international handbookof clinical hypnosis · international handbookof clinical hypnosis edited by...

InternationalHandbook ofClinical Hypnosis

Edited by

G rah am D. Bu rro w s AO‚ KSJ

The U niversity of M el bourne‚ Australia

Robb O. StanleyThe University of M elbourne‚ Australia

Peter B. BloomTh e U n i versi t y o f Pen n syl van i a‚ U SA

J O HN W I LEY & SO N S LT D‚Chichester · New York · Weinheim · Brisbane · Singapore · Toronto

Innodata0470851686.jpg

InternationalHandbook of

International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley, P. B. BloomCopyright © 2001 John Wiley & Sons Ltd

Clinical Hypnosis

InternationalHandbook ofClinical Hypnosis

Edited by

G rah am D. Bu rro w s AO‚ KSJ

The U niversity of M el bourne‚ Australia

Robb O. StanleyThe University of M elbourne‚ Australia

Peter B. BloomTh e U n i versi t y o f Pen n syl van i a‚ U SA

J O HN W I LEY & SO N S LT D‚Chichester · New York · Weinheim · Brisbane · Singapore · Toronto

Copyright © 2001 by John Wiley & Sons, Ltd.,Baffins Lane, Chichester,West Sussex PO19 1UD, UK

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Library of Congress Cataloging-in-Publication Data

International handbook of clinical hypnosis [edited by] / Graham D. Burrows, Robb O. Stanley,Peter B. Bloom

p. ; cm.Includes bibliographical references and index.ISBN 0-471-97009-3 (cased)

1. Hypnotism. I. Burrows, Graham D. II. Stanley, Robb O. III. Bloom, Peter B.[DNLM: 1. Hypnosis. WM 415 H23551 2001]RC495 .H357 2001

´2001024254

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

ISBN 0-471-97009-3

Typeset in 10/12pt Times from the author’s disks by KeytecPrinted and bound in Great Britain by Antony Rowe Ltd, ChippenhamThis book is printed on acid-free paper responsibly manufactured from sustainable forestry,in which at least two trees are planted for each one used for paper production.

616.89 �162—dc21

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Contents

List of Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

PA RT I THE N ATU RE OF HYPN OSIS

1 Introduction to Clinical Hypnosis and the Hypnotic Phenomena . . . 3Graham D. Burrows and Robb O. Stanley

2 Training in Hypnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Peter B. Bloom

PART II GENERAL CLINICAL CONSIDERATIONS

3 Patient Selection: Assessment and Preparation, Indications andContraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Julie H. Linden

4 Memory and Hypnosis—General Considerations . . . . . . . . . . . . . 49Peter W. Sheehan

5 Neuropsychophysiology of Hypnosis: Towards an Understandingof How Hypnotic Interventions Work . . . . . . . . . . . . . . . . . . . . . . 61Helen J. Crawford

PART III THE PSYCHOTHERAPIES

6 Injunctive Communication and Relational Dynamics:An Interactional Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85Jeffrey K. Zeig

PART IV SPECIFIC DISORDERS AND APPLICATIONS

7 Hypnosis and Recovered Memory: Evidence-Based Practice. . . . . . 97Kevin M. McConkey

8 Hypnosis in the Management of Stress and Anxiety Disorders. . . . . 113Robb O. Stanley, Trevor R. Norman and Graham D. Burrows

9 Hypnosis and Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129Graham D. Burrows and Sandra G. Boughton

10 Hypnosis, Dissociation and Trauma . . . . . . . . . . . . . . . . . . . . . . . 143David Spiegel

11 Conversion Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159C. A. L. Hoogduin and Karin Roelofs

12 Personality and Psychotic Disorders. . . . . . . . . . . . . . . . . . . . . . . 171Joan Murray-Jobsis

13 Dissociative Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187Richard P. Kluft

14 Eating Disorders—Anorexia and Bulimia . . . . . . . . . . . . . . . . . . . 205Moshe S. Torem

15 Hypnotherapy in Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221Johan Vanderlinden

16 Hypnotic Interventions in the Treatment of Sexual Dysfunctions . . . 233Robb O. Stanley and Graham D. Burrows

17 Hypnosis in Chronic Pain Management . . . . . . . . . . . . . . . . . . . . 247Frederick J. Evans

18 Hypnosis and Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261Leonard Rose

19 The Use of Hypnosis in the Treatment of Burn Patients . . . . . . . . . 273Dabney M. Ewin

vi CONTENTS

20 Hypnosis in Dentistry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285Dov Glazer

21 Dental Anxiety Disorders, Phobias and Hypnotizability . . . . . . . . . 299Jack A. Gerschman

22 Applications of Clinical Hypnosis with Children . . . . . . . . . . . . . . 309Daniel P. Kohen

23 The Negative Consequences of Hypnosis Inappropriatelyor Ineptly Applied . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327Robb O. Stanley and Graham D. Burrows

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335

CONTENTS vii

Contributors

Peter B. Bloom, MD Department of Psychiatry, University of Pennsylvania, School of Medicine, c/o416 Riverview Avenue, Swarthmore, PA 19081-1221, USA.

Sandra G. Boughton, DipClinPsych Department of Psychiatry and Behavioural Science, Universityof Western Australia, Perth, Western Australia 6009, Australia.

Graham D. Burrows, AO KSJ MD Department of Psychiatry, University of Melbourne, Austin andRepatriation Medical Centre, Heidelberg, Victoria 3084, Australia.

Helen J. Crawford, PhD Department of Psychology, Virginia Polytechnic Institute and StateUniversity, Blacksburg, VA 24061-0436, USA.

Frederick J. Evans, PhD Pathfinders: Consultants in Human Behavior, 736 Lawrence Road, Law-renceville, NJ 08648-0412, USA.

