Am
Hypnosis BY
FRED
and H.
Related
FRANKEL,
M.B.CH.B.,
Clinical
SCIENCE has known about hypnosis for two centuries. The procedure, described initially as “animal magnetism” (1) and later as hypnosis (2), has enjoyed several periods of limited popularity, has been used and abused, and has known both fame and failure. However, something about this remarkable piece of human behavior has withstood the vicissitudes of fortune and seems constantly to beckon those who are captivated by it to explore it further. Terms like “hypnosis” and “hypnotizability” have been used very loosely over the years, so much so that various authors have implied widely different meanings for them. Hypnosis has been variously interpreted in the past and recently as the control ofone person by another, transcendence of normal physical and mental abilities, a special form of relaxation, heightened concentration, a placebo, direct access to the unconscious, and a special type of relationship between two persons, the hypnotist and the subject. This list is not exhaustive, but it provides a sense of the wide variety of meanings attached to the term. They stem from several sources: anecdotal reports of clinical events, stage
664
1978
performances, drama and literature, and clinical attempts to use hypnosis in the uncovering of repressed events. Some of the statements contain a shade of the truth, a few have been proven inaccurate, and none is an adequate explanation. Fortunately, careful efforts have been made in mecent years, primarily by experimental psychologists, to study the complex event of hypnosis, and there is now a fascinating and slowly evolving basic science of hypnosis. By refining the scales measuring the mesponses to hypnotic induction procedures and then investigating the responses of large numbers of individuals, Hilgard and associates (3) have thrown considerable light on the manifestations and correlates of hypnosis. Omne and coworkers, by finely honing the methodology of research in hypnosis, have clarified considerably what belongs to hypnosis and what does not (4, 5). There are, of course, many other contributors, too numerous to mention here, who have added to the theoretical understanding of hypnosis and who have helped to amplify the concept. The truth is that, to date, no observable or measurable physiological changes uniquely associated with hypnosis have been convincingly demonstrated; it is only when we question and talk with subjects who have experienced hypnosis that we gain some understanding of the event. It seems to be an essentially subjective happening. In the main, individuals describe an altered perception of themselves, their bodies, or the world around them. From our experience with clinical events and the clinical literature, we also know that altered physical perceptions in hypnosis seem sometimes to lead to observable physical changes, e.g., imagining that one’s skin is being warmed by the sun might actually lead to a rise in skin temperature. There have been too many psychosomatic effects initiated in the clinical context by the introduction of hypnosis for us to ignore this area. Unfortunately, the mechanisms responsible for these changes are still in need of verifiable explanations. Hypnosis per se might or might not be the factor of primary importance in these changes.
DESCRIBING
Dr. Frankel is Associate Professor, vard Medical School, and Head, Beth Israel Hospital, 330 Brookline
June
D.P.M.
MEDICAL
on a luncheon and Experimental
135:6,
Behavior
The essential aspect in the experience of the hypnotized person is the altered or distorted perception that is suggested to him. Not allpeople are capable ofthe experience, but it is possible that spontaneous distortions occur in those with high hypnotizability. These distortions are frequently experienced asfrightening symptoms. The author draws attention to the similarity between hysterical symptoms and events in hypnosis and to the high hypnotic responsivity in hysterical subjects reported in the clinical literature ofthe nineteenth century. Phobic patients have relatively high hypnotic responsivity. The author believes that it is sometimes possible to predict hypnotizabilityfrom clinical behavior, and that hypnotic responsivity can be utilized in psychodynamically sensitive therapy to teach such patients that they can learn to gain control of their symptoms.
This paper is based Society for Clinical June 26, 1976.
J Psychiatry
address at the workshops Hypnosis, Philadelphia,
of the Pa.,
Department of Psychiatry, HarAdult Unit, Psychiatric Service, Ave., Boston, Mass. 02215.
0002-953X/78/0006-0664$0.50
© 1978
AND
DEFINING
HYPNOSIS
In the light of our current knowledge, the following description of hypnosis provides a reasonable approach to an understanding of the event. Ten years from now, we may have altered our position, but at American
Psychiatric
Association
Am J Psychiatry
135:6,
June
1978
this point in time hypnosis is understood by many as the experience of altered or distorted perceptions brought about as a result of ideas that are offered in the context of a trusting relationship, when the subject is motivated and willing to experience them. It seems, too, that in hypnosis subjects may experience increased or decreased ability to remember, and they have a remarkable capacity for tolerating logical inconsistencies. It is to Shom (6) that we owe the clear differentiation of the three separate dimensions of the experience I have described. Combining the most persuasive of the prevailing theories about hypnosis, Shor drew our attention to the fact that the success of the hypnotic encounter depended not only on the subject’s capacity to experience the trance or altered perception of reality in general but also on his willingness to participate in hypnotic behavior and on the kind of trusting relationship that allowed him to respond favorably to the operatom. When these three dimensions are all strongly present, a full and rich hypnotic experience can occur. When they are present in varying degrees they lead to less intense and somewhat different kinds of expemiences. In this presentation my special concern is the dimension oftmance capacity, i.e., the capacity to experience altered perceptions when the relationship and the motivation are appropriate. The capacity to experience the trance is not distributed equally. Some persons have considerable ability to experience it, others can do so only minimally if at all, and the remainder, the majority of the populace, seems to be distributedin a bell-shaped curve. Given reasonable motivation and a reasonably good relationship between the subject and the hypnotist, 5%-10% of individuals appear to be markedly responsive to hypnotic induction procedures, 20%-30% appear to be minimally responsive, and 60%-75% fall between the two extremes. Surveys in the last century reveal how remarkably consistent this distribution seems to be in any unselected population (3). One cannot fail to be impressed in the clinical situation by the ease and speed with which some patients enter the trance in response to an induction procedure-occasionally after an acquaintanceship ofonly a few minutes. Is it possible that such people cannot avoid entering the trance at times without the help of an induction procedure? It is hard to believe that the trance never occurs for these individuals unless another person provides a ritual of suggestions and coaxing sounds. The question of spontaneous occurrence of trance and the manner of its manifestation has frequently been raised in the past. It seems to have been noticed first by the Marquis de Puys#{233}gur (7), who referred to the similarity between the intense experience of hypnosis (or magnetism) and spontaneous somnambulism. He considered an induced hypnotic experience to be the equivalent of sleepwalking, an aspect of behavior that had captured the attention of the public at that time.
