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HYPNOSIS: THEORIES, RESEARCH AND APPLICATIONS No part of this digital document may be reproduced, stored in a retrieval system or transmitted in any form or by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in rendering legal, medical or any other professional services.

HYPNOSIS: THEORIES, RESEARCH AND APPLICATIONS

GAEL D. KOESTER AND

PABLO R. DELISLE EDITORS

Nova Science Publishers, Inc. New York

Copyright © 2009 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS TLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. LIBRARY OF CONGRESS CATAG-IN-PUBLICATION DATA Hypnosis : theories, research, and applications / [edited by] Gael D. Koester and Pablo R. Delisle. p. ; cm. Includes bibliographical references and index. ISBN 978-1-61668-216-3 (E-Book) 1. Hypnotism--Therapeutic use. I. Koester, Gael D. II. Delisle, Pablo R. [DNLM: 1. Hypnosis. 2. Psychotherapy--methods. WM 415 H99833 2009] RC495.H985 2009 615.8'512--dc22 2009029340

Published by Nova Science Publishers, Inc.  New York

CONTENTS Preface Chapter 1

Chapter 2

vii A New Theory for Understanding and Appreciating the Power of Hypnosis: Comparing this Theory to Previous Theories and Noting its Many Benefits Alfred Barrios Patterns of Interactional Harmony: The Phenomenology of Hypnosis Interaction Katalin Varga, Emese Józsa, Éva I. Bányai and Anna C. Gősi-Greguss

Chapter 3

Applications of Waking Hypnosis to Difficult Cases and Emergencies Carlos Lopes-Pires, M. Elena Mendoza and Antonio Capafons

Chapter 4

Language, Metaphor and Neuroscience: Scientific Explanation and Pragmatic Rules for Effective Communication in Hypnosis Renzo Balugani, and Giuseppe Ducci

1

53 99

131

Chapter 5

The Relational (Intersubjective) Approach to Hypnosis Udi Bonshtein

145

Chapter 6

Hypnosis, Absorption and the Neurobiology of Self-Regulation Graham A. Jamieson

161

Chapter 7

The Neurophysiology of Hypnosis in Mass Psychogenic Illness Felipe A. Tallabs G

175

Chapter 8

Relaxation, Meditation, and Hypnosis for Skin Disorders and Procedures Philip D. Shenefelt

187

Chapter 9

Hypnosis and Cancer: A Dead-End Story? Fabrice Kwiatkowski, Nancy Uhrhammer, Yves-Jean Bignon and Alain Blanchet

Chapter 10

The Valencia Model of Waking Hypnosis and its Clinical Applications 237 Antonio Capafons and M. Elena Mendoza

207

vi Chapter 11

Index

Contents Hypnosis in the Management of Chronic Pain Conditions, and the Acute Pain Accompanying their Treatment John F. Chaves

271 293

PREFACE This book presents new research on hypnosis, including a clinical review comparing the effectiveness of hypnotherapy to psychoanalysis and behavior therapy. Some of the recent clinical evidence contradicting the common criticisms and misconceptions surrounding hypnotherapy are presented, providing a good indication of how to make the best use of this tool, and to provide a rational explanation for its hard-to-believe therapeutic effects. This book also describes and illustrates the use of waking hypnosis based on the Valencia Model and applied to clinical cases considered difficult and/or emergencies. Furthermore, the relationship between hypnosis and psychoanalysis is extensively reviewed. The main assumptions of the intersubjective approach and how it is used in hypnosis, through case stories, is presented as well. Finally, this book presents evidence that the neural mechanisms of hypnosis is a fundamental prerequisite for the environmental context to provide the onset of MPI (Mass Psychogenic Illness). Other topics examined in this book include the effects of hypnosis on cancer patients and its use on people with skins disorders and procedures, as well as its effect on people with chronic pain. Chapter 1 - This chapter will first present a clinical review comparing the effectiveness of hypnotherapy to psychoanalysis and behavior therapy. This review indicated that the average number of sessions needed and success rates were: 600 and 38% for psychoanalysis; 22 and 72% for behavior therapy; and 6 and 93% for hypnotherapy. This is followed by an overview of a comprehensive theory of hypnosis based on principals of conditioning and inhibition explaining hypnosis including why hypnotherapy is so much more effective. The theory is then compared to three other current hypnosis theories, the Sociocognitive, the Dissociation / Neo-Disassociation, and the Response-Expectancy perspectives as well as with Erickson’s strategic approach to therapy. Research in of the theory is next presented, including an experiment done by the author on the effectiveness of post-hypnotic suggestion which presents ways of eliminating many of the methodological shortcomings of previous hypnosis experiments. Finally, additional benefits of the theory are discussed. This includes its providing: (1) a further understanding of the hallucinogens, schizophrenia, bi-polar disorder, bio, higher-order conditioning, placebos and religion; (2) development of more effective methods of hypnotic induction; (3) development of more effective methods of giving post-hypnotic suggestions; (4) and development of Self-Programmed Control (SPC), a positive-oriented behavioral improvement program aimed at achieving self-actualization, greater self-efficacy, and higher emotional intelligence. The dramatic positive results of

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SPC’s application in the areas of: education, welfare, industry, medicine and drug rehabilitation are presented. Chapter 2 - In this chapter the authors review the process of the formulation of our interactional approach to hypnosis together with the development of a new methodology through various experiments. The first interactional method developed to detect interactional synchrony between hypnotist and subject on the subjective level is the Parallel Experiential Analysis Technique (PEAT). PEAT is suitable for eliciting and simultaneously gathering free reports on the subjective experiences from both interactants that later can be parallelly processed. On the basis of four experimental series, characteristic data are shown as examples of the phenomenology of the subjective experiences of hypnotists and subjects. The free reports of hypnotists about their subjective experiences were analysed separately as well and yielded three common topics that are illustrated by verbatim quotations from the original reports. Another possibility of the interactional analysis is the use of the same paper/pencil tests for the hypnotist and subject. First we used the Phenomenology of Consciousness Inventory (PCI) for this purpose, and in several of our experiments the authors compared their subjective experiences along their scores on the PCI factors. Later they developed a new paper/pencil test, the Dyadic Interactional Harmony (DIH) questionnaire, for directly measuring the synchrony of an interaction. DIH was validated in a series of experiments and it is a promising measure for tapping the interactional aspects of a hypnotic relationship. They used PCI and DIH from hypnotist and subject as means of interactional analysis of subjective data along with the concept of hypnosis styles (maternal/paternal scores) in a real-simulator design. They exemplify the special possibilities of the interactional approach of phenomenological data by a recent empirical result: they demonstrate the very different pattern of heritability in the case of subjective data as opposed to the behavioral score of hypnosis. In their experiments, in which standardised hypnosis interactions of subjects of various kinship had been analyzed, results showed that the phenomenological experience of hypnosis is not based on genetic determination, but the way interactants evaluate the session (the interaction itself) seems to be closely related to the degree of kinship. All of these empirical results seem to add special new possibilities to the understanding of hypnosis and the authors encourage every researcher to follow this interactional approach and methodology. Chapter 3 - In this chapter, the authors describe the use of this approach for difficult cases and/or emergencies based on the Valencia Model, albeit introducing substantial modifications to adapt it to the specific characteristics of the intervention in these cases. Difficult cases and/or emergencies are defined as follows: 1) people who have gone through a number of treatments without receiving significant benefits, and, consequently, they have fewer therapeutic options; 2) people in despair (for several reasons); 3) people whose problem needs to be solved or improved immediately; 4) people in shock; 5) people who, due to their poor clinical condition, are not amenable to starting a treatment using the choice techniques for their problem, such as exposure, behavioral activation, etc. As a result, their approach puts forth three intervention models for difficult cases and/or emergencies, which correspond to the different types of cases that have been considered the most relevant according to our clinical experience. Chapter 4 - Neuroscience, in particular thanks to imaging techniques, now makes it possible to express the embodied, sensorimotor nature of many cognitive domains including

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action perception, simulation and imagery. There is also growing neurophysiological evidence regarding the sensorimotor basis of language and concept formation, as previously theorized by cognitive linguistics. The role of metaphor posited by Lakoff and Johnson in the construction of the thought and abstract thinking is described. Conceptual metaphors and their use in everyday language are discussed, emphasizing both their universality and their variations in specific pathological populations. Arguments about the close link between hypnosis and metaphor are given; the opportunity of a finely graded assessment of the particular use of metaphors in any particular patient is suggested in order to build up a more effective intervention in the practice of Ericksonian psychotherapy. Chapter 5 - The main aim of this chapter is to discuss how intersubjectivity can be applied to hypnosis. Intersubjectivity is the sharing of subjective states by two or more individuals. This is a major perspective in psychoanalysis. Adopting an intersubjective perspective in psychoanalysis means, above all, abandons the myth of the isolated mind. First, the chapter reviews the relationship between hypnosis and psychoanalysis. Three splits are described: a) psychoanalysis splits off from brain science; b) psychoanalysis splits off from hypnosis and c) splits occur within psychoanalysis. I discuss how these splits can be healed, so that hypnosis can be considered a two-person rather than a one person process. Next, the chapter presents the main assumptions of the intersubjective approach and how it is used in hypnosis, through case stories. The assumptions are based on theoretical and empirical from neuroscience. Chapter 6 - In hypnosis, suggested behaviours are characteristically accompanied by a diminished sense of effort and personal agency while suggested experiences, which strongly contradict objective reality, appear to be accepted without conflict. Dissociated control theory is a cognitive neuroscience of hypnosis that emphasises functional disconnections (dissociations) within the predominantly anterior brain networks, which implement cognitive control. Profound alterations in the ongoing experience of the self outside the hypnotic context (labelled by Tellegen as absorption) are a key predictor of a person’s ability to experience suggested distortions of reality. Tellegen (1981) defined the trait of absorption as arising from the interplay of two mutually inhibitory mental sets, the instrumental and the experiential mental sets. The capacity to set aside an instrumental set finds a clear counterpart in current neuroimaging and EEG studies of dissociated control in hypnosis. The consequent ability to adopt an experiential set has a clear counterpart in the recent discovery of a characteristic brain network during quiescent mental activity. Neuroimaging studies of suggestions used to induce hypnotic analgesia show strongly overlapping activations with the loci of this network which generates core aspects of internally focused self experience. Tellegen pointed to distinctive roles for the instrumental and experiential mental sets in psychophysiological self-regulation in order to explain the importance of the trait absorption in mediating the mixed pattern of results in earlier bio studies. This finds further in recent studies on the roles of these mutually inhibitory neural networks in differing patterns of regulation of peripheral physiology. These findings provide an important foundation from which to understand the unique contributions of absorption and hypnosis in effective practices of self-regulation. Chapter 7 - Mass Psychogenic Illness (MPI) is typically defined as the collective occurrence of a constellation of similar physical symptoms and related beliefs, for which there is no plausible pathogenic explanation, and which can be divided in two possible conditions, Mass Anxiety Hysteria and Mass Motor Hysteria. Evidence has emerged that the

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cultural context is of utmost importance in the mechanism of both variants of Mass Psychogenic Illness. However, there is an underestimated variable that relates both conditions even in a more meaningful manner, and this is the neurophysiology of hypnosis. This study presents evidence that the neural mechanism of hypnosis is a fundamental prerequisite for the environmental context to exert pressure and provoke the onset of MPI; the role of empathy is assessed as a part of the mechanism of suggestibility during MPI, as well as a possible mirror neuron system that could be the cornerstone of symptomatology transmission. Fundamental differences are presented from the two variants of MPI, Mass Anxiety Hysteria and Mass Motor Hysteria. Chapter 8 - Relaxation, meditation, and hypnosis can help calm and rebalance the inflammatory immune response, which in turn can ameliorate inflammatory skin disorders. The relaxation response has been shown to help rebalance immune functioning. Mindfulness meditation has been shown to enhance the response of psoriasis to ultraviolet light treatments. Hypnosis has been shown to decrease inflammation and discomfort in a number of skin disorders and to improve the patient's attitude about having the condition. Hypnosis has also been shown to be more effective than relaxation alone in alleviating inflammatory skin disorders. Psychocutaneous hypnoanalysis permits diagnostic evaluation as to whether psychosomatic issues are initiating or exacerbating specific skin disorders. If psychosomatic issues are present, hypnoanalysis also permits treatment by reframing the initiating event in a way that defuses the negative emotional charge associated with it. Rapid induction hypnosis followed by deepening and then self-guided imagery has also been effective in alleviating anxiety and discomfort associated with dermatologic procedures. Chapter 9 - Oncology is a domain where hypnosis has a role to play, since medical treatments are still not sufficient. Although the impact of many types of psychosocial intervention have been tested in cancer patients with disappointing results on survival, hypnosis has not yet been assessed using appropriate methodology. Surveys testing hypnosis that include survival as an end-point need still to be performed. On the other hand, the impact of hypnosis on patients’ well-being has been well studied, and appears to be very useful against depression, pain, treatment side-effects and other symptoms. It can now be proposed to children or adults, and has proven to be a great help to terminally ill cancer patients. It can also prevent distress during invasive medical procedures. In most trials, hypnosis appears to be superior to standard educational and/or cognitive-behavioral interventions. Sometimes sessions can be performed by nurses and physicians having followed a short course in the technique, although for prospective trials testing wider end-points, we suggest that welltrained hypnotists participate, preferably practitioners trained in psychology. These trials should explore various dimensions of the patient’s psyche, examine the impact of the alleviating past trauma, promote behaviors known to reduce the risk of relapse, including physical activity, diet, and biological rhythms. The effect of hypnosis on immunity should also be evaluated since some authors have shown a positive impact on natural killer cell count and activity. For research purposes, measures concerning susceptibility to hypnosis should be collected and new indicators developed in order to facilitate future progress. Oncology is only just beginning to take advantage of the diverse possibilities of hypnotism. Chapter 10 - In this chapter, authors describe in detail the Valencia Model of Waking Hypnosis. The concept of waking hypnosis, originally introduced by Wells in 1924, was developed in Spain, and several standardized methods were generated shaping this Model. It is based on the socio-cognitive or cognitive-behavioral paradigm of hypnosis, and represents

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the first approach to waking hypnosis that disregards the concept of trance. Rather it advocates the continuity between hypnotic and everyday life behaviors, and is focused on variables such as expectations, motivation, attitudes, beliefs, etc. The model consists of a number of efficient methods intending to be straightforward and pleasant for the patient as well as quick to learn and to apply. The procedures implemented as part of the model in order to achieve good rapport with clients are the following: a cognitivebehavioral introduction to hypnosis, a clinical assessment of hypnotic suggestibility, and a metaphor for hypnosis. Furthermore, two induction methods of waking hypnosis are added to these procedures, namely, Rapid Self-Hypnosis and Waking-Alert Hypnosis, the latter also known as Alert-Hand Hypnosis. During the intervention, hypnosis is used in combination with motivational questions to help clients understand the relevance of their thoughts in the maintenance of their problems and the usefulness of hypnosis in changing them. The sequence is structured while flexible to be adapted to the intervention. Thus, the ultimate aim is to enable patients to activate therapeutic suggestions in those everyday situations in which they need them. Some of the advantages of waking hypnosis are the following: clients show less fear of losing control; it usually takes less time to obtain results; clients can remain self-hypnotized with eyes open while engaged in other activities, which enables them to give themselves therapeutic self-suggestions that can go unnoticed when the problem occurs in public situations; it is easy to generalize to everyday life; it is versatile and efficient; and it is easily convertible into a general coping and self-control set of skills. Therefore, due to its versatility, the Valencia Model of Waking Hypnosis presents many clinical applications. An illustrative case of the clinical application of this model is described in this chapter. Chapter 11 - The effective management of chronic pain continues to present a serious challenge to the health professions. Even though we now have a wide array of medical therapies that are relatively safe and largely effective in managing many forms of chronic and acute pain, these therapies have significant limitations, especially in the management of chronic pain. The pain relief achieved with traditional biomedical and surgical therapies is often incomplete and sometimes ineffective. Moreover, relief too often comes at a high cost in of the patient’s quality of life. Adding to these considerations has been our growing awareness of the limitations of a narrow biomedical perspective on health and well-being and a recognition of the need to embrace a broader biopsychosocial perspective that encourages our examination of alternative approaches to pain management. This chapter describes and evaluates the ways in which one such alternative, clinical hypnosis, has been used in the management of chronic pain, including the management of acute pain associated with the treatment of underlying medical conditions producing chronic pain. It describes the nature of hypnotic interventions and the manner in which they have been used in chronic pain management. It also considers the spectrum of application of hypnosis in chronic pain management and reviews systematically collected data as well as case studies pertaining to several chronic pain problems. The emphasis is placed on finding reported since recent critical reviews by Spanos and Chaves. My goal is to provide a framework for clinicians who may be unfamiliar with this modality to understand better the nature of hypnotic treatment, help them appreciate the empirical evidence ing its use, and introduce some of the practical issues involved in its effective use in chronic pain management.