Dabney M. Ewin, MD Departments of Surgery and Psychiatry, Tulane University, c/o 318 BaronneStreet, New Orleans, LA 70112-1606, USA.

Jack A. Gerschman, BDSc, PhD School of Dental Science, University of Melbourne, c/o Suite 5, 3rdFloor, 517 St. Kilda Road, Melbourne, Victoria, 3004, Australia.

Dov Glazer, DDS Lousiana State University School of Dentistry, 3525 Prytania Street, Suite #312,New Orleans, LA 70115-3566, USA.

C.A.L. Hoogduin, MD, PhD Department of Psychology and Personality, University of Nijmegen, POBox 9104, NL-6500 HE Nijmegen, The Netherlands.

Richard P. Kluft, MD Department of Psychiatry, Temple University, c/o 111 Presidential Boulevard,Suite 231, Bala Cynwyd, PA 19004-1004, USA.

Daniel P. Kohen, MD Behavioral Pediatrics Program, Department of Pediatrics – University ofMinnesota, Gateway Center – Suite 160, 200 Oak Street SE, Minneapolis, MN 55455-2002, USA.

Julie H. Linden, PhD Private Practice, 227 East Gowen Avenue, Philadelphia, PA 19119-1021, USA.

Kevin M. McConkey, PhD School of Psychology, University of New South Wales, Sydney, NewSouth Wales 2052, Australia.

Joan Murray-Jobsis, PhD Human Resource Consultants, 100 Europa Center, Suite 260, Chapel Hill,NC 27514-2357, USA.

Trevor R. Norman, PhD Department of Psychiatry, University of Melbourne, Austin and RepatriationMedical Centre, Heidelberg, Victoria 3084, Australia.

Karin Roelofs, MA Department of Psychology and Personality, University of Nijmegen, PO Box9104, NL-6500 HE Nijmegen, The Netherlands.

Leonard Rose, MBBS Melbourne Pain Management Clinic, 96 Grattan Street, Suite 14, Carlton,Victoria 3053, Australia.

Peter W. Sheehan, PhD, AO Vice-Chancellor, Australian Catholic University, PO Box 968, NorthSydney, New South Wales 2059, Australia.

David Spiegel, MD Department of Psychiatry & Behavioral Sciences, Stanford University School ofMedicine, 401 Quarry Road, Office 2325, Stanford, CA 94305-5718, USA.

Robb O. Stanley, DClinPsych Department of Psychiatry, University of Melbourne, Austin andRepatriation Medical Centre, Heidelberg, Victoria 3084, Australia.

Moshe S. Torem, MD Center for Mind-Body Medicine, Northeastern Ohio Universities, College ofMedicine, 4125 Medina Road, Suite 209, Akron, OH 44333-4514, USA.

Johan Vanderlinden, PhD Department of Behavior Therapy, University Centre St-Josef, B-3070Kortenberg, Belgium.

Jeffrey K. Zeig, PhD The Milton H. Erickson Foundation, 3606 North 24th Street, Phoenix, AZ85016-6500, USA.

x CONTRIBUTORS

Preface

The editors of this volume, the International Handbook of Clinical Hypnosis, firstmet to discuss the idea for it during the 13th International Congress of Hypnosisheld in Melbourne, Australia, in 1994. During the Congress, sponsored on behalfof the International Society of Hypnosis by the Australian Society of Hypnosis andthe Department of Psychiatry of the University of Melbourne, the presidency of theInternational Society of Hypnosis was passed from Graham D. Burrows AO toPeter B. Bloom, while Robb O. Stanley continued as secretary treasurer.

From that vantage point and following the publication of Contemporary Interna-tional Hypnosis, the proceedings of the 13th Congress, we realized the need for ahandbook authored by senior clinicians and researchers, who could present topicsin greater length and depth that would substantially contribute to the field ofhypnosis and its applications.

We hope that interested readers from many and varied disciplines who seek moredefinitive knowledge on how clinical hypnosis is used in a variety of medical,dental and psychological conditions will benefit from reading this volume. We alsohope that health care professionals from many disciplines, whether they areexperienced or inexperienced with the principles of clinical hypnosis, will findways to better serve their patients or clients in the future.

The editors wish to thank our colleagues for their contributions to this handbook.Our contributors are experts in their fields and come with broad experience inmedicine, dentistry, and psychology. Most are professors at major universities,some are chairman of their departments, and all are members of the leadinghypnosis societies in their own countries. These societies, of which most of ourauthors have served as president, promote clinical training and research in theunderstanding of this immensely useful modality in the healing arts.

We sincerely thank Mrs Gertrude Rubinstein for her excellent editorial assis-tance; and we are grateful to our publisher, John Wiley & Sons, who hasconsistently helped us to shape these endeavors to the benefit of us all.

Graham D. Burrows, AO KSJ MD, AustraliaRobb O. Stanley, DClinPsych, Australia

Peter B. Bloom, MD, USA

PART I

The Nature ofHypnosis


1

Introduction to ClinicalHypnosis and the HypnoticPhenomenaGRAHAM D. BURROWS and ROBB O. STANLEYUniversi ty of M elbourne ‚ Australia

This volume presents a collection of brief monographs by specialists in variousapplications of hypnosis to the alleviation of chronic debilitating conditions.Hypnosis has an established role as an adjunct to the healing professions. The manysocieties and associations of hypnosis practitioners worldwide provide standards oftraining that enhance the learning, accreditation, and public trust in practitioners ofhypnotic interventions in individuals seeking responsible health care.

The chapters range from general issues of training and choice of clients, throughtheoretical considerations of memory, the neurophysiology of hypnosis, and thepsychotherapies. A generous admixture of clinical case histories is given. The morespecific directions for applications of hypnosis techniques include cautions againstproblems encountered over years of clinical practice.

