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American Journal of Clinical Hypnosis Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujhy20
Scales Measuring Hypnotic Responsivity: A Clinical Perspective Fred H. Frankel M.B.Ch.B., D.P.M.
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Psychiatric Service, Beth Israel Hospital Department of Psychiatry , Harvard Medical School , Boston, Massachusetts, USA Published online: 22 Sep 2011.
To cite this article: Fred H. Frankel M.B.Ch.B., D.P.M. (1978) Scales Measuring Hypnotic Responsivity: A Clinical Perspective, American Journal of Clinical Hypnosis, 21:2-3, 208-218, DOI: 10.1080/00029157.1978.10403972 To link to this article: http://dx.doi.org/10.1080/00029157.1978.10403972
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THEAMERICAN JOURNAL OF CLINICAL HYPNOSIS Volume 21, Number 2 & 3, October 1978 / January 1979 Printed in U . S . A .
Scales Measuring Hypnotic Responsivity : A Clinical Perspective FRED H. FRANKEL, M.B.Ch.B., D.P.M.
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Psychiatric Service, Beth Israel Hospital Department of Psychiutry, Harvard Medical School Boston, Massachusetts
Differences in the experiences of clinicians and laboratory investigators regarding the distribution of hypnotizability are addressed. The use of various rating scales in the clinical context is reviewed, and the importance of the scales in defining the difference, conceptually, between hypnosis and other procedures capable of achieving similar results is emphasized. The use of the scales in determining the treatment strategy is compared with the customary practice of the experienced clinician, and with the importance of the characteristics of the total clinical situation. An illustrative case report is included.
Standardized rating scales in the field of hypnosis have developed in the context of laboratory studies for almost half a century, but attention to the clinical relevance of such ratings has grown primarily during this past decade. The benefits to our general understanding of hypnosis directly attributable to the ratings have been immeasurable (Hilgard, 1965). This paper attempts to evaluate their role in the clinical setting. We recognize, largely as a result of the laboratory findings, that hypnosis is not a unitary phenomenon (Hilgard, 1965; Evans, 1968); furthermore, the ability to respond to a hypnotic induction procedure is not universally distributed and tends to be stable in any given subject (Morgan, Johnson and Hilgard, 1974; Diamond, 1974; Gur, 1974). While this has been suspected by some clinicans throughout the history of hypnosis, others among those engaged in its clinical use have paid little heed. On the other hand, important developments in the
methodology of the experimental laboratory have been based on the finding that different subjects can demonstrate impressive but different aptitudes in hypnosis, and also on comparing the behavior of very highly responsive subjects with that of subjects who are minimally so (Orne, 1972). Several other important findings, too numerous to list here, but also derivatives of the scales, have broadened our knowledge of the event of hypnosis. One such result is the recognition that no measurable physiological response has thus far been observed to be uniquely associated with the event of hypnosis (Sarbin and Slagle, 1972). In other words, alterations in blood pressure, heart rate and electroencephalographic tracings might occur after a hypnotic induction procedure whether the subject is highly hypnotizable or not. In fact, most procedures inducing a state of relaxation are capable of altering these physiological responses (Benson, Beary and Carol, 1974).
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By questioning highly responsive subjects about their experiences in hypnosis, we have come to appreciate that an essential element in hypnosis appears to be the subjective appreciation of an altered perception or altered state of awareness. We observe, too, that in some way, memory seems to be affected; either amnesia or hypermnesia can be achieved by hypnotic suggestion. Furthermore, illogic prevails over logic (Orne, 1959), and access to the psychosomatic interaction is increased. These items, as part of a working definition, articulate well with clinical experience and permit the development of concepts to account for behavior that might be closely intertwined with the event of hypnosis, but that is not essential to it. Until the advent of the standardized rating scales, clinical understanding of hypnosis grew out of the individual case history. Improvement in the symptoms following the administration of a hypnotic induction procedure was taken as evidence that hypnosis had occurred and had been used effectively. Therapeutic success following the application of an induction procedure was frequently the only criterion on which the presence of hypnosis was assessed. Clinicians were, and some still are challenged by the suggestion that they probably are not able to induce hypnosis in about 25-35% of their patients. Some claim that they rarely, if ever, fail to achieve some relief of pain or discomfort after an induction procedure. In the light of the data accumulated in the laboratory setting, and our working definition of hypnosis, we expect that at least a quarter of the patients who feel better after the hypnotic procedure do so for reasons other than the occurrence of hypnosis. Unless events in clinical hypnosis are different from those in experimental hypnosis, we must continue to expect that 25-35% of patients are not likely to be able to achieve altered perception to any apprec-
iable extent. They might be highly motivated to experience hypnosis; they might feel very comfortable and trusting in their relationship with the therapist undertalung the hypnosis with them, and the resulting relaxation and reassurance might help them to tolerate or reduce their experience of pain. The effective therapeutic factor in such instances, however, is not necessarily hypnosis. Viewed in this light, the clinical paradox disappears. Relaxation, reassurance and placebo are probably the important therapeutic agents. When the hypnotic induction procedure is unquestionably successful in achieving hypnosis, the trusting relationship between patient and therapist and the interest of the patient in achieving the altered perception suggested to him provide the milieu against which the altered perception occurs. This paraphrases Shor’s concept of the three dimensions of hypnosis (Shor, 1962). Distracted attention, relaxation and the effect of placebo are usually intricately woven into the therapeutic mechanism at work in hypnotic procedures. Those fortunate enough to be able, also, to alter perception, have the capacity to achieve even greater relief. That this is possible, was confirmed by an impressive laboratory study (McGlashan, Evans and Orne, 1969). A BRIEFOVERVIEW OF THE SCALES IN CLINICAL CONTEXT
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Since the time that the experimental psychologists turned their attention to the study of hypnosis in the laboratory half a century ago, the first rating procedure to appear with the clinical situation uppermost in mind was the Hypnotic Induction Profile (HIP) (Spiegel and Bridger, 1970). The original version and the scoring have been revised (Stern, Spiegel & Nee, 1979). Initially the scale was purported to measure hypnotic responsivity in order to plan treatment strategy. As we shall see below,
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great emphasis by Spiegel and his coworkers is now being placed on the predictive value of the profile regarding therapeutic success with hypnosis, and on the recognition of the likelihood of severe psychopathology in the patient. Despite the brevity and clinical convenience of the HIP, it has not bridged the gap between the relatively hard data provided by the laboratory scales and the anecdotal orientation of the clinicians. The novelty of the Eye-Roll and the restricted number of items by comparison with those used in the laboratory scales initially left several investigators in a state of disinterest. Many experienced clinicians, uninvolved in investigative studies, and having used hypnosis effectively in the clinical situation for years without standardized rating scales, remained unconvinced of the need for formal measurements, and though intrigued by the notion of the Eye-Roll remained unenthusiastic about using the HIP. The Stanford Hypnotic Susceptibility Scales (SHSS:A, B&C) (Weitzenhoffer and Hilgard, 1959, 1962), the Stanford Profile Scales of Hypnotic Susceptibility, Forms MI1 (SPS M I ) (Weitzenhoffer and Hilgard, 1963), the group modification of the SHSS:A, namely the Harvard Group Scale (HGS) (Shor and Orne, 1962) and the Barber Suggestibility Scale (BSS) (Barber and Glass, 1962) appear not to have been developed with the requirements of the clinical situation foremost in mind. They have been regarded as lengthy for clinical use, and possibly tiresome to patients. Nevertheless the SHSS:A and the HGS have been used with relative case in the clinical field to provide data that have been generally acceptable to both laboratory investigators and clinicians (Frankel and Orne, 1976; Frankel, Apfel-Savitz, Nemiah and Sifneos, 1977). Stanford HypThe notic Clinical Scale (SHCS) (Morgan and Hilgard, 1975) represents an attempt to in-
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corporate the most appropriate items in the SHSS:A&C, and to offer them in a manner that is convenient to the bedside and the clinic. Although comparatively brief, it tests most of the hypnotic skills likely to be required in a treatment procedure. The BSS grew out of the laboratory context, and because of its authoritative nature and an approach unfamiliar to clinical hypnosis was, to my knowledge, rarely applied to the clinical situation. The Creative Imagination Scale (CIS) (Wilson and Barber, 1978) is a very recent attempt to provide an instrument suitable for clinical work, which is nonetheless congruent with Barber's conceptual orientation (Barber, Spanos and Chaves, 1974). GENERAL AIMSOF MEASUREMENT As indicated above, the accentuated focus of attention specifically on clinical measurements is relatively recent. It seems appropriate at this point to examine the impetus behind this investigative thrust in the clinical field. One of the reasons must be the wealth of material that is available. Hypnosis sprang from the clinical situation, and clinical hypnosis contains many challenging aspects that cannot be found or wholly reproduced in the laboratory. As a fuller understanding of hypnosis demands further studies in the clinical area, the measurement of hypnotic responsivity in that context becomes necessary if meaningful communication is to take place. A second reason for ratings in the clinical field is the assertion that they will be of value in the planning of treatment procedures. Spiegel (Stern, Spiegel and Nee, 1979), as we will see below, suggests a third reason, namely the possible uncoverI My limited experience with the scales for children precludes my specific reference to them. As they are derived from adult scales considered i n this paper, what applies to the adult versions might apply to them.