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To put this topic in context, it is important to note that contemporary approaches to chronic pain management have increasingly coming to reflect an awareness of the significant contribution of psychosocial factors in the etiology, diagnosis, and treatment of many painful medical conditions. That fact is due, in part, to the reconceptualization of pain perception provided by the gate control theory of pain that offered new ways of understanding the neurophysiological mechanisms by which psychosocial factors could amplify or attenuate the pain experience. Although the basic observation that pain could be profoundly modulated by various psychological interventions was already well known, the articulation of a formal theory that provided explicit mechanisms by which this modulation of pain could be produced had an enormous impact on research and clinical practice and helped to encourage the development of multidisciplinary approaches to pain management. Soon, systematic efforts were underway to refine older therapeutic strategies and to develop new strategies for exploiting psychological resources that were already available to patients as well as assisting them in developing new skills that could be beneficially applied to reducing their symptoms. Although substantial gains in the clinical practice of pain management have been made since the Gate Control Theory was promulgated, the biomedical perspective has continued to dominate contemporary medical practice, even as more sophisticated psychological interventions for pain management were developed. In recent years, however, there has been substantial growth in the amount of research, including randomized clinical trials, being conducted on psychological interventions for chronic pain management. Favorable results have contributed to a growing acceptance of the notion that interventions like hypnosis, that can augment more traditional medical or pharmacological approaches, or reduce reliance on them, have the potential to play an important role in contemporary pain management.

In: Hypnosis: Theories, Research and Applications Editors: G. D. Koester and P. R. Delisle

ISBN 978-1-60456© 2009 Nova Science Publishers, Inc.

Chapter 1

A NEW THEORY FOR UNDERSTANDING AND APPRECIATING THE POWER OF HYPNOSIS: COMPARING THIS THEORY TO PREVIOUS THEORIES AND NOTING ITS MANY BENEFITS Alfred Barrios SPC Center, Culver City, CA, USA

ABSTRACT This chapter will first present a clinical review comparing the effectiveness of hypnotherapy to psychoanalysis and behavior therapy. This review indicated that the average number of sessions needed and success rates were: 600 and 38% for psychoanalysis; 22 and 72% for behavior therapy; and 6 and 93% for hypnotherapy. This is followed by an overview of a comprehensive theory of hypnosis based on principals of conditioning and inhibition explaining hypnosis including why hypnotherapy is so much more effective. The theory is then compared to three other current hypnosis theories, the Sociocognitive, the Dissociation / Neo-Disassociation, and the Response-Expectancy perspectives as well as with Erickson’s strategic approach to therapy. Research in of the theory is next presented, including an experiment done by the author on the effectiveness of post-hypnotic suggestion which presents ways of eliminating many of the methodological shortcomings of previous hypnosis experiments. Finally, additional benefits of the theory are discussed. This includes its providing: (1) a further understanding of the hallucinogens, schizophrenia, bi-polar disorder, bio, higher-order conditioning, placebos and religion; (2) development of more effective methods of hypnotic induction; (3) development of more effective methods of giving post-hypnotic suggestions; (4) and development of Self-Programmed Control (SPC), a positive-oriented behavioral improvement program aimed at achieving self-actualization, greater self-efficacy, and higher emotional intelligence. The dramatic positive results of SPC’s application in the areas of: education, welfare, industry, medicine and drug rehabilitation are presented.

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Alfred Barrios

INTRODUCTION The work and ideas presented herein evolved from my 1969 Ph.D. dissertation in psychology at UCLA entitled “Toward Understanding the Effectiveness of Hypnotherapy: A Combined Clinical, Theoretical & Experimental Approach” and which I am proud to say was nominated that year for the national Creative Talent Award. The presentation will start with a review of the clinical literature of the time comparing the effectiveness of hypnotherapy to psychoanalytic therapy and behavior therapy. This review – which comprised the first third of my Ph.D. dissertation – was published as an article entitled “Hypnotherapy: A Reappraisal” in the APA journal Psychotherapy: Theory, Research and Practice (1970). One important point to keep in mind when assessing this review is that although the studies referred to took place over forty years ago, the results and conclusions still hold true today.

HYPNOTHERAPY: A REAPPRAISAL Introduction Throughout the years there have been periodic surges of great interest in hypnosis. Many extraordinary phenomena have been attributed to its effects and great claims made as to its effectiveness in therapy. Yet, in spite of such claims, there still appear to be relatively few therapists using hypnosis as a major tool. Why? Is it because the criticisms usually leveled at hypnosis are true? That it is overrated, actually limited to a small range of problems, unable to produce lasting changes? Will removal of symptoms by hypnosis lead to new symptoms? Is it dangerous? No, there is far too much clinical evidence contradicting these statements. Such evidence can no longer be ignored. It is felt that the major reason behind the rejection of hypnosis has been that for most people it is still virtually an unknown. It seems to be human nature to stay clear of or reject anything that doesn’t seem to fit in or be explained rationally, especially when it seems to be something potentially powerful. It is mainly its unknown nature that has led to the many misconceptions surrounding hypnosis and has kept us from making the best use of it. The purpose of the present paper is to present some of the recent clinical evidence contradicting the common criticisms and misconceptions surrounding hypnotherapy, to provide a good indication of how to make the best use of this tool, and to provide a rational explanation for its hard-to-believe therapeutic effects.

Overview of Recent Literature There have been 1,018 articles dealing with hypnosis in the past three years (1966 through 1968), approximately forty per cent of which dealt with its use in therapy. In the same period we find 899 articles on psychoanalytic therapy and 355 on behavior therapy. Contrary to popular opinion that hypnosis is only effective in certain specific symptomremoval cases, a wide range of diagnostic categories have been successfully treated by hypnotherapy. This includes anxiety reaction, obsessive-compulsive neurosis, hysterical

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reactions and sociopathic disorders (Hussain, 1964), as well as epilepsy (Stein, 1963), alcoholism (Chong Tong Mun, 1966), frigidity (Richardson, 1963), stammering and homosexuality (Alexander, 1965), various psychosomatic disorders including asthma, spontaneous abortions, dysmenorrhea, allergic rhinitis, ulcers, dermatitis, infertility and essential hypertension (Chong Tong Mun, 1964, 1966). Also in the past few years an increasing number of reports indicate that the psychoses are quite amenable to hypnotherapy (Abrams, 1963, 1964; Biddle, 1967).

Three Large Scale Studies Three large scale studies in the past five years contain basic findings. Richardson’s (1963) study dealt with seventy-six cases of frigidity. He reports 94.7% of the patients improved. The average number of sessions needed was 1.53. The criterion for judging improvement was increase in percentage of orgasms. The percentage of orgasms rose from a pre-treatment average of 24% to a post-treatment average of 84%. Follow-ups (exact length not given) showed that only two patients were unable to continue realizing climaxes at the same percentages as when treatment terminated. Richardson’s method of treatment was a combination of direct symptom removal, uncovering, and removal of underlying causes, since he had found that direct symptom removal alone was not always sufficient. He reports no hypnotic induction failures. Chong Tong Mun’s (1964, 1966) study covered 108 patients suffering from asthma, insomnia, alcoholism, dysmenorrhea, dermatitis, anxiety state, and impotence. The percentage of patients reported improved was 90%. The average number of sessions was five. The criteria for judging improvement were removal or improvement of symptoms. The average follow-up period was nine months. Chong Tong Mun’s method of treatment was a three-fold approach. With some patients he would work on reeducating the patient with regard to the behavior patterns immediately underlying the symptoms. With others he would first regress the patient back to the original onset of the symptom. Once regressed, he would reeducate the patient to the fact that the original cause was no longer operative. In addition, he usually used supplementary suggestions of direct symptom removal. Hussain’s (1964) study reports on 105 patients suffering from alcoholism, sexual promiscuity, impotence and frigidity, sociopathic personality disturbance, hysterical reactions, behavior disorders of school children, speech disorders, and a number of different psychosomatic illnesses. The percentage of patients reported improved was 95.2%. The number of sessions needed ranged from four to sixteen. The criteria for judging improvement were complete or almost complete removal of symptoms. In follow-ups ranging from six months to two years no instance of relapse or symptom substitution was noted. Hussain’s approach is illustrated by the case of a 35 year old woman exhibiting the following symptoms: anxiety, alcoholism, depression with suicidal tendencies, sexual promiscuity, insomnia, and inability to make decisions and future plans. Prior to treatment, Hussain pinpointed the various fears and negative attitudes which he felt were underlying the symptoms – e.g., the patient feeling unloved and unwanted in regards to her marriage, feelings of inadequacy at being a mother, fear of her own mother, fear of responsibility and making decisions, and guilt over her sexual promiscuity.

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Hussain then used a therapeutic technique somewhat similar to Wolpe’s (1958) desensitization technique to eliminate these fears and negative attitudes. For example, he would have the patient think of a particular fear-producing situation and recondition her by suggesting she would find herself calm and relaxed in the situation. This particular approach is very often used now in one form or another. Abrams (1963) refers to it as an “artificial situation” technique. Through hypnosis the patient is able to experience his new attitudes in an “artificial situation,” an imagined situation. This artificial situation technique was incorporated into the SPC program discussed below and is referred to as the “Projection Method” for self-programming of positive suggestions (Barrios, 1985, pp. 43-51). It differs from Wolpe’s approach in two respects. First of all, Wolpe does not often use hypnosis. Secondly, Wolpe has the patient go through a hierarchy of “imagined situations,” going from easiest to deal with to most difficult. (There is no reason, however, why this hierarchy approach cannot be incorporated into hypnotherapy.) With the above patient Hussain also used direct symptom-removal suggestions. For example, “aversion to the thought and sight of alcohol was also built up by direct suggestion.” This patient was discharged from the hospital after twelve sessions. “No relevant symptoms were left behind and there was no relapse during the six-month follow-up period.”

Current Method of Using Hypnosis As one can see in the above studies, and this probably comes as a surprise to most therapists, the main use of hypnosis is not as a means of direct symptom removal. Nor is its main use as an uncovering device. The current trend is to use hypnosis to remove the negative attitudes, fears, maladaptive behavior patterns, and negative self-images underlying the symptoms. Uncovering and direct symptom removal are still used to a certain extent, but usually in conjunction with this new main function. In the past, so much emphasis was directed towards symptoms and disease processes that some of us were guilty of forgetting the person in the body. It is incumbent upon us [hypnotherapists] to concentrate on treating the particular patient who presents the symptom rather than the symptom presented by the patient (Mann, 1963). Psychiatric hypnotherapy, as practiced today by the leading practitioners in the field, has in common with all other forms of modern psychiatric treatment that it concerns itself not only with the presenting symptoms but chiefly with the dynamic ime in which the patient finds himself and with his character structure (Alexander, 1965). The objection that the results of symptom removal will seldom be permanent is certainly not valid. This may have been so in the past, when direct symptom removal alone was practiced and nothing was done to strengthen the patients’ ability to cope with his difficulty or to encourage him to stand on his own two feet (Hartland, 1965). This change is being stressed in the present paper because it is part of its purpose to fit hypnotherapy into “the scheme of things.” Many therapists have rejected hypnosis because its direct symptom approach of the past clashed violently with their dynamic approach. Now we see that such a clash need no longer exist.

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The Ahistorical vs. the Historical Approach in Therapy Some hypnotherapists use, in part, a historical approach, going back into the patient’s childhood and changing his attitudes regarding the causes of these patterns (Fromm, 1965; Abrams, 1963; Chong Tong Mun, 1964, 1966). However, most hypnotherapy is ahistorical and, it would seem, faster. If we wanted to change the direction of a river it might be much easier to work on the main current directly (once it had been located) rather than going back upstream, locating all the tributaries, and pointing each one in a new direction.

A Comment on the Dangers Ascribed to Hypnosis In the past there have been certain dangers ascribed to the use of hypnosis – for example, the danger of a psychotic break, or the substitution of more damaging symptoms. According to a number of investigators (Kroger, 1963; Abrams, 1964) these dangers have been grossly exaggerated. However, whatever dangers there were have been virtually eliminated by this new approach. The few mishaps that have occurred in the past resulted either from (1) the misuse of hypnosis as an uncovering agent, or (2) its misuse as a direct symptom remover. The first type of mishap was produced by a therapist, who would allow, or force, the patient to become aware of repressed information which he was not strong enough to face. The second type of mishap occurred when the therapist wrested away a symptom which the patient was using as a crutch before he was strong enough to stand on his own.

Hypnotizability of Patients Freud abandoned hypnosis because of “the small number of people who could be put into a deep state of hypnosis” at that time and because in the cathartic approach, symptoms would disappear at first, but reappear later if the patient-therapist relationship were disturbed (Freud, 1955, p. 237). In the above studies the only hypnotic induction failures were reported by Chong Tong Mun (eight failures out of 108 patients.) This can mean one of two things: the hypnotic induction procedures have improved since Freud’s day, or that the reconditioning approach used in these studies (as opposed to Freud’s cathartic approach) does not require very deep levels of hypnosis. There is evidence that both factors may be involved. Although many have thought that hypnotic susceptibility was a set character trait, there are a number of studies which now seem to indicate that this is not the case, and that responsiveness can be increased by certain changes in the hypnotic induction procedure (Pascal and Salzberg, 1959; Sachs and Anderson, 1967; Baykushev, 1969), as well as by means of a pre-induction talk aimed at insuring a positive attitude, an appropriate expectancy and a high motivation toward hypnosis (Dorcus, 1963; Barber, 1969; Barrios, 1969). With regard to the depth of hypnosis required for the reconditioning approach to work, there are a number of therapists who feel that only a light state of hypnosis is necessary (Van Pelt, 1958; Kline, 1958; Kroger, 1963) A study by Barrios (1969) gives this contention some ; it was found that an increase in the conditioning of the salivary response could be produced almost as effectively by lighter levels of hypnosis as by deeper levels.

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The latter point brings us to the question of whether hypnotic induction is necessary at all for the re-conditioning approach to work. Judging from the work of Wolpe (1958) it would appear that hypnosis is not an absolutely necessary requirement. This would also be ed by the work of Barber (1961, 1965) who found that hypnotic phenomena could be produced without a prior hypnotic induction. However, the real question to be answered is not whether hypnotic induction is absolutely necessary, but whether it can further facilitate the conditioning process. Wolpe, himself, concedes the hypnosis apparently does facilitate the conditioning: “Patients who cannot relax will not make progress with this method. Those who cannot or will not be hypnotized but who can relax will make progress, although apparently more slowly than when hypnosis is used.” (Wolpe, 1958, p. 141; italics added). Also, although Barrios’ (1969) study indicated that conditioning could be increased during lighter levels of hypnosis, it was also found that there was no increase in conditioning with those subjects indicating no response to the hypnotic induction. As pointed out in the theory (Barrios, 1969), hypnotic and waking suggestion are on the same continuum and hypnotic induction should be looked upon as a procedure whereby we can increase the probability of getting a more positive response to suggestion. The next question to be decided now is not so much whether hypnotic induction procedures increase responsiveness (this is fairly well accepted – e.g., Barber, 1969) but what variables in the hypnotic induction are playing the key roles and what can be done to strengthen the effectiveness of these factors.

Comparison with Psychoanalysis and Behavior Therapy In Wolpe’s comparison of his and the psychoanalytic approaches (Wolpe, Salter, and Reyna, 1964), we find the following: Based on all psychoneurotic patients seen, the number of patients cured or much improved by psychoanalysis was 45% in one study involving 534 patients and 31% in the other study involving 595 patients (the only two large scale studies in the literature on psychoanalysis). The average duration of treatment for the improved patients (given only for the first study) was three to four years at an average of three to four sessions per week, or an average of approximately 600 sessions per patient. For Wolpe’s approach we find that, based on all patients seen, the recovery rate was 65% in his own study involving 295 patients (usually [misleadingly] reported as 90% of 210 patients) and 78% in a study by Lazarus involving 408 patients. The duration of treatment for the improved patients was an average of thirty sessions in the former and fourteen in the latter. Averaging the above figures, we find that for psychoanalysis we can expect a recovery rate of 38% after approximately 600 sessions. For Wolpian therapy, we can expect a recovery rate of 72% after an average of 22 sessions, and for hypnotherapy we can expect a recovery rate of 93% after an average of 6 sessions. It is interesting to note the negative correlation between number of sessions and percentage recovery rate. At first sight this seems paradoxical. However, if a form of therapy is truly effective, it should not only increase recovery rate, but also shorten the number of sessions necessary (as well as widen the range of cases treatable).

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The Need for a Rational Explanation In spite of all the encouraging reports, there continues to be considerable hesitation on the part of psychotherapists to use hypnosis. Hypnosis is still looked upon as an “unknown” by most therapists. They are as yet not aware of any reasonable rational explanation for hypnotic phenomena that would satisfy them, one that would tie these phenomena down to observable facts and laws. As long as hypnosis continues to exude an air of mysticism and charlatanism, it will continue to be rejected by many, no matter how great the claims on its behalf.