At a basic level, researchers are taking advantage of developments over the lastdecades in imaging the brain to gain a better understanding of the neurophysio-logical basis of hypnotic phenomena.

At the clinical level, the current open attitudes of society to problems thatpreviously were brushed under the carpet, while solving some problems havesometimes raised as many new ones. There has been much heated controversyabout repressed memories, but in the long term we gain from such controversies inwisdom as well as knowledge about the complexities of the human mind.

WHAT IS HYPNOSIS?

Like many psychological phenomena, intelligence, depression and anxiety, hypno-sis is defined according to the subjective experience and report of participants andby the phenomena that accompany the ‘hypnotic state.’ The characteristics of thisstate include a redistribution of attention to an inward focus, a reduction of critical

International Handbook of Clinical Hypnosis. Edited by G. D. Burrows, R. O. Stanley and P. B. Bloom© 2001 John Wiley & Sons, Ltd


judgment and reality testing, a suspension of forward planning, increased suggest-ibility, heightened imagery or involvement in fantasy, and hypnotic role behaviour.While there are many definitions of hypnosis, the most widely accepted is thatproposed by the British Medical Association as a result of their investigation intothe use of hypnosis in medicine in 1955 (BMA, 1955, 1982):

Hypnosis is a temporary condition of altered perception in the subject which may beinduced by another person and in which a variety of phenomena may appear sponta-neously or in response to verbal or other stimuli. These phenomena include alterationsin consciousness and memory, increased susceptibility to suggestion, and the produc-tion in the subject of responses and ideas unfamiliar to him in his normal state ofmind. Further phenomena such as anaesthesia, paralysis and the rigidity of muscles,and vasomotor changes can be produced and removed in the hypnotic state.

HISTORICAL USE IN THE TREATMENT OFCLINICAL PROBLEMS

The use of hypnosis, under other names, for the treatment of clinical problems hasa long history, being recorded in ancient scripts describing ritual and religiousceremonies. The phenomena of hypnosis have been used to account for miraculouscures that in the middle ages were attributed to sacred statues, healing springs andthe ‘laying on of hands’ by those of high status or religious power. The moremodern use of hypnosis began with the work of the Viennese physician FranzMesmer, who achieved many spectacular cures which he attributed to the appro-priate redistribution of invisible ‘magnetic fluid’ within the body. In 1784, acommission of Louis XVI could find no evidence of animal magnetism, andattributed Mesmer’s successes to suggestion.

Despite Mesmer’s fall from popularity following the Royal Commission, interestin the clinical application of hypnosis developed rapidly throughout the nineteenthcentury. The term hypnosis was coined in 1841 by James Braid, a Manchestersurgeon, who believed that a psychological state similar to sleep accounted for thephenomena observed. The use of hypnosis by the French neurologist Charcot, andby Breuer and Freud in the 1880s, extended its use to the treatment of neuroticdisorders broadly referred to as ‘hysterical.’ Freud subsequently abandoned the useof hypnosis in favour of psychoanalytic techniques (Sulloway, 1979).

The development of behavioural approaches in psychology in the early twentiethcentury saw a temporary lessening of interest in internal psychological processessuch as hypnosis. Despite this, the use of hypnosis to induce relaxation inbehavioural therapies for anxiety was frequently described (Beck & Emery, 1985;Clarke & Jackson, 1983; Marks, Gelder & Edwards, 1968; Rubin, 1972; Rossi,1986). Hypnotic phenomena were also used to induce behavioural change (Hussain,1964; Wolpe, 1958, 1973; Kroger & Fezler, 1976) but the nature of the hypnoticcomponent was not always discussed. The more recent development of cognitivetherapies which focus on altering the patient’s perceptions and cognitions (Brewin,

4 INTE R NATIONAL HANDB OOK OF CL INICAL HY P NOSIS

1988) have all but ignored the use of hypnosis, in spite of the cognitive phenomenawhich have been demonstrated to accompany the hypnotic state.

A variety of phenomena accompany the hypnotic state, which may be induced onthe instruction of a therapist or self-induced by the subject. The extent that thephenomena are experienced and observed depends upon the depth of the hypnoticstate, which is a characteristic of the subject and commonly referred to ashypnotizability or hypnotic susceptibility.

During the hypnotic process the focus of attention is narrowed and shiftedtowards an internal cognitive focus. This leads to a reduction in awareness of thesensory input requiring a response. There is a relative reduction in arousal ofsensory and response systems of the central nervous system, in contrast to themobile shifting of attention which occurs as the anxious patient scans the environ-ment for potential of imagined danger or threat.

Shor (1969) described the operation processes which characterize normal informa-tion processing. The ‘generalized reality orientation’ brings into play the frame ofreference whereby the individual interprets and gives meaning to experience. In thehypnotic state this orientation is to a considerable degree suspended, resulting inconcrete uncritical thought processes. Clarke and Jackson (1983) noted in theirsubjects, that ‘ability to rouse oppositional self statements/beliefs is low [duringhypnosis]’ (p. 242).

Persuasive communications are a part of effective therapy interventions. Studiesof hypnosis and hypnotizability are observed to produce a similar reduction incritical thinking. Malott, Bourg & Crawford (1989) demonstrated experimentallythat hypnotized subjects generated fewer counter-arguments to persuasive com-munications, and that highly hypnotizable subjects experience more favourablethoughts and a positive attitude towards messages, whether hypnotized or not.Accompanying the suspension of critical thinking and the ‘generalized realityorientation’ is the readiness to accept as reality changes in perception and cognitionthat are suggested by the therapist.

In the hypnotic state, subjects, through their narrowed focus of attention,suspended thoughts of future actions or events. The contemporary focus of thehypnotic state encouraged this process.

