIENTIFIC EVIDENCE
For the past century, the majority of research on hypnosis has been in the form of case reports, often based on the descriptions of the treating clinician. Supporters of evidence-based medicine often frown on the lack of thorough methodology; for example, use of anecdotal case reports, selection biases, retrospective designs, non-standardized interventions, or vague outcome measures. As such, hypnosis had suffered from lack of availability of such data from randomized studies (Blankeld, 1991). Nowadays, however, empirical support for the effectiveness of hypnotic techniques for medical purposes is available from both experimental and clinical studies. Modern developments in neuro-imaging provide insight into the physiological mechanism of hypnosis. In experimental studies, hypnotic instructions have been shown to alter the way pain or other distressful events are processed in the brain and perceived by an individual (Rainville et al., 2005; Rainville et al., 1999; Rainville et al., 1997). For example, changing the wording of suggestions under hypnosis affects the activation of different brain centers during exposure to the same stimulus (Rainville et al., 1997). Rainville et al. (1997) demonstrated that suggestions targeting the sensory dimension of the pain (such as you will feel a tingling sensation) resulted in activation changes in the primary sensory cortex. Suggestions targeting the affective dimension of the pain (such as you will remain calm) resulted in changes in the anterior cingulate cortex. Clinical studies with superior methodology using prospective randomized control designs have demonstrated the effectiveness of hypnotic techniques in the peri-operative domain, that is, before (Saadat & Kain, 2007), during (Lang et al., 2000; Lang et al., 2006), and after surgery (Huth et al., 2004). To name a few examples, hypnotic techniques have been used for various treatment of breast cancer, burn care, plastic surgery, tumor embolization, labor and delivery, and the removal of appendices, bone marrow, teeth, and tonsils (Butler et al., 2005; Faymonville et al., 1995; Huth et al., 2004; Lang et al., 2000; Lang et al., 2006; Montgomery et al., 2007; Patterson, Questad, & deLateour, 1989; Wright & Drummond, 2000; Zeltzer & LeBaron, 1982). Faymonville et al. (2000) reviewed 1,650 various surgical procedures from retrospective and randomized prospective studies in which hypnosis was used as an adjunctive treatment to conscious sedation. The authors concluded that patients greatly beneted from hypnosis as a result of greater
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active participation, procedural comfort, faster recovery time, and shorter hospital stays. To date, the literature on hypnosis documents that this brief psychological intervention signicantly reduces pain intensity, pain unpleasantness, anxiety, nausea, fatigue, medication use, and procedure time (Butler et al., 2005; Faymonville et al., 2000; Lang et al., 2000; Lang et al., 2005; Montgomery et al., 2007). Montgomery, David, Winkel, Silverstein, & Bovberg (2002) conducted a meta-analysis of 20 randomized-controlled trials evaluating the effectiveness of hypnotic techniques in conjunction with pharmacologic treatments for various medical procedures. Results indicated that on average about 90 percent of surgical patients proted from adjunctive treatment compared to control groups. Outcomes were evaluated according to negative affect, pain, medication, recovery, and treatment time; hypnosis produced better results in all of these domains. The authors concluded that hypnosis is an effective adjunctive procedure for a wide variety of surgical patients (Montgomery et al., 2002). Particularly in the realm of interventional radiology, using interventions with documented benecial outcomes that are safe and easy to apply on the procedure table is of prime concern. The current gold standard to assess efcacy and treatment safety is evidence from prospective randomized controlled trials in which patients are randomly assigned to different treatment conditions. In the experimental group, patients receive an intervention such as a self-hypnotic relaxation exercise. In the control group, patients receive the standard medical care without any specic intervention or without an additional person attending to them. There is an ongoing debate as to which group of patients represents an appropriate control group. Jensen and Patterson (2005) have argued that an additional control should be included that does not receive hypnosis or pharmacologic treatment. However, the intervention still needs to be credible but minimally effective to control for the social aspects and additional care through the hypnosis provider present in the hypnosis condition (Jensen & Patterson, 2005). Lang et al. (2000) presented the most comprehensive study using a prospective randomized-controlled design to establish hypnosis outcomes to date. In this study, 241 patients underwent interventional radiology procedures in the kidneys and vascular system. Patients were randomized to selfhypnotic relaxation, structured attention, and standard care. All patients had access to local anesthetic and IV medication if they requested it. Hypnosis signicantly reduced anxiety, pain, drug use, and complications. As a result, procedure time was reduced by 17 minutes compared to standard care. In addition, hypnosis reduced costs an average of $330 per procedure compared to standard care (Lang & Rosen, 2002). Lang et al. (2006) conducted another randomized-controlled trial on 236 women undergoing large core breast biopsies comparing hypnosis to standard care and empathic attention. Large core breast biopsies are known
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to often cause distress in patients and are usually performed solely under a local anesthesia (Bugbee et al., 2005). Hypnosis and empathic attention were administered in addition to local anesthesia; both signicantly reduced pain perception, but only hypnosis also reduced anxiety (Lang et al., 2006). Montgomery et al. (2007) have presented the most recent randomized study on brief hypnosis interventions in 200 patients undergoing breast cancer surgery. Women were randomized to either a pre-operative hypnosis session with a psychologist or non-directive empathic listening (attention control). Hypnosis resulted in signicantly less drug use for sedation and pain management during the procedure compared to the control group. Patients in the hypnosis group also reported less pain, nausea, fatigue, discomfort, and emotional upset than the controls. The authors also documented that hypnosis reduced costs by $772.71 per patient for the institution, mainly as a result of shorter stays in the procedure room (Montgomery et al., 2007). In summary, there is overwhelming support for the effectiveness of hypnosis to manage pain and anxiety in patients undergoing invasive medical procedures. In addition, complications and cost can be reduced by its use.
PATIENTS RESPONSIVENESS AND ACCEPTANCE

In recent years, patients have become more educated about their health and surgical interventions. Patients want to become more actively involved in their care. This includes using alternative treatments to reduce pain and distress. Western medicine has traditionally not met these needs, and patients have therefore turned toward more alternative sources of healing. About a third of Americans use alternative treatments for their medical problems, and it is therefore not surprising that patients present with their own coping strategies to the procedure suite (Campion, 1993; Eisenberg et al., 1993). Many patients use mind-body techniques that can reduce pain and anxiety including imagery, distraction, relaxation, hypnosis, and meditation (Quirk, Letenre, Ciottone, & Lingley, 1989; Astin, 2004; Astin, Shapiro, Eisenberg, & Forys, 2003). In recent years, the Internet, books, and tapes have become valuable tools for patients, and their authors claim extensive widespread use. It is becoming more common to see patients checking in for their procedures with hypnosis tapes or requests for specic coping rituals. Introduction of hypnosis into the procedure suite may thus become a consumer-driven event. As David Spiegel (2007) recently stated, hypnotic techniques suffered the disadvantage of not involving drugs or other products that can be purchased. If this were the case, the industry would have worked hard to try selling this product. However, the tide may be turning in favor of such patient-centered therapy based on patient demand and the superior outcome prole for procedures performed under hypnosis. What
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held true for Esdaile in the nineteenth century still holds in the twentyrst centuryhospitals with better outcomes will attract more patients, and healthcare facilities would be advised to take note in order to compete in the consumer-driven market of health care. The question then becomes, which patients can benet from hypnosis during surgery? Highly hypnotizable individuals have undergone open surgery solely under hypnosis without general or local anesthesia (Wain, 2004). Wain (2004) has described these talented patients as hypnotic virtuosos, but these represent only a small percentage of patients. However, even hypnosis-naive and moderately hypnotizable individuals can be guided quickly into self-hypnotic relaxation during minimally invasive procedures as described previously. For minimally invasive surgery that does not require general anesthesia, patients can benet from hypnosis even when their hypnotizability is average or low (Flick et al., 1999). A recent study showed that in a cohort of patients aged 1892, age had no effect on hypnotizability (Lutgendorf et al., 2007), a nding contradictory to previous reports (Morgan & Hilgard, 1972).
CHALLENGES
Despite the empirical support for the effectiveness of hypnotic techniques, hypnosis is still underused. Reasons for the slow acceptance of hypnosis into mainstream medicine are numerous and include inaccurate perceptions of this practice. One such inaccurate perception is that hypnosis requires additional time and nancial costs (Anbar, 2006); the opposite has been documented (Lang & Rosen, 2002; Montgomery et al., 2007). Another reason for slow acceptance may rest with the fact that successful use of hypnosis in the procedure room depends on the cooperation of all members of the treatment team. Treatments that depend on interpersonal skills and not a technical gadget are often met with skepticism and sometimes ridiculed by more empirically trained health care professionals. Research ndings on the effectiveness of audio tapes and computerized interventions have been mixed (Ghoneim, Block, Sarasin, Davis, & Marchman, 2000; Hart, 1980). It appears that such interventions can be effective for both treatment outcomes and costs, but more patient-centered approaches with a personal hypnosis provider have resulted in more consistent benets. As attractive as it might be to give patients a tape or some high-tech device such as virtual reality helmets developed by Patterson et al. (2006), proceedings in the operating room are complex. Providing patients with the best medical care including procedural hypnosis requires that the patients individual preferences are respected and that the whole treatment team is willing to go along or at least not to interfere. It takes a village to attend to the patients needs and solicit the collaboration of everybody in the procedural suite for a successful outcome.
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Some medical providers believe that stating how painful and distressing a procedure can be helps the patient and expresses sympathy. With good intentions physicians and nurses often use terms with unpleasant content such as stinging sensation, is it hurting yet, dont worry, it will be over soon, or sharp burning pain. It is assumed that such words help patients, but the opposite has been shown to be true (Lang et al., 2005). Such negatively loaded suggestions can create nocebo effects and increase pain and anxiety (H. Spiegel, 1997). The idea that words can both heal or harm is far from new. One of the oldest documents on medical practice, the Hippocratic Corpus, explicitly states that physicians should pay attention to both talk and silence (Jones, 1923/1972). Compassionate and empathic communication is often considered essential for good medical practice and has become an important part in training health care professionals. However, there remains considerable debate around what constitutes real empathy and whether it improves the patients well-being. A recent study by Lang et al. (unpublished manuscript) found that hypnosis techniques and empathic attention reduce pain, anxiety, and medication during interventional radiology procedures. Yet, empathic techniques alone, without tapping into the patients self-coping, resulted in more pain, anxiety, and complications. These complications were related not only to psychosocial well-being but also to adverse effects on blood pressure and oxygen supply. Just providing emotional support without guiding the patient into a more relaxed state seems counterproductive. Chatting and touching the patient may not only be unhelpful, but potentially harmful if not practiced with caution. Trying to be nice does not sufce in helping patients help themselves.
PRECAUTIONS AND SAFETY CONSIDERATIONS