An Explanation Based on Principles of Conditioning The experienced therapist really should not be so surprised at the effectiveness of hypnosis in facilitating therapy. Hypnotic induction can be looked upon as a technique for establishing a very strong rapport, for establishing a greater confidence, a greater belief in the therapist, whereby the latter’s words will be much more effective. As Sundberg and Tyler (1962) point out, one of the common features among all methods of psychotherapy is the attempt to “create a strong personal relationship that can be used as a vehicle for constructive change… It is a significant fact that many theoretical writers, as their experience increases, come to place much more emphasis on this variable” (pp.293-294). The question still remains, however – what exactly is the process whereby “mere words” can produce such great changes in personality. As pointed out in Barrios’ (1969) theory of hypnosis, the ability of words to produce behavior changes is really not so difficult to understand if we are familiar with the principles of higher-order conditioning. First of all, we know that words can act as conditioned stimuli. Pavlov recognized this fact: Obviously for man speech provides conditioned stimuli which are just as real as any other stimuli… Speech, on of the whole preceding life of the adult, is connected up with all the internal and external stimuli which can reach the cortex, signaling all of them and replacing all of them, and therefore it can call forth all those reactions of the organism which are normally determined by the actual stimuli themselves (Pavlov, 1960, p. 407).

Now, according to principles of high-order conditioning we know that by paring word B with word A we should transfer the response produced by word B to word A and consequently anything that would evoke word A. Thus, for example, if we wanted to condition a person to be more relaxed in the presence of people, we would pair the words “people” (A) and “relaxed” (B), using a sentence or suggestion such as, “From now on you will find yourself more relaxed in the presence of people.” Mower’s theoretical formulations on the sentence as a conditioning device (Mowrer, 1960) tend to this contention. Of course, we know that under ordinary circumstances suggestions are not always accepted (and thus conditioning doesn’t always result when an appropriate suggestion is given). Why is this? Osgood (1963) holds that a suggestion will tend to be rejected if it is incongruent with the subject’s previously held beliefs and attitudes or his present perceptions. It would seem that if there were some means of eliminating the latter we should be able to

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have a suggestion more readily accepted and thus facilitate the higher-order conditioning. Hypnosis is such a means. Thus we come to the reason hypnosis is so effective in facilitating therapy: the incongruent perceptions, beliefs, and attitudes are kept from interfering with the suggestion (and thus with the conditioning). As put by Pavlov: The command of the hypnotist, in correspondence with the general law, concentrates the excitation in the cortex of the subject (which is in a condition of partial inhibition) in some definite narrow region, at the same time intensifying (by negative induction) the inhibition of the rest of the cortex and so abolishing all competing effects of contemporary stimuli [present perceptions] and traces left by previously received ones [previously held beliefs and attitudes]. This s for the large and practically insurmountable influence of suggestions as a stimulus during hypnosis as well as shortly after it (Pavlov, 1960, p. 407; italics added).

As an illustration, let us say we wanted to change a patient’s self-image from that of an inadequate person to a more self-confident one. If under ordinary circumstances we suggested that he would no longer feel inadequate, it would most likely accomplish little. This is because the patient’s negative self-image, usually ever-present and quite dominant, would quickly suppress any positive image suggested, or at least keep it from being too vivid or real. But in the hypersuggestible hypnotic state conditions are different. The patient’s negative self-image is now more easily inhibited and should therefore be less likely to interfere when we attempt to evoke the positive self-image through suggestion. As a result, the conditioning can take place and new associations can be made. The person can truly picture himself feeling self-confident in various situations and these new conditioned associations in turn can lead to new behavior. This new attitude can now become permanent by means of self-reinforcement, just as his old negative attitude had been kept permanent by self-reinforcement. As long as the patient has negative attitudes, these are self-reinforcing. They lead to his ten, acting awkward and making numerous mistakes. Also, he is unlikely to believe any praise or any positive occurrences should they chance his way. But if this negative self-image has been replaced by a positive one, the opposite cycle can result. Being more confident and relaxed he will naturally be more likely to be accepted. Also, he will now be more open to believing and accepting praise and positive outcomes.

OVERVIEW OF MY THEORY OF HYPNOSIS* In the theory (Barrios,1969,2001) a hypnotic induction is defined as the giving of a series of suggestions so that a positive response to a previous suggestion predisposes the subject to respond more strongly to the next suggestion. Hypnosis is defined then as the state of heightened suggestibility, also referred to as a state of heightened belief, produced by a hypnotic induction. What occurs during a hypnotic induction to increase suggestibility is a process of conditioning of an inhibitory set. The latter increases responsiveness to suggestion

*

Much of the remainder of this chapter is taken verbatim from my commentary articles, Part I & II, in Contemporary Hypnosis (Barrios, 2007 a & b)

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by inhibiting thoughts and stimuli which would contradict the suggested response. The more effective the hypnotic induction, the greater this inhibitory set. It is postulated that at any point in time there are any number of stimuli (both cognitive and sensory) that one can be responsive to, some more strongly than others. This is referred to as the stimulus dominance hierarchy. The various hypnotic and post-hypnotic phenomena can be explained in of how the inhibitory set can rearrange the dominant position of a particular stimulus (cognitive or sensory) focused on by the suggestion. Post-hypnotic behavior changes are explained as produced through a process of higher order conditioning where the inhibitory set facilitates such conditioning by suppressing any dominant stimuli present (cognitive or sensory) that would interfere with the intended conditioning. From the theory, a number of ways can be deduced for increasing responsiveness to suggestion and thereby increasing the effectiveness of hypnotic induction. These include: the amplification of minute responses to suggestion such as with the use of bio devices; the minimization or inhibition of competing stimuli such as in sensory deprivation or under the influence of inhibitory drugs; and the subtle introduction of stimuli that would naturally evoke the suggested response. Since the theory defines hypnosis as a state of heightened belief, one can see that hypnosis can be a natural everyday occurrence. Salesmen, lawyers and politicians are constantly benefiting from a variation of hypnosis (the powers of persuasion). So too are doctors (the power of the placebo) and ministers (the power of faith).

COMPARISON WITH OTHER THEORIES Comparison with Sociocognitive Theories Similarities Both perspectives discuss the importance of the part played by individual differences in affecting initial responsiveness to suggestion. The following are included as individual influencing factors in both perspectives: subjects' expectations and beliefs about hypnosis; motivation and imagination (or fantasy proneness). Two areas of individual differences mentioned in the theory which apparently are not mentioned in the literature on sociocognitive theories are age of the subject and prestige of the hypnotist in the eyes of the subject. It is expected that sociocognitive theorists would agree that these are also important individual difference factors. However, the explanation for how these factors play a part according to the theory might differ from the sociocognitive perspective. With regards to age, for instance, the theory states that the reason initial suggestibility varies with age, may be traced to certain factors that vary with age. One of these is language ability. Since [according to the theory] hypnosis is dependent to a great extent on the conditioned response evoked by words, we can understand why very young children whose language ability is not yet well-developed would make very poor subjects for hypnosis, and thus why we would expect an initial gradual increase in suggestibility with increasing age ...

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An explanation for the gradual decline in suggestibility after the age of eight is that with continued increasing age the number of cognitive stimuli competing with a suggestion increases (that is, knowledge increases with age) and a corollary to the 'reciprocal inhibition' or 'stimulus dominance hierarchy' postulate is that the more stimuli in the hierarchy, the lower the probability of a reaction to any one of them ... with increasing age there will be a greater number of possible contradictory stimuli [competing with] a suggestion; that is, subjects have more information available with which to or contradict the suggestion. (Barrios, 2001: 185) With regards to prestige, It is fairly well accepted that the more 'prestige' a hypnotist has in the eyes of subjects, the better his chances of success. It is felt this is so because the statements, commands or suggestions of a person with prestige tend to be questioned less, that is, such a person evokes a greater inhibitory set to begin with. In general, people have previously been conditioned to accept at face value the statements of someone who is an authority in his field. That is, an inhibitory set which inhibits contradictory stimuli [in the stimulus dominance hierarchy] has been previously conditioned (in much the same way as in the hypnotic induction process). This is so because what the authority says has usually turned out to be true! (Barrios, 2001: 181)

It will be recalled that in the theory a positive response to a series of suggestions (the hypnotic induction) conditions in an inhibitory set to automatically inhibit any stimuli (cognitive or sensory) in the stimulus dominance hierarchy that would contradict the suggestion. Another similarity between the sociocognitive and the theory's perspective revolves around the use of what the sociocognitives refer to as 'goal directed fantasies' (GDFs). GDFs are defined as 'imagined situations which, if they were to occur, would be expected to lead to the involuntary occurrence of the motor response called for by the suggestion' (Spanos, Rivers and Ross, 1977: 211). In other words, the more cognitive stimuli used associated with the suggested response, the more likely the response. In the theory, Hypothesis IV states: 'A suggestion produces the desired response by first evoking a cognitive stimulus which is associated with that response.' And a corollary to this hypothesis, Corollary 8, states: 'The more (compatible) cognitive stimuli associated with the response evoked by the suggestion, the stronger the response to the suggestion’. For example, to increase the probability of producing the involuntary response of salivation and/or the secretion of pepsin, you might want to suggest that the subject was eating a delicious steak or, better yet, a thick juicy steak smothered in onions. A third similarity between the two perspectives is how they apparently both seem to fit in with Milton Erickson's strategic approach to therapy. How Erickson's approach fits in with the sociocognitive perspective is discussed in a very extensive article by Lynn and Sherman (2000). The following includes some examples of how Erickson's ideas parallel those presented in the theory:

Scripts In the section of Lynn and Sherman's article where they are discussing Erickson's strategy of using scripts, they point out that

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Erickson found this technique useful in engendering a 'yea saying' response pattern. He would start with questions with an obvious 'yes' answer; to establish a pattern or response set, he would keep asking such questions. Patients would [then] apparently agree to things that they would not have agreed to in the absence of such a response set. (Lynn and Sherman, 2000: 306)

This also explains the effectiveness of persuasive salesmen who 'prep' a person to buy by getting the person to respond with 'yeses' to a series of questions. If we can look upon these 'questions' as a variation of suggestions, then in both cases the individual is being put through a form of hypnotic induction according to the theory. As stated by Hypothesis III of the theory: 'a positive response to a suggestion will induce within the responding person a more or less generalized increase in the normally existent tendency to respond to succeeding suggestions' (Barrios, 2001: 178). Also related to this 'yea saying' technique of Erickson is another he often used to get positive responses to his suggestions: 'He often tied suggestions to naturally or frequently occurring responses, or more broadly to whatever response the patient made (Erickson, Rossi and Rossi: 1976). Certain naturally occurring responses, such as lowering of an outstretched arm, provide immediate positive propioceptive ' (Lynn and Sherman, 2000: 307). To see the similarity of this to what is said in the theory, see Corollary 6 following Hypothesis III of the theory: 'The response could be "artificially" induced in a number of ways. For instance, the suggestions that the eyes are going to get tired may be helped if a slight eye strain is placed on them by having the subjects look at an object at a difficult angle' (Barrios, 2001: 180).

Erickson's Altering Accessibility According to Lynn and Sherman (2000: 306), 'Response sets can be established and reinforced by altering the accessibility of facts or events in memory ... For example, imagining negative outcomes of smoking and overeating and positive outcomes of not doing so can make it easier to resist these urges.' This very same procedure is referred to as the 'Punishment-Reward' technique, one of several visualization techniques for facilitating reprogramming, in the self-programmed control (SPC) program for improving behavior (see Barrios, 1973b and Barrios, 1985: 49 and 50). These techniques and others for facilitating suggestion and post-hypnotic suggestion are derived from Corollary 8 of the theory (see above) and will be discussed further in Part II of the Commentary. (Barrios, 2007b) Reframing Reframing was a technique of Erickson's to make general positive suggestions or treatment goals more attainable. For example, one of his approaches to break a patient out of depression over certain deficits was to 'turn the patient's deficits into assets'. This is very similar to one of the positive attitudes, Positive Attitude 4, 'Learn to look for the good in even the worst of situations,' in the chapter on positive attitudes in the SPC program (see Chapter IV of Barrios, 1985). If the goal of therapy is to help the patient break free of a depression caused by some negative life occurrence, for instance, instead of the hypnotherapist giving only the general suggestion that the patient will no longer be depressed, it would be more effective if the patient is also given the suggestion that he will learn to look for the good in even the worst of situations, in this way turning the patient's deficits into assets.

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In essence, this is saying that general suggestions alone (regarding treatment goals) without guidance to substantiate the suggestions are not as effective as the combination of the general suggestion plus guidance. This basic premise will be explored again later in Part II in the section on faith healing when pointing out that belief alone (e.g. a placebo) is not as effective as belief plus guidance. In so many words, this is similar to what Lynn and Sherman (2000: 307) mean when they state that 'As implied by these examples, Erickson's approach involves considerable reframing of behaviors [so] as [to be] consistent with treatment objectives.' Another area where Erickson's ideas fit in with the theory is where he talks about how it is that hypnosis plays a part in facilitating change in behavior. According to Lynn and Sherman (2000: 305): Erickson's appreciation of the crucial role of response sets is further revealed by his (Erickson, et al. 1976) observation that, 'much initial effort in every trance induction is to evoke a set or framework of associations that will facilitate the work that is to be accomplished' (p. 58). In fact, the authors define the 'therapeutic aspects of trance' as occurring when 'the limitations of one's usual conscious sets and belief system are temporarily altered so that one can be receptive to an experience of other patterns of association and modes of mental functioning ... that are usually experienced as involuntary by the patient (p. 20). All of these comments concur with the general thrust of response set theory [except for the concept of trance]. This is very similar to what is said following Hypothesis VII of the theory (in the section on posthypnotic suggestion) about how the inhibitory set aspect of hypnosis facilitates cognitive-cognitive conditioning and thereby facilitates positive behavioral change by eliminating any stimuli present that would interfere with the conditioning: 'Hypnosis, it is felt, provides an especially effective means (the inhibitory set) whereby interfering stimuli can be readily inhibited' (Barrios, 2001: 194-5). What Erickson refers to as 'the limitations of one's usual conscious sets and belief systems' the theory refers to as interfering stimuli, cognitive stimuli whose presence would ordinarily preclude the establishment of the desired new cognitive patterns and need to be 'temporarily altered' or as the theory puts it, 'inhibited,' in order for the new patterns to be made; or as Erickson puts it, 'so that one can be receptive to an experience of other patterns of association and modes of mental functioning' (Erickson, Rossi and Rossi, 1976: 20).

Differences Relative Importance of Hypnotic Inductions One major difference between the theory's perspective and the sociocognitive one revolves around the perceived importance of hypnotic inductions. The sociocognitive perspective seems to feel that hypnotic inductions increase suggestibility only to a minor degree whereas the theory does not agree with this. As Lynn and Sherman (2000: 298) put it, 'Suggestions can be responded to with or without hypnosis, and the function of a formal induction is primarily to increase suggestibility to a minor degree (see Barber, 1969; Hilgard, 1965).'

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The problem with this perspective is that it implies that all hypnotic inductions are able to increase suggestibility only to a minor degree, and thus it is implied that hypnotic inductions are really not that necessary. Yes, it may be true that the standard hypnotic induction emphasizing relaxation used in many of Barber's studies, for instance, is capable of increasing suggestibility only to a minor degree, but as indicated by Corollaries 5 and 6, following Hypothesis III of the theory, there are ways of increasing the effectiveness of hypnotic inductions even more (see: Wilson, 1967; Wickless and Kirsch, 1989; Kirsh, Wickless and Moffit, 1999 and Wickramasekera, 1973).

State vs Non-state Another significant difference between the sociocognitive and the theory's perspective revolves around the state vs non-state issue. According to Lynn and Sherman, because researchers like Barber and his colleagues (Barber, 1969; Barber and Calverley, 1964, 1969; Barber, Spanos and Chavez, 1974) in demonstrating the importance of individual differenced in hypnotic responding showed that non-hypnotized subjects exhibited increments in responsiveness to suggestions that were as large as the increments produced by hypnotic procedures. This research ed the idea that despite external appearances, hypnotic responses were not particularly unusual, and therefore did not require the positing of unusual states of consciousness. Accordingly, there is no need for clinicians to insure that their patients are in a 'trance' before meaningful therapeutic suggestions are provided. (Lynn and Sherman, 2000: 298)

There is some truth to this last statement. Some meaningful therapeutic changes can be produced with suggestions even without a formal hypnotic induction for some individuals. This would be true especially amongst those subjects who were highly suggestible even without a hypnotic induction. And even those who might not initially be highly suggestible could have their initial responsiveness to suggestion increased by manipulating certain individual difference factors such as attitude, motivation and fears, as pointed out on pages 183 and 184 of the theory (see Weitzenhoffer, 1953; Dorcus, 1963; and Barber and Calverley, 1965 as cited in Barrios, 2001: 183 and 184). However, by following such recommendations as those presented by corollaries 5 and 6 following Hypothesis III of the theory, the effectiveness of hypnotic inductions can be increased considerably more and responsiveness to suggestion (and therapeutic success) as a result raised significantly more than after a standard hypnotic induction (see: Wilson, 1967; Wickless and Kirsch, 1989; Kirsch et al., 1999; and Wickramasekera, 1993). If it is true that certain hypnotic inductions can produce significantly higher levels of suggestibility (even in already highly suggestible individuals), then I feel we can talk in of a hypnotic and nonhypnotic state. A hypnotic state could be defined simply as the heightened state of suggestibility (or as Skinner would put it, a heightened state of belief; see Barrios, 2001: 171) produced by the hypnotic induction. Yes, it is true that on an inter-individual basis, i.e. comparing one individual to another individual, some people can respond to suggestions without a hypnotic induction at the same level as another person who has gone through a hypnotic induction. In this sense there is no difference between states. But if we go on an intra-individual basis, i.e. comparing the same

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individual before and after a hypnotic induction, the hypnotic state for a given individual can be different than the waking state, especially after an effective hypnotic induction. Just one more thing: I would not recommend using the term 'trance' to designate a hypnotic state as it has 'zombie-like' connotations and we know a person can be in a hypersuggestible hypnotic state and still appear perfectly normal.

