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Probably no sphere within the psychosociobiological universe has been hampered by so many myth-encumbered misconceptions and so much complacent ignorance than the domain of hypnosis. And yet, the ubiquitous manifestations of hypnotic phenomena occur so often without knowing recognition by clinicians or even subsumed under some other behavioral label. It is as if many clinicians and behavioral scientists not only reject Mesmer's "fluid" concept, but also reject the observable daf!a as well. By simply substituing the concept "imagination" for "fluid," the observed behavior of Mesmerism becomes understandable in modern behavioral terms. In fact, the French Royal Commission (whose members included Benjamin Franklin, Lavoisier and Guillotin) studied Mesmerism then intensively dismissed it with the astute critique that it was nothing but "overheated imaginations."1
At that time, scientific scrutiny of imagination ... possible since there were no known instrument measurement. Now we do have standardized ... to measure imagination, concentration and ... (voluntary and nonvoluntary). They may still be ... fined, but nevertheless, do indicate a capacity disciplined scientific inquiry - especially when the ... surements are made with full appreciation of ... issues.
As we further develop adequate measurement ... for the biological substrate of imagination, ... focal attention, amnesia, motivation and even ... concentration, we shall be able to also identify biological components of hypnosis. There are ... already that the right-left brain interactions with ... other and with the limbic system are also ... hypnotic capacities.
... has hypnosis been ignored for so long? Medicine ... has struggled over the past century to replace the ... of charlatanism and the use of anecdotal data for a ... scientifically disciplined approach for treating .... Indeed, this shift has been impressive but not ... fault. For example, the emphasis upon fighting ... has distracted many clinicians from the relevance ... the person with the disease in order to effect ... change. Without too much exaggeration, it ... said that the main thrust of medical care in the ... States during the past half centry has been largely ... and engineer oriented. The preferred focus been upon the pill, the surgical technique, or the ... that will fight the disease, rather than educating ... to prevent disease and training the person to ... in re-aligning his resources to live more .... To put it bluntly, the patient has been lead to ... the doctor to "fix me up" - like taking a car to the ... to be repaired.
..., this is exactly what does happen. If ... is accurately diagnosed, all the patient need ... to make his body available and the doctor does all ... work to solve the problem. But so often, in ... domain of therapy and even with the surgical ..., this neat model is not enough. Unless the ... is informed about living well and actively ... in his own health care, the relief is not ... or effective. With some dramatic exceptions ...as the judicious use of antibiotics, the success of ... medical care depends upon appropriate patient ...and commitment,
... bias in favor of the engineer model for medical care entirely consistent with the unreceptive and indif... atmosphere for the re-emergence of hypnosis and psychological implications in the 1930s, largely use of the influence of the late Milton Erickson.2 ... concurrent development tended to trivialize relevance of hypnosis in therapy: the emerging ... of the psychoanalytic movement, which empha... the critical importance of psychodynamic insight ... behavioral change was desirable or possible. ... experience over the past half-century does not ... that belief.
..., Erickson's reintroduction of hypnosis did stir up the medical and political world as did ... in the latter part of the 18th centry. The ... context was quite different in mid-20th century ....
... Mesmer's France, a growing discontent with the of Reason establishment and-a protect against cold rationalism was emerging that eventually led to the Revolution and transformation into the Age of Romanticism. By coincidence, Mesmer's fluid hypothesis resonated well with other discoveries of the invisible world - Newton's breakthrough on the laws governing gravity, Lavoisier's caloric concept, Franklin's discovery of the power of electricity and various experiments with heated gases making possible those popular and amusing balloon flights.
The popularity of Mesmer's tubs and treatment sessions became innocent and safe ways for expressing discontent with the academic and political establishment. In a sense, Mesmerism was used along with other science to bring about change culminating in the French Revolution. After the Revolution, however, the Mesmerism movement fell apart.1
No such social-political swell engulfed Erickson's work. Instead, during the last half century more modest issues have accounted for the survival and gradual growth and reluctant acceptance of hypnosis. On the positive side, Erickson's machismo approach to hypnotic induction, conveying the notion that the hypnotist is "doing something to the patient" synchronized well with the medical engineer mentality of his time.
In a sense, this macho approach served to bridge with the establishment. It also added some animation and zest to the dull treatment atmosphere where most clinical attention in psychiatry was given to classification of diseases and predicting the course of the disease. Effective therapeutic intervention was not a frequent occurrence. The leverage effect of hypnosis brought about quick and dramatic change. Anecdotal case reports using hypnosis gradually appeared. Professional societies and journals devoted to hypnosis evolved. World War II spurred interest in quick treatment procedures using hypnosis. By 1960, the American Psychiatric Association and the American Medical Association had formally accepted hypnosis as a legitimate therapeutic mode.