Safety of the patient needs to be considered rst before any procedures are implemented. Research studies on the medical use of hypnosis suggest that it carries little risk for adverse effects, and patients are generally satised with outcomes (Jensen et al., 2006). If adverse effects emerge, these are usually minor and transient. Possible adverse effects of hypnosis in the experimental context include drowsiness and headaches (Coe & Ryken, 1979). Therefore, several safety precautions should be considered and the potential for adverse effects needs to be recognized early (Barber, 1998). Since comprehensive training in hypnosis is associated with a lesser likelihood of adverse effects (Lynn, Martin, & Frauman, 1996) its practice should be limited to health care professionals with adequate training. Health care professional should use hypnosis as an adjunct for a treatment that they are trained to deliver in the rst place. For example, members of the treatment team in the interventional radiology suite could deliver hypnosis in the procedure room but should not attempt to treat post-traumatic
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stress syndrome. Hypnotic techniques should also not be used as the only tool or the last resort to manage pain, anxiety, or medical emergencies. As a precaution, it is not recommended that hypnosis be used with patients whose reality testing is compromised since mental health professionals are best qualied to treat this population. However, psychotic patients typically are not very hypnotizable (D. Spiegel, Detrick, & Frischolz, 1982). Lang and colleagues have shown that hypnotic techniques are safe and effective in the interventional radiology setting (Lang, Joyce, Spiegel, Hamilton, & Lee, 1996). Use of hypnotic scripts can ensure safety and reproducibility that are particularly important in research and procedural settings. The script used by our group places an emphasis on rapid trance induction, patient-centered imagery, and permissiveness, and was originally developed by Dr. D. Spiegel (Lang et al., 1999). The script is quick and easy to apply, immune to disruptions, and also addresses fears of patients early before these become more difcult to manage.
CONCLUSIONS
Research has demonstrated that hypnotic techniques can be safely and effectively integrated into a medical high-tech environment. Integration of hypnosis in modern medicine does not add costs nor time. Even hypnosisnaive patients can learn hypnotic techniques on the operating table without disturbing or prolonging the procedure. In summary, hypnosis is ideally suited as an adjunctive treatment for modern minimally invasive procedures. The union of high-tech medicine and hypnosis, the oldest form of psychotherapy, would make for a happy marriage (D. Spiegel, 2006).
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Saadat, H. and Kain, Z. (2007). Hypnosis as a therapeutic tool. Pediatrics, 120(1), 179181. Schupp, C., Berbaum, K., Berbaum, M., & Lang, E. V. (2005). Pain and anxiety during interventional radiological procedures. Effect of patients state anxiety at baseline and modulation by nonpharmacologic analgesia adjuncts. Journal of Vascular & Interventional Radiology, 16, 15851592. Simpson, J. Y. (1847). Account of a new anaesthetic agent as a substitute for sulphuric ether in surgery and midwifery. Communications to the MedicoChirurgical Society of Edinburgh 10th November. Edinburgh: Sutherland & Knox. Skolnick, A. A. (1996). Sesquicentennial of rst publicly performed surgery under anesthesia. Journal of the American Medical Association, 276(15), 1205. Spiegel, D. (2007). The mind prepared: hypnosis in surgery. Journal of the National Cancer Institute, 99(17), 12801281. Spiegel, D. (2006). Wedding hypnosis to the radiology suite. Pain, 126(13), 34. Spiegel, D., Bierre, P., & Rootenberg, J. (1989). Hypnotic alteration of somatosensory perception. American Journal of Psychiatry, 146(6), 749754. Spiegel, D., & Bloom, J. (1983). Pain in metastatic breast cancer. Cancer, 52, 341345. Spiegel, D., Detrick, D., & Frischolz, E. (1982). Hypnotizability and psychopathology. American Journal of Psychiatry, 139, 431437. Spiegel, H. (1997). Nocebo: The power of suggestibility. Preventive Medicine, 26, 616621. Spiegel, H., & Spiegel, D. (1978). Trance and treatment: Clinical uses of hypnosis. New York: Basic Books. Stewart, J. H. (2005). Hypnosis in contemporary medicine. Mayo Clinical Proceedings, 80, 511524. Wain, H. J. (2004). Reections on hypnotizability and its impact on successful surgical hypnosis: A sole anesthetic for septoplasty. American Journal of Clinical Hypnosis, 46(4), 313321. Wright, B. R., & Drummond, P. D. (2000). Rapid induction analgesia for the alleviation of procedural pain during burn care. Burns, 26(3), 275282. Zeltzer, L., & LeBaron, S. (1982). Hypnosis and nonhypnotic techniques for reduction of pain and anxiety during painful procedures in children and adolescents with cancer. Journal of Pediatrics, 101, 10321035. This work was supported by the U.S. Army Medical Research and Material Command (DAMD 17-01-1-0153), National Institutes of Health & National Center for Complementary and Alternative Medicine (RO1 AT-0002-05 & K24 AT01074-01), Ruth L. Kirschstein National Research Service Award, National Institutes of Health & National Institute of Cancer (T32-59367).
Chapter 6
Hypnosis in the Treatment of Smoking, Alcohol, and Substance Abuse: The Nature of Scientic Evidence
Kent Cadegan and V. Krishna Kumar
The Substance and Mental Health Services Administration (2007) reported that in 2006, 72.9 million Americans (29.6 percent) aged 12 or older were current users (past month) of a tobacco product, the largest (61.6 million or 25 percent) were cigarette smokers. Furthermore, illicit drug use was almost 9 times higher (47.8 percent) among youths aged 12 to 17 who smoked cigarettes in the past month than it was among youths who did not smoke cigarettes in the past month (5.4 percent). Generally, illicit drug use was reported by 9.6 million persons aged 12 or older. Marijuana, a popular drug of choice of 14.8 million users, was smoked daily or almost daily over a period of 12 months by 3.1 million persons among past marijuana users, aged 12 or older. Heavy alcohol was reported by 17 million (6.9 percent) of the population aged 12 or older, or 17 million people, and binge drinking by 57 million people (23 percent). Even more troublesome is that in 2006, 10.2 million people (4.2 percent) aged 12 or older reported driving under the inuence of illicit drugs during the past year. Smoking is the leading contributor to premature death, cardiovascular disease, stroke, lung cancer, and, more recently, it has been linked to Alzheimer disease and dementia. A study of 6,868 people age 55 and older in the Netherlands, followed for seven years, showed current smokers, without an APOE e4 allele, were at increased risk to develop Alzheimer dementia, than those who had never smoked. There was no association in whom the allele was present. There was, however, no association between current smoking and risk for vascular dementia, or past smoking and risk for dementia, Alzheimer dementia, and vascular dementia (Reitz, den Heijer, van Duijn, Hofman, & Breteler, 2007). Alcohol, cocaine opiates, other street and prescription drugs, and gambling wreak havoc in the lives of many people and stress the health
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care system, law enforcement, and employment agencies to a very high level in many developed countries. The social costs of addictions are indeed very high (Rehm, Taylor, Patra, & Gmel, 2006), given that there are multiple consequences of substance abusepremature mortality, conicts with family, unemployment, various psychiatric disorders, transmission of infectious diseases, automobile accidents, cancer, and a host of other medical ailments (Wagner et al., 2007). Treatment options abound for people addicted to tobacco and illicit and prescription drugs. These include self-help groups such as Alcoholics Anonymous and Narcotics Anonymous; pharmacological interventions in the form of emetics, patches, and pills; acupuncture; and, psychological interventions that use behavioral, cognitive-behavioral, stress management, motivational, and hypnotic strategies to beat addictions. Of course, people often simultaneously attempt one or more interventions, for example acupuncture, patches, and cognitive-behavioral. The rising cost of the dominant conventional allopathic system of pharmaceutical antidotes appears to be driving individuals to seek alternative systems of healing and wellness, including hypnosis. With over 300 alternative systems of health care the world over, it is necessary to establish the effectiveness of hypnosis as a treatment modality, particularly since it could be a very costeffective treatment strategy. To think a simple daily self-hypnosis practice and timely hypnotherapy could offer signicant relief begs more careful scrutiny than given Franz Mesmer by the French Academy of Sciences. The purpose of this chapter is to review experimental evidence on the effectiveness of using hypnosis in the treatment of smoking and drug and alcohol abuse. The review is restricted to experimental work and is an examination of the Cochrane Database of Systematic Reviews (20002005), other past reviews, and recent individual experimental studies using hypnosis for the treatment of smoking, drug, and alcohol abuse.
HYPNOSIS IN THE TREATMENT OF SMOKING

Excellent reviews of literature (Holroyd, 1980; Green & Lynn, 2000; and most recently, Abbot, Stead, White, & Barnes, 2006) are already available on the impact of hypnosis on smoking cessation. They all paint a fairly grim picture about the effectiveness of hypnosis for smoking cessation with a minimal intervention of one or two sessions. The reviews of Green and Lynn (2000) and Abbot et al. (2006) suggest that the most available studies suffer from one or more methodological weaknesses, thus failing to meet the criteria for meeting the highest levels of evidence for evidence-based research on the effectiveness of therapy. From a comprehensive review of clinical reports, nonrandomized/nonequivalent sample studies, experimental investigations with less than recommended sample size, and rigorous experimental studies, Green and Lynn
Hypnosis in the Treatment of Smoking, Alcohol, and Substance Abuse
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(2000) concluded: giving hypnosis the stamp of a well-established treatment for smoking cessation is premature, although hypnosis can, with some justication, be regarded as a possibly efcacious, yet by no means specic, treatment for smoking cessation (p. 216). In a review on the effectiveness of a variety of smoking cessation interventions, Marlow and Stoller (2003) highlighted Abbot, Stead, White, Barnes, and Ernst (2000), nding no efcacy of hypnosis for smoking cessation (p. 1251), noting that the main challenges to validating the efcacy of hypnosis had to do with small sample size of most of the trials and confounding issue of separating the impact of time spent with the therapist from the hypnosis itself (p. 1251). Furthermore, they observed that The USDHHS Clinical Practice Guideline do not recommend hypnosis (p. 1251). There is little evidence that hypnosis for smoking cessation does any better than other treatments (relaxation, behavior modication, and health education), attention, or placebo comparisons (see also Covino & Bottari, 2001). Re-examining the data reported by Green and Lynn (2000; Table 1), the median abstinence rates in clinical reports using 3, 6, and 12 months time frames were found to be 29, 25, and 19 percent, respectively. Furthermore, data on nonrandomized/nonequivalent sample studies, abstinence rates reported in Table 2 by Green & Lynn (2000) ranged from 1 month to 19 months in 5 very different studies, making it difcult to evaluate the effect of hypnosis in terms of specic time frames on abstinence rates. The median abstinence rate for hypnosis alone, for these varied time frames, was about 22 percent. The median abstinence rate was 31.5 percent for experimental studies with less than recommended sample size, using individual and group hypnosis conditions and using follow-up periods of 1 week to 6 months (based on Table 3, Green & Lynn, 2000). The median abstinence rate was 21 percent for follow-up time periods of 3 weeks to 6 months in rigorous experimental studies (estimates based on Table 3, Green & Lynn, 2000). Abbot et al. (2006) considered only those studies that used randomized controlled trials that reported abstinence over at least 6 months after the beginning of the treatment. They found only nine such studies (through search of various data bases, 19662005) from which they concluded: (a) there was wide variation of results in individual studies, with conicting results about the effectiveness of hypnosis, relative to other treatments or control conditions (wait listed/no treatment control, attention/placebo, psychological treatments, rapid/focused smoking, hypnosis plus group therapy vs. group therapy alone), (b) there was no evidence of a greater effect of hypnotherapy on 6-month abstinence rates, compared to other treatments or no treatment, (c) studies used a wide range of hypnotherapies, but did not describe them fully, (d) none of the studies used biochemical markers for determining abstinence at follow-up, (e) the increased likelihood of abstinence, in studies reporting success, may be due to non-specic factors such as contact with a therapist, and (f) the encouraging results
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from uncontrolled studies may be due to the inclusion of highly motivated participants and may not be reective of long-term abstinence. A recent study by Elkins and Rajab (2004) used a non-randomized control group study. The control was a consult-only group of nine patients (who chose not to participate after session 1) who were compared with patients who had experienced one (n 9) or two sessions (n 12) of hypnosis treatment. During the second session, patients were provided with a cassette tape (direct suggestions for relaxation and comfort) following hypnosis with individually adapted hypnosis suggestions at the end of the second session and were asked to practice four or more times per week. Although encouraging results were reported (48 percent abstinence rate at one year post-treatment), no results pertaining to the use of practice or its effects were reported. Elkins, Marcus, Bates, Rajab, and Cook (2006) noted that many of the randomized studies have used a minimal approach to hypnotherapy, involving one or two sessions or group interventions yielding outcomes about 20% to 25% cessation (p. 304). Elkins et al. (2006) conducted a prospective randomized control group pilot study, involving intensive hypnotherapy for smoking cessation involving eight sessions, in which hypnotic interventions were conducted in sessions 1, 2, 4, and 7. Individualized suggestions were embedded in general common suggestions (across all subjects) of deepening relaxation, absorbing in relaxing imagery, commitment to stop smoking, decreased craving for nicotine, posthypnotic suggestions, practice of self-hypnosis, and visualization of the positive benets of smoking cessation (p. 307). The 20 participants in the experimental group were also provided with self-help materials from the National Cancer Institute and brief counseling each session, plus a self-hypnosis tape recording and tape player and instructed in the daily practice of self-hypnosis. The participants also received supportive phone calls three days after the target quit date, and in weeks 2, 4, and 5. The 20 participants in the wait-listed group received self-help material, were encouraged to set a quit date, and received supportive phone calls. Using biochemical markers, they reported a 40 percent continuous abstinence rate (from quitting date) for the hypnosis participants as opposed to zero percent in the control group. Unfortunately, again, the study did not examine either the effects of hypnotic susceptibility or the effects of practice. Lynn and Kirsch (2006) described a two-session program approach, using cognitive-behavioral training in conjunction with self-hypnosis training. Their program included the following components: self-hypnosis training, cognitivebehavioral skills, education, enhancing motivation and self-efcacy, being a nonsmoker, relapse prevention and gain maintenance, minimizing weight gain, and contracting and social support. They reported continuous abstinence rates of 24 to 39 percent at six-month follow-up (n 236) across different trainers.
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HYPNOSIS IN THE TREATMENT OF ALCOHOL AND SUBSTANCE ABUSE