FRED
Historical Perspective: Hypnotizability
Personality
H.
FRANKEL
and
Ellenberger (8) described a group of clinical conditions considered during the latter half of the nineteenth century as “magnetic diseases”-diseases associated in some way with animal magnetism. These included the clinical pictures of lethargy, catalepsy, multiple personality, and, of course, spontaneous somnambulism or sleepwalking. Later, attention was focused on hysteria and the hysterical fugue. The association of animal magnetism or hypnosis with these clinical conditions seemed to be affirmed by the following findings: I) individuals who were subject to these conditions were usually easily hypnotized, 2) it was fairly easy to establish rapport with them and to have them shift from their clinical condition into one of hypnosis, and 3) persons who remembered nothing of the events during a fugue or an episode of spontaneous somnambulism could often recall them when hypnotized. The essential difference was clear; hypnosis was induced, whereas the clinical conditions occurred spontaneously. Most of these conditions were subsequently included under the heading of hysteria. Charcot (9) and, later, his pupil Pierre Janet, were strong proponents of the view that hypnosis and hysteria were identical, apart from their mode of onset. Janet (10) declared that when the patient was cured of her hysteria, she would no longer be hypnotizable. Gradually, during this century, the assumption of a close association between hysteria and hypnosis began to be challenged. The doubts probably arose initially in the clinical setting and were later strengthened by careful laboratory studies. Mistrust of hypnosis on the part of clinicians rapidly followed its excessive and often inappropriate use-particularly in attempts to memove hysterical symptoms by means of suggestions given when the patient was hypnotized. Once it had been ‘oversold, the use of hypnosis readily led to disappointment. The magical expectations that had become associated with it were only rarely met, and there were few reliable predictors that could be depended upon. The marked hypnotizability of a patient was itself no guarantee that that individual would mespond to therapeutic suggestions, or that the effect of such suggestions would endure. It is but a small step from that realization to the inference that hypnotizability has little clinical relevance. It should be added that it is now more clearly understood that the total hypnotic situation is of major importance, rather than the mere capacity to experience the trance. The way the patient feels about the hypnotist and the extent of his or her motivation to undergo hypnosis to resolve problems and relinquish symptoms are as relevant to the outcome of the treatment as the ability to experience the trance. In addition to disappointment with the clinical outcome of hypnosis, laboratory studies, mainly with healthy undergraduate students as subjects, failed to demonstrate a correlation between personality styles ‘
‘ ‘
665
HYPNOSIS
AND
CLINICAL
Am
BEHAVIOR
and hypnotizability (3). The Minnesota Multiphasic Personality Inventory and the Rorschach Test were used to determine whether a personality style such as that described as hysterical is more likely than other personality patterns to be associated with marked hypnotizability. Of several reputable studies, none confirmed that notion. In fact, the results generally supported the idea that healthy, well-adjusted, and outgoing individuals were likely to be more hypnotizable than those who were neurotic or psychotic (3, 1 1). Authors who reported on clinical studies (12) reaffirmed that generally held view, although they noted that among their neurotic patients, the hysterical individuals were more hypnotizable than those not considemed hysterical. In recent years the pendulum has begun to swing back somewhat. Based primarily on clinical observations, Spiegel (13) suggested the association of a distinct personality pattern and marked hypnotizability. In what he described as the “grade S syndrome,” Spiegel outlined a clinically identifiable configuration of personality traits. These include marked hypnotizability, readiness to trust, relative suspension of critical judgment, ease of affiliation with new experiences, telescoped time sense, easy acceptance of logical incongruities, excellent memory, capacity for intense concentration, overall tractability, and, paradoxically, a rigid core of private beliefs. Under duress, the grade S or somnambule becomes the so-called hysterical patient. Spiegel’s description is in some ways reminiscent of Janet’s comments: number of traits of character have often been pointed out in hystericals. Their transitory enthusiasms, their exaggerated and quickly appeared despairs, their irrational convictions, their impulses, their caprices-in a word, this excessive and unstable disposition seems to us to depend upon this fundamental fact that they always give themselves entirely up to the present idea, without any of that reserve, that mental restriction, which give to the thought its moderation, its equilibrium, and its transitions. (14, p. 502) a great
.