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ing of the presence of severe psychopathology. Yet a fourth reason for the use of scales is proposed by Barber (Wilson and Barber, 1978). He suggests they can provide training and practice for clients in responding later to the same kind of suggestion during therapy. Before proceeding along these lines, let us briefly review the role of hypnosis on the clinical scene, and the possible mechanisms involved. The general therapeutic gains that are available through the use of the hypnotic induction procedure include: 1) general physical and mental relaxation with an accompanying sense of selfesteem and well-being; 2) relief of, or greater tolerance of discomfort or pain as a result of distracted attention, relaxation, or altered perception; 3) the resolution of conflicts as a result of the recall of relevant memories, and the use of imaginative fantasies or amnesia in the futherance of psychotherapy; 4) the control of habits; 5 ) improvements in pathophysiology; and 6) the acquaintanceship and familiarization with dissociative processes and events that lead to a sense of mastery over previously fearsome situations. The mechanisms on which these therapeutic achievements are generally based include: 1) a trusting relationship; 2) motivation; 3) physical and mental relaxation; 4) the distraction of attention; 5 ) the establishment of the trust, conviction and optimistic anticipation included in the placebo response; 6) heightened suggestibility; 7) the lessening of resistance and defense mechanisms; 8) the enhancement of imagination; 9) the encouragement of memories or amnesia;
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10) the apparently increased access to the psychosomatic interaction; and 11) altered perception and the dissociative process. A cursory examination of the mechanisms readily reveals that the majority, although often associated with hypnosis, are not essential to it, and can occur independently of a hypnotic induction procedure. Only the altered perception associated with the dissociative process, the involvement of memory and perhaps some aspects of the psychosomatic interaction are currently conceptualized as essentially hypnotic. Measurements in the clinical field, to be helpful, must aid us in differentiating between the essentially hypnotic experience, and that which can develop in a trusting relationship with a therapist whose manner and utterances help to achieve relief in the absence of hypnosis. Futhermore, by knowing more about the hypnotic responsivity of an individual patient, we will not only understand his behavior following a hypnotic induction procedure, we might also be assisted in planning the strategy of his therapy. We might learn when to depend on evoking an altered perception or distant memory, and when to rely solely on the relaxation, sense of well-being and possibly increased selfconfidence that can result from an induction procedure. If we cannot accumulate evidence in the clinical field that we are indeed dealing with an event not too dissimilar from that which has been studied in the laboratory and conceptualized essentially as a dissociative process characterized by altered perception and a shift in access to memory, then we will have to concede that the hypnotic induction procedure leads to a universal response, obtainable in all patients, and undifferentiated from an admixture of transference phenomena, relaxation, suggestibility and placebo. Hypnosis would then be indistinguishable from other
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therapeutic and relaxing procedures. For this reason, primarily, measurements in the clinical arena are essential. We do not yet know, however, whether a standardized rating is necessarily the best guide to the formulation of treatment strategy. Statistical reliability and validity notwithstanding, many clinicians will be loath to abandon all attempts at achieving, for example, an altered perception or memory recall in the course of treatment purely on the strength of a poor response to a three minute item in the process of a formal rating scale. Skillful clinicians sensitive to the need to protect the illusion in hypnosis, have for years mapped out their strategy as they proceed, careful not to present demands or suggestions that are beyond the capacity of the patient. They avoid creating a sense of failure by couching their suggestions in permissive terms such as, “you will probably feel” or “you might experience,” or “I do not know exactly when or how, but you will begin to notice. . . . They then wait for signals, verbal or otherwise, that some change is taking place, or they specifically request the patients to communicate whether or not they are experiencing the suggested event, and in what way. We might question whether the verisimilitude of the situation in a standardized rating scale is as reliable or as valid an indicator as the clinical experience itself. By encouraging the patient, after an induction procedure, to try to recall events from a meaningful period in his past as vividly as he can, and to report on how real the situation appeared to be, the therapist is likely to know more about his ability to accomplish that task than by asking him to regress to an unrelated and emotionally neutral event as part of a standardized rating. However, approaches are not necessarily mutually exclusive, and can both contribute to the treatment plan. It is also worthwhile noting that there are as yet few data to convince us that the suc,7
cess of age-regression in the clinical context is necessarily related to or dependent on high hypnotic responsivity. We do not yet know how much in clinical ageregression is achieved by the lowered resistance or weakened defense mechanisms in patients who are trusting and relaxed after the induction procedure, and how much is directly attributable to the increased access to memory assumed to be associated with the event of hypnosis. Furthermore, the feasibility of trying to administer rating scales to all patients must be considered. The demands of the clinical situation, as demonstrated below, will often preclude that from taking place.