On the negative side of the emerging clinical applications of hypnosis, induction procedures, conveying the erroneous notion of "going to sleep," and imitation of the many vaudevillean rituals, tainted' the reputation of hypnosis because of their earlier associations with "black magic^ and charlatanism. No systematic critical followup studies involving a significant number of cases were reported. Hypotheses about hypnosis were not formulated in such a way as to be testable. Treatment strategies and hypnotizability were fused and regarded as one and the same. Attributions to the power of hypnosis were exaggerated and other factors accounting for treatment change were ignored.
All of this was compounded by the big fact, in the eyes of the reductionist medical mind, that hypnotism was only "in the mind, not real." As a consequence, hypnosis remained essentially outside the mainstream of the medical and psychiatric establishment. Meetings and training workshops occurred mostly in homes or hotels and varied greatly in quality. Unfortunately, this led to the formation of many subgroups, some of which lack the sobriety of a profession and have the aura of cultism.
Despite this, some secure medical schools encouraged the study and disciplined use of hypnosis in medicine. Among these few, the College of Physicians and Surgeons at Columbia University has had continuous annual courses on hypnosis since 1962 and has always been open to peer scrutiny. Other universities and medical centers have occasional courses and several have On-going research programs.
Quite apart from the clinical and medical scene, a simultaneous laboratory development was going on in experimental psychology. Weitzenhoffer and Hilgard3 were refining a method for measuring hypnotic capacity in college students. In addition to demonstrating that grading trance capacity on a continuum was possible, they discovered that this same capacity was relatively stable when measured over time.
Several limitations, however, hampered the scales' usefulness in the clinic. First, it took too long to administer (one hour or more). Second, some of the questions were inappropriate in a clinical context, e.g. "listen to a (hallucinated) mosquito that has been buzzing." Third, it conveyed the erroneous notion that going into trance was similar to falling asleep. Fourth, it implied that being hypnotizable was a weakness, e.g. a "susceptibility" test. Fifth, the test was standardized on college students in a laboratory setting, which is quite different from basing it on results obtained from persons of all ages seeking help in real life. Sixth, it did not account for the presence of mental illness in the population.
In essence, the project showed that measurement of trance is possible. But the next step needed was a testing procedure that was clinically feasible, esthetically appropriate and standardized with a population sampling for which treatment application could be used. In other words, more contextual rigor was needed.
Could this challenge be met? Was it possible to bring these extremes together? instead of opposing each other or ignoring each other, could they help each other? Could they enrich each other? Could the measurement potential developed in the laboratory be adapted for the ... thus serve to bring more discipline to clinical ... of hypnosis? Was there enough convergence of know and circumstance to expect this to ensue? Was ... middle-way?
If such a middle way were to be reached, agret about the premises and definition of hypnosis woi needed. First, many prevalent misconceptions req clarification, including the following:
Hypnosis is sleep. Hypnosis is not sleep, it ... opposite of sleep. It is a form of intense ... integrated concentration. None of the ... graphic findings of sleep are present in hypnosis. ... tracings typical of alert concentration are found ... hypnotic state.
Hypnosis is projected upon the patient. The ... projects nothing whatsoever. Instead, he taps the ... trance capacity inherent in the patient. Trance ... a relatively fixed phenomenon in each adult. The ... from light- to middle-range and deep trance ... usually consistent throughout the adult years, ... physician simply activates this capacity - a capacity ... patient uses spontaneously any time he is ... motivated concentration.
Only mentally weak or sick people are ... is the mentally healthy persons that are ... Schizophrenics, the depressed, those with severe ... disorders, the mentally retarded, and people neurological deficits that interfere with ... have difficulty in concentrating enough to shift ... trance state.
Hypnosis occurs only when the doctor decides to ... It can occur when the doctor decides to use it if the ... cooperates, but it often occurs spontaneously, ... under duress or highly motivated challenge ...
Symptom-removal means a new symptom will ... This is not necessarily true, but if the doctor predicts a new symptom will occur or if the patient ... ... learns that one is expected, then it may indeed as a fullfillment of that prophecy. There is no ... that a new symptom will occur if it is not ... and the symptom removal is done noncoercively. ... is dangerous. Hypnosis itself is not dangerbut the trance state can be used mischievously. The ... state itself is a neutral state of attentive ... If the therapist introduces a therapeutiwrong proposal of if he unethically exploits the ... then, of course, harm may result. But the mistake ... is the result of the quality of the intrusion rather hypnosis itself.
... is therapy. Not at all. At most, hypnosis ... a receptive matrix in which a treatment strategy ... used with a high leverage effect. The state of ... without an appropriate therapeutic strategy to no therapeutic effect at all unless the patient ... to use the ceremony of being in a trance to bring ... spontaneous corrective change.