The Best Way to Measure Hypnotizability Also related to the question of whether there is that much difference between waking and hypnotic suggestion is the question of how best to measure hypnotizability. Many in the field, especially those from the sociocognitive perspective, seem to feel that a measure of suggestibility after the hypnotic induction is more than sufficient to measure hypnotizability. They feel they need not use the difference between hypnotic and waking suggestion as the measure since they find the correlation between the two to be very high (see especially Kirsch, 1997b: 213). However, this high correlation could be due to the fact that the researchers are basing their results on studies where only the standard hypnotic induction has been used, which tends to increase suggestibility 'only to a minor degree'. As more effective hypnotic inductions are used, this correlation will be less and it will become more appropriate to use the difference between hypnotic and waking suggestibility as the more correct measure of hypnotizability or hypnotic depth as I prefer to refer to it (See also section below on preventing methodological shortcomings in hypnosis experiments taken from Barrios, 1973a)

A Comparison of the Theory with Hilgard's Neo-dissociation Theory There are a number of similarities as well as a number of key differences between the theory and Hilgard's neo-dissociation theory of hypnosis. In discussing ways that determine what actions a person will take at any one time, Hilgard talks about a hierarchy of subsystems (habits or cognitive structures) that would vie for dominant position to determine the final common path leading to action. This is very similar to the stimulus dominance hierarchy referred to in the theory except, as per the theory, sensory stimuli are also included along with cognitive stimuli in this stimulus dominance hierarchy. Hilgard proposes two possible means for determining which subsystem will be in the dominant position of the hierarchy determining which action will take place. One, which he considers the old way, is where the subsystems would fight for control of the final common path leading to action according to their relative strengths. The other possible way of determining dominant position, and the way he seems to have finally leaned towards, is by way of a central regulatory mechanism. As he puts it, the subsystems are actuated according to the demands and plans of the central system. This central regulatory mechanism is responsible for the facilitations and inhibitions that are required to actuate the subsystem selectively. A hierarchy of subsystems is implied, although it is a shifting hierarchy under the management of the central mechanism. Once a subsystem has been activated it continues with a measure of autonomy. (Hilgard, 1977: 217-18)

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He then states 'Suggestions from the hypnotist may influence the executive functions themselves and change the hierarchical arrangement of the subsystem' (p. 218). According to the original version (Barrios, 1969), the theory leaned more to the old way of looking at how the subsystems arranged themselves in the hierarchy according to their individual strengths, and the inhibitory set part of the hypnotic suggestion was seen as directly influencing the eventual positioning of the dominant subsystem by inhibiting the competing subsystems. But now I also see the possibility of a central function playing a part in certain situations. This central control function I would describe as the will of the hypnotic subject, which can be listed as another of the individual differences of hypnotic subjects which can influence a hypnotic induction, i.e. everyone has a different level of willpower or free will that they bring with them. As presented in the paper 'Science in of religion' (Barrios, 2002), free will is defined as control over one's involuntary functions (one's subconscious) via the power of belief, belief in one's ability to control one's destiny (control one's involuntary functions). This free will factor can have developed over the years or in a short period of time by means of a series of reinforced self-suggestion much like a self-hypnotic induction where the subjects come to develop their power of controlling their involuntary behavior through the power of belief. In a hypnotic induction this free will factor could either add to the depth of hypnosis achieved (the amount of heightened belief) or work against it. If the individuals see the suggestions given as working to their benefit, it would work in favor of a deeper induction. If against their benefit, it would work against a deeper induction. It would more likely work in favor of a deeper induction if in the pre-induction talk the subject is assured that all suggestions given will be positive ones or to the benefit of the subject; or if the induction is presented along the lines of self-hypnosis, i.e. as a means of developing even greater self control over one's involuntary behaviour. Now with regards to how according to Hilgard, does the hypnotic induction rearrange the hierarchy of subsystems, Kirsch and Lynn (1998: 110) feel that Hilgard 'leaves many unanswered questions: How do the hypnotist's words produce this rearrangement? ... and how does this contribute to the production of suggested responses?' In fairness to Hilgard, I feel he does present at least a partial explanation or answer to these questions. He posits two ways that hypnosis facilitates this rearrangement of the hierarchy (Hilgard, 1977): (I) 'Looked at in other ways, we find that hypnotic procedures are designed to produce a readiness for dissaociative experiences by obstructing the ordinary continuities of memories and by distorting or concealing reality orientations through the power that words exert by direct suggestion, through selective attention and inattention, and through stimulating the imagination appropriately' (p. 226)

And (2) 'The stress on muscular relaxation, familiar in hypnotic inductions assists in disorientation ... The lack of appropriately aroused memories makes the hypnotically responsive person less critical. To be critical requires comparing a present observation with familiar ones to judge its veridicality. If the memory context recedes, criticism also recedes. Hence imagination more readily becomes hallucination ... These illustrations show how memory interference has

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Alfred Barrios helped produce the dissociations found in hypnosis ... Under such circumstances, response to stimulation provided by the hypnotist takes precedence over planned or self-initiated action [the central regulatory mechanism] and the voice of the hypnotist becomes unusually persuasive'. (p. 227)

In somewhat different wording, Hilgard is saying the same thing that the theory is saying as to how and why hypnotic phenomena occur. The theory states that the suggested response occurs because the stimulus focused on by the suggestion rises to the dominant position in the hierarchy because the inhibitory set produced by the hypnotic induction inhibits the competing cognitive stimuli in the hierarchy (what Hilgard refers to as 'critical memories') as well as any present 'critical' sensory stimuli - something Hilgard does not include in his explanation. Something else that Hilgard does not include, which the theory does, is how this inhibitory set referred to is built up during the hypnotic induction through a process of conditioning. Hilgard does talk about selective attention and inattention (both of which have inhibitory components) and stimulating the imagination appropriately (i.e. triggering a cognitive stimulus) as part of the power that words exert through direct suggestion, but he does not explain why or how the hypnotist's words have become even more powerful after a hypnotic induction - which the theory explains as the build-up of, or conditioning in, of a strong inhibitory set. With regards to the part suggestions of relaxation play in producing the state of hypnosis, it is pointed out in the theory that suggestions of relaxation or sleep may help since the relaxed or sleep-like state 'may provide for even greater inhibition of stimuli competing with the suggestion' (Barrios, 2001: 172). However, the theory makes clear that a hypnotic state can be produced without any suggestions of relaxation or sleep.

Involuntary Behavior and the Subconscious There is one more thing that I would like to point out regarding similarities and differences between my perspective and Hilgard’s (and the sociocognitive & response set perspectives as well). It has to do with the automaticity of most behavior. It appears that all current theories concur with this apparent fact. One difference is that I have gone on to label this behavior as subconscious behavior or “the subconscious”: “The subconscious, or subconscious behavior, can be defined as behavior (learned or innate) that is so deeply programmed as to occur automatically without the need for that much conscious attention, if any (i.e. below conscious awareness). Driving a car is an example of learned subconscious behavior. When first learning to drive, you had to be aware of (be conscious of) every little movement. Now all the movements have pretty much become automatic. The ‘subconscious’ is to be differentiated from the ‘unconscious’ which can be defined as engrams or memories below immediate conscious accessibility. Most adult human behavior falls under the heading of subconscious behavior. The advantage of subconscious behavior is that it allows us to do many things at once, and relatively quickly. The main disadvantage is that once programmed in, the behavior is so automatic that it becomes difficult to change.” (Barrios, 2002, p.7) It is the latter fact, i.e. that certain automatic behaviors are so hard to change, that makes hypnosis such a valuable tool. Hypnosis provides us a systematic means of controlling the subconscious, of being able to rearrange the hierarchies of automatic behavior. And the more

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deeply imbedded this automatic behavior that we wish to change is (i.e. the higher in the hierarchy it is), the more effective a hypnotic induction is needed. It is this ability of hypnosis to facilitate post-hypnotic behavior change that plays the biggest part in making hypnotherapy so much more effective than any other form of therapy. The biggest problem with most people is that it is very hard for them to change. So anything that can facilitate change or re-programming will play a major role in achieving therapeutic success. In a way one can say that all humans are automotons because most of their behavior is automatic. But one major difference between humans and robots is that humans have the potential (through the free will factor) to reprogram themselves when necessary. Keep in mind, however, I said humans have the potential for re-programming but this potential has to be brought out and it is with tools like hypnosis and self-hypnosis that this can be done. It should be realized that when hypnosis is used in a therapeutic setting there are two ways that a hypnotherapist can help: One is to help add to the suggestibility (belief) factor sufficiently with an effective hypnotic induction in order to transcend or overcome certain negative automatic habits or cognitions that the patients with their own level of free will have been unable to accomplish. The other way the therapist can help is by providing the patients with some good guidance, a good idea of what habits and cognitions need to be changed. Now sometimes the latter is all that is needed and together with a sufficient level of free will to begin with the patients can then bring about the needed restructuring of the hierarchy on their own even without a hypnotic induction. But if the negative behavior is too high in the hierarchy for the patients’ own level of free will (own willpower) to rearrange it, this is when an effective hypnotic induction can be especially beneficial.

A Comparison with the Response Set and Response Expectancy Theory of Hypnosis There are a number of similarities and differences between the theory and the response expectancy perspective (Kirsch, 1985, 1997a, 2000). The following will present both the similarities and the differences. First, a major difference between the two is that Kirsch believes, as do most sociocognitivists, that 'The induction of hypnosis, for example, has a relatively small effect on the degree to which people respond to typical hypnotic suggestion' (Kirsch, 2000: 276). As already pointed out, although this statement might be true for the standard relaxation-type induction, it is not for other more effective types of hypnotic induction (see: Wilson, 1967; Wickless and Kirsch, 1989; Kirsch et a1., 1999; and Wickramasekera, 1973). The second major difference (and similarity) between the two revolves around his use of the term 'response expectancy'. Kirsch seems to feel that the key to increasing hypnotic responding is by increasing the subject's response expectancy (see Kirsch 2000: 275). I would be more inclined to agree with Kirsch if he were to use the term 'belief' in place of 'response expectancy'. Kirsch prefers to use the latter to describe what is being manipulated by a hypnotic induction whereas I would prefer to use the term 'belief'. As Kirsch puts it: 'A path analysis ed the hypothesis that hypnotic inductions enhance responsiveness by altering response expectancies' (1985: 1195). In the original theory I do refer more to 'suggestibility' as to what is being manipulated by a hypnotic induction. However, I have come to see the term 'suggestibility' as having some negative connotations, with some people possibly relating it to the term 'gullibility'.

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Consequently I now prefer to follow Skinner's lead of using the term 'belief' in describing hypnosis. As Skinner put it: With respect to a particular speaker, the behavior of the listener is also a function of what is called belief (a term very similar to suggestibility) ... our belief in what someone tells us is similarly a function of, or identical with, our tendency to act upon the verbal stimuli which he provides. If we have always been successful when responding with respect to his verbal behavior, our belief will be strong ... Various devices used professionally to increase belief of a listener (for example by salesmen or therapists) can be analyzed in these . The therapist may begin with a number of statements which are so obviously true that the listener's behavior is strongly reinforced. Later a strong reaction is obtained to statements which would otherwise have led to little or no response. Hypnosis is not at the moment very well understood, but it seems to exemplify a heightened 'belief' in the present sense (Skinner, 1957, pp. 159-160). (See Barrios, 2001: 171)

Now getting back to 'response expectancy' and why I prefer the term 'belief': one problem with the former term is that it implies that there is a visible response connected to the expectancy. Yes, you can get someone to produce the visible response of 'arm rising' if he has a strong response expectancy of 'arm rising'. But where is the visible response when the response expectancy is that the subject will see the color red? Not all cognitions necessarily have a clearly visible response attached to them. Next comes the question of how response expectancy or belief produces responses. Kirsch himself poses the question thusly: 'To accept a suggestion is to believe or expect that these events will in fact happen. So the real problem is to understand the effects of response expectancy on experience, behavior and physiology. How does response expectancy produce these changes?' (Kirsch 2000: 279). (Note how Kirsch uses the 'believe' and 'expect' interchangeably here which would lead one to believe that he might also be willing to use 'belief' and 'expectancy' interchangeably.) Kirsch's answer to this question is to posit some underlying substrate or connection between actual responses and the expectancy of that response. As he puts it, 'if we assume that there is a physiological substrate for any experiential state, then a change in perception is always a change in physiology, as well. For that reason, expectancy induced changes in experience will always be accompanied by at least some physiological change' (Kirsch, 2000: 280). And, 'Just as the expectation of an experiential response tends to generate that response, so too the expectation of an overt automatic response promotes its occurrence' (p. 280). The main difference between mine and Kirsch's explanation for how belief/response expectancy leads to responses is that first of all I explain how there is a response connected to the suggestion (as a result of classical conditioning - see the Pavlov quote on page 167 of the theory, Barrios 2001); and second, I explain the heightened response to hypnotic suggestion as resulting because of the greater inhibitory set produced by the hypnotic induction which inhibits competing stimuli. A third major difference between our perspectives is how we explain how response expectancy/belief can be increased in hypnotic situations. According to Kirsch: There are three kinds of cognitions that ought to affect response expectancies in hypnotic situations: (a) perceptions of the situation as more or less appropriate for the occurrence of

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hypnotic responses; (b) perceptions of the response as being appropriate to the role of a hypnotized subject ... and (c) judgments of one's hypnotizability. (Kirsch, 1985: 1194)

As for his first two ways (a and b) I agree. These are covered in the theory under the heading of 'Subjects' expectation' in the section on 'Individual differences factors influencing hypnotic induction' (see Barrios, 2001: 181-3). It is pointed out that (a) as a result of the expectancy of being hypnotized, subjects are more likely to ascribe correctly the occurrence of the 'strange' phenomena to the hypnotist than to some external cause' (p. 182); and (b) 'Subjects' expectations of what hypnosis is like can influence hypnotic induction in other ways. For example if the subjects are told that a catalepsy of the dominant hand occurs when they experience hypnosis (Orne, 1959), then as subjects feel themselves responding, they are also indirectly being given the suggestion of catalepsy of the dominant hand. This response can, in turn influence the hypnotic induction, as can any positive responses to previous suggestions' (p. 183). With regards to how Kirsch describes methods of affecting response expectancies by manipulating 'judgments of one's hypnotizability', I differ significantly with Kirsch. What he describes as one way of manipulating judgments of hypnotizability by surreptitiously provided experiential simply as 'an expectancy modification procedure' (Wickless and Kirsch, 1989: 762), I would directly refer to as an actual hypnotic induction according to Corollary 6, following Hypothesis III of the theory, which states that surreptitiously provided would facilitate a hypnotic induction (p. 180). As indicated on page 171 of the theory, hypnotic induction is defined as the giving of two or more suggestions in succession so that a positive response to one increases the probability of responding to the next one. And Hypothesis III states 'A positive response to a suggestion will induce within the responding person a more or less generalized increase in the normally existent tendency to respond to succeeding suggestions.' It is interesting that Kirsch states that: 'According to response expectancy theory, people's beliefs about their hypnotic ability are one of the determinants of the number of suggestions to which they are able to respond successfully' (Wickless and Kirsch, 1989: 762). Now if he would also say that the number of suggestions to which subjects are able to respond successfully is in turn a determinant of people's belief about their hypnotic ability, he would be coming very close to saying what is said in Hypothesis III of the theory.