PRACTICAL CONSEQUENCES OF MEASUREMENT From a practical clinical standpoint it is useful to bear in mind that even when the patient lacks hypnotic ability, the induction procedure is not necessarily abandoned. The more precise aspects of the suggestions relating to altered perception will be dropped, but the reassuring, relaxing and encouraging comments are still most appropriate, and the hypnotic mode offers as good a vehicle as any other treatment method for achieving a state of tranquility, or improved self-esteem. The goad to measuring responsivity and accumulating information is wielded by the urge to understand what is taking place, not to ring the death knell of hypnotic procedures. The analogy that comes to mind is a concept that has been useful for psychiatry and clinical psychology trainees engaged in providing supportive psychotherapy to patients. Insight into the psychodynamics of a situation is essential if the therapist is to know what he is doing, but this understanding does not necessarily have to be shared with the patient. Insight-oriented therapy has as one of its major goals the development of understanding and insight in the
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patient. Supportive psychotherapy requires that the therapist use the insights in the interests of his patient, but he should know that very little but harm might come if he, the therapist, feels forced to share immediately with his patient the fact, for example, that he considers him characterologically manipulative or excessively dependent. Nonetheless, the treatment plan must take these factors into account. Similarly, patients are not necessarily informed that they are poor hypnotic subjects. The treatment strategy applied, however, must subtly take that into account. The caveat implied in all of the above springs from the need to bear in mind that with suitable measurements we aim to harness clinical hypnosis, not to hamstring it. THERATING SCALES In focusing on the scales developed primarily for clinical use, our immediate problems spring from the limited experience with the SHCS and the CIS, and from the unexplained paradox in the measurements of the HIP and the widely used SHSS:A,B&C. The dependability of the SHSS:A,B&C, and the HGS have been reaffirmed by time and the experience of many investigators. They are lengthy and possibly tiresome for some patients; they use the sleep metaphor extensively in the induction procedure although this is now not a popular approach, and they emphasize the scientific not the therapeutic purpose of the testing situation. Their use, however, has led to an impressive body of information about hypnosis. We cannot yet fully evaluate the advantages of the clinical scales. The SHCS and the CIS are both administered in the clinical situation with relative ease, they are considerably briefer than the laboratory scales, and they include both motor and cognitive items. We await with interest reports of their widespread application in a clinical
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context. (Because of the different nature of the HIP, it will be considered separately, below. ) Theoretically, we must raise the question of whether or not brief induction procedures allow sufficient time for some patients to be able to achieve their optimal capacity. We must also ask to what extent the composition of the new clinical scales improves adaptability to the clinical situation. To what extent do their findings facilitate treatment strategy more than the findings on the SHSS: A&B and the HGS? In addition, we know from the laboratory use of scales that a single assessment o f , hypnotic responsivity is often an inadequate reflection of a subject’s capacity. This knowledge should guard against our overinterpreting any of the facts that emerge from a single test situation. FOR T H E SUGGESTED GUIDELINES CLINICAL USE OF SCALES
In the absence of firm data at this time, I can but offer this summary of my personal views on the use of the scales in the clinical context: 1) The scales provide a means for bridging the gap between knowledge accumulated in the experimental laboratory and the study of clinical events; 2) They should be applied diligently whenever possible, to aid in the understanding of the clinical effects of the hypnotic induction procedure, thereby helping to elucidate the event of hypnosis; 3) Clinical reports, studies, and investigations prepared for publication should include a rating on an acceptable standardized rating scale. Although we cannot always be sure of the clinical occurrence of hypnosis, the likelihood of its happening is strengthened by a high score and diminished by a low one; 4) The scales can provide clues to the patient’s specific hypnotic skills, and in this
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way can contribute to the formulation of individual treatment plans. Rather than using any formal scales, some clinicians prefer to depend on a flexible clinical interaction, and on monitoring the responses of their patients to but one or two pertinent items of a motor or cognitive kind, when determining treatment strategy. Those who incline toward the use of the scales as an aid in the treatment strategy should be encouraged to use them widely, and to study their effectiveness in predicting clinical hypnotic performance and outcome; 5 ) Data might accumulate which will affirm the suitability and efficacy of a scale already currently available. O n the other hand, the scale ideally suited to the clinical situation might yet evolve as a compromise among those already in existence; 6) It is noteworthy that, in general, the decision to add hypnosis to a treatment plan is dependent mainly on the nature of the problem and the whole clinical situation, not on whether or not the patient is hypnotizable. The particular capacity possessed by the patient merely helps to determine how the procedure is used.
Spiegel and Nee (1979) further information is needed. However, it is clear at this time that more work should be done on the ER, the clinical relevance of which, it seems, cannot be dismissed. Those authors cauat this time that more work should be done on the ER which, it seems, will not yet go away nor be dismissed. Those authors caution us that the inferences regarding therapeutic outcome and the presence or absence of severe psychopathology are valid in a probabilistic sense for groups but not for individuals; and that any one individual’s profile pattern, for instance, does not indicate the presence of severe psychopathology. They underscore what is a generally accepted finding, namely, that psychometric tests do not preempt clinical judgment. However, the rating scales should be nurtured and helped to develop in the clinical context. Ultimately and ideally, we might hope for the agreement of clinicians generally on the wide and repeated use of one, or preferably two scales, the second for affirmation of the findings; as the reports accumulate and contribute to the data, we will be led to a greater appreciation of the clinical events.
THEHIP
ILLUSTRATIVECASEHISTORY Because the HIP constitutes an obvious departure from the accepted paradigm and The following case history captures, I beapproaches the problem from a different lieve, the essence of my comments relating standpoint, it presents a special challenge. to the role of the rating scales in the clinical The Eye-Roll (ER), the most controver- use of hypnosis: Hypnosis was requested for a twentysial aspect of the HIP, appears to have predictive value when it is positive and when it two-year old unmarried man on the surgical is compared with the success or otherwise service who had been bothered by continuof elements in the induction score IND. ous hiccoughs for eight days. They had Consistently positive scores on all predict a begun shortly after a cholecystectomy, and good therapeutic outcome with hypnosis. apart from subsiding during sleep, had conPoor scores on the IND in the presence of a tinued uninterruptedly since their onset. positive ER suggest severe psychopath- The patient felt exhausted. The clinical encounter was complicated ology. In any discussion of the therapeutic out- by the ceaseless and obstructive heaving of come of the patients reported by Stern, his abdomen as he lay almost flat on his
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back, and the fact that he had become partially deaf as a result of an antibiotic that had been prescribed in the past. His left arm was connected to a continuous intravenous drip. His unfortunate history revealed that he had been healthy until the age of seventeen when an infection of his kidneys suddenly made its appearance, leading to surgical removal and a kidney transplant. A few months prior to our meeting he had been admitted to hospital with pneumonia attributed to the necessary use of immunosuppressive drugs. As the pneumonia improved, cholecystitis supervened; this led to a cholecystectomy followed two days later by the complication of a faulty drainage tube. Within hours after this had been adequately attended to i n the operatingroom, the hiccoughs commenced. That was eight days before our first meeting. Despite his hearing loss, and the disruptive nature of the hiccoughs, every effort was made by me to establish some relationship with him by discussing his complaint, his medical problems, and his past history. He was the only child of a working-class family, involved since his first illness at seventeen in an undemanding supervisor’s job. In answer to direct questioning he talked of his enjoyment, when well enough, of hiking on mountain trails. When given an opportunity to discuss his concern and anxiety about the gall-bladder disease that appeared for the first time while he was recovering in t h e hospital from t h e pneumonia, he went to some length to explain that he had become used to disappointments in recent years, and that he was more enthusiastic about having the surgery than his physicians had been because he was keen to have the problem behind him. He denied any sense of anxiety or concern. He had never been exposed to hypnosis, but was hopeful that i t would help end his hiccoughs. Because of his hearing difficulty, the induction procedure had to be
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delivered fortissimo. He was encouraged to relax by closing his eyes and thinking about being on a mountain top surveying the surrounding valleys and hills. He was then asked to allow his right arm to relax completely and to float into an upright position. He was then encouraged to permit it to float over to the upper part of his abdomen and rest there; the relaxed feeling would then spread to the abdominal musculature. He was told this would relax the muscles so that the hiccoughs would become gentler and less frequent. He was encouraged to continue to imagine himself in the mountain setting. About twenty minutes after the commencement of the induction procedure the hiccoughs gradually decreased in intensity and frequency. He was instructed i n how to induce hypnosis on his own, and advised to practice the procedure after waking, as often as he wished. He was told that when he opened his eyes and wakened from the hypnosis he would continue to be relaxed and comfortable, that he would have a feeling of well-being, and that the condition of the hiccoughs would continue to improve. After a period of about forty-five minutes from the commencement of the induction he was asked to waken and as he did so the hiccoughs ceased. On my return visit about four hours later, he was found lying with his eyes closed, his hand resting on his upper abdomen, and with no evidence of the hiccoughs. In answer to questions he recounted that he had been symptom-free for almost an hour after the first session, and that the self-induced exercises had then been difficult to accomplish because of constant but necessary nursing interruptions. He had finally succeeded, however, about half an hour prior to my return visit. He rapidly agreed to the idea of another induction procedure to reinforce his own abilities, and chose to remain in that completely relaxed and hiccoughfree state at the end of that procedure, pre-
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pared to lie with his eyes closed and his hand on his abdomen, totally relaxed, until the time of his evening meal. Next day, when visited, he was walking about the ward, cheerful and bright, having rid himself of both his symptom and the intravenous apparatus. He was extremely grateful, and very surprised at the ease with which he had been able to respond. He left the hospital the following day.
