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Hpnosis has long occupied an important place in psychiatry and, according to Elenberger,1 has had a major role in the department of dynamic psychiatry. For many years hyponsis was associated primarily with the hysteria; Charcot and Babinski believed it was a psychopathological phenomena related to hysteria.2 Since then it has become evident that hypnosis is a normal phenomenon and that psychopathology may make a person less hypnotizable.
In recent years, several factors have led to an ... awareness of the importance of hypnosis in the ... of phobias. Wolpe, in his classic book Psychotherapy Reciprocal Inhibition? introduced the treatment ... nique of systematic desensitization in which he ... used hypnosis as a method of producing relaxation. ... Frankel and Orne4 compared the hypnotizability of group of phobic patients with a group of patients who ... come for therapy to control smoking. They found that ... ... patients were more hypnotizable than the control ... who smoked.
...5 later presented some clinical evidence suppor... the concept previously suggested by others that ... hypnotizability may contribute to the genesis of ... behavior in some instances by the development of ... trancelike state as a coping mechanism ... panic or intense emotional experience. It has also ... noted that phobic patients, as well as patients with ... other conditions,6 respond to treatment more ... if they are highly hypnotizable.
... is true that John Locke referred to the inculcation of ... at an early age by implanted associations in An ... Concerning Human Understanding.1 But except that single 1 7th century reference, there was little or no ... on understanding phobias until Westphal first ... agoraphobia in 1 87 1 . Following this there was a ... to name phobias, and Laughlin8 lists 76 specific ..., some of them with such exotic names as ... (fear of airplanes), pathemaphobia (fear of ...), and verkisophobia (fear of vermin). Phobias ... been classified differently by various authors- first ... neurasthenia and later under compulsive insanity Kraeplin, under psych asthenia by Janet, und&r anxiety ... by Fenichel, and under anxiety disorders in the ... and Statistical Manual of Mental Disorders SM III).
According to DSM III, the essential feature of phobic orders is "persistent and irrational fear of a specific ..., activity or situation that results in a compelling ... to avoid the dreaded object, activity or situation ... phobic stimulus). The fear is recognized by the ... as excessive or unreasonable in proportion to ... actual dangerousness of the object, activity or ...." Phobic disorders have been treated by a range therapies from psychoanalysis to suggestive therapy, ... has often been used to facilitate these various ... approaches and this article will focus on the ... of hypnosis in the facilitation of treatment for ... disorders.
... IN PSYCHOTHERAPY
Although hypnosis is sometimes referred to as a ... of treatment, it is more accurate to regard ... as a facilitator of a number of different ... methods. When reference is made to hypno..., it usually implies suggestive techniques but may ... broader meanings especially when including hyprto..., which usually involves exploratory techniques.
The generic term hypnosis is usually used with little or ... specification of the various factors in hypnosis that are of particular significance. To further our understanding of how hypnosis is useful in various treatment methods, it may be helpful to consider three major components of hypnosis that are important in psychotherapy. These are the hypnotic state, the hypnotic context and the hypnotic suggestion.
In two classic papers, Shor10'1' described what he calls three dimensions of hypnotic depth: (1), role-taking involvement; (2), trance, and (3), depth of archaic involvement (transference). He defines role-taking involvement as "the extent to which the complex of motivational strivings and cognitive structurings regarding the role of hypnotized subjects has sunk below the level of conscious compliance and volition and has become unconsciously directed." Trance is "the extent to which the usual generalized reality orientation has faded in non-functional awareness;" generalized reality orientation is defined as the frame of reference that is mobilized in the background of attention in the usual state of consciousness, which supports, interprets and gives meaning to all experiences. The third dimension, depth of archaic involvement (transference), is the extent to which during hypnosis archaic object relationships are formed onto the person of the hypnotist.
The hypnotic state is a state of attentive, receptive, focal concentration12 in which a subject is able to respond to appropriate suggestions with distortions of perception or memory.13 The hypnotic state often results from a specific induction procedure but may be present without a formal induction or may not be present even after a formal induction is performed. The capacity to achieve this altered state varies from individual to individual but tends to remain stable over time. This capacity will be referred to here as, hypnotizability and can be assessed by a number of standard clinical and experimental scales. The tests most commonly used experimentally for the assessment of hypnotizability are the Stanford Hypnotic Susceptibility Scales Form A and B and the Harvard Group Scale. In the clinical setting, the scales most used are the Hypnotic Induction Profile and the Stanford Clinical Hypnotic Scale.