.
.
.
.
.
From a close examination of the clinical scene, it seems that there is not only an apparent association between personality style and marked hypnotizability but also a possible association between aspects of clinical behavior and marked hypnotizability. The clinical appearance of episodes of perceptual distortion associated with marked anxiety strongly resembles the effects of suggestions in hypnosis. When these episodes are especially apparent in patients who are highly responsive to hypnosis, the resemblance is probably significant.
CASE
J Psychiatry
/35:6,
June
/978
Her fianc#{233}persuaded her that they should fly home from their honeymoon. She was convinced that she would be terrified, and the experience was a dismal failure. A year later she and her husband took a second flight to prove that she could overcome her problem. From the moment that she boarded the plane, her mounting anxiety engulfed her in terror that persisted throughout the trip. She clung tearfully to her husband’s side and was captured by a pervasive sense of imminent catastrophe. She was convinced her world was about to end and was oblivious to everything but her panic. She observed but was uninfluenced by the relaxed and casual
activities
ofthe
other
passengers
and
crew.
When
the
plane landed, she recovered. Her request for treatment was prompted by her wish to take a trip to Europe, which would be possible only if she and her husband flew there and back. Her rating on the Hypnotic Induction Profile (15) was very high, indicating that she was
highly
responsive
to hypnosis.
She
to a modified and accelerated program tization ( 16), during which considerable marked suggestibility in hypnosis. 2.
Case
Mr.
persistent
pain
mained
unexplained
in a minor
B, an academician in the
rapidly
in his
mid-thirties,
had
left scapular region that refor almost 7 years after he was involved collision. Despite surgical intervention,
motor
neck
responded
of imaginal desensiuse was made of her
and
including spinal fusion, the symptoms continued unabated until about 18 months after his surgery. Six months later. a slap on the back by a colleague led immediately to a recurrence of the excruciating symptoms. Extensive studies revealed no organic pathology. and psychiatric consultation ensued. He was almost totally preoccupied with the pain in his shoulder great detail. claims
and He
upper arm and described it vividly and had been unable to work, and insurance
in
accumulated.
His rating on the Hypnotic Induction Profile (15) was extremely high. He was also able to respond to the idea that the hour hand on the clock face would disappear when he looked at it. He was immediately and remarkably capable of creating a numb and tingling feeling in the affected areas when this was suggested to him and rapidly learned to do so in self-hypnosis exercises. This brought his primary symptoms
under
control.
Case 3. Mr. C, a man in his mid-20s, sought hypnosis because of his fear of dentistry. This fear had so crippled him that he had avoided seeing a dentist for over 10 years apart from one occasion when an infected impacted wisdom tooth drove him to seek help. He was remarkably responsive to hypnosis and has a very high rating on the Hypnotic Induction Profile (15). On emerging from the experience of the induced trance, he volunteered the comment that it had felt not unlike what he remembered of his childhood experiences in the dentist’s chair. He referred to feelings of dissociation in parts of his body and to his total preoccupation with particular parts of his body: all other stimuli were completely excluded. He was also able to make rapid use of strong hypnotic suggestions that he would be totally in the dentist’s office and would experience only and numb sensations in his jaw.
relaxed tingling
ABSTRACTS
DISCUSSION
Case I. Ms. A, a woman in her mid-20s, complained of an overwhelming fear of flying. Her mother was extremely afraid of air travel, so Ms. A had never been allowed to fly. 666
Clearly, not
fully
the
psychopathology
explained
by
of these their
marked
individuals hypnotizability,
is
Am
J Psychiatry
135:6,
June
1978
and it is not my intent to account for their clinical histories in terms limited to their hypnotizability. Similarly, there is no intent here to describe a series of rapid therapeutic successes. My purpose is to draw attention to the possible relatedness of the marked hypnotizability and the nature of the clinical symptoms. There can be little doubt that the three people I have described have a well developed ability to alter perceptions when subjected to persuasive comments to do so in hypnosis. In that state, they are also able to fix their attention on the altered perception to the almost total exclusion ofall other sensory stimuli and are able to continue in that experience despite logical inconsistencies. It is difficult to ignore the strong likelihood that the mental mechanism underlying this ability is involved in the development and maintenance of their symptoms, which comprised essentially altered or distorted perceptions of bodily sensations or of the environment, a fixed preoccupation from time to time with those perceptions, and inability to register or disregard any contradicting logic. The strong impression that some clinical behavior correlates with marked hypnotizability was generally supported by my routine measurements of clinical problems broadly classifiable as hysterical in nature. These included cases of hysterical fugue, multiple personality, and phobic behavior. None of the patients scored in the low range of hypnotizability, and most scored high or very high. One ofthe groups, the phobic patients, was selected for closer study. This group was chosen primarily because the number of phobic patients is greater than that in the other categories. The hypnotizability of phobic patients applying for private treatment or for therapy in the Psychiatric Clinic of Beth Israel Hospital was systematically measumed and reported in a previously published study (17). Their scores were compared with the hypnotizability of an equal number of patients applying to the clinic for therapeutic hypnosis for help in quitting smoking (the control group). The mean score of the phobic patients was consistently higher than the controls’ Among the smokers, 30% were essentially nonresponsive, with scores of0-4 on the 12-point Stanford Hypnotic Susceptibility Scale (18) or its group modification, the Harvard Group Scale (19). There were no nonresponsive individuals in the group of 24 phobic patients. Furthermore, patients reporting more than one phobia had significantly higher mean scores than those reporting only a single phobia. These findings can be ofconsidemable diagnostic and therapeutic relevance. They suggest that we can predict hypnotizability to some extent from the clinical picture, which many workers in recent years have tended to doubt. It should be borne in mind that these findings and those of the many very reputable studies of undergraduate student populations are not necessarily contradictory. The populations under investigation are vastly different. The findings I have cited are based on patients who were sufficiently troubled by their symptoms to seek treatment. The laboratory .