Comments: The patient’s hypnotizability was not measured at any point, and in discussing the event he referred only to the remarkably relaxed feeling he had experienced. A review of the event does not clarify what the active therapeutic principle had been. The whole procedure had been carried out in a very solicitous setting. My hand had often rested gently on his forearm during our initial discussion, and my manner and comments were purposefully reassuring. He had been reminded during the historytaking that most patients would have been deeply disappointed had they been exposed to the repeated major illnesses that he had had to endure. He had indicated that he had not discussed his concerns with any of his physicians, and prior to the request for hypnosis, had not been interviewed by a psychiatrist. Given the strenuous nature of engaging in conversation with him because of his deafness, it was entirely plausible that at no time prior to our interview had his feelings about his illness been adequately explored by a professional person trained to do so. It is pertinent that we ask what the role of hypnosis in this case was. Would a psychiatric interview repeated once or twice, with no hypnosis but including an understanding of his concern about his health have been sufficient to alleviate the symptoms? How therapeutic would a state of induced relaxation on its own have been? How satisfying were we able to do a neat
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controlled study - to find other similar cases, and treat them in random fashion with either psychiatric interviews, relaxation exercises, or hypnotic induction procedures. Although all the additional variables make such a study well nigh impossible, the challenge to the clinician persists. To assume simply that the recovery in this case was due to hypnosisprr se is to deny the complexity of the question. We need to know whether the active therapeutic principle here was (1) the trust and warm feeling that arose in the positive transference toward someone who took the time to sit down and discuss the awesomeness of his clinical history sympathetically; (2) the state of relaxation encouraged by using relaxing images and gentle phrasing; (3) the distraction of his attention; (4)the placebo effect created by his faith i n the procedure and his expectation that it would work; ( 5 ) some special quality of the hypnotic experience itself; or (6) a combination of these forces. Even though I prefer to believe that he did experience hypnosis because of the way he behaved, I would be able to support that position in only two ways. Learning from him, after questioning, that his imagined experience on the mountaintop was vivid and realistic and that he could smell the mountain air and feel the cool wind on his cheeks, I would be in a strong position to assume that he had experienced hypnosis. I f , i n addition, he scored well on a standardized rating scale, I would be in a position to compare this man’s experiences with those of others who had similar, greater or less hypnotic ability. Clearly this clinical situation did not permit the use of a rating scale prior to the application of the therapy, and the opportunity to question or test him subsequently was not readily available. Such steps are essential if a case report is to be used to demonstrate the benefit of hypnosis as opposed to other therapeutic procedures, and
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if we are to increase our understanding of what we do.
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MORGAN, A. H., JOHNSON, D. L . , & HILGARD, E. R. The stability of hypnotic susceptibility: A longitudinal study. Interntrtional Journal of Clinical and Experimental Hypnosis, 1974,22, 249257. Department of Psychiatry ORNE,M. T. The nature of hypnosis: Artifact and Beth Israel Hospital essence. Joiirnal of Abnormal und Social Psychol330 Brookline Avenue ogy, 1959,58, 277-299. Boston, Mass. 02215 O R N E M. , T. On the simulating subject as a quasicontrol group in hypnosis research: What, why and how. In E. Fromm & R. E. Shor (Eds.)Hjpnosis: Research developments arid perspectives. REFERENCES Chicago: Aldine Atherton, 1972. R . W. Hypnosis and BARBER, T. X . , & GLASS,L. B. Significant factors in SARBIN, T. R., & SLAGLE, psychophysiological outcomes. In E. Fromm & R. hypnotic behavior. Joiirnal of Abnormal Social. E. Shor (Eds.) Hypnosis: Research developments Psychology, 1962,64, 222-228. arid perspectives. Chicago: Aldine Atherton, BARBER, T. X . , SPANOS, N. P., & CHAVES, J. F. 1972. H y p n 0 /is i n : I m ti g i n ti ti on , an cl h rr man p o ten titrlities. New York: Pergamon Press, Inc., 1974. SHOR,R. E. Three dimensions of hypnotic depth. International Joi4rnal of Clinical and E.wperimenta1 BENSON, H., BEARY,J. F., & CAROL,M. P. The Hypnosis, 1962, 10, 23-38. relaxation response. Psychiatry, 1974,37, 37-46. DIAMOND, M. J. Modification of hypnotizability: A SHOR,R . E . , & ORNE,E M I L YC. The Harvard Group scale of hypnotic susceptibility. Form A . review. Psychological Bulletin, 1974, 81, 18& Palo Alto, California: Consulting Psychologists 198. Press, 1962. EVANS, F. J . Recent trends in experimental hypnosis. SPIEGEL, H. & BRIDGER, A. A. Manual for hypnotic Behavioral Science, 1 968, 13, 477-487, induction profile: Eye-roll levitation method. R., NEMIAH, J. C., F R A N K EF. L ,H., APFEL-SAVITZ, New York: Basic Books, 1970. & SIFNEOS, I ) . E. The relationship between hypnotizability and alexithymia. Psychotherapy and STERN,D. B., SPIEGEL, H., & NEE, J. C. M. The Hypnotic Induction Profile: Normative observaPsychosomatics, 1977, 28, 172-178. tions, reliability and validity. American Journal of F R A N K E LF,. H . , & ORNE,M. T. Hypnotizability Cliriic~cilHypnosis (this issue), and phobic behavior. Archives (if General Psychiatry, 1976,33, 12591261. WEITZENHOFFER, A. M., & HILGARD, E. R. StanG U R , R. C. An attention-controlled operant proceford Hypnotic Susceptibility Sccile, Forms A and dure for enhancing hypnotic susceptibility. JorrrB . Palo Alto, California: Consulting Psychologists nal of Abnormal Psychology, 1974,83, 64&650. Press, 1959. HILGARD, E. R . Hypnotic sirsceptibility. New York: WEITZENHOFFER, A . M., & HILGARD, E. R. StanHarcourt, Brace and World, Inc., 1965. ford Hypnotic Susceptibility Scale, Form C . Palo HILGARD, E. R. The Stanford Hypnotic SusceptibilAlto, California: Consulting Psychologists Press, ity Scales as related to other measures of hypnotic 1962. responsiveness. American Journal of Clinical WEITZENHOFFER, A. M., & HILGARD, E. R. StanHypnosis, this issue. ford Profile Scules of Hypnotic Susceptibility, MCGLASHAN, T. H . , EVANS, F. J . , & ORNE,M. T. Forms I and 11. Palo Alto, California: Consulting The nature of hypnotic analgesia and placebo rePsychologists Press, 1963. sponse to experimental pain. Psj~cho,somatic Medicine, 1969,31, 227-246. S . C., & BARBER, T. X . The Creative ImWILSON, MORGAN, A. H. & HILGARD, J. R. The Stanford agination Scale as a measure of hypnotic responHypnotic Clinical Scale. Appendix in Hilgard, E. siveness: applications to experimental and clinical R. & Hilgard, J. R. Hypnosis in the relief of pain. hypnosis. The Artrericati Journal of Clinical HypLos Altos, Calif.: William Kaufrnan, Inc., 1975. nosis, 1978,20, 235-249.
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FRED H. FRANKEL. M.B .Ch .B .. D.P.M Fred H. Frankel is an Associate Professor of Psychiatry at Harvard Medical School, Boston, and is Head of the Adult Psychiatry Unit at the Beth Israel Hospital where he also directs the Clinic for Therapeutic Hypnosis. He received his training at the Witwatersrand Medical School, Johannesburg, South Africa, and at the Massachusetts General Hospital. He has been interested in relating the findings of laboratory studies in hypnosis to the clinical situation, in clarifying the concepts in clinical hypnosis, and in relating specific types of clinical behavior to high hypnotic responsivity. He is the author of Hypnosis: Trunce c i s o Coping Mechunism, and acts as the Medical Editor of the Internntional Journal of Clinical cintl E.rperimentcil H~pnosis.
