Applications of Hypnosis
Because of the intrinsic qualities of the hypnotic state, it can be an effective adjunct to the treatment of a variety of symptoms and problems, both in psychiatry and in medicine in general. The first criterion to consider is the patient’s level of hypnotizability. Once it has been determined that the patient has usable hypnotic capacity (defined by high scores in hypnotizability scales), a dis-cussion about the nature of the hypnotic process follows. It is important at this point to dispel any myths and correct miscon-ceptions the patient may have about the process. This includes the cooperative nature of the hypnotic process, rather than the “tell me what to do” most patients expect. Finally, the therapist must decide whether the problem presented by the patient is ame-nable to hypnotic intervention or whether other steps should be taken instead.
We have divided the discussion of the applications of hypnosis into five areas: general psychiatry, general medicine, psychosomatic disorders, habit control and forensic psychiatry (Table 72.6).
The use of hypnosis in the context of conventional psycho-therapy can facilitate the therapeutic process in a number of ways. For example, hypnotherapeutic techniques may be used to enhance the patient’s sense of self, restructure traumatic and phobic experiences, or access to repressed memories that havenot emerged with use of other techniques. This is true not only of painfully repressed memories but also of situations in which both the patient and the therapist have worked on resistance issues and feel that some additional leverage is necessary. In conventional psychotherapy, the transference is observed and analyzed; in hypnosis, the transference is used as part of the therapeutic process.
Conventional psychoanalytic psychotherapy involves observation and analysis of the meaning of the transference reaction that arises during therapeutic interactions. On the other hand, when hypnosis is used, transference is not avoided or bypassed but may be amplified. All the usual therapeutic rules and processes of psychotherapy apply when hypnosis is used in the psychotherapy context, which may intensify or accelerate the therapeutic process.
Because of the intense emotions that are characteristic of the hypnotic retrieval (which facilitates expression of inner fantasies), intense feelings and deep personal experiences may be elicited. Some patients may find that the hypnotic state facilitates a sense of infantile dependency in which the therapist becomes the transferential object. The quality of this transference reaction will be based on the patient’s early object relations, just as in any other therapeutic relationship. Indeed, the transference reaction may develop so fast that the inexperienced therapist may not have the opportunity to recognize it or may do so too late. The difference here is the intensity of the feelings developed as a result of the strong emotions that arise during trance. As in the case of victims of abuse, the therapist may use the transference relationship under hypnosis to foster the patient’s ability to help herself or himself.
The difficult aspect of doing hypnosis is not the induction of the hypnosis trance, but what happens once the patient is under trance. Remember that all hypnosis is self-hypnosis. Thus, there are two factors which will predict the success of the hypnosis in-tervention: the patients’ hypnotizability and the therapeutic skills of the therapist.
Anxiety disorders are among the most widely prevalent psy-chiatric disturbances. They afflict as much as 15% of the pop-ulation (Myers et al., 1984). Anxiety can be seen as a state of hyperarousal experienced by both emotional and somatic discomfort. Patients describe their experience in physical terms, such as palpitations, gastrointestinal discomfort, chest pain, sweating and motor restlessness. Among anxiety disor-ders most responsive to hypnotic intervention are generalized anxiety disorder, panic disorder, phobias and post traumatic anxiety disorders.
Most of the strategies in the treatment of anxiety disor-ders employing hypnosis combine instructed physical relaxation with a restructuring of cognition, using imagery coupled with physical relaxation. As in the treatment of anxiety disorders by systematic desensitization (Marks et al., 1968) or progressive relaxation, patients are instructed to maintain a physical sense of relaxation (e.g., floating) while picturing the feared situation or stimulus. It is important that the relaxation instruction use an image that connotes reduced somatic tension, such as floating or lightness, rather than being a direct instruction to relax. The more cognitive term “relax” may actually induce more anxiety, whereas affiliation with a somatic metaphor usually produces some reduction in tension. Unlike systematic desensitization, hypnosis produces a physically relaxed state that can be rapidly achieved with a quick induction. Also different from systematic desensitization, the coupling of relaxation to a fearful stimu-lus does not require the development or working through of a hierarchy.