The person in the hypnotic state is often considered to be completely passive. In her ego-psychological theory of altered states, Fromm14 points out that the ego is not passive in hypnosis. She describes the role of ego activity, ego passivity and ego receptivity in various trance states. She feels that hypnosis is characterized by ego receptivity in which critical judgement, strict adherence to reality orientation and active goal directed thinking are held to a minimum, while the individual allows himself freely to let unconscious and preconscious material float into his mind.
This receptive mode of functioning in the hypnotic state may be related to the functions of the right cerebral hemisphere. Reyher15 describes this receptive mode of functioning of the right cerebral hemisphere and contrasts it to the expressive mode of the left hemisphere, with its analytic and critical functions. The receptive mode is engaged by the subject's adoption of a passive receptive open minded attitude wherein he silently waits for instructions. He feels that this receptive mode is further enhanced by the subject's dependency strivings especially when the subject is in a helpless position. On the other hand, when the induction of hypnosis is a source of anxiety, the analytical and critical functions of the expressive mode are engaged and suggestibility is lowered.
Some of the characteristics of the hypnotic state that are important in psychotherapy are (1), a feeling of deep relaxation, which persists after the termination of the hypnotic state; (2), the ability to visualize experiences and recall experiences from the past; (3), increased suggestibility; and (4), increased control over certain physiological responses.
When, with the prior agreement of the subject, an hypnotic induction is performed, this establishes what we may call the hypnotic context. Some researchers in the field, notably Barber, define hypnosis as that condition following an hypnotic induction. This is particularly important to be aware of in trying to compare the research done by this group of authors to the research where the hypnotic state is defined in terms of the ability to alter perception and memory.
The hypnotic induction procedure may result in no response along the parameter of hypnotic depth if the subject has no hypnotic capacity. In subjects with hypnotic capacity, the hypnotic depth will vary, depending on the degree of this capacity or hypnotizability. Regardless of the degree of hypnotic state produced by the induction procedure, establishing this hypnotic context results in certain expectations and conscious feelings, thoughts, and fantasies associated with the subject's perception of hypnosis. In addition, the unconscious transference and countertransference reactions will be somewhat modified by the hypnotic context, as differentiated from the usual psychotherapeutic context. Establishing the hypnotic context and doing an induction tends to encourage a positive transference. Fromm16 points out that the hypnotic context is more prone to foster an infantile dependency transference with the therapist cast into the role of the omnipotent parent. It may also stimulate an oedipal transference with fantasies of seduction or competition. Shevrin17 emphasizes that the conscious wish to cooperate may be strongly augmented by the unconscious temptation to ... Both the conscious reaction and the transference ... more influenced by the personality of the therapist ... analytically oriented psychotherapy because of increased activity of the therapist.
The countertransference may also be modified by hypnotic context. The most common fantasies or are of omnipotence and control. For some therapist countertransference feelings are disruptive and ... use of hypnosis difficult or impossible. If these ... transference reactions are strong and not recognized, may result in the misuse of hypnosis with ... complications.
Hypnotic suggestion or the hypnotic mode of ... cation may be used with or without the presence ... hypnotic state, although there is evidence that it is ... effective if the subject is in the hypnotic state, hypnotic mode of communication may also be without the situation being defined as hypnosis, ... not in the hypnotic context. Most often, of course hypnotic mode of communication is used in the ... of a hypnotic state and in the presence of a ... context.
In his description of Erickson's techniques, ... describes hypnotic suggestion as a mode of ... communication and utilization. He states, "these ... forms are communication devices that facilitate application and utilization of the patient's own ... tions, potentials, and natural mental mechanisms in ... that are usually experienced as involuntary by patient." Hypnotic suggestion, then, may be defined direct or indirect suggestion, even though he is ... produce the response by conscious volition. In ... where the response is one that he could produce conscious volition, the subject is not aware of ... the response voluntarily.
The hypnotic response is the nonvolitional ... a suggestion. For example, if a person is told to "put ... hand up" this will usually result in a volitional ... ... lifting his hand mto the air. If, in contrast, the on is asked to imagine that the hand is feeling light a balloon and that it may float up to an upright ..., the same action may occur but the subject ... this as a nonvolitional response accompanya change in perception when the hand feels light.
... treatment methods for the phobic disorders to be ... here are restructuring therapy, systematic ..., dynamically oriented psychotherapy and ... therapy.