American Journal of Clinical Hypnosis Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujhy20
Scales Measuring Hypnotic Responsivity: A Clinical Perspective Fred H. Frankel M.B.Ch.B., D.P.M.
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Psychiatric Service, Beth Israel Hospital Department of Psychiatry , Harvard Medical School , Boston, Massachusetts, USA Published online: 22 Sep 2011.
To cite this article: Fred H. Frankel M.B.Ch.B., D.P.M. (1978) Scales Measuring Hypnotic Responsivity: A Clinical Perspective, American Journal of Clinical Hypnosis, 21:2-3, 208-218, DOI: 10.1080/00029157.1978.10403972 To link to this article: http://dx.doi.org/10.1080/00029157.1978.10403972
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THEAMERICAN JOURNAL OF CLINICAL HYPNOSIS Volume 21, Number 2 & 3, October 1978 / January 1979 Printed in U . S . A .
Scales Measuring Hypnotic Responsivity : A Clinical Perspective FRED H. FRANKEL, M.B.Ch.B., D.P.M.
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Psychiatric Service, Beth Israel Hospital Department of Psychiutry, Harvard Medical School Boston, Massachusetts
Differences in the experiences of clinicians and laboratory investigators regarding the distribution of hypnotizability are addressed. The use of various rating scales in the clinical context is reviewed, and the importance of the scales in defining the difference, conceptually, between hypnosis and other procedures capable of achieving similar results is emphasized. The use of the scales in determining the treatment strategy is compared with the customary practice of the experienced clinician, and with the importance of the characteristics of the total clinical situation. An illustrative case report is included.
Standardized rating scales in the field of hypnosis have developed in the context of laboratory studies for almost half a century, but attention to the clinical relevance of such ratings has grown primarily during this past decade. The benefits to our general understanding of hypnosis directly attributable to the ratings have been immeasurable (Hilgard, 1965). This paper attempts to evaluate their role in the clinical setting. We recognize, largely as a result of the laboratory findings, that hypnosis is not a unitary phenomenon (Hilgard, 1965; Evans, 1968); furthermore, the ability to respond to a hypnotic induction procedure is not universally distributed and tends to be stable in any given subject (Morgan, Johnson and Hilgard, 1974; Diamond, 1974; Gur, 1974). While this has been suspected by some clinicans throughout the history of hypnosis, others among those engaged in its clinical use have paid little heed. On the other hand, important developments in the
methodology of the experimental laboratory have been based on the finding that different subjects can demonstrate impressive but different aptitudes in hypnosis, and also on comparing the behavior of very highly responsive subjects with that of subjects who are minimally so (Orne, 1972). Several other important findings, too numerous to list here, but also derivatives of the scales, have broadened our knowledge of the event of hypnosis. One such result is the recognition that no measurable physiological response has thus far been observed to be uniquely associated with the event of hypnosis (Sarbin and Slagle, 1972). In other words, alterations in blood pressure, heart rate and electroencephalographic tracings might occur after a hypnotic induction procedure whether the subject is highly hypnotizable or not. In fact, most procedures inducing a state of relaxation are capable of altering these physiological responses (Benson, Beary and Carol, 1974).
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By questioning highly responsive subjects about their experiences in hypnosis, we have come to appreciate that an essential element in hypnosis appears to be the subjective appreciation of an altered perception or altered state of awareness. We observe, too, that in some way, memory seems to be affected; either amnesia or hypermnesia can be achieved by hypnotic suggestion. Furthermore, illogic prevails over logic (Orne, 1959), and access to the psychosomatic interaction is increased. These items, as part of a working definition, articulate well with clinical experience and permit the development of concepts to account for behavior that might be closely intertwined with the event of hypnosis, but that is not essential to it. Until the advent of the standardized rating scales, clinical understanding of hypnosis grew out of the individual case history. Improvement in the symptoms following the administration of a hypnotic induction procedure was taken as evidence that hypnosis had occurred and had been used effectively. Therapeutic success following the application of an induction procedure was frequently the only criterion on which the presence of hypnosis was assessed. Clinicians were, and some still are challenged by the suggestion that they probably are not able to induce hypnosis in about 25-35% of their patients. Some claim that they rarely, if ever, fail to achieve some relief of pain or discomfort after an induction procedure. In the light of the data accumulated in the laboratory setting, and our working definition of hypnosis, we expect that at least a quarter of the patients who feel better after the hypnotic procedure do so for reasons other than the occurrence of hypnosis. Unless events in clinical hypnosis are different from those in experimental hypnosis, we must continue to expect that 25-35% of patients are not likely to be able to achieve altered perception to any apprec-
iable extent. They might be highly motivated to experience hypnosis; they might feel very comfortable and trusting in their relationship with the therapist undertalung the hypnosis with them, and the resulting relaxation and reassurance might help them to tolerate or reduce their experience of pain. The effective therapeutic factor in such instances, however, is not necessarily hypnosis. Viewed in this light, the clinical paradox disappears. Relaxation, reassurance and placebo are probably the important therapeutic agents. When the hypnotic induction procedure is unquestionably successful in achieving hypnosis, the trusting relationship between patient and therapist and the interest of the patient in achieving the altered perception suggested to him provide the milieu against which the altered perception occurs. This paraphrases Shor’s concept of the three dimensions of hypnosis (Shor, 1962). Distracted attention, relaxation and the effect of placebo are usually intricately woven into the therapeutic mechanism at work in hypnotic procedures. Those fortunate enough to be able, also, to alter perception, have the capacity to achieve even greater relief. That this is possible, was confirmed by an impressive laboratory study (McGlashan, Evans and Orne, 1969). A BRIEFOVERVIEW OF THE SCALES IN CLINICAL CONTEXT
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Since the time that the experimental psychologists turned their attention to the study of hypnosis in the laboratory half a century ago, the first rating procedure to appear with the clinical situation uppermost in mind was the Hypnotic Induction Profile (HIP) (Spiegel and Bridger, 1970). The original version and the scoring have been revised (Stern, Spiegel & Nee, 1979). Initially the scale was purported to measure hypnotic responsivity in order to plan treatment strategy. As we shall see below,
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great emphasis by Spiegel and his coworkers is now being placed on the predictive value of the profile regarding therapeutic success with hypnosis, and on the recognition of the likelihood of severe psychopathology in the patient. Despite the brevity and clinical convenience of the HIP, it has not bridged the gap between the relatively hard data provided by the laboratory scales and the anecdotal orientation of the clinicians. The novelty of the Eye-Roll and the restricted number of items by comparison with those used in the laboratory scales initially left several investigators in a state of disinterest. Many experienced clinicians, uninvolved in investigative studies, and having used hypnosis effectively in the clinical situation for years without standardized rating scales, remained unconvinced of the need for formal measurements, and though intrigued by the notion of the Eye-Roll remained unenthusiastic about using the HIP. The Stanford Hypnotic Susceptibility Scales (SHSS:A, B&C) (Weitzenhoffer and Hilgard, 1959, 1962), the Stanford Profile Scales of Hypnotic Susceptibility, Forms MI1 (SPS M I ) (Weitzenhoffer and Hilgard, 1963), the group modification of the SHSS:A, namely the Harvard Group Scale (HGS) (Shor and Orne, 1962) and the Barber Suggestibility Scale (BSS) (Barber and Glass, 1962) appear not to have been developed with the requirements of the clinical situation foremost in mind. They have been regarded as lengthy for clinical use, and possibly tiresome to patients. Nevertheless the SHSS:A and the HGS have been used with relative case in the clinical field to provide data that have been generally acceptable to both laboratory investigators and clinicians (Frankel and Orne, 1976; Frankel, Apfel-Savitz, Nemiah and Sifneos, 1977). Stanford HypThe notic Clinical Scale (SHCS) (Morgan and Hilgard, 1975) represents an attempt to in-
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corporate the most appropriate items in the SHSS:A&C, and to offer them in a manner that is convenient to the bedside and the clinic. Although comparatively brief, it tests most of the hypnotic skills likely to be required in a treatment procedure. The BSS grew out of the laboratory context, and because of its authoritative nature and an approach unfamiliar to clinical hypnosis was, to my knowledge, rarely applied to the clinical situation. The Creative Imagination Scale (CIS) (Wilson and Barber, 1978) is a very recent attempt to provide an instrument suitable for clinical work, which is nonetheless congruent with Barber's conceptual orientation (Barber, Spanos and Chaves, 1974). GENERAL AIMSOF MEASUREMENT As indicated above, the accentuated focus of attention specifically on clinical measurements is relatively recent. It seems appropriate at this point to examine the impetus behind this investigative thrust in the clinical field. One of the reasons must be the wealth of material that is available. Hypnosis sprang from the clinical situation, and clinical hypnosis contains many challenging aspects that cannot be found or wholly reproduced in the laboratory. As a fuller understanding of hypnosis demands further studies in the clinical area, the measurement of hypnotic responsivity in that context becomes necessary if meaningful communication is to take place. A second reason for ratings in the clinical field is the assertion that they will be of value in the planning of treatment procedures. Spiegel (Stern, Spiegel and Nee, 1979), as we will see below, suggests a third reason, namely the possible uncoverI My limited experience with the scales for children precludes my specific reference to them. As they are derived from adult scales considered i n this paper, what applies to the adult versions might apply to them.