A typical self-hypnosis induction can be rapid. For exam-ple, a patient can be told:
Now just get as comfortable as you can. There are many ways to enter a state of self-hypnosis. One simple but useful method is to count to yourself from 1 to 3. On 1, do one thing: look up. On 2, do two things: slowly close your eyes and take a deep breath. On 3, do three things: let your eyes relax but keep them closed, let your breath out, and let your body float. Then let one hand or the other float up into the air like a buoyant balloon. This is your signal to yourself and to me that you are ready to concentrate.
Initially, the use of hypnosis in the session can help in demon-strating to patients that they have a greater degree of control over somatic responsiveness than they had imagined. It is often useful to begin by teaching patients to create a place in their mind’s eye where they feel safe and secure. On occasion, it helps the subjects to learn how to project their image onto an imaginary screen. Later, they can learn to manipulate the screen by making it either bigger or smaller, having the screen nearer or farther away, as needed:
Just allow your body to float, as if you were floating in a bath, a lake, or a hot tub. Enjoy this sense of floating lightness. Now, picture in your mind’s eye an imaginary screen. It might be a movie screen, a television screen, or a piece of clear blue sky. First picture a pleasant scene, somewhere you enjoy being.
Allow the patient to experience this state for a minute or two, then inquire about the experience:
With your eyes closed and remaining in this state of concentra-tion, describe how your body is feeling right now. What image are you picturing?
After receiving the answers, add:
Notice how you can use your store of memories and fantasies to help yourself and your body feel better.
After they have learned to manipulate the screen and their physical sensations, patients may be ready to do therapy work. They may, for example, learn to re-create the physical state of relaxation while projecting the fearful situation onto the screen. This, then, becomes a useful procedure by which to control and obtain mastery over anxiety-producing situations by dissoci-ating the somatic reaction from the psychological response to the feared stimulus. Initially, the patient is asked to re-create the physical feeling of relaxation. Then, the patient projects onto the screen images associated with the feared situation, only this time the somatic reactions associated with anxiety do not develop. On occasion, it helps for patients to foresee likely physical sensations or situations associated with a fearful expe-rience to master them. For example, in the case of plane phobia, the patient can learn to couple the real sensation of floating in the air with the hypnotic experience: “Learn to float with the plane”.
Patients may also use the trance state as a means of facing their concerns more directly. As in the preceding cases, they may make use of the screen technique. They can achieve this by plac-ing an image of an upcoming performance or fearful situation on one side of the screen, testing out various strategies for mastering the situation on the other side.
Other approaches using hypnosis have included instructing patients in a trance to imagine that they are literally somewhere else, away from the fearful stimulus, thus separating themselves from the anxiety-producing experience (Erickson and Haley, 1967). Positive reinforcement or “ego-strengthening” techniques have also been used; for example, hypnotic instructions are given to patients suggesting that their capacity to master the situation and their response to it will improve (Crasilneck and Hall, 1985). There is little reason to use uncovering techniques seeking to link anxiety to some early traumatic experience in cases of phobia or generalized anxiety disorders. This is different in cases of PTSD (DSM-IV-TR), however, in which more work may be needed to confront and place into context the traumatic experience.
Certainly, in some cases, understanding the cause of the feared situation may help resolve the conflict. One of the tech-niques used to facilitate the recovery of traumatic memories associated with fearful situations is the affect bridge technique (Watkins, 1987).
Trauma constitutes a sudden discontinuity in both physical and mental experiences. The effect of the traumatic experience forces the victim to reorganize mental and psychophysiological proc-esses to buffer the immediate impact of the trauma. This process is meant to be an adaptive mechanism to maintain psychologi-cal control during a time of enormous stress. Unfortunately, a number of trauma victims go on to suffer acute or chronic symp-toms, such as dissociation, intrusive thoughts, anxiety, with-drawal and hyperarousal, leading to a diagnosis of acute stress disorder or PTSD.
There may be a relationship during childhood between stress, such as early trauma, and high hypnotizability. In support of this idea are reports of high hypnotizability in children who were victims of severe punishment during childhood (Nash and Lynn, 1986; Spiegel and Cardeña, 1991). It is possible that the impact of the stress suffered encouraged them to use their self-hypnotic abilities more effectively (Kluft, 1984, 1992; Spiegel et al., 1982).