INTRODUCTION 5

PHENOMENA OF HYPNOSIS

REDUCTION IN CRITICAL THINKING‚ REALITY TESTING ANDTOLERANCEOFREALITY DISTORTION

HEIGHTENED IMAGERY VIVIDNESS OR REALITY

The heightening of imagery or fantasy generation has been suggested to be aneffect of the hypnotic procedure and a characteristic of hypnosis and hypnotiz-ability (Sheehan, 1979; Lynn & Rhue, 1987), and yet the correlations betweenimagery vividness and hypnotizability are moderate. With the internal/cognitivefocus of attention and the suspension in critical judgment referred to earlier, it islikely that imagery experienced will be accepted and responded to as if it hasgreater reality rather than greater sensory vividness.

VOLITIONAL CHANGES AND ALTERATIONS IN VOLUNTARYMUSCLE ACTIVITY

Subjects undergoing hypnotic induction procedures frequently report a sense oftheir behaviour as being under their normal control. Weitzenhoffer (1978) dis-cussed this as a feature of the ‘classic suggestion effect’ that is a characteristic ofhypnosis. This suggestion effect has two component criteria: (a) that there must bea response to a suggestion; (b) that the response must be experienced as avolitional.

Relaxation, paralysis, automatic movements and rigid catalepsy may all beexperienced as avolitional changes in response to hypnotic suggestion. Enhancedmuscle performance may also be reported, but this may be due to reducedperception of muscle fatigue, rather than to actual improved performance.

ALTERATIONS IN INVOLUNTARY MUSCLES‚ ORGANS ANDGLANDS

Extensive experimentation and clinical accounts have demonstrated that manyphysiological processes assumed to be outside conscious control can be alteredin response to hypnotic suggestions (Kiernan, Dane, Phillips & Price, 1995).(Whether these changes are due exclusively to hypnotic interventions or aremodulated by hypnotic susceptibility remains to be demonstrated.) A recentexperiment by Kiernan et al. (1995) has demonstrated such a physiologicalresponse to hypnosis.

ALTERATIONS IN PERCEPTIONS

While many phenomena associated with hypnosis are subtle and few are exclu-sively related to the hypnotic state, the alterations in sensation, particularly pain,have not been demonstrated to the same extent in nonhypnotic states when suitablesubjects and techniques of hypnosis are used. Many descriptions have been givenof major and minor surgery carried out with hypnotic anesthesia alone. While thisapproach is not suggested as the intervention of choice, given the ready availability


of chemical anesthesia, the procedures described confirm the effect of the hypnoticstate.

DISTORTIONS OF MEMORY

Post-hypnotic amnesia, either suggested or spontaneous, is a common accompani-ment of the hypnotic process. While the changes in cognitive functioning referredto earlier may suggest that this phenomenon is due to differences in encodingmemories in the hypnotic state, research on memory distortions and enhancementsuggests that the differences result from changes in retrieval rather than encoding(Barnier & McConkey, 1992; McConkey, 1997).

HEIGHTENING OF EXPECTATIONS AND MOTIVATIONS

Given the generally held public beliefs and expectations of the ‘magic’ of hypnosis,the clinician may appropriately use these expectations to maintain patient motiva-tions at the highest possible level and to diminish therapeutic resistance. Theexperience of the involuntary nature of responses to hypnotic suggestions furtherenhances motivation promoting success in its application to clinical problems.

INCREASED REALITY ACCEPTANCE OF FANTASY EXPERIENCES

Many psychotherapies utilize imagery and fantasy to facilitate the process ofchange. Certain patients in hypnotically assisted therapies may more readilyrespond to imagery and fantasy as reality, since the hypnotic process provides apowerful way of enhancing imagery. For the most effective and responsible use ofthis potent tool, members of the healing professions seek training in hypnosis toprovide an adjunct to their own particular disciplines.

TRAIN IN G IN HYPN OSIS

Training programs in using hypnosis differ from each other around the world. Eachprogram strives for standards of training that enhance the learning, accreditation,and public trust in practitioners of hypnotic interventions in individuals seekingresponsible health care. While many clinicians want to learn hypnosis in order totreat the more difficult cases which they encounter, true proficiency occurs overtime and requires advanced workshops in subsequent months or years. Moreover,an important principle is that no one should treat those patients with hypnosis thatone is not trained and comfortable treating without hypnosis. A final part oftraining is devoted to ethical principles, professional conduct, and certification.Joining national and international organizations ensures future personal and profes-sional development.

I NTR ODUC TI ON 7

Current controversies in hypnosis research and their applications to clinicalpractice raise major issues. Dr Bloom stresses the danger of accepting as literallytrue uncorroborated claims of perinatal and prenatal memories and recollectionsfrom past lives. The problems of accepting recovered memories of early childhoodsexual abuse are of universal concern. While such abuse certainly does occur, thereis the possibility that these memories may be due more to an artifact of thehypnosis than an indication that the abuse occurred. There are guidelines to aid theclinician in using hypnosis in uncovering memories of sexual abuse (Bloom, 1994),but in the final analysis, it is the clinician’s own judgment with a particular case onhow to proceed.

Dr Linden’s chapter outlines a four-step process for establishing the hypnoticrelationship with a client: evaluation, education of client, assessment of hypno-tizability, and the teaching of self-hypnosis phase, during which time positiveexpectancies about hypnosis and motivation of the client are enhanced. As theauthor points out, the public is more open to and more educated abouthypnosis than in the past. Moreover, the criteria for patient selection havealtered with increased understanding of the interactive nature of the treatmentprocess and its relation to the doctor–patient partnership. Case histories revealthat often the client wants help not with the presenting problem but with anentirely different concern. Therefore diagnostic skills are no less important thanhypnotic skills.