FRED
H.
FRANKEL
studies that found no correlation between personality style and hypnotizability were carried out on apparently healthy groups of students. Although we might acknowledge that the mental mechanism in hypnosis and the mechanism involved in the manifestation of the symptoms briefly described in the three case vignettes are in all probability the same, the precise nature of that mechanism remains open to conjecture. It appears to be initiated in hypnosis by procedures of induction, and in the clinical context seems to be associated with the spontaneous onset of a trance or trance-like experience. We know that under stress, dissociation can occur as a mechanism of defense. It is suggested that under circumstances of intense fear, rage, or sadness, individuals predisposed to dissociate may do so and then experience the world and their bodies in a perceptually distorted manner. This distorted perception can be more frightening than the original distress against which it was intended to defend and could mark the onset ofa series of learned, repeated, or imagined happenings of a similar nature, each of which is associated with considerable anxiety (20). In 1907, Janet considered dissociation to be the mental mechanism underlying events in hypnosis (10), and in recent years, Hilgard (21), in his essay on neodissociation, has again drawn attention to the relevance of the concept of dissociation to account for the phenomena in hypnosis and the clinical symptoms described above. From the therapeutic standpoint, I would suggest that the patient’s marked trance capacity can be fashioned into a coping mechanism (22). By demonstrating to highly hypnotizable patients, in the reassuring envimonment of the therapist’s office, that they can, under hypnosis, alter their perceptions and either create or increase the discomfort of their symptoms, or relax and thereby alleviate them, the therapist provides an outstanding learning experience. He or she not only makes the fearsome experiences familiar and therefore less frightening but also demonstrates to the patient that the patient does, in fact, have control over the mechanism which creates the distortions in the first place. The careful integration of self-hypnosis into the strategy braces and reinforces patients’ conviction that they can exert effective control. The overall treatment plan is complex and does not aim at the removal of symptoms by direct suggestion. It recognizes the importance of motivation and secondary gain and depends for its efficacy on an adequate initial psychiatric evaluation.
Shaping
an
individual’s
trance
capacity
in-
to a coping mechanism can readily be made part of a psychodynamically sensitive treatment plan, but this can be accomplished only if the therapist is aware of the existence of marked hypnotizability and alert to the types of clinical behavior associated with it.
REFERENCES
I. Mesmer mal.
Paris,
FA:
M#{233}moiresur Ia D#{233}couverte du Magn#{233}tisme AniDidot,
1779
667
HYPNOSIS
2.
AND
CLINICAL
Braid J: Neurypnology: sidered in Relation with
Am
BEHAVIOR
The
Rationale
Animal
of Nervous
Magnetism,
merous Cases of its Successful Application Cure of Disease. London, John Churchill, 3.
Hilgard
4.
Orne
Brace
ER:
and World, MT:
The
Soc Psychol 5.
Orne
Hypnotic
MT.
Susceptibility.
Con-
in the Relief 1843
New
York,
of hypnosis:
58:277-299, FJ:
artifact
and
9.
Ellenberger tory and
HF: Evolution
Social
Books,
1970
Charcot
JM:
The
Oeuvres
of
control
in the
psychological
experi-
Discovery Dynamic Complete
of the Unconscious: Psychiatry. New (Complete
The HisYork, Basic
Works),
9
vols.
Paris, Aux Bureaux de ProgrCs Medical, 1886 10. Janet P: The Major Symptoms of Hysteria: Fifteen Lectures Given in the Medical School of Harvard University. New York, Macmillan, 1907 11. Ehrenreich GA: The relationship of certain descriptive factors to hypnotizability. Trans Kans Acad Sci 52:24-27, 1949
668
Stigmata Translated
Abnorm
antisocial behavior and hypnosis. J Pers Soc Psychol 1:189-200, 1965 6. Shor RE: Three dimensions of hypnotic depth. Int J Clin Exp Hypn 10:23-38, 1962 7. Puys#{233}gurAM Marquis de: Letter on the discovery of artificial somnambulism to a member of the Soci#{233}t#{233} de Harmonic, March 8, 1784, in Practical Manual of Animal Magnetism. Edited by Teste A; translated by Spillan D. London, Bailli#{232}re, 1843
Brenman Studies Press,
M: Hypnosis
in Regression. 1959
135:6,
and Related New
York,
June
1978
States:
Psycho-
International
Uni-
13. Spiegel H: The grade 5 syndrome: the highly hypnotizable person. Int J Clin Exp Hypn 22:303-319, 1974 14. Janet P: The Mental State of Hystericals: A Study of Mental
1959
ment:
8.
analytic versities
and
Harcourt,
essence.