The major categories of symptoms in PTSD are similar to the components of the hypnotic process (American Psychiatric Association, 1994; Maldonado and Spiegel, 2002a). Hypnotic absorption is similar to the intrusive reliving of traumatic events experienced by these patients. When in a flashback, trauma victims become so absorbed in the memories of the traumatic event, they lose touch with their present surroundings and even forget that the events took place in the past. Likewise, highly hypnotizable individuals may become so intensely absorbed in the trance experience that they can reenact a previous life event (during hypnotic age regression) as if they were reliving it. A hypnotized patient may dissociate a body part to the extent of not recognizing it as part of his or her body. Similarly, PTSD patients may dissociate feelings to the extent of experiencing the so-called psychic numbing. This allows them to disconnect current affects from their everyday experience in an attempt to avoid emotions triggering memories associated with the trauma. Finally, suggestibility is comparable to hyperarousal. The heightened sensitivity to environmental cues observed in those patients suffering from PTSD is similar to that experienced by a hypnotized individual who responds to suggestions of coldness by shivering.
Because many patients suffering from PTSD are highly hypnotizable, and because of the resemblance between the symp-toms of PTSD and the hypnotic phenomena, it makes sense to use hypnosis in its treatment. If patients suffering from PTSD are unknowingly using their own hypnotic capacities (Kluft, 1991, 1992; Maldonado and Spiegel, 2002a; Spiegel 1986, 1989; Spiegel et al., 1988), it is therapeutically useful to teach them how to enter, access and control their trance potential. Hypnosis may be invaluable as a tool to access previously dissociated traumatic material.
We do not refer here to uncontrolled abreaction. The purpose is not simply to help the patient remember the trauma, because in a way, every time a patient goes through a flashback, an uncontrolled abreaction is experienced. An abreaction that is not conducted within the context of cognitive restructuring and before new defenses are in place can lead to the further retraumatization of the patient (Kluft, 1992; Spiegel, 1981). At the end of the following section (Dissociative Disorders), we summarize a comprehensive approach to the use of hypnosis in the treatment of psychiatric syndromes associated with severe trauma.
Hypnosis is one of the most helpful tools in the treatment of patients suffering from dissociative disorders (Maldonado and Spiegel, 2002a; Maldonado et al., 2000). As a rule, these patients experience their symptoms (i.e., fugue states, dissociated identities and blackouts) as occurring unexpectedly and beyond their control. Because these patients are unknowingly using their hypnotic capacities, it makes sense to teach them how to turn their weakness into a strength (Maldonado and Spiegel, 1995). Hypnosis can be used formally both as a diagnostic tool and for therapeutic purposes. The hypnotic state can be seen as a controlled form of dissociation (Nemiah, 1985). Hypnosis is useful in the treatment of these patients, first in determining whether they have a dissociative disorder, and second in providing rapid access to these dissociated states. When used by the therapist in the context of treatment, it can demonstrate to patients the amount of control they have over this state, which they normally experience as “automatic and unpredictable”. This not only serves to teach patients how to control dissociation but also allows them to establish a process of communication that will eventually lead to a reduction in spontaneous dissociative symptoms. Therapists must remember that many of these patients have suffered physical, emotional, or sexual abuse. It is imperative that we recognize and take account of the impact of whatever trauma occurred and help patients work through their reactions to it, as in the case of PTSD. Recognizing and teaching patients with dissociative disorders how to master their capacity to dissociate are among the most important psychotherapeutic tasks in the course of their treatment (Maldonado and Spiegel, 2002a; Maldonado et al., 2000).
We can make use of hypnotic techniques as a way to help patients access repressed and dissociated memories. Teaching patients to use self-hypnosis allows them to obtain a sense of control over their symptoms and eventually their lives. The repression or dissociation of traumatic events and the realities that surround them may serve a defensive pur-pose of avoiding painful affect associated with the memories. The memories are there, either transformed or interspersed with fantasy. Our approach to the treatment of these victims is directed at helping them acknowledge the extent of the emo-tional pain caused by the trauma. Then, through therapy, we can assist in the development of mature and adequate coping mechanisms that will allow the patient to place the experi-ence into proper perspective. The goal is to allow the patient to come to terms with the trauma and to redefine herself or himself in view of the past, but with a firm hold on the reali-ties of the present.