Several important but widely differing issues for concern may be mentionedhere. Before initiating hypnotic intervention, the nonmedical clinician is advised toinquire of clients as to whether any medical evaluation of their condition has beenperformed. Many common presentations to the hypnotherapist may have organicetiologies which require surgical or pharmaceutical treatment. In obtaining thetrauma history the clinician must be capable of dealing with abreactive materialwhich may surface as normal psychological defenses are evaded. And when inquiryinto childhood physical and/or sexual abuse is being made, it is crucial to avoidsuggestive or leading questions which may compromise the validity of activatedmemories.

Some clinical presentations which are poorly suited to hypnotic intervention arelisted. Forensic subjects also can pose a particular challenge to clinicians. Finally,when a client’s presenting problem is outside the clinician’s field of expertise theclient should be referred elsewhere.

Chapter 4, on memory in hypnosis, is especially important in view of controver-sies about repressed memories. The author attempts to give unbiased considerationto the complexity of memory itself, as well as complications introduced by theinteraction between client and therapist. The use of hypnosis provides no guaranteeto assessing veracity; a degree of confidence (both in hypnosis and in the wakingstate) should in no way be taken as a reliable indicator of accurate memory. Thischapter examines the association between hypnosis and memory by first exploringbriefly the nature of both hypnosis and memory, and then looking specifically at


two relevant memory phenomena: pseudomemory, and the recovery of repressedmemories of sexual abuse.

As Professor Sheehan points out, while hypnosis may increase the volume ofmaterial recalled, there is no dependable enhancement in the accuracy (vs inaccu-racy) of the information retrieved. Demonstrations of increases in the accuracy ofremembered material are, in fact, relatively rare. Moreover, it is probably very rarein the clinical or forensic setting to find any participant who can lay claim to beemotionally neutral.

The data to be collected must always be gathered in a way that shows respect forgeneral clinical considerations affecting the welfare of those involved. The futurewelfare of the client concerned and those of others accused of the act of abusing,for example, depends on the strict enforcement of ethical guidelines which are nowin place relating to the reporting of recovered memories (Bloom, 1994).

There are general clinical considerations that must be respected in the conduct ofhypnosis. And these considerations can only be met if the appropriate guidelinesare followed.

We have at last an opportunity to explore activity in the brain during hypnosiswith neuroimaging techniques such as regional cerebral blood flow (rCBF),positron emission tomography (PET), single photon emission computer tomogra-phy (SPECT), and functional Magnetic Resonance Imaging (fMRI).

Dr Crawford reports how these techniques are addressing questions aboutpsychological and physiological phenomena. There is evidence that hypnoticphenomena selectively involve cortical and subcortical processing. At a neurophy-siological level, highly hypnotizable subjects often demonstrate greater EEGhemispheric asymmetries in hypnotic and nonhypnotic conditions. Cerebral meta-bolism studies have reported increases in certain brain regions during hypnosis (seeChapter 5 for references). Given that increased blood flow and metabolism may beassociated with increased mental effort, these data suggest hypnosis may involveenhanced cognitive effort.

This chapter also reports on preliminary neurophysiological research in the roleof opioid and nonopioid neurotransmitters and modulators which may be involvedin hypnoanalgesia. Recent fMRI research by the author (Crawford, Knebel &Vendemia, 1998) has certainly found shifts in thalamic, insular and other brainstructure activity. Future neuroimaging and neurochemical studies will greatlycontribute to our expanded knowledge of how hypnotic analgesia is so effective asa behavioural intervention for acute and chronic pain.

Despite the theoretical title, the chapter by Dr Zeig has a very practical touch, asbefits one by a disciple of Milton Erickson. Erickson used multilevel communica-tion, both within and outside trance, to stimulate the patient’s own initiative ingenerating more desirable behaviour. As a first step, the therapist should make surethat the patient is responding. Therapeutic change is then promoted by the patient’sability to hear and respond to what the therapist has said indirectly. Moreover, sincethe change has appeared through the patient’s own initiative, it will be more

INTRODUCTION 9

complete and lasting. Table 6.1 gives a very clear exposition of how Ericksondeveloped his strategy.

To obtain the best response, the therapist must understand that individuals maybe working together in any of the following positions: one-up, one-down or equal.Zeig has given accounts of these different situations. These accounts are not onlyclear but entertaining, especially the metacomplementary relationships leading tosecondary gain.

Erickson worked at modifying his technique where necessary to promote thatresponsiveness. Similarly, during induction, the therapist may need to experimentsomewhat, before success is obtained in conveying covert messages to which thepatient will respond and initiate self-change.

The first chapter of specific clinical applications of hypnosis is concerned withthe currently relevant and controversial one of recovered memory in traumavictims. Clinicians must recognize that clients’ remembrance of a previouslyforgotten trauma has clinical relevance; but recovered memories of abuse cannot beaccepted as self-validating. Using hypnosis, it has been demonstrated that memorycan be reconstructed (e.g. Barnier & McConkey, 1992).

Clinicians working with individuals who report recovered memories of child-hood abuse must display the sensitivity appropriate for dealing with any possibilityof childhood abuse (McConkey, 1997). In doing so, however, they need to maintainand use justifiable methods of diagnosis and treatment. Because of its long historyof misuse, clinicians when using hypnosis must be scrupulous in applyingscientifically based and clinically sound therapeutic intervention.

Hypnosis is particularly suited to use as an adjunct in treatment of anxietydisorders; 95% of practitioners of hypnosis use it to assist in the treatment ofanxiety. Hypnosis can be a powerful adjunct to desensitization and to copingrehearsal, since it attributes realism to imagined events. Arousal reduction andrelaxation may be enhanced using hypnotic procedures. Self-hypnosis techniquesor hypnotic interventions have proved useful in simple phobias, for panic patientsand in the treatment of agoraphobia. As Frankel and Orne (1976) have noted,phobic patients tend to be more hypnotizable than other patients or the generalpopulation. Apart from general anxiety reduction, hypnotic techniques may beapplied to re-establish a sense of self-worth and self-esteem.