12. Gill MM,
by Nu-
1965
nature
Evans
Sleep
Illustrated
J Psychiatry
and Mental by Caroline
Accidents. Rollin
With Corson.
a Preface by JM Charcot. New York, GP Putnam’s
Sons, 1901
15. Spiegel Eye-Roll 16. 17. 18.
19.
20. 21.
22.
H, Bridger
AA: Manual for Hypnotic Induction Profile: Levitation Method. New York, Soni Medica, 1970 J: Psychotherapy by Reciprocal Inhibition. Stanford,
Wolpe Calif, Stanford Frankel FH,
University Press, 1958 Orne MT: Hypnotizability and phobic behavior. Arch Gen Psychiatry 33:1259-1261, 1976 Weitzenhoffer AM, Hilgard ER: Stanford Hypnotic Susceptibility Scale, Forms A and B. Palo Alto, Calif. Consulting Psychologists Press, 1959 Shor RE, Orne EC: The Harvard Group Scale of Hypnotic Susceptibility, Form A. Palo Alto, Calif. Consulting Psychologists Press, 1962 Frankel FH: Trance capacity and the genesis of phobic behavior. Arch Gen Psychiatry 3 1:261-263, 1974 Hilgard ER: Dissociation revisited, in Historical Conceptions of Psychology. Edited by Henle M, Jaynes J, Sullivan JJ. New York, Springer Publishing Co. 1973 Frankel FH: Hypnosis: Trance as a Coping Mechanism. New York, Plenum Publishing Co. 1976
Hypnosis BY
FRED
and H.
Related
FRANKEL,
M.B.CH.B.,
Clinical
SCIENCE has known about hypnosis for two centuries. The procedure, described initially as “animal magnetism” (1) and later as hypnosis (2), has enjoyed several periods of limited popularity, has been used and abused, and has known both fame and failure. However, something about this remarkable piece of human behavior has withstood the vicissitudes of fortune and seems constantly to beckon those who are captivated by it to explore it further. Terms like “hypnosis” and “hypnotizability” have been used very loosely over the years, so much so that various authors have implied widely different meanings for them. Hypnosis has been variously interpreted in the past and recently as the control ofone person by another, transcendence of normal physical and mental abilities, a special form of relaxation, heightened concentration, a placebo, direct access to the unconscious, and a special type of relationship between two persons, the hypnotist and the subject. This list is not exhaustive, but it provides a sense of the wide variety of meanings attached to the term. They stem from several sources: anecdotal reports of clinical events, stage
664
1978
performances, drama and literature, and clinical attempts to use hypnosis in the uncovering of repressed events. Some of the statements contain a shade of the truth, a few have been proven inaccurate, and none is an adequate explanation. Fortunately, careful efforts have been made in mecent years, primarily by experimental psychologists, to study the complex event of hypnosis, and there is now a fascinating and slowly evolving basic science of hypnosis. By refining the scales measuring the mesponses to hypnotic induction procedures and then investigating the responses of large numbers of individuals, Hilgard and associates (3) have thrown considerable light on the manifestations and correlates of hypnosis. Omne and coworkers, by finely honing the methodology of research in hypnosis, have clarified considerably what belongs to hypnosis and what does not (4, 5). There are, of course, many other contributors, too numerous to mention here, who have added to the theoretical understanding of hypnosis and who have helped to amplify the concept. The truth is that, to date, no observable or measurable physiological changes uniquely associated with hypnosis have been convincingly demonstrated; it is only when we question and talk with subjects who have experienced hypnosis that we gain some understanding of the event. It seems to be an essentially subjective happening. In the main, individuals describe an altered perception of themselves, their bodies, or the world around them. From our experience with clinical events and the clinical literature, we also know that altered physical perceptions in hypnosis seem sometimes to lead to observable physical changes, e.g., imagining that one’s skin is being warmed by the sun might actually lead to a rise in skin temperature. There have been too many psychosomatic effects initiated in the clinical context by the introduction of hypnosis for us to ignore this area. Unfortunately, the mechanisms responsible for these changes are still in need of verifiable explanations. Hypnosis per se might or might not be the factor of primary importance in these changes.
DESCRIBING
Dr. Frankel is Associate Professor, vard Medical School, and Head, Beth Israel Hospital, 330 Brookline
June
D.P.M.
MEDICAL
on a luncheon and Experimental
135:6,
Behavior
The essential aspect in the experience of the hypnotized person is the altered or distorted perception that is suggested to him. Not allpeople are capable ofthe experience, but it is possible that spontaneous distortions occur in those with high hypnotizability. These distortions are frequently experienced asfrightening symptoms. The author draws attention to the similarity between hysterical symptoms and events in hypnosis and to the high hypnotic responsivity in hysterical subjects reported in the clinical literature ofthe nineteenth century. Phobic patients have relatively high hypnotic responsivity. The author believes that it is sometimes possible to predict hypnotizabilityfrom clinical behavior, and that hypnotic responsivity can be utilized in psychodynamically sensitive therapy to teach such patients that they can learn to gain control of their symptoms.