Relative to smoking, very few experimental studies exist on the use of hypnosis in the treatment of alcohol and even fewer on substance abuse, although there appears to be a growing interest in using hypnosis for treating alcoholism and other addictions (Potter, 2004). Early reviews by Wadden and Penrod (1981), Wadden and Anderton (1982), and Schoen (1985) suggest mixed ndings. Experimental studies showed little effects of hypnosis on alcohol abstinence, but case studies reported encouraging results. All reviews pointed to various methodological aws in the reviewed studies that make it highly problematic to conclude that hypnosis qualies as an evidence-based approach (or even possibly efcacious) for treating alcohol abuse. Examining more current literatures suggests that this has not changed. There have been a few dissertations on the adjunctive usefulness of hypnosis (Chierici, 1989; Crocker, 2004; Smith, 1988; Young, 1996) in the treatment of alcohol abuse. Unfortunately, none of these studies say much about the efcacy of hypnosis as an evidence-based approach, either as an adjunctive technique or as stand-alone treatment strategy in the treatment of alcohol abuse or dependence. They worked with small sample sizes, short-follow-up time frames (1 week to 90 days), and outcomes were assessed via self-report. As mentioned before, experimental studies with substance abuse patients are even more rare. A recent randomized controlled trial by Pekala et al. (2004) was a step in this direction. They used random assignment across four conditions (hypnosis, transtheoretical, cognitive-behavioral, and attentionplacebo labeled as stress management conditions). All 261 veterans included in the study were involved in either a 21 or 28 (dual diagnosis) substance abuse day treatment program involving intensive group and individual therapy ve days a week, approximately six hours a day. The veterans received an additional four hours of training in self-hypnosis, a cognitive-behavioral transtheoretical intervention (based on Prochaska, Norcross, & DiClemente, 1992), or an attention-placebo (stress management) intervention program. Thus, the treatment conditions in the study were all adjunctive to the regular domiciliary programs. The veterans received treatment manuals in the four conditions, which they could refer to use and use on a regular basis during treatment and postdischarge. The hypnosis treatment included four hypnosis protocols: self-esteem enhancement, relapse prevention, serenity enhancement, and anger and anxiety reduction/management. The relapse prevention hypnotic protocol used suggestions based on H. Spiegel (1970) and suggestions for relapse prevention based on Marlatt and Gordon (1985). All protocols included body-scan relaxation and mind-calming suggestions. The participants were encouraged to practice whatever self-hypnosis protocol they wanted, but to do so at least once per day for the next 3 months (p. 285). A two-month self-report
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follow-up was conducted. Of the 54 percent of participants contacted, 87 percent reported total abstinence in all four groups. While there were no signicant overall differences in the four experimental conditions in relapse rates, possibly due to the excellent residential program everyone received, some interesting ndings did emerge, with severely addicted individuals, practicing self-hypnosis tapes regularly (at least 4 times a week) postdischarge was associated with increased self-esteem and serenity, and decreased anger impulsivity (p. 292). Additionally, participants were more likely to be abstinent to the extent they practiced the audiotapes, and at the beginning of the study had lower levels of self-esteem, were already practicing counterconditioning strategies, and did not practice stimulus control (p. 293). Given that hypnotic responsivity was associated with those who practiced the self-hypnosis tapes, the results suggest a specic mediating effect of hypnosis. The studys results can be considered encouraging as an evidence-based adjunctive treatment strategy, in as much as it suggests the use of multiple hypnotic protocols and the signicance of self-hypnosis practice for more hypnotically responsive patients. Although the study used random assignment, treatment manuals, and had adequate sample size in each condition, the follow-up relied upon self-reports, and the number of individuals available for nal analyses were small. Unfortunately, the data on what protocols were actually practiced were not collected, thus it is not possible to determine what mechanisms were actually at work in the participants who found hypnosis helpful.
GENERAL DISCUSSION
Examining both extant reviews and recent experimental studies on the use of hypnosis for smoking cessation suggests that the conclusion of Green and Lynn (2000) of hypnosis as a possibly efcacious, yet by no means specic, treatment for smoking cessation (p. 216) still remains valid. If a potential client calls and asks, does it work, we are still unable to give a clear substantive answer as to what would be a reasonable expectation of success. Given abstinence rates of zero to 88 percent in different studies, even with rather gross estimates of about 20 percent success rates, it is not clear what statement can be made to a potential client as to what to expect. In contrast, it is noteworthy that Law and Tang (1995) reported that an estimated 2 percent of smokers stopped smoking and did not relapse up to a year as a result of brief unsolicited advice from their physician, leading them to conclude that although the effect is modest, this is a very cost-effective strategy. It would be interesting to determine if physician-referred patients for hypnosis are more successful than those referred from other sources (e.g., friends, families, self). The conclusion with regard to the use of treatment of alcohol and drugs is even bleaker, despite the number of good ideas that are available in the
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designing of hypnotic treatment protocols and tested in somewhat less rigorous studies that suggest that hypnotic strategies are valuable for at least some clients. Some key recommendations emerge from a review of these various studies. There is a need to standardize the measurement of outcomes by way of using biochemical markers. There appears to be an over-reliance on the more conveniently obtained self-report measures. Follow-up intervals tend to be short, possibly because of inadequate funding of such projects and perhaps also the increasing difculty of maintaining contacts over time with the participants. However, there is a need for systematizing the follow-up intervals in different studies. Possibly the minimal requirement for such outcome studies should use follow-up time frames of 3, 6, and 12 months. With increasingly longterm follow-ups, there is an increasing problem for internal validity, in as much as there is a potential for greater within-conditions variability (Westen, Novotny, & Thomson-Brenner, 2004). Investigators should also report whether the participants were continuously abstinent over the time frames used in the study, along with frequency of lapses and relapses, and not just whether they were abstinent at the single point of time at follow-up. A study of lapses and how participants recover from lapses would be valuable. There is also a need to evaluate the effectiveness of hypnosis for different types of smokerslight, medium, or heavyand chronic (hardened smokers) versus those have smoked for a short period of time. In designing studies, one needs to employ a hypnosis-alone condition, along with hypnosis-plus another treatment such as cognitive-behavioral, cognitive-behavioral alone, and an attention-placebo condition to more accurately assess the role of hypnosis as an adjunctive technique. The question of how many sessions do we need remains to be addressed. There is a need to systematically examine the popular one-session approach with a more multiple-session approach, especially in view of the popular one-large group sessions that are offered by lay hypnotists in hotels around the country. Studies are needed to examine the effectiveness of particular suggestions used in hypnosis protocols. This can be done by both asking patients what they found most helpful in the hypnotic protocol used and more rigorously by conducting controlled experiments. Yet another possibility is to examine if stages of change (Prochaska et al., 1992) are important in the type of suggestions used. Such analyses will be helpful in making specic recommendations to clinicians. Currently, a wide range of suggestions are used and it is not known what suggestions are particularly helpful and when (i.e., in terms of stages of change). In studies where multiple protocols are used, addressing tangential, but relevant aspects, such as improving selfesteem, reducing anger (e.g., Pekala et al., 2004), it is important to follow up on understanding their contribution to the treatment process. Studies are needed to examine the effectiveness of individualizing suggestions versus using pre-scripted versions and their association with
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hypnotizability. The chief advantage of pre-scripted protocols is that they can be administered by a minimally trained technician and/or via audiotapes. In contrast, individualized protocols clearly require experience and would require individual taping. Hypnotizability needs to be routinely assessed in treatment outcome studies, as Bowers (1984) noted the effects of a treatment intervention are not due to a suggestion unless treatment outcome is correlated with hypnotic ability (p. 444), the point of view is referred to as the Bowers Doctrine (Woody, 1997, p. 227). Pekala et al.s study suggests the importance of self-hypnosis practice (see also Potter, 2004). However, not much is known about the role of self-hypnosis practice as it relates to treatment outcomes. Specically, how much practice is needed and for how long? Is distributed practice better than massed practice? Is it better to use taped scripts or have the patients practice without audiotapes on self-generated suggestions? And, is there a role for hypnosis booster sessions in maintenance? Since hypnosis is popularly sought as treatment of smoking cessation, it is imperative that studies are urgently needed to not just establish it as an effective treatment, but also to determine the essential components of a hypnotic intervention. Thus, there is a need to know what works and what does not work and for whom (i.e., types of suggestions, types of practice, individual vs. group, types of adjunctive treatment, individually tailored vs. pre-scripted versions, inuence of individual difference variables; see Spiegel, Frischholz, Fleiss, & Spiegel, 1993). There is indeed a signicant body of work (case studies, quasi-experimental studies, and experimental studies) that suggests hypnosis is a viable treatment option, and there is no dearth of good ideas about how hypnotic protocols are to be designedbut there is a need for testing these ideas using experimental methods. Eventually, it should be possible to say to a potential client that hypnosis can help you control your addiction if you have certain characteristics (e.g., hypnotizability, motivation to quit; availability of social support), and if you are willing to practice (with specication about the nature and amount of practice). There is no exclusive methodology by which science progressesthere is a place for a variety of different types of methodologies, informing one another. On a cautionary note, it is important to realize that the randomized controlled trials, the gold standard (Cooper, 2003, p. 106) of evidence-based practice, has weaknesses. Most importantly, such trials address narrow issues, use carefully selected samples, use short-trial periods, and provide information about a group, not individual treatment (see Cooper, 2003; Williams & Garner, 2002), among other problems. Williams and Garner (2002) pointed out that even a single successfully treated patient might provide information on a breakthrough procedure, for example, the rst surgical operation for mitral stenosis (p. 11). Thus, evidence that is based on randomized controlled trials is not to be construed as a guarantee of success in practice At best, they
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provide guidance and needs to combine with clinical experience for making treatment decisions. Williams and Garner (2002) noted: Sophisticated clinical experience with regard to an individual patient needs to be balanced with an evidence base derived from a group. Too much emphasis on a narrow range of acceptable evidence oversimplies the complex nature of clinical care (p. 11). Furthermore, even well-established medical practices do not always work for everyone. And, what may generally not work may have extraordinary effects in some individuals. Williams and Garner (2002) observed: The EBM [Evidence-Based Medicine] data on donezpil show marginal improvement in patients with mild to moderate dementia. On the other hand, there are good examples of individual patients showing impressive improvement in patients (Dening & Lawton, 1998; Manchip & Morrison, 1999). Evidence of this nature must be recognized and not dismissed as anecdotal (p. 10). A recent exciting nding was reported by Naqvi, Rudrauf, Damasio, & Bechara (2007) concerning the role of the insula in controlling conscious urges for nicotine. Damage to the insula was accompanied by disruption of smoking addiction, characterized by the ability to quit smoking easily, immediately, without relapse, and without persistence of the urge to smoke (p. 531). A patient who had smoked 40 unltered cigarettes per day and was enjoying smoking very much (p. 534) quit smoking immediately after suffering a stroke; he stated he quit because his body forgot the urge to smoke (p. 534), suggesting that smoking serves to satisfy a bodily need. In a media report, one of the authors of the study, Bechara, stated: The quitting was like a light switch turned off and he never wanted a cigarette again (Dunham, 2007, pp. 12). Naqvi et al. (2007) suggested that therapies that modulate the function of insula will be useful in helping smokers quit (p. 534) Well, can hypnosis practitioners design suggestions to turn odown the insula when faced with cravings, or, to gain greater control by being able to turn it up and down volitionally?
REFERENCES
Abbot, N. C., Stead, L. F., White, A. R., & Barnes, J. (2006). Hypnotherapy for Smoking Cessation. The Cochrane Database for Systematic Reviews, the Cochrane Library, the Cochrane Collaboration, Volume 4. Retrieved November 17, 2006, from http://grateway.ut.ovoid.com/gw1/0vidweb.cgi. Abbot, N. C., Stead, L. F., White, A. R., Barnes, J., & Ernst, E. (2000). Hypnotherapy for Smoking Cessation. The Cochrane Database for Systematic Reviews, the Cochrane Library, the Cochrane Collaboration, Volume 2. Bowers, K. S. (1984). Hypnosis. In N. S. Endler & J. M. Hunt (Eds.), Personality and the behavioral disorders (pp. 2354). Washington, DC: American Psychological Association. Chierici, S. (1989). The use of hypnosis to increase self-concept with drug and alcohol abusers. Dissertation Abstracts International, 50, 1676 (University Microlm No. 8912409).
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Cooper, B. (2003). Evidence-based mental health policy: A critical appraisal. British Journal of Psychiatry, 183, 105113. Covino, N. A., & Bottari, M. (2001). Hypnosis, behavioral theory, and smoking cessation. Journal of Dental Education, 65, 340347. Crocker, S. M. (2004). Hypnosis as an adjunct in the treatment of alcohol relapse. Unpublished dissertation, Washington State University, Washington. Dening, T., & Lawton, C. (1998). New drug treatment to Alzheimers disease. British Medical Journal, 317, 945. Dunham, W. (2007). Brain damage makes heavy smoker quit. News in Science abc. net.au/science/news. Retrieved January 26, 2007 from http://www.abc.net.au. science/2007/1834202.htm/. Green, J. P., & Lynn, S. J. (2000). Hypnosis and suggestion-based approaches to smoking cessation: An examination of the evidence. International Journal of Clinical and Experimental Hypnosis, 48, 195224. Elkins, G., Marcus, J., Bates, J., Rajab, M. H., & Cook, T. (2006). Intensive hypnotherapy for smoking cessation. International Journal of Clinical and Experimental Hypnosis, 54, 303315. Elkins, G., & Rajab, M. H. (2004). Clinical hypnosis for smoking cessation: Preliminary results of a three-session intervention. International Journal of Clinical and Experimental Hypnosis, 52, 7384. Green, J. P., Lynn, S. J. (2000). Hypnosis and suggestion-based approaches to smoking cessation. International Journal of Clinical and Experimental Hypnosis, 48(2), 195223. Holroyd, J. (1980). Hypnosis treatment for smoking: An evaluative review. International Journal of Clinical and Experimental Hypnosis, 28, 341357. Law, M., & Tang, J. L. (1995). An analysis of the effectiveness of interventions intended to help people stop smoking. Archives of Internal Medicine, 155, 19331941. Lynn, S. J. & Kirsch, I. (2006). Essentials of clinical hypnosis: An evidence based approach. Washington, D.C.: American Psychological Association. Manchip, S., & Morrison, C. (1999). A case report. British Medical Journal, 139, 1510. Marlatt, G. A., & Gordon, J. R., (1985). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford. Marlow, S. P., & Stoller, J. K. (2003). Smoking cessation. Respiratory Care, 48, 12381256. Naqvi, N. H., Rudrauf, D., Damasio, H., & Bechara, A. (2007). Damage to the insula disrupts addiction to cigarette smoking. Science, 315, 531534. Pekala, R. J., Maurer, R., Kumar, V.K., Elliott, N.C., Masten, E., & Moon, E. et al. (2004). Self-hypnosis relapse prevention training: Its effects on self-esteem, affect, and relapse with drug and alcohol users. American Journal of Clinical Hypnosis, 46, 281297. Potter, G. (2004). Intensive therapy: Utilizing hypnosis in the treatment of substance abuse disorders. American Journal of Clinical Hypnosis, 47, 2128. Prochaska, J. O., Norcross, J. C., & DiClemente, C. (1992). In search of how people change. American Psychologist, 47, 11021114.
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Rehm, J., Taylor, B., Patra, J., & Gmel, G. (2006). Avoidable burden of disease: Conceptual and methodological issues in substance abuse epidemiology. International Journal of Methods in Psychiatric Research, 15, 181191. Reitz, C., den Heijer, T., Van Duijn, C., Hofman, A., & Breteler, M. M. B. (2007). Relation between smoking and risk of dementia and Alzheimer disease. Neurology, 69, 9981005. Schoen, M. (1985). A conceptual framework and treatment strategy for the alcoholic urge to drink utilizing hypnosis. International Journal of Addictions, 20, 403415. Smith, M. B. (1988). The hypnotic modication of alcohol expectancies. Dissertation Abstracts International, 49, 5034 (University Microlm No. 8903527). Spiegel, D., Frischholz, E. J., Fleiss, J. L., & Spiegel, H. (1993). Predictors of smoking abstinence following a single-session restructuring intervention with self-hypnosis. American Journal of Psychiatry, 150, 10901097. Spiegel, H. (1970). A single treatment method to stop smoking using ancillary selfhypnosis. International Journal of Clinical and Experimental Hypnosis, 18, 235250. Substance and Mental Health Services Administration (2007). Results from the 2006 National Survey on Drug Use and health: National Findings. Ofce of Applied Statistics, NSDUH Series H-32, DHHS Publication No. SMA 074293, Rockville, MD. Wadden, T. A., & Anderton, C. H. (1982). The clinical use of hypnosis. Psychological Bulletin, 91, 215243. Wadden, T. A., & Penrod, J. H. (1981). Hypnosis in the treatment of alcoholism: A review and appraisal. American Journal of Clinical Hypnosis, 24, 4147. Wagner, T. H., Harris, K. M., Federman, B., Dei, L., & Luna, Y., & Humphreys, K. (2007). Prevalence of substance use disorders among veterans and comparable nonveterans from the national survey on drug use and health. Psychological Services, 4, 149157. Westen, D., Novotny, C. M., & Thomson-Brenner, H. (2004). The empirical status of empirically supported psychotherapies: Assumptions, ndings, and reporting in controlled clinical trials. Psychological Bulletin, 130, 631633. Williams, D. D. R., & Garner, J. (2002). The case against the evidence: A different perspective on evidence-based medicine. British Journal of Psychiatry, 180, 812. Woody, E. Z. (1997). Have the hypnotically susceptibility scales outlived their usefulness? International Journal of Clinical and Experimental Hypnosis, 45, 226 238. Young, G. K. (1996). Hypnosis as an adjunctive modality in the relapse prevention component of an alcoholism treatment program. Unpublished doctoral dissertation, Pacic Graduate School of Psychology, Palo Alto.
AUTHORS NOTE
The authors thank Dr. R. J. Pekala for his comments on an earlier version of this chapter. Reprint requests are to be addressed to V. K. Kumar, Department of Psychology, West Chester University of Pennsylvania, West Chester, PA 19393; e-mail: vkumar@wcupa.edu
Chapter 7
Hypnosis and Medicine: In from the Margins