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ing of the presence of severe psychopathology. Yet a fourth reason for the use of scales is proposed by Barber (Wilson and Barber, 1978). He suggests they can provide training and practice for clients in responding later to the same kind of suggestion during therapy. Before proceeding along these lines, let us briefly review the role of hypnosis on the clinical scene, and the possible mechanisms involved. The general therapeutic gains that are available through the use of the hypnotic induction procedure include: 1) general physical and mental relaxation with an accompanying sense of selfesteem and well-being; 2) relief of, or greater tolerance of discomfort or pain as a result of distracted attention, relaxation, or altered perception; 3) the resolution of conflicts as a result of the recall of relevant memories, and the use of imaginative fantasies or amnesia in the futherance of psychotherapy; 4) the control of habits; 5 ) improvements in pathophysiology; and 6) the acquaintanceship and familiarization with dissociative processes and events that lead to a sense of mastery over previously fearsome situations. The mechanisms on which these therapeutic achievements are generally based include: 1) a trusting relationship; 2) motivation; 3) physical and mental relaxation; 4) the distraction of attention; 5 ) the establishment of the trust, conviction and optimistic anticipation included in the placebo response; 6) heightened suggestibility; 7) the lessening of resistance and defense mechanisms; 8) the enhancement of imagination; 9) the encouragement of memories or amnesia;
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10) the apparently increased access to the psychosomatic interaction; and 11) altered perception and the dissociative process. A cursory examination of the mechanisms readily reveals that the majority, although often associated with hypnosis, are not essential to it, and can occur independently of a hypnotic induction procedure. Only the altered perception associated with the dissociative process, the involvement of memory and perhaps some aspects of the psychosomatic interaction are currently conceptualized as essentially hypnotic. Measurements in the clinical field, to be helpful, must aid us in differentiating between the essentially hypnotic experience, and that which can develop in a trusting relationship with a therapist whose manner and utterances help to achieve relief in the absence of hypnosis. Futhermore, by knowing more about the hypnotic responsivity of an individual patient, we will not only understand his behavior following a hypnotic induction procedure, we might also be assisted in planning the strategy of his therapy. We might learn when to depend on evoking an altered perception or distant memory, and when to rely solely on the relaxation, sense of well-being and possibly increased selfconfidence that can result from an induction procedure. If we cannot accumulate evidence in the clinical field that we are indeed dealing with an event not too dissimilar from that which has been studied in the laboratory and conceptualized essentially as a dissociative process characterized by altered perception and a shift in access to memory, then we will have to concede that the hypnotic induction procedure leads to a universal response, obtainable in all patients, and undifferentiated from an admixture of transference phenomena, relaxation, suggestibility and placebo. Hypnosis would then be indistinguishable from other
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therapeutic and relaxing procedures. For this reason, primarily, measurements in the clinical arena are essential. We do not yet know, however, whether a standardized rating is necessarily the best guide to the formulation of treatment strategy. Statistical reliability and validity notwithstanding, many clinicians will be loath to abandon all attempts at achieving, for example, an altered perception or memory recall in the course of treatment purely on the strength of a poor response to a three minute item in the process of a formal rating scale. Skillful clinicians sensitive to the need to protect the illusion in hypnosis, have for years mapped out their strategy as they proceed, careful not to present demands or suggestions that are beyond the capacity of the patient. They avoid creating a sense of failure by couching their suggestions in permissive terms such as, “you will probably feel” or “you might experience,” or “I do not know exactly when or how, but you will begin to notice. . . . They then wait for signals, verbal or otherwise, that some change is taking place, or they specifically request the patients to communicate whether or not they are experiencing the suggested event, and in what way. We might question whether the verisimilitude of the situation in a standardized rating scale is as reliable or as valid an indicator as the clinical experience itself. By encouraging the patient, after an induction procedure, to try to recall events from a meaningful period in his past as vividly as he can, and to report on how real the situation appeared to be, the therapist is likely to know more about his ability to accomplish that task than by asking him to regress to an unrelated and emotionally neutral event as part of a standardized rating. However, approaches are not necessarily mutually exclusive, and can both contribute to the treatment plan. It is also worthwhile noting that there are as yet few data to convince us that the suc,7
cess of age-regression in the clinical context is necessarily related to or dependent on high hypnotic responsivity. We do not yet know how much in clinical ageregression is achieved by the lowered resistance or weakened defense mechanisms in patients who are trusting and relaxed after the induction procedure, and how much is directly attributable to the increased access to memory assumed to be associated with the event of hypnosis. Furthermore, the feasibility of trying to administer rating scales to all patients must be considered. The demands of the clinical situation, as demonstrated below, will often preclude that from taking place.