Contrasted with the treatment of anxiety, there appears to be a widespreadassumption that hypnosis is inappropriate for the management of depressionbecause of the risk of suicide. Given our understanding that hopelessness is the bestpredictor of suicide risk, the clinician needs to decide whether to avoid the use ofhypnosis with patients high on this variable, or to utilize hypnosis as a tool for itsreduction.

Major depression remains a challenge to all treatment modalities, includingpharmacotherapy, cognitive-behaviour therapy, and psychotherapy. The traditionalprejudice against its use in depression has prevented a serious assessment ofwhether hypnosis has anything significant to contribute to this widespread disabling


problem. The authors of Chapter 9 present a series of arguments in favour of a trialof hypnotherapy augmenting cognitive-behavioural management of depression.

To complete the anxiety–depression spectrum, Spiegel’s lucid and comprehen-sive presentation of PTSD symptoms and treatment approaches in Chapter 10begins with an account of the vicissitudes undergone in developing the concept ofpost-traumatic stress disorder. It provides a cautionary tale that however confidentwe feel in the accuracy of our knowledge we can never know all the answers, andtherefore should retain an open mind for opposing views.

Dr Spiegel notes the growing interest in the overlap between hypnotic anddissociative states and post-traumatic stress disorder, in particular a clear analogybetween the three main components of hypnosis: absorption, dissociation, andsuggestibility (Spiegel, 1994), and the categories of PTSD symptoms.

Like PTSD, conversion disorders are particularly suited for treatment usinghypnosis. In 1986 Trillat made the hasty conclusion that hysteria was an illness thatwould no longer be seen, but conversion disorders still present neurologists,psychiatrists and psychotherapists with a considerable problem. Chapter 11 by DrHoogduin and Dr Roelofs views the relationship between conversion disorders anddissociative disorders from a modern cognitive psychological standpoint. Hyp-notherapeutic strategies are described and illustrated by case histories. Finally, it isemphasized that in an appreciable percentage of patients misdiagnosed as having a(psychological) conversion disorder, there may be an organic cause for thecomplaint.

A further note for caution is sounded. Is hypnosis an essential element in all thecases where treatment involving it leads to a favourable result? There is great needfor controlled research in this area. On the other hand, there has been no controlledresearch relating to other treatment strategies, although some well-documentedcase descriptions indicate that behaviour therapy and physiotherapy achieve verypositive results with conversion disorders.

As Dr Murray-Jobsis notes in Chapter 12, it is over a century and a half sincehypnotic methods have been applied to the treatment of the extremely difficultconditions of psychosis and personality disorder. Most experimental work supportsthe conclusion that psychotic and personality disordered patients possess hypnoticcapacity which can be used productively and safely.

The clinician dealing with the severely disturbed patient must have experiencewith this type of population, and also requires sensitivity. Moreover empathy inpacing is an essential in hypnotherapy of these psychologically fragile patients.

The conceptual framework of hypnotherapy in dealing with psychotic patientsand personality disorder has a psychoanalytic framework. The aim is to redo lifeexperiences and allow the disturbed patient to redevelop potential for healthygrowth and development. Virtually all traditional psychotherapy techniques can beadapted for use with hypnosis in the treatment of these patients.

The use of hypnosis for dissociative trance disorder is also presented from astrongly psychoanalytical viewpoint. Treatment involves interrupting pathological

I NTRODUC TI ON 11

trance states and restructuring the dissociative experiences, often with the use ofautohypnotic techniques, so that the patient can retain control over his or herproclivity for slipping into trance.

In considering the use of hypnosis with the dissociative disorders, we come againto current concerns about the contribution of hypnosis to pseudomemory formation.Firstly, can hypnosis contribute to the worsening of dissociative identity disorder?Secondly, it has been argued that trauma may not be at the root of many of thesedisorders, so that hypnotic searching for memories of childhood traumatizationsmay generate confabulations with far-reaching consequences.

Dr Kluft maintains in Chapter 13 that all perspectives have contributions to maketo this complex area of study, and that a rational view of the subject precludes thecomplete or peremptory discounting of either perspective. Although there isconcern about confabulations with this use of hypnosis, it is also possible forpatients to recover well-being by working through a confabulated trauma. Since therecovery of the patient rather than the recovery of historical truth is the goal, thisshould not be a major concern in most instances.

Dissociation is a commonplace reaction to trauma in psychiatric patients andin nonpatient populations This chapter offers a detailed review of methods oftreatment and clinical techniques are presented for hypnotic interventions in thedissociative disorders. In the absence of contraindications Dr Kluft considers mosttraumatized persons with major dissociative manifestations to be excellent candi-dates for the use of therapeutic hypnosis.

Both Dr Torem and Dr Vanderlinden comment that with anorexia nervosa andbulimia there has been remarkably little utilization of hypnosis as a therapeutictool, whereas hypnotherapists have been intensively engaged in the treatment ofobesity. Nevertheless, the effectiveness of hypnotic interventions in patients witheating disorders has been recorded in the literature over and over again since thetime of Pierre Janet.

The clinical literature identifies a variety of psychodynamics attributed to thepsychopathology of eating disorders. Many patients with these disorders feelhelpless, hopeless, and ashamed of having to seek psychological help. Ego-strengthening suggestions are therefore an important part of most hypnotherapyinterventions. Assignments which they are asked to complete are designed so thatthe patient will metaphorically and concretely experience a feeling of success, aswell as a sense of gaining mastery, control, and exercising new choices and options.Ego State Therapy has become a frequent focus in the hypnosis literature.