Nicholas A. Covino, Jessica Wexler, and Kevin Miller
A signicant relationship between psychological variables, most notably anxiety and depression, has been found to be present in a variety of medical illnesses (Roy-Byrne et al. 2008). Psychological interventions in medicine commonly employ cognitive-behavioral and relaxation strategies that target the autonomic nervous system and improve social support for patients. Behavioral medicine strategies seek to manage increases in heart rate, respiration, muscle tension, and the overproduction of glucose, neurotransmitters, and hormones that result from sustained sympathetic arousal and benet patients with pain, insomnia, asthma, gastrointestinal disorders, and some others (Giardion, McGrady, & Andrasik, 2007). Cognitive processes are thought to play a key role in the maintenance of these medical illnesses and somewhat in their treatment (Grossman, Neimann, Schmit, & Walach, 2004; Lehrer, Carr, Sargunaraj, & Woolfolk, 1993). Social supports are purported to provide emotional and instrumental assistance for patients and contribute benecially to longevity (Anderson, 2003). Hypnosis interventions with pain patients have been found, in varying degrees, to be efcacious (Montgomery, DuHamel, & Redd, 2000; Patterson & Jensen, 2003). Reviews of the hypnosis literature and in other areas propose that medical illness and conditions such as insomnia, asthma, bulimia, and irritable bowel syndrome and illness behaviors such as cigarette smoking and hyperemesis point to opportunities for symptom reduction and illness management via hypnosis (Covino, 2008; Mendoza & Capafons, 2009; Pinnel & Covino, 2000). Recent research with children and adults who are undergoing painful medical procedures supports the use of hypnosis as a distraction and pain management technique not only to decrease discomfort, but also, the use
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of medication and the time required for treatment (Butler, Symons, Henderson, Shortliffe & Spiegel, 2005; Lang et al., 2000). Hypnotic interventions have a long history in the treatment of the medically ill. However, apart from the role of hypnosis in pain management, much of the research support for the use of hypnosis with the medically ill is dated or lacks sufcient methodological rigor to qualify for recommendation as an adjunct to medical care by mainstream practitioners. Most limiting are the parochial experimental models and idiosyncratic treatment protocols of hypnosis that ignore the research ndings of other psychology and behavioral medicine investigators. The hypnosis literature on pain management provides signicant reason to believe that hypnotic techniques can be of benet to medical patients (Patterson & Jensen, 2003) and that there is some support for its extension to other illness areas (Pinnel & Covino, 2000). However, methodological weaknesses in the hypnosis literature, such as absent or dated research, a paucity of randomized control experiments, and the common failure of hypnosis researchers to integrate the results of studies from behavioral science investigators and other medical research, limit the acceptance of hypnosis as an adjunctive technique by patients and professionals. Advancement in this area seems achievable, but greater recognition requires the hypnosis community to update its literature, integrate ndings from other researchers in psychology and medicine, and bring increased methodological rigor to research strategies to accomplish this. Several medical illnesses and conditions serve as good examples of the promise and challenge for hypnosis in medicine, and these will be reviewed in this chapter. Since the efcacious role of hypnosis in pain management is best established and has been the subject of several excellent analyses (Montgomery, DuHamel, & Redd, 2000; Patterson & Jensen, 2003) we will not discuss it in further detail in this chapter.
ABSENT RESEARCH SUPPORT: INSOMNIA

Between 40 and 70 million Americans experience at least one episode of sleeplessness each year with chronic insomnia claiming about 20 percent of the adult population and close to 30 percent of those in senior years (Foley et al., 1995; NIH, 2005). Psychophysiologic insomnia is second in frequency only to the complaint of pain among primary care patients (Hauri & Linde, 1996) and it is the result of the combination of autonomic nervous system (ANS) arousal and injudicious behavior. Consistent with a pattern of chronic ANS arousal, insomniacs use increased oxygen during the day and at night (Bonnet & Arand, 2003); demonstrate persistent elevations in temperature, heart rate, basal skin response, and vasoconstriction prior to and during sleep (Bonnet & Arand, 1998; Lushington, Dawson, & Lack, 2000); and report more frequent pre-sleep negative cognitive activity (Harvey, 2000; Kuisk, Bertelson, & Walsh, 1989; Nelson & Harvey,
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2003). In an effort to cope with chronic insomnia, individuals commonly self-medicate with alcohol, establish irregular sleep habits, and engage in behaviors such as reading and watching television in bed that are incompatible with sleep. A repetitive cycle of arousal that includes catastrophic thinking, increased cardiopulmonary activity, maladaptive behaviors, and the release of hormones and neurotransmitters maintains the disorder. Sedative medications are sometimes prescribed, but psychological treatments such as cognitive behavioral therapy (CBT) that emphasize relaxation, cognitive restructuring (e.g., challenging and revising catastrophic thinking, such as I must get to sleep soon or I will have a terrible day tomorrow.) and sleep hygiene (e.g., regularizing bedtime, avoiding daytime naps, leaving the bed when sleep is delayed more than 20 minutes), are recommended treatments (NIH, 2005). Seventy-eight adults with chronic insomnia who were randomly assigned to receive medication (Temazepam), CBT, CBT medication, or placebo reported better results for all active treatment conditions. While the best results were obtained by patients in the combined condition, CBT not only outperformed the medication-alone group, but, at one- and two-year followup, subjects reported greater relief and satisfaction with the psychological intervention over medication alone (Morin, Colecchi, Stone, Sood, & Brink, 1999). In a double-blind, placebo, controlled study, patients who were offered six weeks of CBT increased their hours of sleep and reduced the time that it took to fall asleep more than those trained with relaxation alone or subjected to desensitization techniques (Edinger et al., 2001). When insomnia patients were, again, randomly assigned to treatment conditions that included CBT, placebo, a popular sleep medication, and the combination medicine and CBT, both of the cognitive interventions had signicant effect at six months on sleep efciency over placebo and medication alone (Jacobs, Pace-Schott, Stickgold, & Otto, 2004). Patients who were offered the psychological intervention reported greater satisfaction with their results than those in the medication group. Interestingly, this type of cognitivebehavioral intervention has been found to be equally successful whether it is administered in a group, individually, or over the telephone in a 20-minute format (Bastien, Morin, Ouellet, Blais, & Bouchard, 2004). A National Institute of Health expert panel, charged with reviewing the state of the science on insomnia, concluded that cognitive and behavioral techniques were the most effective psychological interventions for this disorder (NIH, 2005). Unfortunately, hypnosis was not recommended by the committee, due to a lack of available evidence in support of it. Although this aptly named (i.e., pnos sleep, from the Greek) technique captures attention, facilitates absorption, alters perception, and offers suggestions for cognitive and behavioral change, researchers have not subjected it to empirical trials. It is easy to hypothesize that those who are blessed with vivid imaginations could be more susceptible to sleep disruption. Furthermore, this same capacity for absorption and imaginative involvement seems
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likely to permit patients with hypnosis to relax deeply and distract themselves from arousing thoughts in a manner that would facilitate sleep. However, only anecdotal case reports exist for hypnotic interventions with sleep-disordered patients, making it impossible to include among the evidence-based treatments in medicine.
DATED RESEARCH SUPPORT: ASTHMA, BULIMIA, HYPEREMESIS Asthma