Summary of the above Similarities and Differences There were a number of similarities and differences presented between the theory and three current theoretical perspectives. Among the similarities between the theory and the Sociocognitive and Response Expectancy theories is the emphasis on the importance of the part played by individual differences in affecting initial responsiveness to suggestion; how both the theory and the Sociocognitive theories seem to fit in with Milton Erickson's strategic approach to therapy; and how similar the theory is to the Response Expectancy theory if one can look upon the term 'response expectancy' as equivalent to the term 'belief'. The main similarity between the theory and Hilgard's theory is the use of a stimulus dominance hierarchy concept to explain what actions a person will take at anyone time and how hypnotic induction influences a rearrangement of the hierarchy. The main difference between the theory and the Sociocognitive and Response Expectancy theories is that the latter two perspectives seem to imply that all hypnotic inductions can

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increase suggestibility only to a minor degree whereas the theory predicts that there are ways of increasing the effectiveness of hypnotic induction beyond just a 'minor degree'. And related to this, the theory, as opposed to these other two perspectives, concludes that there can be such a thing as a 'hypnotic state' which is significantly different from the 'waking state'.

for the Theory Numerous studies and experiments in of the theory were presented in the original publication of the theory (Barrios, 1969). This included the experiment done by the author to Hypothesis VII of the theory – that hypnosis facilitates the higher-order conditioning produced via post-hypnotic suggestion (the explanation provided by the theory for how posthypnotic suggestion works). The results ed the three predictions made from the hypothesis: (a) The hypnosis group (N=43) showed greater conditioning (p<.01) than the control group (N=42); (b) the amount of conditioning for the hypnotic group was correlated with hypnotic depth (p<.01); and (c) this conditioned response, once formed, was a strong one, as evidence by little extinction and the phenomenon of spontaneous recovery. (Barrios, 1973a) Further for the Theory Further for the theory since its original writing (Barrios, 1969) comes from at least three areas: (1) studies on the use of subtle sensory reinforcement; (2) the area of bio; and (3) studies on sensory deprivation.

Subtle Reinforcement Studies Corollary 6 following Hypothesis III of the theory states: 'An hypnotic state can be facilitated if, along with each of the first few suggestions given in a hypnotic induction, the actual sensory stimuli which would ordinarily evoke these suggested responses accompany the suggestions without the subject's knowledge.' There are at least three studies whose results this corollary. The first was part of a Ph.D dissertation submitted in 1967 (Wilson, 1967), which I did not become aware of until after I had submitted my dissertation. Wilson had subjects experience surreptitiously provided reinforcement of suggestions. 'After suggesting that subjects imagine the color red, for example, Wilson imparted a faint red tinge to the room via a hidden light bulb. Subsequent testing of waking suggestibility on the Barber Suggestibility Scale (Barber, 1969) revealed substantially higher scores among these subjects than among controls' (Wickless and Kirsch, 1989: 762). A subsequent study by Wickless and Kirsch (1989) essentially confirmed Wilson's findings. They found that 53% of the group that had been given surreptitiously provided experiential scored as highly hypnotizable as compared to only 6.7% of the control group. In a follow-up study Kirsch et al. (1999) found that, once again, surreptitiously provided experiential significantly increased responsiveness to suggestion. And this time an additional important fact was determined - that for this to occur it was important that the subjects not be aware of the artificial source of the reinforcement (as stated in Corollary 6).

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Those subjects that were allowed to detect that the reinforcement was artificial showed no increase in responsiveness.

Bio Studies Bio can be defined as the use of special devices to amplify automatic responses for the purpose of gaining greater control of these responses. For the most part, the typical responses have been relaxation-related such as Galvanic Skin Response (GSR), heart rate, Electromyography (EMG) and fingertip temperature, although bio need not be limited to just relaxation responses. A typical procedure might involve having the subject focus on thoughts of relaxation and being given the goal of causing the movement of the bio measure in the appropriate direction; for example, slowing the heart rate down or raising fingertip temperature. As I see it, the reason bio has proven to be so effective for gaining control of involuntary physiological responses is that in actuality, subjects being treated with bio are being put through a form of hypnotic induction as defined by the theory. , a hypnotic induction 'is defined as the giving of two or more suggestions in succession so that a positive response to one increases the probability of responding to the next one' (Barrios, 2001: 17). Suggestions (or goals) of relaxation, whether instigated by the bio operator or by the subjects themselves, produce initial minute relaxation responses which are immediately amplified by the device and thus made more visible to the subject. These act as an immediate reinforcement letting the subjects know that they have responded positively to the suggestions of relaxation. The resultant heightened belief should in turn allow the subjects to respond even more strongly to succeeding suggestions of relaxation. Although the widespread use of bio devices has been around only since about the 1970s, the basic principle behind bio has been used to facilitate hypnotic induction long before that if we can look upon the Chevreul Pendulum as a hypnotic aid device; for if you stop to think about it, the Chevreul Pendulum is in actuality a bio device. What the pendulum does is amplify minute ideomotor movements of the hand when the thought of a particular movement is suggested. Many in the hypnosis field recommend use of the Chevreul Pendulum as a 'warm up' procedure to get subjects in a more receptive mood for hypnosis (e.g. see Lynn and Sherman, 2000: 202). In fact a complete hypnotic induction procedure starting with suggestions of movements of the pendulum has been devised (see pendulum technique in Barrios, 1985: 36-8). There has been at least one study where the use of autonomic bio did lead to an increase in suggestibility. Wickramasekera (1973) using forms A and B of the Stanford Hypnotic Susceptibility Scale found a significant increase (p = 0.001) in suggestibility upon using EMG bio to reinforce suggestions of relaxation. There is, however, one caveat to this study. One does not know whether it was the deepened state of relaxation or the use of bio, or a combination of the two that increased suggestibility. One way to truly test the hypothesis that the use of bio devices, per se, sans relaxation suggestions, can increase suggestibility is to not use relaxation suggestions. For instance, one could use a temperature bio device with suggestions of coldness in the hands (e.g. 'as if you were placing your hand in cold or ice water') to cause the device to indicate a drop in hand temperature. One could also use a heart rate bio device to feed back heart rate

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increase in response to suggestions of heart rate increase ('as if you were in an athletic competition').

Sensory Deprivation Studies Corollary 9 following Hypothesis V of the theory states that 'suggestibility should be increased if sensory stimulation is curtailed'. Further of this corollary was provided by a number of different studies: Sanders and Rehyer (1969) using the Stanford Hypnotic Susceptibility Scale (SHSS) forms A and B and working with ten subjects initially resistant to hypnosis and an equivalent control group found sensory deprivation did significantly increase enhancement of hypnotic susceptibility. Also using SHSS forms A and B, Wickramasekera in two separate studies (1969, 1970) achieved similar results.

PREVENTING METHODOLOGICAL SHORTCOMINGS IN HYPNOSIS EXPERIMENTS The main problem in many hypnosis experiments prior to the publication of the theory (Barrios, 1969) and very possibly afterwards as well lies in their methodological shortcomings. This problem was specifically addressed in the above-mentioned study on testing Hypothesis VII of the theory (Barrios, 1973a): Several such shortcomings are reviewed below with reference to the way in ' which the present study attempts to eliminate them. (Shortcomings 1-4 will be familiar to most readers as those expounded upon recently by Barber [1969b] and Barber and Calverley [1966a].) 1. In many cases there was no comparison with a non-hypnotic control group. In such studies one could not be sure that presenting the suggestion, without inducing hypnosis might not have· achieved the same results. (This is especially true of the clinical studies.) In the present study not only was there a non-hypnosis group, but, in addition, each S acted as his own control. 2. When control Ss were used, the experimental Ss were usually pre-selected for their high hypnotic susceptibility, whereas controls were not, or, even worse, the controls were sometimes selected for their poor hypnotic susceptibility. In such cases one could not be sure that it was the actual hypnotic induction, and not the high initial level of suggestibility of the experimental Ss, that produced the difference in effect. . In the present study there was no pre-selection of Ss for hypnotic susceptibility, directly or indirectly. The standard procedure for recruiting college Ss was followed, and Ss were randomly assigned to one of the two groups. It should be mentioned that still another often referred to shortcoming was eliminated by the design - there was no more time or special attention spent on the hypnotic Ss than on control Ss. 3. In experiments where hypnotic Ss have been used as their own controls it is usually obvious to these Ss which is the control state. As Barber (1962) points out, these Ss could ensure a worse performance in the control state, sensing that this is what E expects of them. This point was also brought out in the study by Scharf and Zamansky (1963). According to Orne (1959), the demand characteristics of an experiment may be particularly pronounced in hypnotic experiments because Ss recognize that they are expected to do better in hypnosis and, thus, we might also anticipate they are more likely to do poorer during the control phase

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(see also Barber, 1969b). In most hypnosis experiments this may very well be the case since the "own-control" session is run after the hypnosis session. In the current experiment the own-control" session was run first for all Ss, and before they even knew hypnosis was to be involved. 4. In experiments where controls have been used, E has not usually controlled for difference in tone of voice or other subconscious differences in treatment of the groups, thus possibly biasing the results in favor of his hypothesis. That differences in tone of voice can have an effect was shown in a study by Barber and Calverley (1964). This shortcoming was taken care of in the current experiment by the extensive use of tapes. 5. Most of the responses used as the dependent variable in PHS experiments are highly subject to voluntary control. Such use of voluntary responses are more apt to lead to the criticism that S was faking - just performing the response to please the hypnotist. In the current experiment use was made of the salivary response, a response that is considerably less subject to voluntary control than most responses previously used in PHS experiments. 6. Controls have usually not been run for the effect of the hypnotic state, per se. Some might feel that the posthypnotic changes can be produced by just the state itself, rather than any specific suggestion. This shortcoming was taken care of in the design by means of a neutral stimulus. If the salivary responses obtained were due solely to the effects of having been hypnotized, we should find no difference between the response to the conditioned stimulus and the response to the neutral stimulus. As can be seen by the results, this was not the case. 7. Perhaps the most prevalent, as well as the most insidious, of the shortcomings is that the usual indicants of hypnosis are misleading. This includes both (a) the "antecedent" type of indicant where E assumes that hypnosis has been induced because Ss have been put through a standard hypnotic induction, and (b) the "consequent" type of indicant where E concludes that hypnosis has been induced because of S's responsiveness to a set of test suggestions given after S is hypnotized. (a) The basic problem with the antecedent indicant is that it usually leads one to the incorrect conclusion that the results of the experiment hold for hypnosis in general, when actually they hold only for the particular hypnotic induction used. For example, many people seem to commit this error with regard to many of Barber's (1969b) experiments where he appears to operationally define hypnosis as a “standard 15 minute induction," and where he concludes that task motivating instructions (TMI) can produce hypnotic phenomena as effectively as a hypnotic induction. The use of such an antecedent indicant is quite acceptable as long as E makes it clear that any conclusions regarding hypnosis refer only to this narrow, operationally-defined band on the hypnosis continuum. Apparently this has not been done sufficiently, for many have mistakenly interpreted Barber as implying that hypnosis is not as effective as had previously been thought. Underlying such overgeneralizations are two basic assumptions, both subject to questioning. First, there is the assumption that hypnotic responsiveness is a fixed charactertrait, heretofore accepted as fact. Recent studies (e.g., Barber, 1964) seem to indicate that such an assumption is not justified, and a considerable number of studies indicate that responsiveness can be increased with improved methods of hypnotic induction (Barber, 1969a; Baykushev, 1969; Dorcus, 1963; Klinger, 1968; Pascal & Salzberg, 1959; Sachs & Anderson, 1967; Wilson, 1967).

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Thus, it is incumbent upon any E "testing the effectiveness of hypnosis" that he make it very clear that his experiment is merely testing the effectiveness of a particular hypnotic induction procedure and not hypnosis in general. The second assumption open to questioning is that hypnotic induction primarily involves the giving of suggestions of relaxation, drowsiness, and sleep (after S has been properly motivated and a positive attitude and expectancy toward hypnosis established). According to the definition of hypnotic induction (discussed later in the paper) given in the theory proposed by the author (Barrios, 1969), this is just one form of hypnotic induction. Barber's TMI followed by his test suggestions in ascending order of difficulty would also classify as a hypnotic induction. Thus, when Barber states that his TMI are just as effective as hypnotic induction, one should realize that he is merely comparing, the relative effectiveness of two forms of hypnotic induction. Thus, it is also incumbent on E to let the reader know how he defines hypnosis and that results refer primarily to this definition and not "hypnosis in general." (b) The trouble with the consequent type of indicant is that it is merely a measure of responsiveness, not increase in responsiveness. A truer indicant of how effective a hypnotic induction is (and the one used in the present study) would be the difference in response to test suggestions given both after and before S is hypnotized (T2 - Tl). Using T2 alone as the indicant can be misleading in a number of ways. For example, a hypnotic induction could be ineffective and we could still get a high T2 score if Ss were high responders to begin with. Conversely, a hypnotic induction could be effective but not show up as such if Ss were very low responders to begin with.

BENEFITS OF THE THEORY Explaining the Effects of Hallucinogens One of the benefits of the theory is that it led to my theory on the hallucinogens (Barrios, 1965). The same principles of inhibition and conditioning used to explain the behavioral and therapeutic effect of hypnosis presented in the hypnosis theory including the Stimulus Dominance Hierarchy concept were used to explain the behavioral and therapeutic effects of the hallucinogens. These effects are seen as resulting from the hyper-responsive, hypersuggestible state produced by the inhibitory aspects of the hallucinogens in the same way as the hypersuggestible state of hypnosis is produced by the inhibitory set aspect of hypnosis. One important point that needs to be made is that for one to achieve therapeutic effects from use of the hallucinogens’ hypersuggestible state, it is most productive if it is a controlled state. In the controlled state positive suggestions can be properly directed at whatever positive therapeutic changes are needed. If uncontrolled, the hypersuggestible, hyper-responsive state can lead to a number of problems. It can lead to uncalled for hallucinations and delusions which to someone not fully understanding what is going on, not in control, can become quite frightening. It is felt that the many cases of psychotic breakdowns reported as resulting from unsupervised ingestion of hallucinogenic drugs could very well have been due to this uncontrolled state of hypersuggestibility with resultant frightening hallucinations and

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delusions and the (heightened) belief that they would be permanently occurring; the latter being possibly the main reason for the psychotic state continuing long after the drug effects wore off.

An Explanation and Possible Cure for Schizophrenia One may wonder if something very similar to this frightening state of uncontrolled hypersuggestibility isn’t at the bottom of non-drug induced psychotic-breakdowns. One question that would need to be answered here of course is what could have led to this state of uncontrolled hypersuggestibility, hyper-responsiveness, in the first place? We know that a certain percentage of the population is highly suggestible to begin with. (Could this possibility be because some individuals have a higher concentration of hallucinogenic-type chemicals in their bloodstream than others? If so, this would fit in with the idea that schizophrenia is caused by a “chemical imbalance”.) Is it possible that a state of high stress or anxiety or certain negative thinking could cause this suggestibility to get out of control? And if uncontrolled heightened suggestibility does play a part leading to psychoses, such as schizophrenia, could a form of controlled hypersuggestibility (such as hypnosis) be used to somehow reverse the psychosis; i.e., cure the psychosis? Could it be used to reverse the belief that the psychotic symptoms would be permanent? We know hypnosis could be used to remove the causes of any precipitating high stress, anxiety or negative thinking. There are some interesting possibilities here. (See the above mentioned studies by Abrams, 1963 & 1964 and Biddle, 1967 on the successful use of hypnosis in the treatment of psychoses.) One of the most phenomenal hypnotherapy cases I have worked on was that of a paranoid schizophrenic whom I cured in one three-hour session by making use of the hypnotic state of heightened belief to reverse the negative thinking, the negative beliefs underlying her paranoia: “Maria, a woman in her late thirties, was brought to me by her sister out of desperation. The woman had been suffering from paranoid schizophrenia for the past three years and she was getting worse. Her primary symptom was the delusion that people were ‘out to get her’. She had also recently shown signs of being homicidal - having so scared her husband with very real threats on his life that he moved out. As with many psychotics, Maria had been put on a drug treatment program and sent home, even though not cured. The drugs had only served to mask the symptoms, and little had been done about getting rid of the root cause of her problem. When I saw her, she had stopped taking the drugs, without approval. One advantage I had was the fact that I had cured her 27-year-old nephew of heroin addiction - in a total of only three sessions, incidentally. The all important belief or prestige factor was thus quite high from the beginning. The first half of the three-hour session was devoted to getting some idea of the root causes of her problem. It wasn't too long before I saw that she had deep-seated feelings of inferiority and as a result she felt that no one could possibly love her. Judging from her background, I could see why she might have thought this. Coming from a minority background, she had been conditioned to think of herself as inferior from an early age. Her subsequent life experience only served to add to this low self-image. She had been a heroin addict for a good part of her life and had resorted to prostitution as well as dealing in

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heroin to her habit. The latter had resulted in her spending five years in prison, so she was an ex-con as well. The breakdown had been triggered by a younger sister who, in a fit of temper, one day threw all this in her face. How did I cure her in just one session? Using the Pendulum technique (p. 36) I put her into a state some people refer to as hypnosis, but which I prefer to think of as a state of increased responsiveness to words. Once she was in this state, I was able to convince her that she was indeed capable of being loved. I pointed out all her good points and assured her that her family, and especially her husband, did love her. Others before me had tried to convince her of this, but to no avail; the words had gone in one ear and out the other. But in this state of increased responsiveness to words, I was now more able to get through. Within a week every one of her symptoms – hallucinations, delusions, etc. - were gone. She had gotten back with her husband and was happily looking forward to a trip to San Francisco with him. Six months later when I called to see how she was doing, her sister informed me that she continued to be fine and free of symptoms. The most amazing thing about this case was that I had been able to cure this woman of paranoid schizophrenia in just one three hour session. Such a feat is considered so extraordinary that I hesitated mentioning it lest I be labeled a charlatan by my fellow professionals - for paranoid schizophrenia is a most difficult mental illness to cure. It usually takes months, even years and many are never cured. So to say that I cured such a case in one session is almost like someone claiming to have cured a case of cancer by "laying on of the hands". I have included it because I want the reader to see the real potential of an approach that allows the power of the word to really get through. This is not to say, of course, that all such problems can be cleared up in just one SPC session. But still, it should take a lot less time and be more effective than if a standard approach were taken.” (Barrios, 1985, pp. 23 & 24)

A Possible Explanation and Cure for Bipolar Disorder Could it be that an explanation for bipolar disorder (once referred to as manic – depressive disorder) lies along similar lines? If in a state of hypersuggestibility, hyperresponsiveness, cognitive stimuli can be amplified to cause psychotic delusions and hallucinations, why not the possibility of manic and depressive thoughts or behavior also being magnified in a similar uncontrolled hyper-responsive state leading to a state of hypermania or hyper-depression? And if so, then one can see the possible use of hypnosis to also helping one regain control and toning down or reversing these hyper states as well as getting rid of any underlying negative states of mind adding to the problem.