This paper is based Society for Clinical June 26, 1976.
J Psychiatry
address at the workshops Hypnosis, Philadelphia,
of the Pa.,
Department of Psychiatry, HarAdult Unit, Psychiatric Service, Ave., Boston, Mass. 02215.
0002-953X/78/0006-0664$0.50
© 1978
AND
DEFINING
HYPNOSIS
In the light of our current knowledge, the following description of hypnosis provides a reasonable approach to an understanding of the event. Ten years from now, we may have altered our position, but at American
Psychiatric
Association
Am J Psychiatry
135:6,
June
1978
this point in time hypnosis is understood by many as the experience of altered or distorted perceptions brought about as a result of ideas that are offered in the context of a trusting relationship, when the subject is motivated and willing to experience them. It seems, too, that in hypnosis subjects may experience increased or decreased ability to remember, and they have a remarkable capacity for tolerating logical inconsistencies. It is to Shom (6) that we owe the clear differentiation of the three separate dimensions of the experience I have described. Combining the most persuasive of the prevailing theories about hypnosis, Shor drew our attention to the fact that the success of the hypnotic encounter depended not only on the subject’s capacity to experience the trance or altered perception of reality in general but also on his willingness to participate in hypnotic behavior and on the kind of trusting relationship that allowed him to respond favorably to the operatom. When these three dimensions are all strongly present, a full and rich hypnotic experience can occur. When they are present in varying degrees they lead to less intense and somewhat different kinds of expemiences. In this presentation my special concern is the dimension oftmance capacity, i.e., the capacity to experience altered perceptions when the relationship and the motivation are appropriate. The capacity to experience the trance is not distributed equally. Some persons have considerable ability to experience it, others can do so only minimally if at all, and the remainder, the majority of the populace, seems to be distributedin a bell-shaped curve. Given reasonable motivation and a reasonably good relationship between the subject and the hypnotist, 5%-10% of individuals appear to be markedly responsive to hypnotic induction procedures, 20%-30% appear to be minimally responsive, and 60%-75% fall between the two extremes. Surveys in the last century reveal how remarkably consistent this distribution seems to be in any unselected population (3). One cannot fail to be impressed in the clinical situation by the ease and speed with which some patients enter the trance in response to an induction procedure-occasionally after an acquaintanceship ofonly a few minutes. Is it possible that such people cannot avoid entering the trance at times without the help of an induction procedure? It is hard to believe that the trance never occurs for these individuals unless another person provides a ritual of suggestions and coaxing sounds. The question of spontaneous occurrence of trance and the manner of its manifestation has frequently been raised in the past. It seems to have been noticed first by the Marquis de Puys#{233}gur (7), who referred to the similarity between the intense experience of hypnosis (or magnetism) and spontaneous somnambulism. He considered an induced hypnotic experience to be the equivalent of sleepwalking, an aspect of behavior that had captured the attention of the public at that time.
FRED
Historical Perspective: Hypnotizability
Personality
H.
FRANKEL
and
Ellenberger (8) described a group of clinical conditions considered during the latter half of the nineteenth century as “magnetic diseases”-diseases associated in some way with animal magnetism. These included the clinical pictures of lethargy, catalepsy, multiple personality, and, of course, spontaneous somnambulism or sleepwalking. Later, attention was focused on hysteria and the hysterical fugue. The association of animal magnetism or hypnosis with these clinical conditions seemed to be affirmed by the following findings: I) individuals who were subject to these conditions were usually easily hypnotized, 2) it was fairly easy to establish rapport with them and to have them shift from their clinical condition into one of hypnosis, and 3) persons who remembered nothing of the events during a fugue or an episode of spontaneous somnambulism could often recall them when hypnotized. The essential difference was clear; hypnosis was induced, whereas the clinical conditions occurred spontaneously. Most of these conditions were subsequently included under the heading of hysteria. Charcot (9) and, later, his pupil Pierre Janet, were strong proponents of the view that hypnosis and hysteria were identical, apart from their mode of onset. Janet (10) declared that when the patient was cured of her hysteria, she would no longer be hypnotizable. Gradually, during this century, the assumption of a close association between hysteria and hypnosis began to be challenged. The doubts probably arose initially in the clinical setting and were later strengthened by careful laboratory studies. Mistrust of hypnosis on the part of clinicians rapidly followed its excessive and often inappropriate use-particularly in attempts to memove hysterical symptoms by means of suggestions given when the patient was hypnotized. Once it had been ‘oversold, the use of hypnosis readily led to disappointment. The magical expectations that had become associated with it were only rarely met, and there were few reliable predictors that could be depended upon. The marked hypnotizability of a patient was itself no guarantee that that individual would mespond to therapeutic suggestions, or that the effect of such suggestions would endure. It is but a small step from that realization to the inference that hypnotizability has little clinical relevance. It should be added that it is now more clearly understood that the total hypnotic situation is of major importance, rather than the mere capacity to experience the trance. The way the patient feels about the hypnotist and the extent of his or her motivation to undergo hypnosis to resolve problems and relinquish symptoms are as relevant to the outcome of the treatment as the ability to experience the trance. In addition to disappointment with the clinical outcome of hypnosis, laboratory studies, mainly with healthy undergraduate students as subjects, failed to demonstrate a correlation between personality styles ‘