Dissociation as a defense serves a dual purpose. It rep-resents an effort to preserve some form of control, safety and identity when faced with overwhelming stress. At the same time, victims use it in an attempt to separate themselves from the full impact of the trauma. Unfortunately, these individuals may ward off memories of the trauma so well that they may act as if it is not happening and later as if it never happened. Some individuals can so effectively repress traumatic memories that they become unable consciously to work through them. As a consequence, they are unable to put the facts surrounding the events associated with the trauma into perspective, but slowly, the dissociated feel-ings and memories leak into consciousness. This creates some of the classic symptoms associated with PTSD and DID, such as flashbacks or intrusive thoughts.
The advantage of using hypnosis comes from the facilita-tion of the recovery of affect or memories, the ability to dis-sociate memories from cognition, and the speed with which the process is achieved. Finally, because of the relationship between a history of childhood abuse and trance, these patients are usually highly hypnotizable (Chu and Dill, 1990; Hilgard, 1984; Nash and Lynn, 1986; Putman, 1993; Spiegel, 1988, 1990; Spiegel et al., 1988).
Many former victims of childhood abuse may unknow-ingly use their hypnotic capacities to keep out of awareness the content of traumatic memories and in effect create different de-grees of psychiatric illness (Sanders and Giola, 1991; Spiegel, 1984, 1986, 1989; Spiegel et al., 1988; Terr, 1991). Teaching these patients self-hypnosis is a way of turning a weakness into a strong tool for self-mastery and control. The controlled use of hypnosis, then, becomes a way systematically to access previously dissoci-ated material.
The use of hypnosis in the treatment of PTSD and disso-ciative disorders can be conceptualized as having two major goals, which can be achieved by the use of six different tech-niques (Maldonado and Spiegel, 1994, 1995, 2002b; Spiegel, 1992) (Table 72.7). The goals are to bring into consciousness previously repressed memories and to develop a sense of congruence between memories associated with the traumatic experience and current self-images. By making conscious pre-viously repressed memories, the patient has the opportunity to understand, accept and restructure them. These goals are achieved by working through six treatment stages: confronta-tion, condensation, confession, consolation, concentration and control.
First the patient must confront the trauma. The therapist helps the patient recognize and understand the factors involved in the development of the symptoms for which help is now being
sought. Hypnosis is then used to help the patient condense the traumatic memories. The hypnotic experience can be used to define a particularly frightening memory during the revision of the patient’s history, which summarizes or condenses the main conflicts. The focused concentration achieved during the hypnotic state not only can facilitates recall of traumatic material but also helps place boundaries around it. After memories are recovered, we can help patients restructure them and even “become aware of things you did at the moment of trauma to survive”. Once memories are recovered, patients usually need to confess feelings and experiences of which they are profoundly ashamed. These are usually things that they may have told no one else before; in fact, they have been running from them all their lives. At this time, the therapist must convey a sense of “being present” for the patient while remaining as neutral as possible. This is followed by the stage of consolation. Here, the therapist needs to be emotionally available to the patient. This stage must be carried on with caution and in a most professional manner. Therapists should be aware that the body and emotional boundaries of these patients may have been violated in the past. Then comes the stage of concentration. This component of the trance experience allows patients to have access or “turn on” the traumatic memories during the psychotherapeutic session and then “shut them off ” once the work has been done. During the final stage, the patient comes to define herself or himself as being in control again.
The underlying principle to remember is that the most damaging effect of overwhelming trauma is that it renders its vic-tims defenseless. Because of the lack of physical and emotional control, patients activate dissociative defenses in an attempt to master their experiences. By using self-hypnosis, the therapist can model and teach the patient to regain control over her or his memories. Patients must be encouraged to remember as much as they feel is safe to remember at a given time. The goal is that pa-tients learn how to think about traumatic experiences, rather than negating their existence. The use of self-hypnosis teaches patients that they are in control of their experiences. Patients must dispel the magical beliefs that therapists “can take away the memories”. Rather, by modeling this sense of trust in their therapists, patients learn to trust themselves. They relearn trust in their own feelings and perceptions.