... hypnotist must be a charismatic, unique or weird ... person. Not so. Of course, if the patient senses the ... as being charismatic or if the patient responds to ... of the doctor, this may well enhance the ... transition. But any sound, sober clinician can learn ... of induction and application of hypnosis ... . The demeanor and conduct of the doctor is no ... from any other proper clinical approach. Trance ... is teachable and learnable. In many instances, ... learners are as fully effective as experienced ... in utilizing hypnosis.
... are more hypnotizable than men. This is not ... objective studies indicate that about 70 percent of men and women are hypnotizable to one degree or ... and the distribution of this trance capacity does differ significantly with sex.
... is only a psychological phenomenon. The ... pathways and mechanisms of concentration, focal attention, motivation and amnesia are still poorly understood. Until we have a clear physiology of these phenomena we will not have a clear physiology of hypnotizability. The hints that we get, however, suggest strongly that hypnotizability is essentially a neurophysiological capacity that has psychological manifestations. The measurements of the physiological phenomena are simply the indices of as yet poorly understood alterations of physiological circuitry.
Definition: In an operational sense, hypnosis can be defined as a psychophysiological set characterized by a complex perceptual capacity for attentive, receptive concentration with parallel awareness. That is, the subject can be aware of a perceptual set and, at the same time, feel along side the set. Perhaps to highlight this feature, a more accurate label for the hypnotic phenomenon would be "paragnosis."
Resolution: It then becomes possible to find a middle way to converge the extremes, together with the extravagances of the cultism, by the guidance of three major propositions:
1. Hypnosis is not sleep. It is the opposite - an alertness, a capacity for attentive, receptive concentration - perhaps poetic sleep, but certainly not physiological sleep.
2. The somatic metaphor can be powerful and versatile. Ortega y Gasset asserted that "metaphor is probably the most fertile of man's resources, its effectiveness verging on the miraculous - [It] aids our escape and creates among real things imaginary reefs, islands pregnant with allusion."5 Vivid, integrated and even poetic imagination is often associated with hypnotizability. Understanding the rational place of hypnosis in the medical domain requires a diligent awareness that somatic metaphors can be experienced and reported with such clarity, dramatic impact and conviction that they can seduce a naive conscientious clinician to ascribe physical causation without adequate evidence, or, on the contrary, can provoke the clinician to acclaim that "there is nothing wrong." In both instances, the clinician is seriously wrong by failing to identify the covert message of the somatic metaphor. Of equal importance is the clinical skill to rule out the subjective report as a metaphor and appreciate it as an accurate report of a sensation in order to focus upon the possible underlying pathophysiological dysfunction. Probably nothing tests the fine skill of differential diagnosis more critically than the ability to sense the subtle, chameleon-like presence of the somatic metaphorical statements.
Figure 1. Grade 3 eye roll.
3. Hypnosis has a biological substrate. The hypnotic experience, like concentration and attention, is embedded in a complex psychophysiological matrix that is subject to the imbalances, aberrancies, dysfunctions and impairments of other complex systems. Thus, a biological potential can exist, but the ultimate expression can be blocked by a variety of pathological contingencies. This sequence or break in sequence can be identified clinically.
Shakow's segmental set theory* is the model that epitomizes this phenomenon. The intact ribbon of concentration identified as hypnotizability under the umbrella "generalized set" is both an indicator of potential capacity and an expression of this capacity to adapt to a barrage of input signals. When, instead, the person abandons the major generalized set and responds to a lesser and segmental set, the ribbon of concentration is broken revealing an impairment in expressing the normal commitment that is fundamental for normal adaptive behavior. This veering toward the segmental set is typical of the schizophrenic person. Also typical of the schizophrenic is a clinical sign of biological potential for hypnotic concentration but an inability to express it, resulting in no operational trance capacity.
Eye-roll sign and the hypnotic-induction profile. An exciting new discovery that the relative mobility of the eyes serves as a presumptive sign of trance capacity places the further study of hypnosis at the body-mind interface. The ability to look upward while closing the eyelids, the eye-roll sign (ERS) (Figure 1), varies on a 0-4 scale (Figure 2) with a normal distribution curve in a general adult population.4 If there is no impediment in the ability to maintain an instructed ribbon of concentration, the ERS generally reflects hypnotic capacity. For example, if the ERS is so high that practically nothing but sclera is visible, the likelihood is that the person is highly hypnotizable. If little or no sclera is seen between the lower eyelid and the lower border of the iris, the odds are that hypnotizability is on the low side. Further, this feature is relatively stable with a minimal learning effect.
Figure 2. The eye-roll sign varies on a 0-4 scale. If the person is able to look upward so high that practically nothing but sclera is ... is probably hypnotizable.