...12 has described an approach, which he calls ...," in the treatment of phobias as well as a ... of other problems. In his description of restructurtherapy, Spiegel points out "the concept is to ... a treatment approach which takes into account ... a person's limitations and his abilities and then ... them in a simple and useful way. The idea is her to focus on the reasons for doing something nor ... on the consequences; but to focus on potential ... of integrating motivation with consequence. The ... 'restructuring' emphasizes the idea that this therapy ... an individual place an old problem in a new ...."He states later that the restructuring strategy ... well suited to use with hypnosis. The trance ... encourages intense focal concentration and "implies ... to synthesize which can then be used in the ... of thought and behavior."
... describes in detail the use of restructuring ... for flying phobia. The crucial strategy in the ... is for the patient to learn to view the airplane as extension of his body and to learn to "float with the ...." The patient is taught that although he cannot ..., he is not entirely trapped, and that he is indeed at ..., but it is a limited and calculated risk, undertaken ... a defined goal in mind. In his outcome studies of ... phobia, Spiegel has observed that the response to a ... session of restructuring therapy facilitated by the of hypnosis is related to the patient's hypnotizability. ... with intact profiles were almost twice as likely to ... some positive benefit from the session as patients ... non-intact profiles. This would suggest that the ... of an hypnotic state is important in some way to ... success of restructuring therapy.
Spiegel also describes restructuring techniques for ..., agoraphobia and phobia of dogs. He reports ... of a 30-year-old woman who had a lifetime cat and ... phobia. Her score on the Hypnotic Induction Profile ... a 2 to 3. The treatment consisted of two sessions of ..." therapy facilitated by hypnosis and followed by a series of "training sessions" in which the patient gradually got closer and closer to a dog and finally let the dog lick her hand. The patient was given a puppy by her ex-husband and she named it Spiegel. In a brief autobiography she says "the following steps in my progressive cure were; to have Spiegel lick my hand, to put my arms around Spiegel, to allow Spiegel to come to me - unleashed - for that final all encompassing hug of acceptance." This quote not only illustrates the effectiveness of the treatment but also suggests the rapid development of a positive transference which often occurs in the hypnotic context.
One of the unique features of Spiegel's restructuring therapy is that it is usually carried out in a single session ór at the most two sessions. The fact that 37 percent of patients with flying phobia and intact profiles reported mastery of the phobia in one session and that 61 percent of patients with intact profiles reported either partial or complete cure suggests that this type of therapy should be considered as an initial approach with hypnotizable patients.
The behavior modification techniques used to treat phobias include systematic desensitization and flooding. Both of these treatment techniques have been described utilizing hypnosis as an adjunct.19'20 Systematic desensitization, however, has been used much more extensively and successfully. The technique of systematic desensitization was origionally described by Wolpe3 in 1958. He described teaching the patient to relax using Jacobson's relaxation method but also frequently used hypnosis to facilitate the technique. In his 1966 book, Behavior Therapy Technique,21 he states that about one third of the cases of desensitization were performed under hypnosis. Although Wolpe finds that hypnosis is not necessary to the production of relaxation in behavior therapy, Dengrove19 quotes him as saying "I have the impression that it has an accelerating effect." Dengrove goes on to state that "hypnosis makes treatment easier in three ways: in relaxing the patient, in easing the path to visual imagery, and in providing techniques which can aid in the management of the more difficult patient." To these I would add (1), when the subject is quite hypnotizable, it is possible to achieve the relaxed state used in desensitization very rapidly because the patient is able to respond with a simple signal; (2), direct and indirect suggestions may be added to the implicit suggestion that visualizing scenes while relaxed will result in remaining relaxed, in the actual situation; (3), the patient can be taught selfhypnosis to increase his feelings of mastery and enhance his ability to relax quickly; and (4), the patient can be given posthypnotic suggestions.
There are many clinical reports in the literature describing the facilitation of desensitization with hypnosis.21"26 Only a few report on hypnotizability of subjects and, therefore, allow speculation about the role of various factors (i.e. hypnotic state, hypnotic context and hypnotic suggestion) in their effectiveness. The following case reports will illustrate the use of desensitization techniques facilitated by hypnosis in the treatment of phobias.
Case No. 1: Flying phobia. A 53-year-old engineer was referred by a psychiatrist because of a fear of flying. He had initially started in treatment because of family problems but had continued because of personal problems related to the flying phobia. His flying phobia had persisted during his several years of psychotherapy.
The patient dated the onset of his fear of flying to about 25 years before the time of his first visit. He became aware of his fear when he was in the Air Force in the South Pacific. He had experienced no fear of flying before that. He described the major part of his fear as being afraid that there would be turbulent weather during the flight. He also described a fear of heights such as ski lifts.