Asthma is a chronic medical illness that is characterized by episodes of inammation and narrowing of the small airways of the lung, leading to symptoms of wheezing, shortness of breath, cough, and chest tightness. Approximately 22 million people in the United States suffer from asthma, and this number has been rising signicantly due to lifestyle issues such as obesity, pollution, and smoking (Yeatts et al., 2006; National Heart Lung and Blood Institute 2008). Asthma results in lost work days and health care costs that exceed $16 billion per year and is among the most common causes of absenteeism among school-age children (NHLBI, 2008). Asthmatic episodes are commonly triggered by allergens, infection, and exercise, but psychological factors such as anxiety and panic are thought to be triggers as well (Kayton, Richardson, Lozano, & McCauley, 2004). For many years, bronchial asthma was regarded as a psychosomatic illness. Early psychoanalysts (Alexander & French 1945; French & Alexander, 1941) grouped asthma among seven illnesses, including ulcerative colitis and neurodermatitis, where psychological conicts were determined to be necessary and sufcient causes of disease. The asthma patients signature wheeze was seen as a symbolic expression of dependency (i.e., a suppressed cry for help from the mother) that would be resolved, along with the medical illness, by psychoanalysis. Later work in the 1970s, inuenced by an understanding of asthma as a hyperreactive airways disease where the smooth muscle surrounding airways in the lung becomes triggered by heightened emotion, identied anxiety as an emotional trigger for an asthma attack. Susceptible individuals would not only be more vulnerable to increased symptoms but characterological anxiety was found to negatively impact the management and course of care (Jones, Kinsman, Dirks, & Dahlem, 1979; Kinsman, Dirks, Jones, & Dahlem, 1980). More recent studies continue to nd a relationship between panic disorder and asthma sufferers. Hasler and her colleagues found that children with panic disorder were six times more likely to develop asthma as adults, and that asthmatic children were found to have a 4.5-fold incidence of panic disorder as adults (Hasler et al., 2005). The World Mental Health Survey of more than 85,000 adults found that asthma patients were 1.5 times more likely than nonasthmatics to experience panic and related anxiety disorders (Scott et al.,
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2007). The more recent medical understanding of asthma as an inammatory disease that is regulated by the immune system has invited researchers in the emerging eld of psychoneuroimmunology to examine the relationship among psychological stress, immune response, and asthma symptomatology (Wright, 2004). Early research utilizing suggestion and hypnosis in the treatment of asthma produced a rationale to include it in asthma care and some measure of hope for its efcacy. An experimental model, developed in the mid1960s, measured airways resistance among asthmatics exposed to saline mist who were given suggestions that they were breathing bronchoconstricting irritants. Nineteen of 40 asthmatics reacted to the experimental situation with a signicant increase in airways resistance and 12 of the asthmatic subjects developed full-blown attacks of bronchospasm that was reversed with a saline solution placebo (Luparello, Lyons, Bleecker, & McFadden, 1968). A meta-analysis of 23 studies that followed this same model found that one-third of the total 427 subjects in these studies demonstrated clinically signicant responses to suggestions for breathing difculties. Two randomized, control studies are some of the best work in this area and each is more than 40 years old (British Tuberculosis Association, 1968; Maher-Loughnan, Mason, Macdonald, & Fry, 1962). At 18 months, asthma patients with hypnosis training demonstrated a signicant decrease in medication use over asthma patient-controls without such training (Maher-Loughnan et al., 1962). A large sample (N 252) randomized clinical trial examined the efcacy of relaxation training alone versus monthly hypnosis training with daily practice and found improvements in both groups. However, signicantly better reduction in symptoms and medication use, especially among female patients, was noted for those in the hypnosis condition (British Tuberculosis Association, 1968). Patients with heightened hypnotizability were found to benet from a supportive visit, but experienced signicantly more benet when trained to use hypnosis to manage asthma symptoms (Ewer & Stewart, 1986). A small group of 10 patients with exercise-induced asthma performed signicantly better on treadmill tests when trained to use hypnosis than when they were offered a medication, a placebo, or standard care (Ben-Zvi, Spohn, Young, & Kattan, 1982). A more recent study (Anbar, 2002) found improvement for 80 percent of children who were offered hypnosis training, but it is unclear whether these children were asthmatic or were pseudo-asthma patients with a signicant psychological component to their symptom presentation. Given the impressive results of the early work in this area and the striking number of children and adults who suffer from asthma, it behooves clinical hypnosis researchers to undertake further study of the impact of hypnosis training in this population of medical patients. The number of studies demonstrating the strong relationship between panic and asthma and suggestibility and asthma offer a signicant promise for the use of hypnosis as an
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adjunctive resource in pulmonary care. However, the dated literature in this area limits any enthusiasm among medical specialists to include this as a treatment strategy.
Bulimia
While the prevalence of bulimia nervosa in the general population is very small, estimates of women, especially young women, with eating disorders range between 1 and 4 percent (American Psychiatric Association, 2000; Howat & Saxton, 1987). Individuals with this disorder are often normalweight individuals, but they feel out of control with regard to their eating, often bingeing on large quantities of food at a time. Despite a normal appearance, they commonly harbor a distorted body image of themselves as overweight, and they become preoccupied with maintaining a certain physical image. Diuretics and vomiting are often employed to reduce the caloric impact of over-eating that leads to a vicious cycle of bingeing and purging. While these disordered eating behaviors are not life threatening per se, serious dental, gastrointestinal, and cardiovascular problems can result from chronic bingeing and purging (Fairburn, Cooper, Safran, & Wilson, 2008). The origin of this disorder is unknown, but symptoms of depression and anxiety are frequently reported by those with bulimia. Cognitive-behavioral treatments have been found to be successful at reducing the frequency and severity of bulimic symptoms, although many women report symptoms of this disorder throughout their lives. Dissociative symptoms of timelessness, depersonalization, derealization, and involuntariness have been linked to experiences of bingeing and purging (Demitrack, Putnam, Brewerton, Brandt, & Gold, 1990). Cognitive-behavioral treatments address several aspects of the symptom picture in bulimia: cognitive restructuring techniques are directed at the patients body image distortions and irrational ideas regarding food; behavioral strategies are employed to reduce bingeing and purging as well as for affect management. In most cases, clinicians ask patients to keep a record of thoughts and feelings, especially those that occur prior to a binge episode. A review of the errors of logic associated with patients thinking about body image, food, and nutrition often leads to the revelation of core beliefs that can be revised with more adaptive ideas substituted. Behavioral strategies for relaxation, affect management, and more adaptive eating behaviors are rehearsed in the clinical setting and applied in daily life. Recent years have seen a number of empirical studies regarding the efcacy of CBT interventions in bulimia. Keel & Haedt (2008) provide a summary of evidence-based studies in this area. Their review supports CBT as a well-established intervention for adults and older adolescents with bulimia nervosa. Randomized controlled trials nd better outcomes correlating with patients advancing age with few successful studies including children and
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very young adults. Follow-up studies with adolescents and adults in this review showed improvement at six months and one year with symptom and social gains lasting as long as 10 years (Fairburn, Jones, Peveler, Hope, & OConnor, 1993; Keel, Crow, Davis, & Mitchell, 2002). Support was found for family, interpersonal, and psychodynamic treatments aimed at self-condence and self-efcacy, offering promise for a more diverse approach to treatment and potential lines of experimental inquiry. Early reports of dissociative symptoms among this population (Demitrack et al., 1990; Torem, 1986) prompted hypnosis researchers to study the levels of hypnotizability among bulimics. First among these studies were Pettinatti, Horne, and Staats (1985) who found that bulimic inpatients showed elevated scores on hypnotizability scales when compared to anorexic inpatients. College outpatients displayed similar scores on a variety of hypnotizability measures in several reports (Barabasz, 1993; Groth-Marnat & Schumaker, 1990; Kranhold, Baumann, & Fichter, 1992). Young women with bulimia and another group of normal-weight controls who volunteered for an investigation of taste preference were tested for hypnotizability by the same investigator who was blind to diagnosis (Covino, Jimerson, Wolfe, Franko, & Frankel, 1994). Bulimic subjects not only had higher scores than the controls, but an unusual number of these individuals (p < .001) scored in the highly hypnotizable range. Despite good evidence of hypnotizability of bulimic patients with various levels of the disorder, psychological interventions utilizing hypnosis in this population are rare. The few studies that do exist lack appropriate controls, employ small sample sizes, and fail to report follow-up data (Grifths, Gillett, & Davies, 1989; Vanderlinden & Vandereycken, 1988). Such limitations make it difcult to be condent about advocating for the use of hypnosis with these patients. One controlled study (Grifths, Hadzi-Pavlovic, & ChannonLittle, 1996) randomly assigned subjects to a CBT group or one employing hypnobehavioral treatment (HBT). Participants received individual psychotherapy along with manualized care that delivered traditional CBT and HBT to the relevant group. HBT subjects received suggestions for behavioral change and self-hypnosis training with ego-strengthening techniques. Both treatment conditions showed equal effect at nine-month follow-up, but they followed an initial period of behavioral treatment that might have been the efcacious element of the care. A recent study reported by Barabasz (2007) found 14 bulimic women who were randomly assigned to a CBT or CBT hypnosis group then followed for three months. Symptom measures found comparable results for both treatments, but the hypnosis group reported signicantly less binge frequency compared to those treated with CBT alone. While encouraging, this is a very small sample and this study is a singular example of the kind of research that is needed in this area. Research ndings of elevated hypnotizability in this population invite us to believe that hypnosis strategies added to the well-supported CBT
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interventions for bulimia should make an important addition to medical and psychological care in this area. Patients who are more suggestible should be able to use trance and new ideas to assist them with managing emotions, changing xed ideas about nutrition and body image, revising maladaptive core beliefs, and practicing more adaptive eating behaviors. The paucity of recent, controlled intervention studies at this point makes it impossible for any provider to be enthusiastic about the use of hypnosis for bulimia. Such work is clearly needed.
Hyperemesis
Uncontrolled nausea and vomiting, also known as hyperemesis, is a common consequence of chemotherapy for cancer and, as we know, of pregnancy. Anticipatory nausea and vomiting (ANV) usually results from the combination of behavioral conditioning and the application of intensive medication regimens that are aimed at reducing cancerous cells (Morrow & Dobkin, 1988). ANV affects between 25 and 50 percent of patients, commonly by the fourth session of treatment (Andrykowski, Redd, & Hateld, 1985; Redd & Andrykowski, 1982), with patients experiencing symptoms of nausea and vomiting in response to hospital odors, images, or personnel or other conditioned stimuli, and their symptoms are escalated by anxiety (Andrykowski, 1987; Jacobsen, Bovbjerg, & Redd, 1993). ANV is a debilitating experience for patients, but it is, also, the most common reason that cancer patients discontinue treatment earlier than advised (Dolgin, Katz, Doctors, & Siegel, 1986; Sitzia & Huggins, 1998; Zeltzer & LeBaron, 1982). While most women experience nausea and vomiting in the early months of pregnancy, a certain number (0.52 percent) experience intractable vomiting leading to dehydration. This condition is called hyperemesis gravidarum (HG), and it results from metabolic changes created by the placenta. Behavioral conditioning can complicate this condition, as with ANV, but psychological factors have not been found to play an etiological role in this condition. Behavioral intervention procedures are the most widely offered psychosocial services at comprehensive cancer centers due to their immediate impact on the presenting complaint, the relative ease of application and the opportunity to offer some measure of control to a disempowered patient (Coluzzi et al., 1995; Meyer & Mark, 1995). Behavioral interventions typically include distraction techniques such as story telling and the use of video games, systematic desensitization, relaxation training, and hypnosis. In their review of 54 published studies of the effectiveness of interventions aimed at the aversive symptoms of cancer treatments, Redd, Montgomery, & DuHamel (2001) report that behavioral techniques can effectively control anticipatory nausea and vomiting along with anxiety and distress related to the medical treatments. Patients treated with relaxation are able to use this skill during aversive procedures to manage accompanying anxiety and to distract themselves
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from the subjective experience of nausea. Numerous studies nd relaxation to be effective at decreasing the incidence of nausea and vomiting prior to chemotherapy (Razavi et al., 1993; Vasterling, Jenkins, Tope, & Burish, 1993). Hypnosis has been employed by pediatric and adult clinicians to manage pain, reduce anxiety, and manage the symptoms of nausea and vomiting. Zeltzer, Dolgin, LeBaron, & LeBaron (1991) treated 54 children who were randomly assigned to receive hypnosis, distraction, or placebo interventions. Observation and interview measures of anticipatory- and post-chemotherapy nausea and vomiting, distress, and functional disruption found that children in the hypnosis group had the greatest reduction in symptoms. Another study with children found that hypnosis decreased the need for antiemetic medicines and reduced chemotherapy-related nausea and vomiting (Jacknow, Tschann, Link, & Boyce, 1994). Furthermore, children in the hypnosis group were still able to manage anticipatory nausea for several months after treatment. Among adults, bone marrow transplant patients who were randomly assigned to groups utilizing hypnosis, CBT, therapist contact, and treatment as usual demonstrated better results with hypnosis than with CBT (Syrjala, Cummings, & Donaldson, 1992). In a related use of hypnosis to manage postoperative nausea and vomiting, patients undergoing breast surgery with hypnosis training four to six days prior demonstrated less vomiting and less need for analgesic medications (Enquist, Bjorklund, Engman, & Jakobsson, 1997). While there is both logic and some empirical support for the use of hypnosis in the management of hyperemesis, especially with regard to ANV among cancer patients, and, perhaps, surgical patients, this literature is dated, the sample sizes are small, and the studies are very few in number. Research combining hypnosis training for distraction, absorption, and anxiety management along with the use of imagined approaches to noxious stimuli in the manner of systematic desensitization holds a great deal of promise for the eld and for patient care.
PAROCHIAL RESEARCH: FUNCTIONAL GASTROINTESTINAL DISORDERS AND SMOKING CESSATION Functional Gastrointestinal Disorders
By denition, the bloating, abdominal pain, and changes in motility and bowel movement that constitute functional gastrointestinal disorders (FGID) are without structural or organic origin (Toner & Cassati, 2002). Disorders such as irritable bowel syndrome (IBS) and functional bowel disorder (FBD) impact as many as 22 percent of the population and comprise close to one-third of the typical gastroenterologists practice (Drossman, Camilleri, Mayer, & Whitehead, 2002; Whitehead, Crowell, Robinson, Heller, & Schuster, 1992). As with insomnia, autonomic hyperarousal, cognition, and behavior