The challenge in treating victims of abuse is to achieve a new sense of unity within the patient after the initial fragmentation caused by the traumatic experience. Overwhelming trauma tends to cause sudden and radical discontinuities in consciousness, which leaves the victims with a polarized view of themselves in-volving, on one hand the old self (before the trauma) and, on the other, the helpless, defenseless and traumatized victim. Our goal is to find ways to integrate these two aspects of the self. Here, the patient’s task is to acknowledge and place into perspective painful life events, thereby making them acceptable to conscious awareness.
One of the advantages of the use of hypnosis is that the affect elicited can be so powerful that most patients do not need to remember every single event of abuse or trauma. In fact, through the use of hypnosis, the therapist may help the patient consolidate the memories in a constructive way, thus facilitating recovery. After a condensation of the traumatic experiences, patients become ready to accept the victimized self. Instead of continuing the self-blame and shame because of what happened to them, they can learn to acknowledge and even thank themselves for what they did to survive. This restructuring allows them to shift their perception of self, changing their self-image from that of a victim to that of a survivor.
Therapeutic Precautions Therapeutic precautions are shown in Table 72.8. The strength of transference during the psycho-therapy of trauma victims is enormous. The use of hypnosis does not prevent development of a transference reaction; it may actually facilitate its emergence earlier than in regular therapy owing to the intensity with which the material is expressed and memories are recovered (Maldonado and Spiegel, 1994, 1995, 2002b).
Reliving the traumatic experience along with the pa-tient may allow a special feeling of “being there with them” at the moment of trauma. This allows the therapist to provide guidance, support, protection and comfort as the patient goes through the difficult path of reprocessing traumatic memo-ries. On the other hand, this kind of traumatic transference between the therapist and the victim of sexual assault is dif-ferent in the sense that the feelings transferred are related not so much to early object relationships but to the abuser or cir-cumstances that are associated with the trauma (Spiegel, 1992). Instead of seeing this expressed anger at the therapist as a form of negative transference reaction, we should explore the pos-sibility that this may be a healthy attempt for the patient to ex-perience anger toward the perpetrator. As therapists, we should not minimize or shut off these feelings. This will only confirm the patient’s former perception that there was something wrong with him or her for having these feelings, which will probably activate further use of primitive defenses, including dissocia-tion or acting out.
A more serious complication of the use of hypnosis with trauma victims is the possible creation of false memories. Hypnosis, with its heightened sense of concentration, allows the patient to focus intensely on a given time or place, en-hancing memory recall. The principle of state-dependent memory also makes it plausible that the mere entrance into this trance state can facilitate retrieval of memories associated with a similar state of mind that may have occurred during the trauma and subsequent flashbacks. However, not every mem-ory recovered with the use of hypnosis is necessarily true. Hypnosis can facilitate improved recall of true as well as con-fabulated material (Dywan and Bowers, 1983). Suggestibility is increased in hypnosis, and information can be implanted or imagined and reported as verdict (Laurence and Perry, 1983; McConkey, 1992). Because of this, therapists are warned about “believing” everything a patient is able to recall. Just as we use therapeutic judgment to analyze and interpret our patients’ (nontraumatic) childhood memories, fantasies and dreams, so should we treat hypnotically recovered material with caution.
To this date, no evidence proves that the patient’s con-frontation with alleged perpetrators of childhood abuse or pursuit of legal retribution toward the perpetrator provides any therapeutic benefit. As therapists, we cannot be certain of which memories are real, which are completely confabu-lated, and which are a combination of both. Because of this, we should not encourage our patients to take legal actions. If, on the other hand, our patients insist in pursuing this avenue, it is our duty to warn them of our concerns but to be support-ive of whatever final decision they make. Certainly we will do a service to our patients if we inform them of all the legal ramifications that the use of hypnosis, or any other form of memory enhancement, may have for their defense, including their ability to testify in court or to use the material recovered by such techniques.