Explaining the Effectiveness of Bio As pointed out in Part I, the reason bio has proven to be so effective for gaining control of involuntary behavior is that in actuality subjects being put through a bio procedure are being put through a form of hypnotic induction.

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Helping Towards a More Comprehensive Theory of Learning We know that dramatic, all-encoming changes can take place in hypnotherapy, sometimes overnight. This often means that all the negative habits, attitudes and beliefs associated with a patient's negative behavior can be transformed even after just one hypnotic session (see pages 23 and 24 of Barrios, 1985, a case of paranoid schizophrenia). 'Understandably, a learning theorist might hesitate before accepting the possibility that it is a process of conditioning which underlies the dramatic changes produced in hypnotherapy. One-trial conditioning and functional autonomy are not commonly encountered in the laboratory' (Barrios, 2001: 196). How is this possible and yet explainable in of principles of conditioning? First of all, we would have to establish that, as stated in Hypothesis VI of the theory: 'Suggestion leads to behavior change by a form of higher-order conditioning called C-C conditioning.' This hypothesis is given considerable by Mowrer's theoretical formulations on the sentence (a form of suggestion) as a conditioning device (Mowrer, 1960: 141-2, 147). But we would still have to explain the fact that suggestions are not always readily accepted, that sentence conditioning does not always take place. As pointed out in the theory (Barrios, 2001: 194 and 195): We will find that the answer to this question will begin to throw some light on the part played by hypnosis in facilitating C-C conditioning. Osgood perhaps best answered this question in his presidential address to the American Psychological Association when discussing Mowrer's concept of the sentence as a conditioning device. According to Osgood (1963), if the assertion made by the sentence (the suggestion) is incongruent with subject's previously held beliefs and attitudes (the cognitive environment) or their present perceptions (the sensory environment), it will tend to be suppressed ... Since incongruent or incompatible beliefs, attitudes, perceptions, etc., tend to suppress the cognitive stimuli to be paired, they thus interfere with the conditioning. Therefore, we hypothesize that anything that would eliminate such interfering stimuli should facilitate C-C conditioning ... This leads to the part played by hypnosis in the facilitation of conditioning. Hypnosis, it is felt, provides an especially effective means (the inhibitory set) whereby interfering stimuli can be readily inhibited.

And this inhibitory set can be so efficient as to have the conditioning take place in only one trial. Regarding the functionally autonomous nature of the posthypnotic response: It is felt that the functionally autonomous nature of the post-hypnotic conditioned response can best be explained if an interference theory explanation of extinction is assumed. This theory states that in order for a response to become extinguished, another incompatible response must become conditioned to the CS. An implication from this interference theory would be that if the CR is stronger than a potentially interfering response, the latter will be the one inhibited. Thus, as long as there is a strong enough CR to begin with, it can keep itself from being extinguished. (Barrios, 2001: 195)

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As implied above in pointing out how the strong inhibitory set aspect of hypnosis can lead to strong one trial conditioning, we can see how this strong inhibitory set can also lead to functionally autonomous posthypnotic responses. The large part played by the inhibitory set in facilitating conditioning and leading to strong conditioned responses is ed by the work of Harry Harlow (1959) and his errorfactor theory. He considered much of learning to involve the inhibition of what he referred to as error-producing factors, referred to in the theory as competing stimuli (Barrios, 2001: 195).

Explaining the Placebo Effect In discussing the broad implications of the definition of hypnotic induction, it was stated that the theory could also be used to explain 'the hypnotic effects (placebo effect) of psychotherapists and doctors of medicine' (Barrios, 2001: 171). The question is how? The section of the theory on prestige helps throw some light on this question: [T]he statements, commands or suggestions of a person with prestige tend to be questioned less; that is, such a person evokes a greater inhibitory set to begin with. In general, people have previously been conditioned to accept at face value the statements of someone who is an authority in his field. That is, an inhibitory set which inhibits contradictory stimuli has been previously conditioned (in much the same way as in the hypnotic induction process). This is so because what the authority says has usually turned out to be true. (Barrios, 2001: 181)

The placebo when given by a doctor or person of authority works in the same way as hypnotic suggestion, for the person is in a heightened state of belief. For example, when the doctor gives a patient an injection 'to kill the pain', he is essentially giving the suggestion 'this is going to ease your pain'. The actual pain relief occurs even if the injection is an inert saline solution because of two factors associated with suggestion. First, the cognitive stimulus 'pain relief' with its associated endorphin (the body's natural pain killing substance) release into the bloodstream. And second, the inhibitory set of the suggestion is evoked that would inhibit anything that might interfere with the cognitive stimulus, such as any doubts about the doctor's skills, or doubts about the painkiller's effectiveness, or even the sensory pain stimulus itself. As another example, when the doctor gives the patient any medicine or treatment that he says will cure the patient, the cognitive stimulus 'healing' is evoked with its attendant immune associated response (e.g. release of t-cells, macrophages, etc.).∗ The next question that needs to be answered is from whence do the cognitive stimuli 'pain relief' or 'healing' derive their meaning: i.e. how did the words or thought 'pain relief' come to be associated with endorphin secretion or how did the word or thought 'healing' come to be associated with the immune response? I would say the answer is: through a process of higherorder classical conditioning. As Pavlov (1960: 407) so aptly put it: 'Speech, on of the whole preceding life of the adult, is connected up with all the internal and external stimuli which can reach the cortex, signaling all of them and replacing all of them, and therefore can ∗

One can also tie in this placebo healing effect with the idea of creating a state of hopefulness through the power of belief. When a patient strongly believes he is being healed you can say a state of hopefulness has been created. And studies have shown that a mental state of hopelessness can suppress the immune system, and replacing the state of hopelessness with one of hopefulness can help revive the immune system (see discussion on faith healing in the next section).

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call forth all those reactions of the organism which are normally determined by the actual stimuli themselves.' In other words, at some point in a person's life, the words or thought 'pain relief' were associated with the body's own natural pain relieving endorphin secretion response; and the word or thought 'healing' was associated with the body's own natural healing response while the person was experiencing the same. There, of course, is another way that a placebo response can occur. This would be more from a form of first-order classical conditioning. For instance, when a person or animal is injected a number of different times with a pain killing medication, the stimuli associated with the injection (e.g. the syringe, the person giving the injection, etc.) are the conditioned stimuli (the CS). The pain relief (the UCR) produced by the actual painkiller, let's say morphine (the UCS), becomes associated with the CS such that the CS can eventually produce a conditioned response (CR) of pain relief. This CR can then also be looked upon as a placebo - in this case produced via first order conditioning. I believe this is what is behind the conditioning explanation of the placebo response of such researchers as Gliedman, Gantt and Teitelbaum, 1957; Hernstein, 1962; Knowles, 1963; and Wickramasekera, 1980. I believe the above two-fold (first-order and higher-order conditioning) explanation may help throw some light on the questions raised in the section on placebos in Kirsch's 1985 paper on response expectancies. This should help eliminate the apparent clash between the 'conditioning' and the 'response expectancy' explanation of placebos if we can look upon the 'response expectancy' and 'belief' as being similar as 1 have previously discussed, and see that conditioning is also a factor in the 'expectancy' placebo, although higher-order as opposed to first-order. One other area that should also be cleared up by the above higher-order conditioning explanation of placebos is the question raised by Kirsch: how can one explain placebos in of conditioning when placebos often exhibit functional autonomy? As put by Kirsch: A second interesting finding of the Montgomery (1995) study is that instead of extinguishing, the placebo effect increased over the course of 10 extinction trials. This is inconsistent with classical conditioning, models of placebo-effects, but is consistent with clinical data indicating that placebo effects can be remarkably persistent. (Kirsch, 1997: p 75)

However, one can see from the previous section 'Helping towards a more comprehensive theory of learning', how one can establish some fairly strong functionally autonomous responses via the conditioning power of the belief or response expectancy aspect of placebos.

The Nocebo and Voodoo Related to the placebo effect are the nocebo and voodoo effects. Just as one can produce positive health or bodily effects through th power of the placebo where positive expectations are created, in the same way (i.e., via similar mechanisms as presented above) negative effects are possible when negative expectations or beliefs are created via the nocebo or voodoo.

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Providing a Natural Explanation for Faith-based Phenomena In the theory, the statement was made that the theory can also be used to explain 'hypnotic effects (faith) of ministers and faith healers' or to put it more broadly; the theory also provides a natural (as opposed to supernatural) explanation for how the power of religious faith (belief) is developed. Understanding how this power can affect human behavior can help provide natural (as opposed to supernatural) explanations for various religious phenomena.

How the Power of Religious Faith (Belief) is Developed In many religions the foundations of belief can be traced to the fulfillment of certain predictions, expectations or prophecies. The following are four key examples of such predicted or suggested outcomes in religion: (1) the fulfillment of religious prophecies; (2) miracles produced through the powers of the religion's prophet; (3) positive responses to one's prayers to God; and (4) the positive occurrences in one's life resulting from following the religion's guidelines. This would fit right in with Hypothesis III of the theory that states that belief, or response to a suggestion, is built up if you have a positive response to a previous suggestion. The following are examples of religious phenomena that the theory helps provide a natural explanation for. Demons, Exorcism and Born again Transformations The above section on how hypnosis can lead to one trial conditioning and functionally autonomous responses as a result of the heightened state of belief under hypnosis also helps to explain the overnight and long lasting changes that can occur as a result of the heightened state of religious belief. As put in the article, 'Science in of religion: from the perspective of a behavioral scientist' (Barrios, 2002: 6): Looking at belief in this new light can also help us better understand the concept of exorcising (blocking out) of demons or the devil (negative programming) within us and the role belief can play ... This also helps us to more fully understand the far-reaching and in depth changes that can often be produced (almost instantaneously) by a 'religious experience'; how it can indeed be possible to be reborn or born again as a result of such an intense heightened belief experience. The Phenomenon of Free Will Religious practitioners tell us that of course we have free will; that God gives us a choice in life, gives us the power to choose between good and evil, between happiness and misery. But then the realists point to all the miserable people in the world and say: 'Are we to believe that all these people have freely chosen to be miserable?' Is there free will or not? In order to answer this question, again we need to define our . As presented in Towards Greater Freedom and Happiness (Barrios, 1985: 16) free will is defined as the ability to transcend one's automatic side, one's subconscious, by means of inner speech or thought ... by focusing sufficiently on the appropriate thought. The key words here are 'by focusing sufficiently on the appropriate thought'. Not all people have developed the ability to focus on the appropriate thought when they wish to. Very often, conflicting and opposite thoughts interfere and do not

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allow the full positive response ... This is why the belief factor is so important ... Belief is the key to allowing an individual to tap into his free will potential. , the definition of belief used herein is: concentration on a thought to the exclusion of anything that would contradict that thought' (Barrios, 2002: 7 & 8).

So we see that the answer to the question 'does man have free will?' is that all humans have the potential for free will because they have the potential to build up belief in their ability to control their automatic behavior via a form of self-hypnosis over time (as discussed in Part I in the section comparing the theory to Hilgard's) and this is why we find that people differ from one another in their level of free will.

The Phenomenon of Faith Healing Many studies in recent years have shown that a person's state of mind and lifestyle can definitely play a key role in determining their state of health. This includes, for example, the effect of stress on diseases such as stroke and heart disease (Friedman and Rosenman, 1974) as well as the effect of the mental state of hopelessness on the immune system and resultant diseases such as cancer (Cousins, 1989; Temoshok and Dreher, 1993). The following excerpts from Barrios (2002: 11-16) help present the case for the power of belief and faith to heal the body: If we accept the fact that a person's state of mind and lifestyle can play a significant role in affecting the body, then it should be obvious that anything that can playa major role in affecting the mind, such as belief and faith, could be a major factor affecting health and well being. Evidence of the power of belief to affect the body health-wise can be found in many studies on the power of the placebo (see for instance the book Timeless Healing: The Power and Biology of Belief, 1996 by Herbert Benson, and the section on placebos in Cousins' book Head First, 1989) ... However, there is something that needs to be made clear. Although strong belief of being healed can be very effective in producing at least temporary improvement in one's health (by allowing for a stronger immune response and creating greater peace of mind at least for the moment), in order for this temporary improvement to remain permanent, the belief factor must also be used to help fully absorb the guidance factor [see subsequent section on making posthypnotic suggestion more effective by adding a guidance factor] so that the immuno-suppressive psychological factors can be more likely to be permanently removed (see Barrios, 1985, pp 124,125 & 154). Thus we can see that one way of differentiating between the concept of belief and the concept of faith is to point out that faith usually means 'guided' belief or belief in a certain way of life... One way of determining how much more effective faith is than belief alone in affecting permanent healing would be to do a thorough search of the placebo literature or to do further studies on the placebo to determine whether the positive effects of the placebo (or belief alone) are long lasting if there were no significant lifestyle changes also taking place. This basic idea that belief alone is not as effective for insuring permanent healing to take place as when the belief is also used to bring about positive lifestyle changes is illustrated when the case of Jolee Marshall is contrasted with some of the other cancer patients I have worked with: Jolee Marshall: After a very strong emotional upheaval Jolee had developed an inoperable cancerous tumor of the intestines and had been given two weeks to live. I worked with

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her for a period of four hours [with the hypnotic belief-building and imaging techniques section of the self-programmed control-psychoneuroimmunological (SPC- PN1) approach presented in the chapter on cancer in Towards Greater Freedom & Happiness (Barrios, 1985)] and left her with a very strong belief that her body's natural defenses would clear away the tumor. The tumor did disappear (in fact overnight) much to the astonishment of her doctor and Jolee did live cancer-free for one more year. However, upon experiencing another similar emotional upheaval one year after my first and only session with Jolee, the cancer returned and this time Jolee soon succumbed to it. The strong belief that she would be cured was apparently sufficient to heal her for one year. However, in the case of Jolee, the complete SPC-PNI approach (which now also includes helping the patient make certain necessary lifestyle changes) had not been followed. (Unfortunately, at this point in time I had not fully realized that belief alone was not enough.) Because of this, there had been no real follow-through for making the necessary changes in her way of life that could have helped her more effectively prevent the second, and this time fatal, emotional upheaval that occurred a year later. This is in stark contrast to other cancer patients I have worked with where the more complete SPC-PNI approach was followed. The following synopses of the approach taken and results achieved with a number of these patients will give you some idea of the different outcomes that can be expected when a more complete “faith healing” approach is taken towards eliminating the contributing psychological factors (hopelessness, etc.): Adele Bucanan: As opposed to just one session with Jolee, I saw Adele once a week for eight weeks. At the time I first saw her, Adele, age 45, was suffering from a fast moving cancer of the spine, lymph glands, the rib cage and the base of the brain - a metastasis from an original cancer of the breast. (At this point in time the only treatment she was undergoing was a very low dosage chemotherapy, as she had had a strong negative reaction to the standard dosage.) Because of the extended amount of time with Adele, I was not only able to build up a strong belief in her body's ability to cure itself of the cancers but through this heightened state of belief I was also able to bring about some major changes in her way of life. In particular, she was able to develop a more assertive personality. This allowed her to break out of the hopeless life situation that had most likely played a key role in making her more susceptible to cancer in the first place. She was now able to stand up to her very dominating and controlling husband. Six months later the cancer had disappeared in all four areas and three years after that, when last ed, Adele was still very much alive. John Roswick: John had been given radiation treatment for cancer of the tongue. However, he refused the recommended follow up radical surgery. At this point he discovered SPC. The following letter was written in August of 1985 upon my request for him to summarize for me what had happened:

Dear Dr. Barrios,

August 5, 1985

Almost 6 years ago on Oct 19, 1979 1 was told I had cancer of the tongue and had a year or less to live. I hit the bottom of the pit. I started praying. Knew nothing of God or Jesus, never read the Bible, but I started. I received 35 massive radiation treatments in the neck. I said to the doctors “am I healed”. They said we now have to do surgery. I said, What surgery?