Since about 25 percent of a general population sample has a positive ERS to one degree or another, but no operational capacity for going into a trance, a test ... be devised to assess the capacity to express ... capacity as well as showing biological potential. This to the development of the Hypnotic Induction ... (HIP) which measures the ERS plus the ... experience three different arm levitations (LEV) ... instructed and monitored conditions.
During this 5-10 minute test period, the patient ... and exits from the trance experience and ... ... sensations while the examiner records overt .... Two scoring systems record a Profile Configurand an actuarial summation. Usually the arm ... relates directly with the ERS and is identified as ... Profile. If the LEV response collapses to zero, ... a break in concentration and no hypnotiz.... It is called a non-intact (or decrement) profile ....
..., a biological baseline and a sensorimotor ... pattern are measured to indicate trance capacity ... 0-5 profile configuration scale and on a 0-10 ... score of 5 items (but not the ERS). In general, ... response is stable over time and has good interreliability. It is clinically appropriate, quick (5-10 ...) and standardized on actual clinical populations, ... the HIP is recorded, the patient is immediately ... how to initiate self-hypnosis. Self-induction ... vary from 5-10 seconds. The primary ... strategy varies with the nature of the problem the trance capacity of the person.
... HIP assessment offers initial information at three ... levels:
The degree of hypnotizability; low, mid-range, high one.
On a psychiatric health-illness continuum, where a person fit? An intact profile implies probably good .... A nonintact profile signals probability of ... degree of concentration impairment due to ..., neurological deficit or chemical tox....
The probable personality style. The high grades ... have Dionysian "heart" features with rich ..., a trusting stance, an easy flow of intuitive ... and deep absorption. The low grades are likely to Apollonian "head" persons with high priority given to ..., reason, orderliness, and impulse to control. The ... grade reflects varying combinations of the ... polarities with trends toward oscillating between ... of relative action and inaction. Or to put it ... way, an Odyssean quest for the middle way.
... and refining clinical tests for hypnotizability ongoing, and more work needs to be done, ... studies with a variety of tests can enhance understanding of hypnosis and consequently stimumore clinicians to measure in the clinic.
... of the assessed hypnosis values can be ... by studying correlations with other domains, example, in determining the health-illness continuum its relfection in measured hypnotizability, personality ... can be studied, with emphasis upon time sense, absorption capacity, space orientation, beliefs, metaphors, learning style and processing techniques.
The predictive ability of the Hypnotic Induction Profile configuration for treatment responsivity needs to be studied further. Both short and long-term follow-up studies are needed.
The ultimate goal of future studies is to validate or disprove the hypothesis that quick assessment of hypnotizability can become a diagnostic probe that can clarify diagnosis and aid in the treatment choice. If the hypothesis is correct, such an assessment might make possible:
1. Identification of those patients capable of internalized change with commitment and self-mastery for whom the various psychotherapies would be the preferred treatment; that is, the cognitive analytic therapies for the Apollonian to the more persuasive affect-laden guidance therapies for Dionysians.
2. Identify those patients with limited capacity for internalized change, who need psychotherapy with the additional help from the extensive psychoactive drug repertory.
3. Identify those with no discernible capacity for internal change or commitment, who therefore will require total dependency upon medication and/ or socialnetwork support and supervision.
This triage model puts a disciplined emphasis upon the patients' needs, rather than on the therapists' preferred school of treatment. Further, it allows for a more systematic study of treatment effectiveness.
Somebody once said, "If you can measure it, it is science; everything else is poetry." It is ironic that a clinical phenomenon that was once dismissed as nothing but imagination is now being subjected to the discipline of measurement and shows promise of becoming a useful clinical instrument to sharpen differential diagnosis, aid in selecting appropriate treatment strategy and accelerate treatment responsivity for selected patients.
1. Darnton, R. Mesmerism and the End of the Enlightenment in France. New York: Schocken Books, 1970.
2. Erickson, M. H, Rossi, E. L-. and Rossi, S. 1. Hypnotic Realities. New York: Irvington Publishers. 1976.
3. Weitzenhoffer, A. M., and Hilgard, E. R. Stanford Hypnotic Susceptibility Scales: Forms A and B. Palo Alto. Calif.: Consulting Psychologists Press, 1959.
4. Spiegel, H., and Spiegel, D. Trance and Treatment; Clinical Uses of Hypnosis. New York: Basic Books, Inc., 1978.
5. Ortega y Gasset. Valazauez, Goya and the Dehumanization of Art. Translated by Alexis Brown. New York: W. W. Norton, 1972.
6. Shakow, D.. Adaptation in Schizophrenia: The Theory of Segmented Set. New York: Wiley-Interscience, 1979.