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play key roles in maintaining these disorders. In response to experimental stressors, patients with FGID show increased gastric motility (Drossman et al., 2002; Maunder et al., 1997) gastric velocity, and gastric activity (Bilhartz and Croft, 2000; Drossman, Whitehead, & Camilleri 1997). However, dismotility is absent during sleep (Fukudo et al., 1992; Kellow, Gill, & Wingate, 1990). FGID patients selectively attend to abdominal sensations and maintain a persistent belief that they are seriously ill, despite medical assurance to the contrary. Psychological factors such as a history of early childhood abuse and chronic mood disorders are common precursors, with a majority of FGID patients failing to see a mind-body dimension to their disorder (Blanchard, 2001; Toner & Casati, 2002). While controlled studies utilizing brief psychodynamic psychotherapy have demonstrated success in reducing FGID symptoms (Guthrie, Creed, Dawson, & Tomenson, 1991), substantial research supports the efcacy of cognitive-behavioral interventions for this population (Blanchard, 2000). Techniques including psychophysiological education, relaxation training, cognitive restructuring, and behavioral rehearsal have improved FGID in randomized controlled studies involving waitlist (Tkachuk, Graff, Martin, & Bernstein, 2003; van Dulman, Fennis, & Bleijenberg, 1996) and crossover (Lynch and Zamble, 1989) designs. Treatment strategies that help FGID patients to correct a tendency toward catastrophic thinking, while acquiring adaptive habits such as relaxation, are accepted interventions by mental health and medical caregivers. Whorwell and his colleagues found that as few as seven 30-minute sessions with hypnosis were effective in reducing IBS symptoms and were more effective than talking therapy alone (Whorwell, Prior, & Faragher, 1984; Whorwell, Prior, & Colgan, 1987; Prior, Colgan, & Whorwell, 1990). Subsequent work from the same group found substantial improvement in pain control, bowel movement, and rectal sensitivity (Houghton, Jackson, Whorwell, & Cooper, 1999) and that bowel symptoms and quality of life remained improved at three months (Gonsalkorale, Houghton, & Whorwell, 2002) and, even, ve years (Gonsalkorale, Perrey, Pravica, Whorwell, & Hutchinson, 2003). Similar symptom amelioration and improved quality of life were effected by hypnosis through audiotapes with gains remaining at 1012 months (Palsson, Turner, Johnson, Burnett, & Whitehead, 2002). Unfortunately, rather than integrate the signicant body of psychological research that nds support for cognitive-behavioral interventions, hypnotic research methods, almost universally, employ the strategy of the earliest hypnosis investigators in this area who specify gut-directed suggestions as the desired hypnosis intervention. This recommendation is supported by their observation that six study subjects had prior, general, hypnotic suggestions without relief and these improved when suggestions for warm hands that could soothe the abdomen and bring better control to bowel function were presented to them (Gonsalkorale, 2006; Whorwell et al., 1987). Generalized
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from such a small and briey analyzed sample, this logic is not only not compelling, it ignores a substantial body of CBT research with its focus on altering cognitions and changing behavior. Only very recently have investigators begun to integrate CBT strategies into hypnosis studies (Taylor, Read, & Hills, 2004), although maintaining the overly specic approach. Such a restricted strategy unnecessarily limits the range of therapeutic interventions for patients with FGID and keeps clinicians and investigators, who are involved in similar work, unnecessarily sequestered. Moreover, such an idiosyncratic logic and clinical approach contributes to the marginalization of our eld by mental health professionals who witness the ignorance of an evidence-based approach with CBT and by medical practitioners who think it unconventional. While there is some enthusiasm for the use of hypnosis in this area, randomized control studies and a better integration of the successful elements of CBT research with this patient population are much needed.
Smoking Cessation
Cigarette smoking is responsible for 30 percent of cancer deaths in this country and it is a major contributor to emphysema, heart disease, and stroke, along with presenting a signicant health risk for nonsmokers who are exposed to it. Despite signicant public education efforts across recent years, the population of smokers in this country remains relatively constant at more than 23 percent (CDC, 2006). Unfortunately, psychological factors of conditioning and suggestion combine with the addictive drug nicotine to create a complex habit disorder that undermines most smokers best intentions. The elements of suggestion are well employed by the tobacco marketers who place attractive people in appealing settings to sell their product. Consumers are invited to become imaginatively involved in the advertisement and open to the suggestion that a particularly disagreeable behavior is as desirable as the images. Catchy phrases are so repetitiously presented that, many years later, the general public of a certain age knows what LSMFT means, how good Winstons taste, and how cool Joe Camel is. By contrast, public health messages that employ cancerous lungs, a dyspneic cowboy, and illness warnings fail to invite smokers to linger long enough on the content of the commercial to absorb the message. While the numbers are small, about 2 percent of patients will stop when their primary care doctor suggests it to them (Law & Tang, 1995). The treatment of cigarette smokers has been quite challenging. Most interventions, be they with nicotine replacement, antidepressants, or CBT, are likely to succeed with only one of ve patients. However, given the number of smokers and the known consequences of long-term use, these numbers represent a signicant health care gain. Research nds support for behavioral techniques such as rapid smoking, stimulus control, and skill
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training, but not for aversive stimuli, contingency, and nicotine fading (Covino & Bottari, 2001). Given the important role that nicotine plays in fostering and maintaining addiction, it is not surprising to nd nicotine replacement almost doubles the chances of success for those who are interested in quitting, regardless of the treatment approach used (Silagy, Lancaster, Stead, Mant, & Fowler, 2004). Most reports on the use of hypnosis for cigarette smoking follow the direct suggestion/motivational model developed by H. Spiegel (1970). This method exhorts patients to know that smoking is a poison for your body; you need your body to live; and to the extent that you want to live, you owe your body respect and protection. Some investigators use hypnosis to achieve relaxation, to focus on individual motivations to change, and to rehearse coping behaviors. A popular, although controversial, theory in habit change work is the transtheoretical Stages of Change model of Prochaska and his colleagues (Prochaska & Velicer, 1997). This model posits a process of six stages that patients with habit disorders such as cigarette smoking are likely to pass through: precontemplation, contemplation, preparation, action, maintenance, and termination. While there is some caution about the success of this model (Hughes, 2000; Riemsma, Pattenden, Bridle et al., 2002), proponents believe that tailoring suggestions and behavioral recommendations to meet the motivational level and needs of the person undertaking to change behavior will improve treatment outcome for this population (Prochaska, Velicer, Fava et al., 2001). The hypnosis literature on smoking cessation is a diverse one with a large number of clinical reports dating back to the 1970s. Several quasiexperimental designs with small, unequal, or incomparable samples and questionably reliable outcome measures, and only three studies that meet the criteria for evidence-based treatment comprise most of the body of work in this area (Green & Lynn, 2000). Reviewers point to methodological weaknesses like incomplete descriptions of the hypnosis intervention, inadequate controls, and an excessive dependence upon unreliable measures of abstinence to assess treatment outcomes (Abbot, Stead, White et al., 1998; Covino & Bottari, 2001; Greene & Lynn, 2000; Law & Tang, 1995). The Cochrane Review assessed nine randomized, controlled studies from 1977 to 1988 and found insufcient evidence to recommend hypnosis; they proposed nonspecic therapist variables as the most likely contributors to treatment success (Abbot, Stead, White, & Barnes, 1998). In a larger review, similar methodological weaknesses were noted, along with the challenge of differentiating the cognitive-behavioral interventional elements from those of hypnosis, but the authors saw hypnotic interventions as superior to various no-treatment conditions (Green & Lynn, 2000). A metaanalysis of 48 investigations found mean quit-rates of 36 percent with hypnosis as superior to physician advice at 2 percent (Viswesvaran and Schmidt, 1992). Most conclude that the use of hypnosis for smoking cessation is better
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than no treatment, but it cannot be seen as superior, except to placebo, aversive conditioning, and physician advice. The use of hypnosis for smoking cessation is among the best examples of what contributes to the marginalization of this technique. On the one hand, research substantiates that it could be effective, and, indeed, that it is more effective than no treatment at all. Thus, it is worth the work to update and to make more sophisticated the research methodologies in this area. However, by largely ignoring the strong evidence in support of nicotine replacement, failing to integrate the compatible behavioral techniques that work and to explore the potential assistance that the transtheoretical model offers, hypnosis researchers make it very difcult for colleagues to take our work seriously and to include it as a component of treatment.
CONCLUSIONS
For many years, hypnosis-trained clinicians have advocated to a largely unreceptive audience of medical practitioners that they had something to offer their patients. The best work in this eld has established a clear role for hypnosis in the treatment of patients with pain (Patterson & Jensen, 2003). Surgical interventions and procedures offer the similar opportunity to address the complex interactions of anxiety, pain, treatment time, and patient compliance with adjunctive hypnotic strategies. There is, as has been shown, some real promise for the use of hypnosis with many medical illnesses and conditions. For this technique to be better accepted, it is imperative that researchers in the eld update outdated studies, integrate promising strategies from related research, abandon idiosyncrasy, bring appropriate scientic rigor to investigations, and pay attention to the excellent work of colleagues in related elds. With enthusiasm for this approach, it is clear that patients will benet from our skills and the eld will be brought closer to mainstream practice.
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THE EDITOR
Deirdre Barrett, PhD, is a psychologist on the faculty of Harvard Medical Schools Behavioral Medicine Program. She is the past president of both the International Association for the Study of Dreams and the American Psychological Associations Division 30: Society of Psychological Hypnosis. Dr. Barrett has written four books: The Committee of Sleep (Random House, 2001); The Pregnant Man and Other Cases from a Hypnotherapists Couch (Random House, 1998); Waistland (Norton, 2007); and Supernormal Stimuli (Norton, 2010). She is an editor of two additional books, The New Science of Dreaming (Praeger/Greenwood, 2007) and Trauma and Dreams (Harvard University Press, 1996), and has published dozens of academic articles and chapters on health, hypnosis, and dreams. She is editor-in-chief of DREAMING: The Journal of the Association for the Study of Dreams. Dr. Barretts commentary on psychological issues has been featured on Good Morning America, The Today Show, CNN, Fox, and the Discovery Channel. She has been interviewed for dream articles in the Washington Post, the New York Times, Life, Time, and Newsweek. Her own articles have appeared in Psychology Today and Invention and Technology. Dr. Barrett has lectured at Esalen, the Smithsonian, and universities around the world.
THE CONTRIBUTORS
Arreed Franz Barabasz, EdD, PhD, ABPP, completed his rst doctoral degree at State University of New York at Albany at the age of 23. His PhD in Clinical and Human Experimental Psychology is from the University of Canterbury, New Zealand, where he conducted the rst studies of EEG and hypnosis in Antarctica. His post-doctoral clinical fellowship was at Massachusetts General Hospital and Harvard Medical School. He is the editor of the International Journal of Clinical and Experimental Hypnosis (IJCEH) and professor at Washington State University. He is a diplomat of the American Board of Professional Psychology;
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a fellow of the American Psychological Association, the American Psychological Society, and the Society for Clinical and Experimental Hypnosis; and past president of the Society for Clinical and Experimental Hypnosis (SCEH) and of APA Division 30: Society of Psychological Hypnosis. Barabasz was an associate professor of psychology at the Harvard Medical School prior to his professorship at Washington State University. He has published over 125 refereed research papers and received numerous awards for his achievements in research, theory, and practice. He is the three-time winner of the Guze Award from SCEH for best research paper published in the previous year, most recently in 1999 for his experimental research showing unique EEG ERP responses to hypnosis. His (2005) text Hypnotherapeutic Techniques, 2E, coauthored with John G. Watkins, was awarded the 2005 Best Book on Hypnosis by the Society for Clinical and Experimental Hypnosis. His latest psychoanalytic text is Watkins & Barabasz (2008, Routledge) Advanced Hypnotherapy: Psychodynamic Techniques. His most recent edited book, also from Routledge, Medical Hypnosis Primer: Clinical and Research Evidence (2010) has been adopted by both the Society for Clinical and Experimental Hypnosis and the International Society of Hypnosis for distribution to clinics and hospitals worldwide. Kent Cadegan, BSc, MD, FCFP, is a medical director at the Glace Bay Site, Cape Breton Regional Hospital, Nova Scotia, Canada. He is also a member of the Medical Advisory Committee of the Cape Breton Regional Hospital. Dr. Cadegan has practiced cradle to grave, home and hospital family medicine for over 33 years in his home town of Glace Bay, Cape Breton. He is a past president of the Clinical Hypnosis Society of Nova Scotia, approved consultant ASCH, Private Practice in Family Medicine, Obstetrics and Hypnosis. He is a founding member of the Canadian Federation of Clinical Hypnosis and serves on its executive board He is a lecturer in the Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia. He is an active organizer and teacher of hypnosis workshops. Nicholas A. Covino is the president of the Massachusetts School of Professional Psychology (MSPP). For twenty years, he was a psychologist at the Beth Israel Hospital and the Harvard Medical School, where he served as director of the psychology division and as the director of training. He is a member of the Boston Psychoanalytic Society and Institute and maintains a small psychotherapy practice. Covino is past president of the Society for Clinical and Experimental Hypnosis and the author of a number of articles and chapters on the application of clinical hypnosis. Nicole Flory, PhD, is a licensed clinical psychologist with a private practice in Arlington, Massachusetts, and a teaching associate in the behavioral medicine program at Cambridge Health Alliance, Harvard Medical School. Dr. Flory is dedicated to womens health issues and has conducted a randomized controlled trial on the psychosocial outcomes of hysterectomy. Her research, clinical, and
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training interests are in cognitive-behavioral interventions, sex and couples therapy, and medical hypnosis. She was born and raised in Europe and completed her initial training on the use of hypnotic techniques in 1995 at the University of Berlin (Freie Universitaet) in Germany. Dr. Flory is the former associate director of the Non-Pharmacologic Analgesics Program, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston. She has published in a variety of scientic journals. Dr. Flory enjoys teaching, writing articles, and has received numerous rewards for her work such as the Student Research Award from the Society for Sex Therapy & Research; a research grant from the Canadian Foundation for Womens Health; and the Ruth L. Kirschstein National Research Service Award from the National Institutes of Health (NIH) and the National Cancer Institute (NCI). V. Krishna Kumar is a professor of psychology at West Chester University of Pennsylvania. He is a clinical associate at the Center for Cognitive Therapy, University of Pennsylvania. He is an elected fellow of APA as well as in two APA divisions, Society of Psychological Hypnosis (Division 30) and Society of Humanistic Psychology (Division 32). He is a two-time recipient of the Milton Erickson Award for Excellence in Scientic Writing on Clinical Hypnosis from the American Society of Clinical Hypnosis. He is also a recipient of the Best Theoretical Paper Award from Division 30 of the American Psychological Association. He is a past president of the Greater Philadelphia Society of Clinical Hypnosis. He is the author or coauthor of over one hundred articles in peerreviewed journals and several chapters in edited works. Elvira Lang, MD, FSIR, FSCEH, is a pioneer and leading expert in the use of hypnosis during medical procedures. Her research-based renement of hypnotic techniques has resulted in greater patient comfort, increased practitioner effectiveness, and improved nancial performance. Dr. Lang is associate professor of radiology at Harvard Medical School and founder of Hypnalgesics, LLC, which trains medical teams in rapid rapport and quick hypnotic techniques. She is internationally known in the eld of interventional radiology; she served as chief of interventional radiology at Beth Israel Deaconess Medical Center, Harvard School of Medicine, in Boston from 1998 through 2006. Dr. Lang has trained nurses, doctors, and technologists to incorporate procedure hypnosis into medical areas from a variety of disciplines including MRI, breast care, oncology, urology, gastroenterology, diagnostic and interventional radiology, obstetrics, and dentistry. She held faculty appointments and leadership positions at the University of Heidelberg, Stanford University, the University of Iowa Hospital and Clinics, and the Beth Israel Deaconess Medical Center. Dr. Lang takes an active leadership role in the advance of hypnosis in the medical setting; she is past president of the New England Society of Clinical Hypnosis and current president of the Society of Clinical and Experimental Hypnosis. She is author of Patient Sedation without Medication: Rapid Rapport