‘ ‘
665
HYPNOSIS
AND
CLINICAL
Am
BEHAVIOR
and hypnotizability (3). The Minnesota Multiphasic Personality Inventory and the Rorschach Test were used to determine whether a personality style such as that described as hysterical is more likely than other personality patterns to be associated with marked hypnotizability. Of several reputable studies, none confirmed that notion. In fact, the results generally supported the idea that healthy, well-adjusted, and outgoing individuals were likely to be more hypnotizable than those who were neurotic or psychotic (3, 1 1). Authors who reported on clinical studies (12) reaffirmed that generally held view, although they noted that among their neurotic patients, the hysterical individuals were more hypnotizable than those not considemed hysterical. In recent years the pendulum has begun to swing back somewhat. Based primarily on clinical observations, Spiegel (13) suggested the association of a distinct personality pattern and marked hypnotizability. In what he described as the “grade S syndrome,” Spiegel outlined a clinically identifiable configuration of personality traits. These include marked hypnotizability, readiness to trust, relative suspension of critical judgment, ease of affiliation with new experiences, telescoped time sense, easy acceptance of logical incongruities, excellent memory, capacity for intense concentration, overall tractability, and, paradoxically, a rigid core of private beliefs. Under duress, the grade S or somnambule becomes the so-called hysterical patient. Spiegel’s description is in some ways reminiscent of Janet’s comments: number of traits of character have often been pointed out in hystericals. Their transitory enthusiasms, their exaggerated and quickly appeared despairs, their irrational convictions, their impulses, their caprices-in a word, this excessive and unstable disposition seems to us to depend upon this fundamental fact that they always give themselves entirely up to the present idea, without any of that reserve, that mental restriction, which give to the thought its moderation, its equilibrium, and its transitions. (14, p. 502) a great
.
.
.
.
.
.
From a close examination of the clinical scene, it seems that there is not only an apparent association between personality style and marked hypnotizability but also a possible association between aspects of clinical behavior and marked hypnotizability. The clinical appearance of episodes of perceptual distortion associated with marked anxiety strongly resembles the effects of suggestions in hypnosis. When these episodes are especially apparent in patients who are highly responsive to hypnosis, the resemblance is probably significant.
CASE
J Psychiatry
/35:6,
June
/978
Her fianc#{233}persuaded her that they should fly home from their honeymoon. She was convinced that she would be terrified, and the experience was a dismal failure. A year later she and her husband took a second flight to prove that she could overcome her problem. From the moment that she boarded the plane, her mounting anxiety engulfed her in terror that persisted throughout the trip. She clung tearfully to her husband’s side and was captured by a pervasive sense of imminent catastrophe. She was convinced her world was about to end and was oblivious to everything but her panic. She observed but was uninfluenced by the relaxed and casual
activities
ofthe
other
passengers
and
crew.
When
the
plane landed, she recovered. Her request for treatment was prompted by her wish to take a trip to Europe, which would be possible only if she and her husband flew there and back. Her rating on the Hypnotic Induction Profile (15) was very high, indicating that she was
highly
responsive
to hypnosis.
She
to a modified and accelerated program tization ( 16), during which considerable marked suggestibility in hypnosis. 2.
Case
Mr.
persistent
pain
mained
unexplained
in a minor
B, an academician in the
rapidly
in his
mid-thirties,
had
left scapular region that refor almost 7 years after he was involved collision. Despite surgical intervention,
motor
neck
responded
of imaginal desensiuse was made of her
and
including spinal fusion, the symptoms continued unabated until about 18 months after his surgery. Six months later. a slap on the back by a colleague led immediately to a recurrence of the excruciating symptoms. Extensive studies revealed no organic pathology. and psychiatric consultation ensued. He was almost totally preoccupied with the pain in his shoulder great detail. claims
and He
upper arm and described it vividly and had been unable to work, and insurance
in
accumulated.
His rating on the Hypnotic Induction Profile (15) was extremely high. He was also able to respond to the idea that the hour hand on the clock face would disappear when he looked at it. He was immediately and remarkably capable of creating a numb and tingling feeling in the affected areas when this was suggested to him and rapidly learned to do so in self-hypnosis exercises. This brought his primary symptoms
under
control.