On the Hypnotic Induction Profile the patient had a grade 1 intact profile with an induction score of 3. Since the highest possible score on the Hypnotic Induction Profile is a grade 4-5 intact profile with an induction score of 10, this patient scored at the lower end of this hypnotizability scale, although he did have an intact profile. Because of his low hypnotizability, an eyefixation technique with relaxation suggestions was used for subsequent inductions.
In the second session, a hierarchy of items was established to gauge the range of his fears. Looking at a magazine advertisement for flying (which he had described as resulting in mild anxiety) was the item causing him the least anxiety. The item with highest anxiety was being in turbulent weather on a transatlantic flight. The patient was taught self-hypnosis using the fixation technique during this session.
During the next three sessions the patient hypnotized and the hierarchy of scenes was progress presented to him. When he would signal that he having any anxiety, his attention was returned comfortable relaxing scene with suggestions of ... again. Near the end of each session he was ... suggestions of being relaxed in the actual situation, ... he had been during the visualizations. By the end of fourth session he was able to go through the entire ... in his visualization without anxiety. He was ... instructed in the use of self-hypnosis during the ... After the fifth session, the patient flew to ... Although there was a lot of turbulence on the ... flight, he was able to enjoy the trip with only mild ... Whereas in the past he had dreaded flying, he ... reported that he was looking forward to flying ....
Case No. 2: Fear of driving. The patient was a 31-... old woman who was seen on the referral of a ... whom she had consulted because of a fear of ... particularly on expressways and bridges. Her fear driving had started the previous year. She had ... driving to work early in the morning when she ... spot on the road where the lights of oncoming ... blinded her through the rails and she* became ... "nervous." Shortly after this experience, her.' fear driving began.
During the first session the patient was tested hypnotizability with the Hypnotic Induction Profile. ... was highly hypnotizable with a grade-4 intact ... Although no specific suggestions were used in that ... session, she reported some improvement following ... session. She was seen for three subsequent ... during which rapid desensitization was combined ... direct hypnotic suggestions of being able to ... comfortably in any situation. She was taught ... hypnosis using an eye-roll hand levitation ... ... of her high hypnotizability. By the fourth visit the ... reported feeling much more relaxed in general and been able to drive on expressways with little or no ....
... patient's high hypnotizability probably contri... to the rapid resolution of her driving phobia. Her ... for trance experience may have been a ... factor to the onset of her phobia. It is ... that the precipitating experience resulted in a ... trance resulting in the association of driving her "nervousness."
... No. 3: Fear of publicspeaking. A 30-year-old case ... requested treatment for her erratic eating habits her fear of speaking before a group. The patient had gaining and losing weight since adolescence as a reof eating binges followed by periods of fasting. Her ... had fluctuated from 110 to 170 pounds during this .... She described feeling anxious and becoming flush ... she had to speak to a group. These symptoms ... present when she participated in group discussions were of particular concern to her when she had to ... in court as part of her social-work duties. She had this fear as long as she could remember.
... the initial session a psychiatric evaluation was ... and the patient was given the Hypnotic Induction file. She had a grade-3 intact profile with a 9.5 ... score. At her next session two weeks later, she taught self-hypnosis using the eye-roll hand lévitation .... She was then asked to hypnotize herself and given "restructuring" suggestions regarding her ..., similar to those described by Spiegel.52
... weeks later she reported improvement in her ... habits and asked to begin treatment for her phobia. ... of items was made, ranging from going to a home for the first time to giving an extemporan... speech before a large group. Desensitization was ... in the fourth session but this was interrupted by her ... death a few days after the fourth interview. The ... over the next six weeks was primarily devoted to ... her resolve her mixed feelings about her mother's .... This was facilitated by using hypnosis to have her some experiences with her mother.
... the eighth session, systematic desensitization was ....This was augmented by giving her the ... suggestion that when she was in a situation ... she felt anxious, she could relax by pressing her ... index finger against her thumb.
At the termination of treatment after 13 sessions, the ... was able to speak before a-group comfortably and ... no longer having anxiety about her court appear....She also reported that she felt her general interpersonal relationships had improved and that she was feeling much more comfortable generally.
Although therapy with this particular patient was complicated by her mothefs death, she made very rapid progress in overcoming her phobia. She reported using self-hypnosis in many situations to relieve her anxiety and improve her functioning. She also reported the "ripple effect" described by Speigel27 in that she felt her interpersonal relationships had improved generally and that she was much more comfortable in many ways.