While only psychological bases are at present considered to be operational inanorexia nervosa and bulimia, the picture is different for obesity. It is assumednowadays that biological and psychological factors can function in combination aspathogenic factors in the development of obesity, therefore it is noted that hypnosisshould always be part of a multidimensional approach.

Dr Vanderlinden offers a very practical commonsense overview of the problem.Thus, for a considerable group of patients, weight reduction is either not a realistic


goal, or the aim of treatment should be adapted; for instance they must learnto accept themselves as overweight, instead of pursuing weight reduction. Theauthor’s own approach (Vanderlinden, Norré & Vandereycken, 1992) contains,among others, behavioural, cognitive, and interactional components.

Most treatments are exclusively aimed at quick weight reduction and ignore thecrucial goal, namely weight stabilization and prevention of relapse. A follow-uplasting 1 to 2 years is absolutely indicated to prevent possible relapse, with regularencouragement of the patient.

The treatment of sexual dysfunction can take a psychodynamic psychotherapyapproach, a brief focused eclectic psychotherapy approach, or a cognitive-behavioural approach, and hypnotic assistance to each of these is advantageous.There is a surprisingly low degree of usage of hypnosis in sexual dysfunction. Andyet, the involvement of thought, image and symbolism in sexual interest, arousaland behaviour cannot be overemphasized. Changing the information, associations,symbols and images that contribute to dysfunction is a primary goal of therapy.Hypnosis provides a powerful means of influencing all these cognitive levels intreatment.

The several chapters dealing with painful conditions highlight the differencesbetween acute and chronic pain, and therefore the need for different strategies intheir management.

Whereas acute pain is best managed by anxiety-reducing strategies, chronic painrequires strategies that deal with effective handling of one’s psychological environ-ment. In many cases chronic pain may have no clear organic basis, but secondarygain issues typically exist with the chronic pain patient and hypnotic strategies needto be developed which will not initially threaten these issues. Hypnotic interventionbased on anxiety reduction will only frustrate the patient and the therapist, and willusually be unsuccessful.

As Dr Evans points out in Chapter 17, the clinical criterion of successfultreatment outcome for chronic pain patients is far more complex than mere painreduction. ‘Multiple outcome measures need to consider decreased depression andmedication and opioid use; improved sleep, social and family relations and qualityof life; increase in range of motion and activity level; and return to work’ (p. 249).

Dr Rose notes in Chapter 18 that, in keeping with modern approaches to patientcare and autonomy, pain patients are encouraged to become more involved in theirown management, both by selecting their own fantasies and maintaining a two-waycommunication with a hypnosis practitioner. Cues to the appropriate utilization ofhypnotic approaches to treat pain are often given in the very terminology patientsuse to describe their pain. At a later stage, training in self-hypnosis gives patients asense of mastery and control over their pain and they can become independent ofthe therapist. A case study reported by Dr Rose repeats the caution by DrVanderlinden that patients coming to hypnotherapists for alleviation of chronicconditions may have an organic etiology for the condition. In this case investiga-tions prior to hypnosis had been unsuccessful in finding the organic cause.

I NTRODUC TI ON 13

The seriously burned patient needs psychiatric help from the time of injury tofull recovery (Chapter 19). Opioids are the treatment of choice for pain relief, eventhough relief is seldom complete. Hypnosis can be a helpful adjunct, and shouldnot be withheld even in patients who test low in hypnotizability.

In the first 2 to 4 hours postburn, hypnosis diminishes the inflammatory response.Later, it is helpful for resting pain, and especially effective for control of pain inthose patients with the most excruciating procedural pain. Infection is minimized,suppressed appetite can be restored, and body image and active participation inrehabilitation are enhanced. A burned patient who has accepted the suggestion thathis wounded area is ‘cool and comfortable’ is easy to treat, optimistic, and healsrapidly.

Commonly, the patient who enters the dentist’s room is at some level of tranceand the dentist has the opportunity to manipulate this hypnotic state to enhancepatient comfort in the dental situation. The hypnotic interaction has begun beforethe first word is uttered.

Another area in which hypnotic strategies are utilized, but the concepts ofhypnosis are not mentioned, is in the 3-minute smoking cessation interaction. Thiscan take place at the conclusion of the oral examination and cancer screening, ifthere is an indication by the patient that there is a desire to ‘quit.’

With the advent of stereophonic headphones, the dentist can offer positivehypnotic suggestions while taking care of the mouth. When preparing the patienttapes, it is recommended that the form of speech be primarily in the passive voiceand the text be devoid of personal pronouns. For the listener, hearing just the ideasand suggestions is empowering. Note that Dr Glazer, in Chapter 20, in this way isusing Ericksonian injunctive communication, as recommended by Dr Zeig. Itshould be noted that the words pain, hurt and discomfort are never introduced.Because the brain does not easily compute ‘no’ in the hypnotic state, it is moreeffective to offer positive suggestions.

The tape is used to teach patients not only to relax but to manage muscle tensionheadaches and to abort bruxism.

Fear of dentists is commonly listed in the top five commonly held fears and isamong the ten most frequent intense fears. There are strong indications that asignificant portion of the dental phobic population is hypnotizable and that thesame high hypnotizability that allows them to develop a phobia is also a useful toolto help them overcome the phobia.

Implicit in these findings is a caution for dentists that they should be aware that asignificant portion of the population is highly responsive to suggestion. Attentionshould therefore be given not to deliver suggestions to patients that may becounter-productive to treatment. Otherwise treatment difficulties and enduringproblems may be created inadvertently.

During the 1970s research began to report both the clinical efficacy andpsychophysiologic changes associated with self-hypnosis in children. At the sametime the benefits of hypnosis training were recognized for children with chronic


illnesses such as cancer, haemophilia, and asthma. Successful applications of self-regulation include a focus on personal control and decision-making by the child,and specific attention to the child’s preferences in using personal imagery skills.