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and Quick Hypnotic Techniques. A Resource Guide for Doctors, Nurses, and Technologists. Stephen R. Lankton, MSW, DAHB, is a licensed clinical social worker in Phoenix, Arizona. He is the editor-in-chief of the American Journal of Clinical Hypnosis and a fellow and approved consultant of the American Society of Clinical Hypnosis. He serves as secretary and treasurer of the Arizona Behavioral Health Examiners Board Credential Committee. He is a diplomate in clinical hypnosis, and past-president of the American Hypnosis Board for Clinical Social Work; a fellow of the American Association of Marriage and Family Therapy; and a fellow and board member of the American Psychotherapy Association. Among his awards, Lankton is the recipient of the Lifetime Achievement Award for Outstanding Contribution to the Field of Psychotherapy from the Milton Erickson Foundation, 1994 and the Irving Sector Award for the Advancement of Clinical Hypnosis from the American Society of Clinical Hypnosis, 2007. He is the author of 18 clinical books, with translations in several languages, regarding techniques of hypnosis, family therapy, and brief therapy. He is currently a psychotherapist in private practice in Phoenix and conducts professional training seminars throughout the world. Kevin Miller is completing his graduate training in psychology at The Massachusetts School of Professional Psychology. Kevin is also a commissioned ofcer in the U.S. Navy. Dr. Jessica Wexler is a graduate of the Massachusetts School of Professional Psychology. After several years as a licensed clinician in Israel working within the immigrant community, Dr. Wexler has returned to the US as a psychologist in private practice. She has a general practice of clinical psychology with a specialty in the treatment of anxiety disorders. Michael D. Yapko, PhD, is a clinical psychologist in Fallbrook, California. He is internationally recognized for his work in advancing clinical hypnosis and outcome-focused psychotherapy, routinely teaching to professional audiences all over the world. Dr. Yapko has had a special interest for more than three decades in the intricacies of brief therapy and the clinical applications of hypnosis and directive methods. He is the author of ten books and editor of three others, as well as numerous book chapters and articles. These include his widely used classic text, Trancework: An Introduction to the Practice of Clinical Hypnosis (3rd ed.), the award-winning Treating Depression with Hypnosis: Integrating Cognitive-Behavioral and Strategic Approaches (2001), Hypnosis and Treating Depression: Applications in Clinical Practice (2006), as well as Essentials of Hypnosis and Hypnosis and the Treatment of Depressions. He has produced many CD and DVD programs. His works have been translated into nine languages. More information about Dr. Yapkos publications can be found on his Web site: www.yapko.com. Dr. Yapko is a member of the American Psychological
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Association, a clinical member of the American Association for Marriage and Family Therapy, a member of the International Society of Hypnosis, and a fellow of the American Society of Clinical Hypnosis. He is a recipient of the Milton H. Erickson Award of Scientic Excellence for Writing in Hypnosis, and the 2003 Pierre Janet Award for Clinical Excellence from the International Society of Hypnosis, a lifetime achievement award honoring his many contributions to the eld of hypnosis. He also received the Milton H. Erickson Foundation Lifetime Achievement Award for Outstanding Contributions to the Field of Psychotherapy.
Index
abreactive effect of hypnotic dreams, 99 adverse effects, 159 affect and emotion protocol, 29 age progression, 129 age regression, 129 aikido, 5 alcohol, treatment of: hypnosis in, 169170 Alcoholics Anonymous, 166 Alice-in-Wonderland, psychedelic distortion scale, 113 ambiguous function assignments, 10 analgesia, 129, 150 analysis paralysis, 135 anecdote, 10 anesthesia, 129, 147, 148 anticipatory nausea and vomiting (ANV), 184 anxiety, 148, 149 anxiety resistance, 5 archetypes personalities, 5051 arousal, 136 asthma, hypnosis in treatment for, 180182 attentive listening, 152 attitude change protocol, 29 authoritarianism, 18 authoritative approach, 17 autonomic nervous system (ANS) arousal, 178 awareness, 52
Barber Suggestibility Scale scores, 105 Bateson, Gregory, 3, 13 Beck, Aaron, 130 behavior, 19, 23 behavioral medicine strategies, 177 behavioral psychotherapy, 126 behavioral rehearsal, 20, 186 behavior change protocol, 30 believed-in imagination, 131132 biochemical markers, 171 borderline personality disorder (BPD), 57 Bowers Doctrine, 172 building realistic expectancy, hypnosis and, 133134 bulimia, hypnosis in treatment for, 182184 central self-image (CSI) construction, 30 childs self, 5354 chloroform, 146 Clinical and Experimental Hypnosis, 103 cognitive-behavioral and relaxation strategies, 177 cognitive behavioral therapy (CBT), 128, 130, 132, 171, 179, 182, 183, 185, 187 cognitive processes, 177 cognitive psychotherapy, 126 cognitive restructuring, 186
204
Index
complementary matching, 19, 20 complex goal-directed metaphors, 29 complex personalities, 5051 conscious, 59 conscious/unconscious therapeutic binds, 37 conscious-unconscious dissociation, 25 conscious waking daydream, 103104 context of the problem, 14 coping skills, 137 covert ego state, 64, 67 daydreams, 107, 112; deep trance subjects, means of variable ratings for, 112, dream reports, 114117, from the same subjects, content of, 107116, means of variable ratings for, 113, medium trance subjects, total subjects, means of variable ratings for, 111. See also dreaming decision-making strategies, 137 delusions, 60 depression, 123140; believed-in imagination, 131132, hypnosis for treating, 127128, hypnotic phenomena, 128129; in combination with hypnosis, 129 131 major, 124125; psychotherapy for treating, 125127 Diagnostic and Statistical Manual of Mental Disorders-IV, 67 diagnostic tools, 129 differentiation, 63 differentiation-dissociation continuum, 6667 direct communication, 7 Directed Daydreaming, 104 direct suggestion, 10, 20 dissociation, 50, 63, 129 dissociative identity disorder (DID), 50, 51, 65, 67 double dissociative conscious/ unconscious therapeutic binds, 3738 dreaming: hypnosis with, continuing or interpretation of a nocturnal dream in the hypnotic state,
116118, to inuence the content or recall of nocturnal dreams, 118119. See also daydreams; hypnotic dreams, nocturnal dreams drive/libido theory, 5354 ego-dystonic nature, 30 ego-energized and object-energized elements, 51 ego energy, 5659. See also energy(ies); psychoses and ego psychology techniques: boundaries of, 6667, characteristics of, 67, efcacy research, 6869; ego energy, 5659; ego state theory, 56; ego state therapy, 6768; ego state therapy, ego states, 6366, ego state therapy treatment, 7071; evolution of, 5052; and hidden observers, 6970; hypnosis and energies, 59 60; in hypnotherapy, 4972; object energy, 5659; personality development, 63; psychoses and, 6061; reality A, 6163; reality B, 6163; self, 5255; subject-object, 52 ego states, 56, 6366; boundaries of, 6667; characteristics of, 67; and hidden observers, 6970 ego state therapy, 6768; evolution of, 5052; treatment, 7071 ego-syntonic nature, 30 embellished reminiscence, 105 emotional experience, 17 empathic techniques, 159 endoscopies, 147 energy(ies); dened, 56; ego, 5659, psychoses and, 6061; hypnosis and, 5960; object, 5659 Ericksonian: ambiguous aspect of: formal induction sequence outline, 2426, goal-directed metaphor protocols, 2930, hypnosis, 2021, hypnosis with families, 2122, induction of hypnosis, 2224, interventions of, 1832, metaphor, 3032, metaphor,
Index
205
use of, 26, metaphoric stories, use of, 2627, simple isomorphic metaphors, 2829, 28, speaking the clients language and matching, 1820 approaches to hypnosis, 1, 13, 133 changes in treatment approach, 1516 changes in treatment duration, Ericksons conceptualization of symptoms, 1617, cure accomplished by reassociation of experience, 17, use of hypnotic suggestion, 1718 history and background, 14 indirect suggestion language: apposition of opposites, 36, binds of comparable alternatives, 3637, conscious/unconscious therapeutic binds, 37, double dissociative conscious/unconscious therapeutic binds, 3738, forms, 3334, illustration of, 3238, implication and presupposition, 3435, openended suggestions, 34, pseudo nonsequitur binds, 38, questions or statements, 35, truism, 35 induction using indirect suggestions, 3840, 39 rationale and philosophy: assessment and treatment planning, 45, client behavior, utilization of, 56, context for change, creating, 12, depathologizing, 12, exibility and direct communication, 78, getting clients active and moving, 13, hypnotic language, 1011, indirection and ambiguity, 810, present and future orientation, 13 15, resistance, reduction of, 67, speak the clients own experiential language, 6 research, 4042 Esdaile, James, 146 establish associations and dissociations, 130 Ether Dome, 146
event-driven perspective, 126 evidence-based approach, 166, 169, 172 existence, 53, 57, 65 expectancy, 133 experience amplication, 130 fabricated case histories, 26 face-to-face communication, 10 Federn, Paul, 51, 55; ego psychology, 55 First World Congress on Ego State Therapy, 68 exibility, 8, 20 focusing inward, 22 formal induction, 2224 formal induction sequence outline, 2426 Freud, Sigmund, 52, 53, 55, 101 functional bowel disorder (FBD), 185 functional gastrointestinal disorders (FGID); hypnosis in treatment for, 185187 goal-directed fantasy, 11 goal-directed metaphor protocols, 29 goal-oriented, skill-building approaches, 126 Haley, Jay, 1516, 19 hallucination, 52, 60, 61 here-and-now behavior, 5 hidden observers, ego states and, 6970 Hippocratic Corpus, 159 Hull, Clark, 3 Human Genome Project, 125 hyperemesis, hypnosis in treatment for, 184185 hyperemesis gravidarum (HG), 184 hypnobehavioral treatment (HBT), 183 hypnosis: asthma, 180182; and building realistic expectancy, 133 134; bulimia, 182184; and energies, 5960; enhancing sleep, 135136, 137, transcript, 138140; Ericksonian approaches to (see
206
Index
Ericksonian approaches to hypnosis); functional gastrointestinal disorders, 185187; hyperemesis, 184185; insomnia, 178180; in interventional radiology and outpatient procedure settings, 145160; and positive psychology, 132133; role in smoking cessation, 187189; targeting rumination, 135136, 137; treating depression, 127128, believed-in imagination, 131132, hypnotic phenomena, 128129, in combination with psychotherapy, 129131; treating insomnia, in combination with psychotherapy, 134135; treatment of smoking, 166168. See also individual entries hypnotherapy, 26; ego psychology techniques in, 4972 hypnotic analgesia, 69 hypnotic approaches, 137138 hypnotic deafness, 69 hypnotic dreams, 97, 98100; comparison with nocturnal dreams, 100107, 104; from the same subjects, content of, 107116, deep trance subjects, means of variable ratings for, 112, dream reports, 114 117, medium trance subjects, means of variable ratings for, 113, total subjects, means of variable ratings for, 111. See also dreaming; hypnotic language, 1011, 32 hypnotic phenomena, 129 hypnotic suggestion, 1718 identication, 58, 59, 63 identofact, 63 in-between ego states, 66 indirect suggestion, 78, 10, 3238; apposition of opposites, 36; binds of comparable alternatives, 3637; conscious/unconscious therapeutic binds, 37; double dissociative conscious/unconscious therapeutic binds, 3738; forms, 3334;
implication and presupposition, 3435; open-ended suggestions, 34; pseudo non-sequitur binds, 38; questions or statements, 35; truism, 35 individuals personal reality, 132 injudicious behavior, 178 insomnia, 99; hypnosis for treating, in combination with psychotherapy, 134135; hypnosis in treatment for, 178180 insula, and smoking cessation, 173 integration, 63 Interpersonal Check List, 10 interpersonal posture, 20 interpersonal psychotherapy, 126 interpersonal relationships, 14 interpersonal therapy (IPT), 130 interventional radiology and outpatient procedure settings, hypnosis in, 145160; challenges, 158159; patients responsiveness and acceptance, 157158; precautions and safety considerations, 159160; procedural environment, 148149; procedural pain management, 149150; scientic evidence, 155157; script, 152155; surgical and anesthetic approaches, evolution of, 146148; techniques, 150152 introjection, 58, 59, 62 irritable bowel syndrome (IBS), 185 Janet, Pierre, 50 Jung, Carl, 50 karate, 5 laboratory-veried lucid dreams, 118119 left brain thinking, 97 libido. See single energy (libido) theory lucidity, 119
Index
207
major depression, 124145. See also depression maladaptive behaviors, 64 maladaptive state, 65 matching the behavior of the client, 18 matching the clients behavior, 19 mental disease, 16 Mesmer, Franz, 146 metaphor, 10, 2627; ambiguous aspect of, 3032; isomorphic, 2829, 28; protocols, goal-directed, 2930 mind-body techniques, 157 multiple personalities (DID), 51, 65 Narcotics Anonymous, 166 National Cancer Institute, 168 National Institute of Health, 179 naturalistic induction method, 2223 negative expectancy, 134 nightmares, 99, 118 nocturnal dreams: comparison with hypnotic dreams, 100107, 104; from the same subjects, content of, 107116, deep trance subjects, means of variable ratings for, 112, dream reports, 114117, medium trance subjects, means of variable ratings for, 113, total subjects, means of variable ratings for, 111. See also dreaming non-pathological hallucinations, 97 object, 53 object energy, 5659. See also energy(ies) object-relations theories, 53, 62 object representation, 59 one-energy (libido) system. See singleenergy (libido) theory outpatient procedure settings, hypnosis in, 157158 outpatient psychotherapy, 9 paradoxical directives, 20 past events and traumas, exploration, 17 perceptions, 52
personalities, 49 personality development, 63 positive expectancy, 133, 134 positive psychology, 133, 140; hypnosis and, 132133 pre-scripted hypnosis protocols, 171172 primary ego energy, 56 primary narcissism, 52 primary process, 97 problem-solving skills, 126 process-driven perspective, 126 pseudo non-sequitur binds, 38 pseudoperception, 60 psychophysiological education, 186 psychoses and ego energies, 6061 quasi-allegory, 105 quasi-dream, 105 randomized controlled trial, 172173 Rapid Eye Movements (REMs), 100; during hypnotic dreams, 116 rapid therapy, 98 reality A, 6163 reality B, 6163 rehearsal technique, 98 relationship and family approach, 4 relaxation, 32, 36, 137, 186 repressed memory, 59 resistance, reduction, 12 right brain thought, 97 rumination, 134135; hypnosis targeting, 135136, 137, 138 Sacerdote, P., 98, 99, 113 schizophrenic, 60, 61 secondary process, 97 sedatives, 150, 179 selbst, 52 self, the, 5255, 70 self-effacing patient, 54 self-esteem, 169, 170 self-hypnosis, 168, 172 self-hypnotic dream, 102 self-hypnotic relaxation, 151 self-image scenarios process, 30
208
Index
self-image thinking protocol, 30 self representation, 59 shock technique, 16 single energy (libido) theory, 56, 57, 62 skill acquisition, 130 skill-building strategies, 126 sleep: hypnosis for enhancing, 135136, 137, transcript, 138140 smoking cessation, 166168, 187189 social supports, 177 Stanford Hypnotic Susceptibility Scale, 106 static pictorial image, 105 strategic assignments, therapeutic ordeals, or family therapy, 20 stronger suggestion, 11 structured attentive behaviors, 152 structured interactions, 20 subject-object, 52 substance abuse, treatment of: hypnosis in, 169170 Substance and Mental Health Services Administration, 165 suggesting eye closure, 33 symmetrical matching, 19 symptoms, 16, 17; management of, 130 tai chi, 5 Thematic Apperception Test (TAT), 107 therapeutic binds, 10
therapeutic conversations, 20 therapeutic language, 32 therapeutic receptivity, 21 time hypnosis, 134 traditional ritualistic induction, 23, 24 trance, 20, 21, 22, 42, 97; depth versus relevance, 40 transtheoretical model, 188189 treatment plan, 136 true multiple personality (DID), 50, 64 truism, 35 two-energy theory, 56, 57, 60, 62 Uncommon Therapy (Haley), 19 unconscious conicts, 98 undifferentiated energy, 56 United States Agency for Health Care Policy and Research (AHCPR) [now the Agency for Healthcare Quality and Research (AHQR)], 126 USDHHS Clinical Practice Guideline, 167 verbal and nonverbal communication, 43 Watkins, John G., 51, 55 Weiss, Eduardo, 55, 59 World Mental Health Survey, 180