PRACTICAL CONSEQUENCES OF MEASUREMENT From a practical clinical standpoint it is useful to bear in mind that even when the patient lacks hypnotic ability, the induction procedure is not necessarily abandoned. The more precise aspects of the suggestions relating to altered perception will be dropped, but the reassuring, relaxing and encouraging comments are still most appropriate, and the hypnotic mode offers as good a vehicle as any other treatment method for achieving a state of tranquility, or improved self-esteem. The goad to measuring responsivity and accumulating information is wielded by the urge to understand what is taking place, not to ring the death knell of hypnotic procedures. The analogy that comes to mind is a concept that has been useful for psychiatry and clinical psychology trainees engaged in providing supportive psychotherapy to patients. Insight into the psychodynamics of a situation is essential if the therapist is to know what he is doing, but this understanding does not necessarily have to be shared with the patient. Insight-oriented therapy has as one of its major goals the development of understanding and insight in the
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patient. Supportive psychotherapy requires that the therapist use the insights in the interests of his patient, but he should know that very little but harm might come if he, the therapist, feels forced to share immediately with his patient the fact, for example, that he considers him characterologically manipulative or excessively dependent. Nonetheless, the treatment plan must take these factors into account. Similarly, patients are not necessarily informed that they are poor hypnotic subjects. The treatment strategy applied, however, must subtly take that into account. The caveat implied in all of the above springs from the need to bear in mind that with suitable measurements we aim to harness clinical hypnosis, not to hamstring it. THERATING SCALES In focusing on the scales developed primarily for clinical use, our immediate problems spring from the limited experience with the SHCS and the CIS, and from the unexplained paradox in the measurements of the HIP and the widely used SHSS:A,B&C. The dependability of the SHSS:A,B&C, and the HGS have been reaffirmed by time and the experience of many investigators. They are lengthy and possibly tiresome for some patients; they use the sleep metaphor extensively in the induction procedure although this is now not a popular approach, and they emphasize the scientific not the therapeutic purpose of the testing situation. Their use, however, has led to an impressive body of information about hypnosis. We cannot yet fully evaluate the advantages of the clinical scales. The SHCS and the CIS are both administered in the clinical situation with relative ease, they are considerably briefer than the laboratory scales, and they include both motor and cognitive items. We await with interest reports of their widespread application in a clinical
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context. (Because of the different nature of the HIP, it will be considered separately, below. ) Theoretically, we must raise the question of whether or not brief induction procedures allow sufficient time for some patients to be able to achieve their optimal capacity. We must also ask to what extent the composition of the new clinical scales improves adaptability to the clinical situation. To what extent do their findings facilitate treatment strategy more than the findings on the SHSS: A&B and the HGS? In addition, we know from the laboratory use of scales that a single assessment o f , hypnotic responsivity is often an inadequate reflection of a subject’s capacity. This knowledge should guard against our overinterpreting any of the facts that emerge from a single test situation. FOR T H E SUGGESTED GUIDELINES CLINICAL USE OF SCALES
In the absence of firm data at this time, I can but offer this summary of my personal views on the use of the scales in the clinical context: 1) The scales provide a means for bridging the gap between knowledge accumulated in the experimental laboratory and the study of clinical events; 2) They should be applied diligently whenever possible, to aid in the understanding of the clinical effects of the hypnotic induction procedure, thereby helping to elucidate the event of hypnosis; 3) Clinical reports, studies, and investigations prepared for publication should include a rating on an acceptable standardized rating scale. Although we cannot always be sure of the clinical occurrence of hypnosis, the likelihood of its happening is strengthened by a high score and diminished by a low one; 4) The scales can provide clues to the patient’s specific hypnotic skills, and in this
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way can contribute to the formulation of individual treatment plans. Rather than using any formal scales, some clinicians prefer to depend on a flexible clinical interaction, and on monitoring the responses of their patients to but one or two pertinent items of a motor or cognitive kind, when determining treatment strategy. Those who incline toward the use of the scales as an aid in the treatment strategy should be encouraged to use them widely, and to study their effectiveness in predicting clinical hypnotic performance and outcome; 5 ) Data might accumulate which will affirm the suitability and efficacy of a scale already currently available. O n the other hand, the scale ideally suited to the clinical situation might yet evolve as a compromise among those already in existence; 6) It is noteworthy that, in general, the decision to add hypnosis to a treatment plan is dependent mainly on the nature of the problem and the whole clinical situation, not on whether or not the patient is hypnotizable. The particular capacity possessed by the patient merely helps to determine how the procedure is used.
Spiegel and Nee (1979) further information is needed. However, it is clear at this time that more work should be done on the ER, the clinical relevance of which, it seems, cannot be dismissed. Those authors cauat this time that more work should be done on the ER which, it seems, will not yet go away nor be dismissed. Those authors caution us that the inferences regarding therapeutic outcome and the presence or absence of severe psychopathology are valid in a probabilistic sense for groups but not for individuals; and that any one individual’s profile pattern, for instance, does not indicate the presence of severe psychopathology. They underscore what is a generally accepted finding, namely, that psychometric tests do not preempt clinical judgment. However, the rating scales should be nurtured and helped to develop in the clinical context. Ultimately and ideally, we might hope for the agreement of clinicians generally on the wide and repeated use of one, or preferably two scales, the second for affirmation of the findings; as the reports accumulate and contribute to the data, we will be led to a greater appreciation of the clinical events.
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ILLUSTRATIVECASEHISTORY Because the HIP constitutes an obvious departure from the accepted paradigm and The following case history captures, I beapproaches the problem from a different lieve, the essence of my comments relating standpoint, it presents a special challenge. to the role of the rating scales in the clinical The Eye-Roll (ER), the most controver- use of hypnosis: Hypnosis was requested for a twentysial aspect of the HIP, appears to have predictive value when it is positive and when it two-year old unmarried man on the surgical is compared with the success or otherwise service who had been bothered by continuof elements in the induction score IND. ous hiccoughs for eight days. They had Consistently positive scores on all predict a begun shortly after a cholecystectomy, and good therapeutic outcome with hypnosis. apart from subsiding during sleep, had conPoor scores on the IND in the presence of a tinued uninterruptedly since their onset. positive ER suggest severe psychopath- The patient felt exhausted. The clinical encounter was complicated ology. In any discussion of the therapeutic out- by the ceaseless and obstructive heaving of come of the patients reported by Stern, his abdomen as he lay almost flat on his
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back, and the fact that he had become partially deaf as a result of an antibiotic that had been prescribed in the past. His left arm was connected to a continuous intravenous drip. His unfortunate history revealed that he had been healthy until the age of seventeen when an infection of his kidneys suddenly made its appearance, leading to surgical removal and a kidney transplant. A few months prior to our meeting he had been admitted to hospital with pneumonia attributed to the necessary use of immunosuppressive drugs. As the pneumonia improved, cholecystitis supervened; this led to a cholecystectomy followed two days later by the complication of a faulty drainage tube. Within hours after this had been adequately attended to i n the operatingroom, the hiccoughs commenced. That was eight days before our first meeting. Despite his hearing loss, and the disruptive nature of the hiccoughs, every effort was made by me to establish some relationship with him by discussing his complaint, his medical problems, and his past history. He was the only child of a working-class family, involved since his first illness at seventeen in an undemanding supervisor’s job. In answer to direct questioning he talked of his enjoyment, when well enough, of hiking on mountain trails. When given an opportunity to discuss his concern and anxiety about the gall-bladder disease that appeared for the first time while he was recovering in t h e hospital from t h e pneumonia, he went to some length to explain that he had become used to disappointments in recent years, and that he was more enthusiastic about having the surgery than his physicians had been because he was keen to have the problem behind him. He denied any sense of anxiety or concern. He had never been exposed to hypnosis, but was hopeful that i t would help end his hiccoughs. Because of his hearing difficulty, the induction procedure had to be
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delivered fortissimo. He was encouraged to relax by closing his eyes and thinking about being on a mountain top surveying the surrounding valleys and hills. He was then asked to allow his right arm to relax completely and to float into an upright position. He was then encouraged to permit it to float over to the upper part of his abdomen and rest there; the relaxed feeling would then spread to the abdominal musculature. He was told this would relax the muscles so that the hiccoughs would become gentler and less frequent. He was encouraged to continue to imagine himself in the mountain setting. About twenty minutes after the commencement of the induction procedure the hiccoughs gradually decreased in intensity and frequency. He was instructed i n how to induce hypnosis on his own, and advised to practice the procedure after waking, as often as he wished. He was told that when he opened his eyes and wakened from the hypnosis he would continue to be relaxed and comfortable, that he would have a feeling of well-being, and that the condition of the hiccoughs would continue to improve. After a period of about forty-five minutes from the commencement of the induction he was asked to waken and as he did so the hiccoughs ceased. On my return visit about four hours later, he was found lying with his eyes closed, his hand resting on his upper abdomen, and with no evidence of the hiccoughs. In answer to questions he recounted that he had been symptom-free for almost an hour after the first session, and that the self-induced exercises had then been difficult to accomplish because of constant but necessary nursing interruptions. He had finally succeeded, however, about half an hour prior to my return visit. He rapidly agreed to the idea of another induction procedure to reinforce his own abilities, and chose to remain in that completely relaxed and hiccoughfree state at the end of that procedure, pre-
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pared to lie with his eyes closed and his hand on his abdomen, totally relaxed, until the time of his evening meal. Next day, when visited, he was walking about the ward, cheerful and bright, having rid himself of both his symptom and the intravenous apparatus. He was extremely grateful, and very surprised at the ease with which he had been able to respond. He left the hospital the following day.