Case 3. Mr. C, a man in his mid-20s, sought hypnosis because of his fear of dentistry. This fear had so crippled him that he had avoided seeing a dentist for over 10 years apart from one occasion when an infected impacted wisdom tooth drove him to seek help. He was remarkably responsive to hypnosis and has a very high rating on the Hypnotic Induction Profile (15). On emerging from the experience of the induced trance, he volunteered the comment that it had felt not unlike what he remembered of his childhood experiences in the dentist’s chair. He referred to feelings of dissociation in parts of his body and to his total preoccupation with particular parts of his body: all other stimuli were completely excluded. He was also able to make rapid use of strong hypnotic suggestions that he would be totally in the dentist’s office and would experience only and numb sensations in his jaw.
relaxed tingling
ABSTRACTS
DISCUSSION
Case I. Ms. A, a woman in her mid-20s, complained of an overwhelming fear of flying. Her mother was extremely afraid of air travel, so Ms. A had never been allowed to fly. 666
Clearly, not
fully
the
psychopathology
explained
by
of these their
marked
individuals hypnotizability,
is
Am
J Psychiatry
135:6,
June
1978
and it is not my intent to account for their clinical histories in terms limited to their hypnotizability. Similarly, there is no intent here to describe a series of rapid therapeutic successes. My purpose is to draw attention to the possible relatedness of the marked hypnotizability and the nature of the clinical symptoms. There can be little doubt that the three people I have described have a well developed ability to alter perceptions when subjected to persuasive comments to do so in hypnosis. In that state, they are also able to fix their attention on the altered perception to the almost total exclusion ofall other sensory stimuli and are able to continue in that experience despite logical inconsistencies. It is difficult to ignore the strong likelihood that the mental mechanism underlying this ability is involved in the development and maintenance of their symptoms, which comprised essentially altered or distorted perceptions of bodily sensations or of the environment, a fixed preoccupation from time to time with those perceptions, and inability to register or disregard any contradicting logic. The strong impression that some clinical behavior correlates with marked hypnotizability was generally supported by my routine measurements of clinical problems broadly classifiable as hysterical in nature. These included cases of hysterical fugue, multiple personality, and phobic behavior. None of the patients scored in the low range of hypnotizability, and most scored high or very high. One ofthe groups, the phobic patients, was selected for closer study. This group was chosen primarily because the number of phobic patients is greater than that in the other categories. The hypnotizability of phobic patients applying for private treatment or for therapy in the Psychiatric Clinic of Beth Israel Hospital was systematically measumed and reported in a previously published study (17). Their scores were compared with the hypnotizability of an equal number of patients applying to the clinic for therapeutic hypnosis for help in quitting smoking (the control group). The mean score of the phobic patients was consistently higher than the controls’ Among the smokers, 30% were essentially nonresponsive, with scores of0-4 on the 12-point Stanford Hypnotic Susceptibility Scale (18) or its group modification, the Harvard Group Scale (19). There were no nonresponsive individuals in the group of 24 phobic patients. Furthermore, patients reporting more than one phobia had significantly higher mean scores than those reporting only a single phobia. These findings can be ofconsidemable diagnostic and therapeutic relevance. They suggest that we can predict hypnotizability to some extent from the clinical picture, which many workers in recent years have tended to doubt. It should be borne in mind that these findings and those of the many very reputable studies of undergraduate student populations are not necessarily contradictory. The populations under investigation are vastly different. The findings I have cited are based on patients who were sufficiently troubled by their symptoms to seek treatment. The laboratory .
FRED
H.
FRANKEL
studies that found no correlation between personality style and hypnotizability were carried out on apparently healthy groups of students. Although we might acknowledge that the mental mechanism in hypnosis and the mechanism involved in the manifestation of the symptoms briefly described in the three case vignettes are in all probability the same, the precise nature of that mechanism remains open to conjecture. It appears to be initiated in hypnosis by procedures of induction, and in the clinical context seems to be associated with the spontaneous onset of a trance or trance-like experience. We know that under stress, dissociation can occur as a mechanism of defense. It is suggested that under circumstances of intense fear, rage, or sadness, individuals predisposed to dissociate may do so and then experience the world and their bodies in a perceptually distorted manner. This distorted perception can be more frightening than the original distress against which it was intended to defend and could mark the onset ofa series of learned, repeated, or imagined happenings of a similar nature, each of which is associated with considerable anxiety (20). In 1907, Janet considered dissociation to be the mental mechanism underlying events in hypnosis (10), and in recent years, Hilgard (21), in his essay on neodissociation, has again drawn attention to the relevance of the concept of dissociation to account for the phenomena in hypnosis and the clinical symptoms described above. From the therapeutic standpoint, I would suggest that the patient’s marked trance capacity can be fashioned into a coping mechanism (22). By demonstrating to highly hypnotizable patients, in the reassuring envimonment of the therapist’s office, that they can, under hypnosis, alter their perceptions and either create or increase the discomfort of their symptoms, or relax and thereby alleviate them, the therapist provides an outstanding learning experience. He or she not only makes the fearsome experiences familiar and therefore less frightening but also demonstrates to the patient that the patient does, in fact, have control over the mechanism which creates the distortions in the first place. The careful integration of self-hypnosis into the strategy braces and reinforces patients’ conviction that they can exert effective control. The overall treatment plan is complex and does not aim at the removal of symptoms by direct suggestion. It recognizes the importance of motivation and secondary gain and depends for its efficacy on an adequate initial psychiatric evaluation.
Shaping
an
individual’s
trance
capacity
in-
to a coping mechanism can readily be made part of a psychodynamically sensitive treatment plan, but this can be accomplished only if the therapist is aware of the existence of marked hypnotizability and alert to the types of clinical behavior associated with it.
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