For behavioural problems indirect approaches are used. These might includeimproved coping, allaying of anxiety, and facilitating improved self-esteem withthe aid of self-hypnosis, rather than expecting problem resolution as one mightreasonably expect in the treatment of habits. The biobehavioural disorders suchas asthma, migraine, encopresis, Tourette’s Syndrome, and inflammatory boweldisease, are all known to be exacerbated by psychological stress. Teaching self-hypnosis promotes a sense of self-control as well as providing a strategy forreducing symptoms. Clinicians should obtain appropriate training in paediatricclinical hypnosis to apply and integrate it within general or specialty paediatriccare.

Since we know that hypnosis used properly by appropriately trained clinicians issafe and effective and has no adverse side effects (Kohen & Olness, 1993), it canbecome an important potential tool in managing a wide variety of clinical issues inchild health care.

SUMMARY

Hypnosis as an adjunct to traditional therapy has a special role in management ofchronic debilitating conditions. To maintain ethical standards and responsiblepractice there are learned societies which offer accreditation to clinicians, offeringguidelines in controversial areas.

In this volume we have been fortunate in obtaining contributions in many areasfrom authors who have achieved distinction in their fields of endeavour. Severalcaveats are stressed in their reports. Among others, there is a consensus thatclinicians should treat with hypnosis only those patients that one is trained andcomfortable treating without hypnosis. The nonmedical practitioner should beaware that many common presentations to the hypnotherapist may have organicetiologies which require surgical or pharmaceutical treatment. In obtaining thetrauma history the clinician must be capable of dealing with abreactive materialwhich may surface as normal psychological defenses are evaded. And when inquiryinto childhood physical and/or sexual abuse is being made, it is crucial to avoidsuggestive or leading questions which may compromise the validity of activatedmemories.

Hypnotic interventions have been particularly successful in managing both acuteand chronic pain, reducing the need for medication and improving the quality oflife in many ways. Hypnotherapy for burn patients can influence the immuneresponse to the degree that there is no need for antibiotics, and a life-savingreduction in the need for fluid to retain blood pressure. From the psychological

INTRODUCTION 15

angle, modern methods of induction and in particular use of self-hypnosis canimprove self-esteem and feelings of mastery.

It is noteworthy that the authors are open-minded in their approach, and arewilling to learn from all available techniques including old-style psychotherapiesas well as new-style ‘alternative medicine.’ Hypnosis gives opportunities forcreativity, and it is obvious that this makes for considerable satisfaction in boththerapist and client.

Barnier, A. J. & McConkey, K. M. (1992). Reports of real and false memories: The relevanceof hypnosis, hypnotizability, and context of memory test. J. Abn. Psychol., 101, 521–527.

Beck, A. T. & Emery, G. (1985). Anxiety Disorders and Phobias: A Cognitive Perspective.New York: Basic Books.

Bloom, P. B. (1994). Clinical guidelines in using hypnosis in uncovering memories of sexualabuse: A master class commentary. Int. J. Clin. Exp. Hypn., 42(3), 173–198.

Brewin, C. R. (1988). Cognitive Foundations of Clinical Psychology. London: LawrenceErlbaum.

British Medical Association Report (1955). Medical use of hypnotism. Br. Med. J., 1,Supplement, 190: cited in Hypnosis in Clinical Practice, Report of the National Healthand Medical Research Council, Canberra, 1982.

Clarke, J. C. & Jackson, J. A. (1983). Hypnosis and Behaviour Therapy: The Treatment ofAnxiety and Phobias. New York: Springer.

Crawford, H. J., Knebel, T., Kaplan, L., Vendemia, J., Xie, M., Jameson, S. & Pribram, K.(1998). Hypnotic Analgesia: I. Somatosensory event-related potential changes to noxiousstimuli, and II. Transfer learning to reduce chronic low back pain. Int. J. Clin. Exp. Hypn.,46, 92–132.

Crawford, H. J., Knebel, T. & Vendemia, J. M. C. (1998). Neurophysiology of hypnosis andhypnotic analgesia. Contemporary Hypnosis, 15, 22–33.

Frankel, F. M. & Orne, M. T. (1976). Hypnotizability and phobic behavior. Arch. Gen.Psychiat., 33, 1259–1261.

Hussain, A. (1964). The results of behaviour therapy in 105 cases. In J. Wolpe, A. Salter &J. Reyna (Eds), Conditioning Therapies. New York: Holt Rinehart Winston.

Kiernan, B. D., Dane, J. R., Phillips, L. H. & Price, D. D. (1995). Hypnoanalgesia reducesr-III nocioceptive reflex: Further evidence concerning the multifactorial nature of hypnoticanalgesia. Pain, 60, 39–47.

Kohen, D. P. & Olness, K. (1993). Hypnotherapy with children. In J. W. Rhue, S. J. Lynn &I. Kirsch (Eds) Handbook of Clinical Hypnosis (pp. 357–381). Washington, DC: Amer-ican Psychological Association.

Kroger, W. S. & Fezler, W. D. (1976). Hypnosis and Behaviour Modification: ImageryConditioning. Philadelphia: Lippincott.

Lynn, S. J. & Rhue, J. W. (1987). Hypnosis, imagination, and fantasy. J. Mental Imagery, 11,101.

Malott, J. M., Bourg, A. L. & Crawford, H. J. (1989). The effects of hypnosis on cognitiveresponses to persuasive communication. Int. J. Clin. Exp. Hypn., 37, 31.

Marks, I. M., Gelder, M. G. & Edwards, G. (1968). Hypnosis and desensitization for phobias:a controlled prospective trial. Br. J. Psychiat., 114, 1263.

McConkey, K. M. (1997). Memory, repression, and abuse: Recovered memory and confident

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