Comments: The patient’s hypnotizability was not measured at any point, and in discussing the event he referred only to the remarkably relaxed feeling he had experienced. A review of the event does not clarify what the active therapeutic principle had been. The whole procedure had been carried out in a very solicitous setting. My hand had often rested gently on his forearm during our initial discussion, and my manner and comments were purposefully reassuring. He had been reminded during the historytaking that most patients would have been deeply disappointed had they been exposed to the repeated major illnesses that he had had to endure. He had indicated that he had not discussed his concerns with any of his physicians, and prior to the request for hypnosis, had not been interviewed by a psychiatrist. Given the strenuous nature of engaging in conversation with him because of his deafness, it was entirely plausible that at no time prior to our interview had his feelings about his illness been adequately explored by a professional person trained to do so. It is pertinent that we ask what the role of hypnosis in this case was. Would a psychiatric interview repeated once or twice, with no hypnosis but including an understanding of his concern about his health have been sufficient to alleviate the symptoms? How therapeutic would a state of induced relaxation on its own have been? How satisfying were we able to do a neat
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controlled study - to find other similar cases, and treat them in random fashion with either psychiatric interviews, relaxation exercises, or hypnotic induction procedures. Although all the additional variables make such a study well nigh impossible, the challenge to the clinician persists. To assume simply that the recovery in this case was due to hypnosisprr se is to deny the complexity of the question. We need to know whether the active therapeutic principle here was (1) the trust and warm feeling that arose in the positive transference toward someone who took the time to sit down and discuss the awesomeness of his clinical history sympathetically; (2) the state of relaxation encouraged by using relaxing images and gentle phrasing; (3) the distraction of his attention; (4)the placebo effect created by his faith i n the procedure and his expectation that it would work; ( 5 ) some special quality of the hypnotic experience itself; or (6) a combination of these forces. Even though I prefer to believe that he did experience hypnosis because of the way he behaved, I would be able to support that position in only two ways. Learning from him, after questioning, that his imagined experience on the mountaintop was vivid and realistic and that he could smell the mountain air and feel the cool wind on his cheeks, I would be in a strong position to assume that he had experienced hypnosis. I f , i n addition, he scored well on a standardized rating scale, I would be in a position to compare this man’s experiences with those of others who had similar, greater or less hypnotic ability. Clearly this clinical situation did not permit the use of a rating scale prior to the application of the therapy, and the opportunity to question or test him subsequently was not readily available. Such steps are essential if a case report is to be used to demonstrate the benefit of hypnosis as opposed to other therapeutic procedures, and
MEASURING HYPNOTIC RESPONSIVITY
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if we are to increase our understanding of what we do.
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MORGAN, A. H., JOHNSON, D. L . , & HILGARD, E. R. The stability of hypnotic susceptibility: A longitudinal study. Interntrtional Journal of Clinical and Experimental Hypnosis, 1974,22, 249257. Department of Psychiatry ORNE,M. T. The nature of hypnosis: Artifact and Beth Israel Hospital essence. Joiirnal of Abnormal und Social Psychol330 Brookline Avenue ogy, 1959,58, 277-299. Boston, Mass. 02215 O R N E M. , T. On the simulating subject as a quasicontrol group in hypnosis research: What, why and how. In E. Fromm & R. E. Shor (Eds.)Hjpnosis: Research developments arid perspectives. REFERENCES Chicago: Aldine Atherton, 1972. R . W. Hypnosis and BARBER, T. X . , & GLASS,L. B. Significant factors in SARBIN, T. R., & SLAGLE, psychophysiological outcomes. In E. Fromm & R. hypnotic behavior. Joiirnal of Abnormal Social. E. Shor (Eds.) Hypnosis: Research developments Psychology, 1962,64, 222-228. arid perspectives. Chicago: Aldine Atherton, BARBER, T. X . , SPANOS, N. P., & CHAVES, J. F. 1972. H y p n 0 /is i n : I m ti g i n ti ti on , an cl h rr man p o ten titrlities. New York: Pergamon Press, Inc., 1974. SHOR,R. E. Three dimensions of hypnotic depth. International Joi4rnal of Clinical and E.wperimenta1 BENSON, H., BEARY,J. F., & CAROL,M. P. The Hypnosis, 1962, 10, 23-38. relaxation response. Psychiatry, 1974,37, 37-46. DIAMOND, M. J. Modification of hypnotizability: A SHOR,R . E . , & ORNE,E M I L YC. The Harvard Group scale of hypnotic susceptibility. Form A . review. Psychological Bulletin, 1974, 81, 18& Palo Alto, California: Consulting Psychologists 198. Press, 1962. EVANS, F. J . Recent trends in experimental hypnosis. SPIEGEL, H. & BRIDGER, A. A. Manual for hypnotic Behavioral Science, 1 968, 13, 477-487, induction profile: Eye-roll levitation method. R., NEMIAH, J. C., F R A N K EF. L ,H., APFEL-SAVITZ, New York: Basic Books, 1970. & SIFNEOS, I ) . E. The relationship between hypnotizability and alexithymia. Psychotherapy and STERN,D. B., SPIEGEL, H., & NEE, J. C. M. The Hypnotic Induction Profile: Normative observaPsychosomatics, 1977, 28, 172-178. tions, reliability and validity. American Journal of F R A N K E LF,. H . , & ORNE,M. T. Hypnotizability Cliriic~cilHypnosis (this issue), and phobic behavior. Archives (if General Psychiatry, 1976,33, 12591261. WEITZENHOFFER, A. M., & HILGARD, E. R. StanG U R , R. C. An attention-controlled operant proceford Hypnotic Susceptibility Sccile, Forms A and dure for enhancing hypnotic susceptibility. JorrrB . Palo Alto, California: Consulting Psychologists nal of Abnormal Psychology, 1974,83, 64&650. Press, 1959. HILGARD, E. R . Hypnotic sirsceptibility. New York: WEITZENHOFFER, A . M., & HILGARD, E. R. StanHarcourt, Brace and World, Inc., 1965. ford Hypnotic Susceptibility Scale, Form C . Palo HILGARD, E. R. The Stanford Hypnotic SusceptibilAlto, California: Consulting Psychologists Press, ity Scales as related to other measures of hypnotic 1962. responsiveness. American Journal of Clinical WEITZENHOFFER, A. M., & HILGARD, E. R. StanHypnosis, this issue. ford Profile Scules of Hypnotic Susceptibility, MCGLASHAN, T. H . , EVANS, F. J . , & ORNE,M. T. Forms I and 11. Palo Alto, California: Consulting The nature of hypnotic analgesia and placebo rePsychologists Press, 1963. sponse to experimental pain. Psj~cho,somatic Medicine, 1969,31, 227-246. S . C., & BARBER, T. X . The Creative ImWILSON, MORGAN, A. H. & HILGARD, J. R. The Stanford agination Scale as a measure of hypnotic responHypnotic Clinical Scale. Appendix in Hilgard, E. siveness: applications to experimental and clinical R. & Hilgard, J. R. Hypnosis in the relief of pain. hypnosis. The Artrericati Journal of Clinical HypLos Altos, Calif.: William Kaufrnan, Inc., 1975. nosis, 1978,20, 235-249.
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FRED H. FRANKEL. M.B .Ch .B .. D.P.M Fred H. Frankel is an Associate Professor of Psychiatry at Harvard Medical School, Boston, and is Head of the Adult Psychiatry Unit at the Beth Israel Hospital where he also directs the Clinic for Therapeutic Hypnosis. He received his training at the Witwatersrand Medical School, Johannesburg, South Africa, and at the Massachusetts General Hospital. He has been interested in relating the findings of laboratory studies in hypnosis to the clinical situation, in clarifying the concepts in clinical hypnosis, and in relating specific types of clinical behavior to high hypnotic responsivity. He is the author of Hypnosis: Trunce c i s o Coping Mechunism, and acts as the Medical Editor of the Internntional Journal of Clinical cintl E.rperimentcil H~pnosis.