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They were going to take out half my neck. I said no. I ed you in the summer of 1980. You agreed to see me once a week for 8 or 9 weeks, instructed me on SPC techniques and other counseling on belief and visualization. I used your garden technique and visualized myself 'well' on a mountain top. During my first visit with you, you gave me your book 'Towards Greater Freedom and Happiness.' You said: you now have two good books (meaning yours and the Bible) and told me to read them both. I thank God for you and your book, you strengthened my belief in what Jesus said in Mark ll:23 ['Believe and all things are possible'] Dr. Barrios, in my opinion your program is bridging the gap between the mind, and the spirit then the body. Your program SPC was the beginning in my healing, reinforcing my belief in Jesus teachings, ridding myself of all pent up fear, especially fear, guilt, doubts, anger, unforgivness, and a bringing together of the Mind, Spirit and Body. My saliva returned to me during my sessions with you, my voice, and I forgot to mention, MY TASTER. [After radiation] I couldn't taste anything. The doctors said my saliva would never be the same, that my taster, taste buds, would be about 50 to 75% returned. Well today I enjoy full saliva, and full tasting abilities I had before radiation. It is sad to note that medical doctors don’t, or won’t advise patients on positive principles laid down in your book or the bible. I would urge anyone who has an illness of any nature to seek out the SPC program. It works. It puts you in tune with the real you, the spirit. It has for me and I know it will for others. I firmly believe you are an instrument of God's. And I thank him for you. I am not the same person you first met, frightened, confused, oh yes confused! My condition is healed. Your holistic approach is a blessing." Pam Roth: When I first started working on Pam’s case, she had just gone through chemotherapy and radiation for metastatic breast cancer. She was also having great difficulty breaking free of a 30 year two pack a day cigarette habit. The following letter (which she wrote on my behalf when I was nominated in 1996 for the Norman Cousins Award in mindbody health) tells her story:

To Whom It May Concern

June 14, 1996

“As CEO of P.J. Roth & Associates and President of The Public Service News Bureau, I have had the honor of knowing Dr. Barrios and observing his work since 1983. Through his SPC approach, Dr. Barrios has developed a program that has allowed people worldwide to tap into their own personal power to change their health, their happiness and their lives for the better! He has made the mind/body link accessible and understandable to the world. Over the years, I observed the extraordinary development of the clinical applications of his pioneering theories, and his enormous influence on the American public. At the same time, I felt it had little to do with me on a personal level. That is until 1992, when I was diagnosed with metastasic breast cancer. It was then that Dr. Barrios made the mind/body link accessible and understandable to me in the most profound way possible! In light of my particular case and my prognosis, my physicians encouraged me to undergo the most strenuous chemotherapy and radiation; which I did. At the same time, even faced with my own mortality, I could not summon up the resources to make necessary changes in my personal lifestyle. In many ways this was not

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surprising, after all, I had previously spent years of therapy unsuccessfully attempting to deal with the underlying lack of self worth that showed itself in an aggressive disregard of and for my own physical and emotional well being.. Years of therapy, will power and even cancer seemed to make little difference to ending my two pack a day habit and a 30 year addiction to nicotine. None of these could change the stress attached to my particular career choice or the fact that I had never developed necessary care and consideration for my physical “self”. I was in trouble and I knew it. I had tried everything including traditional hypnosis but nothing seemed to work. I was depressed, anxious about the cancer that I was sure was still with me, debilitated by my treatment and more out of touch than ever with the body that had betrayed me. It was then that Dr. Barrios stepped back into my life bringing all the benefits of his years of clinical experience in mind-body health. Within two sessions, I made the remarkable breakthroughs that years of therapy and prior hypnosis were unable to achieve! And it was all so easy. Dr. Barrios’ approach not only convinced me that I had the power to tap into my own subconscious – it showed me how to use and apply that power to achieve deep seated change. Within weeks, through applying these powerful hypnotic and visualization techniques to my cancer and my personal “mind/body” split – I not only stopped smoking once and for all, I was transformed into a person in touch with and caring for her own physical and emotional needs. Today, I am a committed ex-smoker, who exercises, eats well and takes care of herself in every way possible. I am also, according to all tests, “cancer free” [still “free” as of October, 2007]. More importantly, I intend to give myself every opportunity to stay that way by continuing to practice the SPC techniques that have made the difference in my recovery!” It should be pointed out that I am not the only one to report such long lasting recoveries from cancer when a more complete “faith healing” approach is taken. In her book, Temoshok cites numerous cases of successful cancer cures brought about by her and other researchers in the field using the more complete healing approach. Take for instance the story of Irwin: Diagnosed initially with testicular cancer, the cancer had eventually spread to his lymph nodes, chest and lungs. One tumor on his neck had grown so large he was forced to keep his head at an odd tilt. His doctors told him that even with the best treatment at the time (a combination of surgery, radiation, cobalt and nitrogen mustard, which he did undergo) he had only three to four months to live and that he had zero chance of survival. At this point he sought the help of a psychotherapist who used hypnosis along with traditional psychoanalysis. Under hypnosis he was much more open to healing suggestions aimed at opening up blocks in his capacity to love and be loved and to work on achieving his long term life goals. Within six months, he had resolved his love problems and gotten married and was ordained as an Episcopal priest - a lifelong goal. On the very day he was ordained “he got the news that his follow-up x-rays showed no more evidence of cancer. His lymph nodes and lungs were completely clear. This seeming miracle occurred six months after his original diagnosis...Today, thirty three years later, Irwin is alive, well and cancer-free.” (Temoshok, 1993, p. 320 italics added). It should be pointed out that my presentation of the above anecdotal evidence of cancer cures through a form of faith healing is done more as for, rather than definitive proof of the ability to cure cancer by using a mental/spiritual, “faith healing”, approach. For this definitive proof we will need larger, controlled studies. In such studies, among other things,

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all the important variables can be studied systematically and under scientifically controlled conditions. For instance, such studies would include accurate and more complete measurements of how strong the belief factor was and how complete were the necessary lifestyle changes for each individual case. The latter would I feel help throw light on the question often posed: “How do you explain counter anecdotal cases whereby terminally ill patients have tried to pray for their recovery substantially but to no avail?” One answer to such a question might be that the degree and length of healing would be directly correlated to strength of belief and depth of relevant life changes that took place.

Developing More Effective Methods of Hypnotic Induction There are a number of ways the theory has helped increase the effectiveness of hypnotic induction both in of providing a proper pre-induction talk as well as providing more effective hypnotic induction techniques. The ideas to be discussed were first presented in a paper delivered at the 6th International Congress for Hypnosis on 3 July, 1973 in Upsala Sweden (Barrios, 1973b). With regards to a proper pre-induction talk, several basic areas that need to be addressed according to the theory are: (1) eliminating misconceptions regarding hypnosis; (2) eliminating the fear of losing control; (3) eliminating fear of the unknown; and (4) minimizing the negative effect of failure. Misconceptions can be eliminated by defining hypnosis as a state of heightened belief produced by responding positively to a series of suggestions (as per the theory) and not a state of sleep or unconsciousness. In fact, it is recommended that the hypnotic induction be referred to as inducing a state of 'self-programmed control' (SPC) and to define SPC as a method for giving an individual greater control over his automatic behavior. As for eliminating the fear of losing control, one can see that by referring to the induction as a means of developing selfprogrammed control, you help the individual see that they will in fact be gaining greater control rather than losing control. Fear of the unknown is eliminated in the pre-induction talk by providing a rational explanation for how this state of greater control is developed as the result of the power of words, the power of thoughts and the power of belief to control automatic responses. The demonstration of salivating to the thought of biting into a sour lemon is one way to help get across this point. The negative effects of failure are minimized by telling subjects that 'because of individual differences there may be some suggestions that work very well for some people but not for others, and therefore it should not bother them if they do not respond to a suggestion. In such a case they should just wait for the next one.' As for providing for more effective hypnotic induction techniques, as suggested by the theory, anything that would ensure a positive response to suggestion would help heighten the belief factor and thus increase the effectiveness of the hypnotic induction. Several ways of doing this are recommended by the theory: the use of easy to respond to suggestions to begin with (see Corollary 5, following Hypothesis III); the use of naturally-occurring responses and the use of subtle reinforcement of suggested stimuli or responses (see Corollary 6); and the use of bio devices.

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The following are some of the SPC techniques I developed as a result (see Barrios, 1985: 36-42): One of the techniques developed by following these guidelines was the already mentioned pendulum technique. In this technique there is first the bio amplification provided by the length of the pendulum to amplify the minute automatic movements of the hand. First, swinging from left to right is suggested; then swinging in a circle. Then there are a series of other naturally reinforced suggestions starting with the suggestion that the fingers will automatically begin to creep open and as a result the pendulum will soon be dropped. This response occurs naturally as the hand slowly begins to bend at the wrist as suggestions are given that the hand will relax. This is followed by suggestions that the hand and arm will be floating down as the state of relaxation continues to deepen (another natural response). The concentration spiral technique (Barrios, 2006) also takes advantage of naturally occurring phenomena. This technique involves having the subjects looking at a spinning spiral. I lead them through a series of suggestions of visual phenomena which I devised by mirroring the subtle visual effects I experienced myself as I visualized the spinning spiral. The following suggestions are given: as your mind becomes more and more concentrated, you will begin to see a fuzziness or waviness in the lines of the spiral; you will see a yellowish fluorescent-like fringe to the black lines; dark rays will appear to spin off the edge of the disk; you will feel as if you are riding backwards on a train in a spiral tunnel looking out the rear window. Throughout, suggestions that the spiral is concentrating the power of the mind continue to be given. Then, to emphasize this point, the suggestion is made that upon looking away from the spiral at the clock on the wall (or some other object like a plant in the room) the clock (or plant) will be magnified and appear to grow larger. This very dramatic effect, unbeknownst to the subject, is a naturally-occurring effect as a result of looking at the spiral spinning in a clockwise direction. Of course, as per the theory, by having responded positively to the series of previous suggestions, the effect is magnified that much more. To minimize any feelings of deception for the few that may think of the spiral technique as pure illusion, prior to going through the technique I first point out that everything the subjects are going to see is naturally there but as a result of the concentrating effect of the procedure, everything will be seen that much more clearly and strongly (which is true). I even tell the subjects afterwards that some people do not experience any of these effects (which is also true for those not paying attention). Other SPC techniques making use of naturally-occurring phenomena are the light bulb, the rapid deep breathing, and the hand levitation techniques. In the light bulb technique, use is made of the after-image produced after staring into a 40-watt light bulb for a short while. In the initial steps the subject is told they will see a yellow colored balloon after they close their eyes and that it will be changing in color from yellow to red to magenta to blue (which would be the natural color changes the after image would go through). Suggestions are also given that the balloon will begin to float up and the head will also begin to float up. The subject is told that the latter will occur with each breath they take in. Unbeknownst to the subject, there is a natural tendency of the head to rise with each breath taken in. (Conversely, there is a natural tendency of the head to sink with each breath let out so one can reinforce suggestions of head sinking in a similar way.) The rapid deep breathing technique (an adaptation of the hyperventilation method discussed by Kroger, 1977: 77-8) takes advantage of such naturallyoccurring responses to hyperventilation as tingling, light-headedness, greater awareness of heart beating, etc.

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In my adaptation of the hand levitation hypnotic technique, I have the subjects begin by first pressing the hand as flat as possible against the surface, with the fingers spread as far apart as possible. I tell them to push down as hard as they can initially. Thus, when suggestions are given that the hand will start to rise and the fingers will start to come together as the hand relaxes this is what would naturally occur as they stop pushing down and relax, thus reinforcing the suggestions. These basic principles for increasing the effectiveness of hypnotic inductions derived from the theory have been presented in such a way that one should be able to extrapolate from them and develop other similar naturally reinforced techniques.

More Effective Methods for Giving Posthypnotic Suggestion How does the theory lead to ideas for increasing the probability of producing positive behavioral changes via posthypnotic suggestion? The answer to this question comes from Corollary 8 (following Hypothesis IV) of the theory, 'The more compatible cognitive stimuli associated with the response evoked by the suggestion, the stronger the response to the suggestion'. This basic concept underlies the value of using imagery (visualization) to ensure the suggestion would hold in a variety of situations and guidance to give the suggestion depth. For example, let's say a patient was suffering from a deep depression due to a poor selfimage and a sense of being a failure in life. Compare the effectiveness of (1) just giving the simple, general, suggestion 'You will no longer feel depressed' to (2) giving this general positive suggestion followed by a series of more in-depth suggestions that included proper guidance on how to become more successful in life, more positive about oneself; and then having the patients visualize themselves in a number of different typical situations responding in these more positive ways. Along the lines of enhancing posthypnotic suggestion with imagery, I have developed five variations of visualization for effectively programming in one's goals. These include: (1) the simple projection method; (2) the approximation version; (3) the negative positive method; (4) the punishment reward method; and (5) the success technique (see Barrios, 1985: 43-50). Following along the lines of enhancing posthypnotic suggestion with positive guidance, the second part of the book Towards Greater Freedom and Happiness (Barrios, 1985: 57196) offers a wide range of positive guidelines to choose from. This includes positive guidance in the following areas: mental attitudes, emotions, health and education. The Development of Self-programmed Control and its Positive Applications This combining of effective hypnosis (and self-hypnosis) techniques with more effective methods of giving posthypnotic suggestions, including a comprehensive guidance component, led to the development of a general program for helping people achieve self-actualization which was christened self-programmed control or SPC. Although Maslow, in defining self-actualization, had done a magnificent job of outlining the ultimate high goals one should strive for in life (Maslow, 1971), I feel he never really outlined an effective systematic method of achieving these goals. It is one thing to tell a person what he needs to strive for to feel more fulfilled in life; it's another to get him to change in this direction. I feel the SPC program by facilitating change provides this missing link to achieving self-actualization.

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This section of the paper will further describe the essence of SPC and will present some of the positive results achieved in its application in a number of different areas: education, welfare, industry, medicine, and drug rehabilitation.

Education After my PhD dissertation (Barrios, 1969), I developed a program to help college students (primarily Mexican American) on scholastic probation avoid dropping out. I used a three-pronged approach (see Barrios, 1973b). The first part consisted of the set of self-hypnosis techniques I had developed from the theory (see the techniques mentioned above). Soon after the school istration asked me if I could avoid using the term hypnosis because of all the associated misconceptions. It was at this point that I came up with the term “self-programmed control” (SPC) techniques in place of “self-hypnosis techniques”. The SPC program eventually came to refer to the entire program of SPC techniques plus guidance. The main purpose of the SPC techniques was to help the students develop a greater belief in the power of their minds. This combined with the other two parts of the program leads to a greater belief in their capabilities. Eight years later, Albert Bandura would coin the term 'selfefficacy' for such belief in one's capabilities. As he at the time so correctly pointed out, without such a belief, people would not even make the effort to help themselves. Or as he put it, 'It is hypothesized that expectations [belief] of personal efficacy determine whether coping behavior will be initiated, how much effort will be expended, and how long it will be sustained in the face of obstacles and aversive experience' (Bandura, 1977: 191). In a prior study by Losak (1972), the lack of belief in their capabilities was felt to be the reason why remedial programs alone were found to be of no help for students at risk of failing. The second part of the three pronged approach was aimed at helping eliminate any school- or outside-of-school-related stress/anxiety problems that can also often interfere with learning and test-taking capabilities. The SPC techniques played a part here also by helping to program in an automatic relaxation response in times of stress as well as stress-reducing positive attitudes. (The book Psycho-Cybernetics [Maltz, 1960] was used initially to introduce the students to these positive attitudes towards life.) In later years the term 'emotional intelligence' was coined to describe the importance of learning to deal effectively with anxiety and emotional problems in order to succeed in life (Goleman, 1995). The third part of the program, the part especially geared for improving students' scholastic abilities, was made up of study, problem solving, and test-taking techniques many of which were taken from Studying Effectively (Wrenn and Larsen, 1955). Following from the theory, a basic theme underlying this three pronged approach was to provide as much immediate positive as possible to increase the belief factor that much more. As previously indicated, the SPC techniques had built-in immediate positive as recommended from the theory and this same immediate approached was followed with the other two components of the program thus further adding to the overall positive belief factor. For instance my invention, the stress control bio card (originally called the 'Colorimeter') was used to immediately reinforce the relaxation response. And with regards to the learning skills section, I started with two memory techniques that provided immediate : (a) the 'numbers' technique where the students were amazed to see how quickly they could memorize a 23 digit number using grouping and association techniques; and (b) the 'names' technique where the students were equally amazed to find out how easy it was to memorize the first names of all the students in the class using

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association techniques. These techniques in turn whetted the students' appetites for other even more practical techniques such as the 'SQ3R' study technique which itself produced immediate positive results in the quizzes which quickly followed. Another source of immediate was the progress reports, a form of journal I asked the students to keep. On the first page of the progress report they were to make a list of the goals they wanted to achieve and at the end of each week they were to look back and note down any positive results they had already achieved regarding these goals. At the beginning of each class meeting I would ask for people to stand up and share any successes they had already achieved. This was especially helpful in getting through to those in the group who for whatever reason still found it hard to believe that SPC could produce results. (See pages 2007 in Barrios, 1985 for examples of these student progress reports.)