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How to go to your page This eBook contains two volumes.

Hypnosis and Hypnotherapy

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Hypnosis and Hypnotherapy

145 161 165

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The Hypnotic Deactivation of Self-Conscious Source Monitoring

Hypnosis and Hypnotherapy

SLEEP, HYPNOSIS, AND THE DEACTIVATION OF SELF-CONSCIOUS SOURCE MONITORING

The Hypnotic Deactivation of Self-Conscious Source Monitoring

SPONTANEOUS AND SUGGESTED HALLUCINATING

Hypnosis and Hypnotherapy

The Hypnotic Deactivation of Self-Conscious Source Monitoring

DISSOCIATED PERCEIVING WITH OR WITHOUT A HIDDEN OBSERVER

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The Hypnotic Deactivation of Self-Conscious Source Monitoring

Hypnosis and Hypnotherapy

The Hypnotic Deactivation of Self-Conscious Source Monitoring

HYPNOTIC HYPERMNESIA FOR SUBCONSCIOUS PERCEPTS

Hypnosis and Hypnotherapy

HYPNOTIC RECOVERY OF DISSOCIATED MEMORIES AND HYPNOTIC CREATION OF FALSE MEMORIES

The Hypnotic Deactivation of Self-Conscious Source Monitoring

Hypnosis and Hypnotherapy

The Hypnotic Deactivation of Self-Conscious Source Monitoring

Hypnosis and Hypnotherapy

Dissociaters, Fantasizers, and Their Relation to Hypnotizability

Hypnosis and Hypnotherapy

Dissociaters, Fantasizers, and Their Relation to Hypnotizability

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Dissociaters (10 Women, 5 Men) Yes

Dissociaters, Fantasizers, and Their Relation to Hypnotizability

Vivid Imagery and Fantasies

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Dissociaters, Fantasizers, and Their Relation to Hypnotizability

Early Memories and Parental Discipline

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Dissociaters, Fantasizers, and Their Relation to Hypnotizability

Fantasizers Experience of Hypnosis

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Dissociaters, Fantasizers, and Their Relation to Hypnotizability

Fantasies, Early Memory, and Parental Discipline

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Dissociaters, Fantasizers, and Their Relation to Hypnotizability

Dissociaters Experience of Hypnosis

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Dissociaters, Fantasizers, and Their Relation to Hypnotizability

Dissociaters (6 Women, 3 Men) Fischer Exact Probability Yes No Test p <

Hypnosis and Hypnotherapy

Dissociaters, Fantasizers, and Their Relation to Hypnotizability

Dissociative Diagnoses and Post-Traumatic Stress Disorder

Hypnosis and Hypnotherapy

Dissociaters, Fantasizers, and Their Relation to Hypnotizability

Hypnosis and Hypnotherapy

Dissociaters, Fantasizers, and Their Relation to Hypnotizability

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Hypnosis, Mindfulness Meditation, and Brain Imaging

Hypnosis and Hypnotherapy

Hypnosis, Mindfulness Meditation, and Brain Imaging

MINDFULNESS MEDITATION Health Benets of Meditation

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Neuroimaging and Mindfulness Meditation

Hypnosis, Mindfulness Meditation, and Brain Imaging