DYNAMICALLY ORIENTED PSYCHOTHERAPY
Hypnosis has been used as an adjunct in dynamically oriented psychotherapy with many types of problems. The early use was in hysterical conversions but there are a number of reports of its use in phobias.28-30
In his paper on hypnoanalysis of phobic reactions, Schneck29 described two cases of phobias treated using hypnosis to facilitate dynamically oriented psychotherapy. The first case is a women in her 20s with a water phobia. She was a good swimmer but had developed the water phobia in connection with numerous dreams about water. Using the crystal-ball-gazing technique while the patient was hypnotized, the therapist found she was able to remember significant occurrences in her childhood related to the phobia. It is noted that at times she would seem to relive these experiences under hypnosis, which would suggest that she was quite hypnotizable. Over a period of time her masculine identification and unresolved Oedipus complex became apparent. After continuing to explore her relationship with her father in and out of hypnosis, the patient was hypnotized and asked to see a scene of the occasion when her water phobia first appeared. The scene was about someone needing help in rough water. At first she was unable to identify the person but later, again using the crystal ball technique, she saw that it was her father following which she had an acute anxiety attack. It was concluded that the phobia served ... a defense against her unconscious death wishes ... her father.
In a second case, Schneck described a woman with a ... phobia in which the phobia reflected the patient ambivalence toward her mother. With this patient, ... association under hypnosis was used and it is noted in ... description that the emotional reactions were much ... marked.
Gruenwald30 reports a case of a 58-year-old ... with a 43-year history of agoraphobia. Although ... patient was able to remember many significant ... experiences, it is noted that she was never able ... experience age regression as reliving the experience. It pointed out by Gruenwald that "achievement of ... results does not necessitate the patient's being a ... hypnotic subject."
In using hypnosis to facilitate uncovering ... apy, the ability to achieve a deep hypnotic state ... significant when the techniques of age ... automatic writing or hypnotic dreaming are being used Hypnotizability is of less consequence when free association is suggested under hypnosis.
It is often assumed that the only use of hypnosis is in suggestive psychotherapy. Certainly hypnosis has an important place in facilitating therapeutic suggestion and has often been used in the treatment of phobias ... suggestive techniques.
Erickson,31 in treating a 19-year-old student nurse ... a water phobia, used an exploratory technique ... followed by an ingenius suggestion which he ... "pseudo-orientation in time." With hypnotic age ... sion, a number of traumatic memories were recovered ... the patient emphatically declared that she would ... remember them when awakened. At the next interviev she was hypnotized and given suggestions of first ... disoriented in time and later being reoriented three week in the future. A detailed posthypnotic suggestion ... given as to how she would go swimming on her ... with suggestions of amnesia for the instruction. When ... was seen in the fall, she described carrying out ... suggestion after which she spontaneously remembered the memories from her childhood.
In treating another patient with an airplane phobia Erickson32 uses a direct suggestive technique without first exploring the underlying dynamics. This patient was first asked to make an absolute commitment to agree to do anything the therapist asked. This was done both in the waking and hypnotic state. While she was hypnotized, she asked to imagine boarding a plane and riding through .... During this she was extremely anxious but this relieved by suggestions of comfort and ease. It was ... suggested that she would suddenly find that all of her ... had slid off into the chair that she was sitting on. ... she was awakened from the trance, she immediately ... from that chair and refused to sit in the chair .... At a later time she was given a post-hypnotic ... to enjoy a plane trip to Dallas. When she ..., she reported enjoying the trip but she avoided ... in the chair where she had "left her fears."
...25 reports a study in which she compares ... posthypnotic suggestion with a desensitization ... and implosive therapy in patients with a snake .... Direct posthypnotic suggestions were given to the ... that the subject would no longer be frightened by ... snakes. In this study it was found that there was positive correlation between hypnotizability and ... outcome.
Marks, Gilder and Edwards25 compared the use of ... desensitization and suggestive therapy utiliz... hypnosis. The patients treated with suggestion were ... and given a forceful suggestion that their phobias would gradually disappear. No imagery was presented and no specific situations were described. Both treatments produced significant improvement in the phobias with slightly more improvement in the patients treated with desensitization. Hypnotizability was not tested in this study.
Hypnosis has an important role in the treatment of phobic disorders and may be related to the etiology of phobias in some instances. The generic term hypnosis covers several factors which may contribute to its usefulness as a facilitator of psychotherapy; these include the hypnotic state, the hypnotic context, and hypnotic suggestion.
The use of hypnosis in facilitating various psychotherapeutic strategies used in treating phobias has been described. These therapeutic approaches include restructuring therapy, behavior therapy, dynamically oriented psychotherapy and suggestive therapy. Cases presented illustrate how hypnosis can be used in each of these therapeutic approaches.
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