Similarities between SPC and Bandura's Self-efficacy What amazes me is how many similarities there are between the SPC approach to helping these students and Bandura's overall approach to building self efficacy. Bandura (1977: 195200) refers to four basic ways in which self-efficacy can be built: performance accomplishments, vicarious experience, verbal persuasion and physiological states. Let's look at each of these areas as it relates to some of the methods used in building the belief factor in the SPC program: Performance accomplishments: Examples of the use of positive performance accomplishments in the SPC program to build belief in oneself, to build self-efficacy, include: (1) the use of the stress control bio card to reinforce the effectiveness of relaxation techniques in a stressful/anxious situation; (2) the demonstration of the 'numbers' and 'names' memory techniques as well as the SQ3R studying techniques to instill belief in one's learning capabilities. Vicarious experience: Bandura's discussion of the use of modeled successful behavior to build self efficacy is similar to my having the students get up at the beginning of each SPC session and share their successes with the class. As Bandura puts it 'Seeing others perform threatening [difficult] activities without adverse consequences can generate expectations in observance that they too will improve if they intensify and persist in their efforts. They persuade themselves that if others can do it, they should be able to achieve at least some improvement in performance' (Bandura 1977: 199). One difference here is that Bandura is referring to actually seeing the other person perform the threatening or difficult task as what is helpful whereas I am saying that hearing the person relating that he has successfully performed the task is also reinforcing. Verbal persuasion: SPC is of course to a great extent founded on the potential power of verbal persuasion (in the form of hypnosis). However, although Bandura does acknowledge that suggestion can influence one's level of efficacy, he tends to downplay it a bit. As Bandura puts it: 'People are led, through suggestion into believing they can cope successfully with what has overwhelmed them in the past.' However, Bandura then goes on to say, Efficacy expectations induced in this manner are also likely to be weaker than those arising from one's own accomplishments ... In the face of distressing threats and a long history of failure in coping with them, whatever mastery expectations are induced by suggestion can be readily extinguished by disconfirming experiences ... Simply informing participants that they

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Alfred Barrios will or will not benefit from treatment does not mean that they necessarily believe what they are told, especially when it contradicts their other personal experiences. (Bandura, 1977: 198)

Nowhere in his section on verbal persuasion does Bandura bring in the potential usefulness of hypnosis in making verbal persuasion more effective. But judging from the following statement of his, it would appear that he should agree that heightening the state of belief(e.g. via an effective hypnotic induction) would most likely make verbal persuasion more effective in building self-efficacy: 'The impact of verbal persuasion on self-efficacy may vary substantially depending on perceived credibility of the persuaders, their prestige, trustworthiness, expertise, assuredness. The more believable the source of information, the more likely are efficacy expectations to change' (Bandura 1977: 202). There is one more important point that Bandura makes regarding the overall effectiveness of verbal persuasion at building self-efficacy: 'However, to raise by persuasion expectations of personal competence without arranging conditions to facilitate effective performance will more likely lead to failures that discredit the persuaders and further undermine the recipients' perceived self-efficacy' (1977: 198). This is of course why the SPC program for students also included giving them effective study, problem solving and test-taking techniques (with lots of immediate positive ) as well as a set of positive guidelines to life (originally supplied via the book Psycho-Cybernetics, Maltz, 1960). Emotional arousal: Bandura definitely agrees with the need of the students to effectively deal with anxiety and emotional problems if they are to succeed in school. The way he puts it is to say that self-efficacy level will definitely be affected by emotional or anxiety problems. 'Because high arousal usually debilitates performance, individuals are more likely to expect success when they are not beset by aversive arousal than if they are tense and viscerally agitated' (Bandura 1977: 198).

Results of the Application of SPC in Education for Reducing Dropout A total of 194 students took part in the study at East Los Angeles Community College (ELAC). There were 105 enrolled in my (SPC) Psychology 22 class (the experimental group) and 89 students taking the regular Psychology 22 class (the control group) where only study skills were taught and by instructors other than myself. The two main dependent variables compared between the two groups were dropout rates and grade points (GPA x units completed) over a one and a half year period. During this period the dropout rate for the study skills only (control) group was 56% (not surprising considering Losak's 1972 finding). The dropout rate for the SPC class (the experimental group) was 16%. As for the grade points, there was an average increase of 3.80 grade points for the experimental group and an actual average 5.45 grade points decrease in the control group (also not surprising to Losak). The total difference of 9.25 grade points between the two groups was statistically significant at the 0.02 level (Barrios, 1973c) There was also an interesting side benefit to the program in of reduced substance abuse and addictions (reduced habits of excess) amongst the students in the SPC classes. The following results were obtained from an anonymous questionnaire given to a total of 236 students at the end of the class (the above original 105 SPC students plus an additional 131 that took subsequent SPC classes). In those students indicating excess in the following areas these percentages cut down:

A New Theory for Understanding and Appreciating the Power of Hypnosis food cigarettes alcohol TV gambling

72% 70% 91% 82% 75%

(65 of 90) (37 of 53) (48 of 53) (84 of 102) (9 of 12)

marijuana pills (‘uppers & downers’) LSD heroin

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69% (22 of 32) 83% (10 of 12) 100% (7 of 7) 100% (1 of 1)

The interesting thing about this curtailment of excesses is that it occurred primarily as a side benefit of the program. No concentrated attack had been made on curtailing excesses. It is felt to have occurred mainly because of three major changes resulting from the program: the general increase in the ability to relax; the greater enjoyment of other areas of life; and the greater amount of self control. Most excesses or addictions can usually be traced to a deficit in one or more of these areas. Corroborating the results achieved at ELAC were those achieved at UCLA in 1972 with 362 freshmen where the SPC program was introduced as part of an overall program to help minority students survive at UCLA. Interestingly enough, one of the students benefiting from this 1972 UCLA class, a former high school dropout prior to taking the class, recently became Mayor of Los Angeles and having seen first hand the benefits of the program has indicated plans to introduce it to the Los Angeles School District as a means of reducing the current high dropout rate of Hispanics and African Americans in the Los Angeles schools (55%).

Welfare and Work Incentive Programs The positive results achieved with incorporating SPC into work incentive programs to help get people off welfare (see Barrios, 1985: 32, 208, 209) tend to a hypothesis I have regarding welfare recipients: Many feel that people on welfare are just plain lazy malingerers and don't real1y want to work. I don't believe this. It's my theory that these people remain on welfare not because they want to but because their low self-image [low self-efficacy] makes them feel incapable of anything else. (Barrios 1985: 208) The essence of what the program can do for these people was captured by the comments of two CETA (Comprehensive Employment and Training Act) instructors who saw the results of what SPC was able to do for their students. First the comments of Maria-Luisa Lopez, CETA instructor in East Los Angeles. She stated that after much searching, she had at last found (in SPC) a means of dealing with the all-important attitudes and fears of her students that had continued to plague her ability to get through to them. In her own words: n the past (prior to SPC exposure) many of our trainees who were sent out on interviews by the staff Job Developer would not even show up, or if they did they projected a negative or insecure attitude and were rejected in many instances. Since SPC exposure, al1 have acquired a more positive, self-confident attitude which has helped them during the interviews and subsequently while learning their duties as new employees. Of the 18 trainees I had in my class when I started using SPC, all have found jobs, ten of them completely on their own - something unheard of before as in the past those who had found work found it as a result of the Job Developer's efforts. Needless to say, I am completely sold on the SPC concept. (Barrios, 1985: 32)

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Alfred Barrios And in the words of CETA counselor Suzanne Bourg in Pasadena California: After seeing the response of the students and hearing examples of their applications of Dr. Barrios' concepts and techniques, I feel strongly that this is an important part of job training that has never been previously recognized. CETA can train a person to obtain job skil1s but if he has no self-confidence, no sense of control over his own destiny, no previous pattern of success, he has great difficulty getting and holding down a job. It is this strategic area of Dr. Barrios' course which applies so directly to our CETA trainees. (Barrios, 1985: 209)

Industry One can also see that there could also be a positive use for SPC in industry. Inefficiency and absenteeism would be diminished; work morale would be higher; there would be a definite lessening of friction among personnel; there would be considerably fewer stress problems; absenteeism due to illness would be much less. All these would result in increased productivity. That such results are possible with SPC was borne out in a study done at Rockwell International and reported in the Journal of Employee Recreation, Health and Education (Barrios, 1975; see also Barrios, 1985: 209-13): The SPC class at Rockwell had a total of 11 participants - 3 women and 8 men - from all levels, including management, and met once a week for two hours for a total of six weeks. Three simple measures were used to get some idea of the effectiveness of the program: (1) The Willoughby test (p. 224) before and after, (2) A before and after selfrating of the goals chosen to be worked on by each participant, using a scale of 0 to 10, and (3) Each participant's own summary of his progress written at the end of the class. The results of the Willoughby test indicated an overall improvement of from the 75th to the 47th percentile. With regards to the changes in rating of goal-reachability, the average self rating went up from 3.36 to 6.80, (see p. 52-53) with each person working on an average of five to six of the following goals (self-confidence being the most common one chosen): Positive Thinking Self-Confidence Learning Ability Creativity Weight Control Tension Control

Excessive Drinking Smoking Health Fears Emotions Sex

Exercise Eternal Youth Headaches Physical Attractiveness Leadership Ability Procrastination

Reading through the following summaries of progress (all 11 are included, including the one failure) will give you a better feel for the type of results achieved. In each case, after the initials of the participant, I have included the before (B) and after (A) Willoughby percentile. (The lower the percentile the better.) J.B. B-62, A-53 Procrastination - Have done one or two extra chores every night instead of putting it off until there is no time left. This includes paying bills, letters, etc.

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Diet & Health - Started doing exercises at home. Have also done pretty well with my meals. Have already lost a few pounds. Smoking - Have cut down considerably. Have gone without one as much as four hours at a time at work where the pressure is the greatest. Work - Work running more smoothly now. Not as many redo's from frustration or aggravation and the time element is no longer creating excessive tension. I am convinced the program works. For years I've read books oriented along these lines, but this course seemed to show how to accomplish your goals. E.B. B-60, A-5 This course has been helpful in many ways toward improving my self-image. My confidence and positive thoughts have strengthened a great amount. My life is a much happier one which gives off a glow of warm vibrations to others around me. I'm able to concentrate on a positive thought whenever I desire. Problems, large or small, at work or at home, no longer pose a threat of failure because I am assured I can solve any. Since my self-image has improved, I find that I like myself even more and am able to do much more than I've done in the past. Now that I realize I have the ability, I know I will be successful most of the time. I am confident I will accomplish my goals, both short and long range. Without this course, I wonder where would I be today? R.O B-30, A-12 I have greatly reduced tension. My sex life has improved considerably and I feel I have a more positive attitude toward the future. My memory and reading comprehension have improved. And I am able to shut out outside interference when thinking. While my problems were not as great as many people, I can see where everyone could benefit from this course. I feel it was worth the time and money. A.P. B-89, A-57 I have learned the techniques, I have the tools - now the rest is up to me. The class has definitely helped me. For instance, no one could have hated a job more than I did; I despised going to work in the mornings. Now, I really enjoy my job - I don't mind getting up and going to work. I really like the people I work with now. I just changed my attitude (after I started the class and started reading “Psycho-Cybernetics”) and everything just seemed to shape up. Also, I have lost 7 lbs. I have started and am continuing an exercise program every day at noon. Have been running a mile at noon instead of eating lunch. I have something light at dinner - absolutely no sweets and sweets were my weakness. So, I will have to say the class has been a success for me. My weight and work problems seem to be going okay now so I think I'll start trying for self-confidence (that will be a tough one but I know I’ll be able to make it).

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Alfred Barrios D.P. B-85, A-52

This has opened my eyes to a lot of little things that are really big. Find myself thinking clearly again and normal. Also, I've noticed that more done lately in shorter time and with less effort. I find that I'm now able to get vivid blue on the Stress Card more and more frequently. I'm definitely going to continue working with this program. L.P. B-88, A-96 (The one apparent failure) I do not feel that SPC has helped me a great deal, but who knows what seeds have been planted. R.P. B-81, A-41 I am convinced now I have made relaxation a habit. I am confident, too, that my new positive, winning attitude can accomplish the results I need to meet all my realistic goals. This is true even though my age [around 65] is such that it is easy to have serious doubts if I were to allow them to develop. At work SPC has helped by teaching me to take a more deliberate and analytical approach and therefore achieve more reasonable solutions to my problems. I think an SPC program is absolutely essential in a corporate organization in order to develop maximum performance and output among its . Corporation work programs such as North American Rockwell have impossible schedules, almost impossible goal requirements and a need for maximum cooperation between all . Almost all workers in such a situation will develop an extremely tense personality where their creative output reaches minimum because of the impossible schedules and goals. SPC will develop a calmness in these individuals so that their efficiency is increased tremendously and their awareness of the other person's point of view and his requirements are greatly enhanced to the point where cooperation and efficiency of the overall program results in a much better end result. B.R. B-98, A-93 In the past, under pressure, I'd run. Now I don't. Example - In a night class I am taking I have noticed a complete change of attitude. Before I would easily become discouraged and be quick to give up and drop the class. Now I find myself sticking to it and no longer so afraid of the teacher. I find that SPC has also helped with my job - because I can keep calm long enough to learn it. Previously I would be so upset during the learning period it took twice as long. I use the quick count-down when I get in a tight spot and it seems to help quite a bit. Also, there is an annoying person whom I work with - I can for the most part, with the countdown, keep my feelings in control so as not to upset the entire office.

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R.R. B-86, A-63 I feel that I have learned the tools to help myself over the past six weeks. I probably would not have read Psycho-Cybernetics at all. Now that I started the book I feel I will complete the book within the month. Before the course I rated myself low in self-confidence and positive thinking. Now I find myself catching myself as soon as I become aware of the situation and program in that I am confident in my abilities. When I think negatively I immediately disregard the thought and think of a positive thought. I think I have reversed my negative pattern. As far as habits are concerned, I am working on one that has grown since childhood. I recently have had success in controlling this habit for the first time in approximately 30 years - three successes in a row. This has helped my ego and my confidence to a great degree. Also, I had trouble sleeping at times. Now when I go to bed I go through a complete programming input and relax much more than before, thereby getting to sleep earlier and more relaxed. As a result I am on time for work and more relaxed during the day. And my mind is not as cluttered up with negative thoughts and fears during the day. Therefore I am able to get more work accomplished. I look forward to working hard on all areas with the tools learned in the class. P.S. B-68, A-12 Have achieved positive results from the 6 week program; feel that this is only the beginning. This course gave me the tools, now I must continue to use them to continue the progress. I was particularly impressed with my ability to names. This was always a weak point with me. I find that I am also starting to gain confidence in my handling of situations at work that bugged me before and am much more relaxed when making presentations to a group of people. I was quite pleased with the "before" and "after" results of the Willoughby test. I really "dig" the "positive thought" technique. I use this every day. This is the basis of Maltz' book [Psycho-Cybernetics] but I didn't really get it until this class. This is the biggest thing I have learned to date. I now try to concentrate on my successes as much as possible. A.S. B-82, A-40 I thought the course was well presented. I have obtained positive results in my blood pressure reduction goal and find I am more relaxed now. I have also made some slight progress in my weight reduction goal. Thanks to the short-cut techniques I can automatically relax when problems come up at work and find I can deal with others more easily.

Medicine One can also see the possibilities of SPC in the area of medicine. Although no study has been done with the specific purpose of testing the effectiveness of SPC for improving health, one can see from many of the above reports as well as others scattered throughout the book

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[Towards Greater Freedom and Happiness] that SPC can be considerably effective with such health problems as: high blood pressure, ulcers, arthritis, asthma, pain, headaches, insomnia, anxiety, depression, smoking, obesity, diabetes, alcoholism, heart disease and cancer. (Barrios, 1985: 213)

Drug Rehabilitation As has already been reported, one of the side benefits of the SPC program for students was considerable reduction in a number of habits of excess or addictions including a number of different drug addictions. A more direct use of SPC with drug addicts and alcoholics was its application at Bridgeback and the House of Uhuru in the predominately Black area of Los Angeles. Both are rehabilitative centers for hard-core drug and alcoholic offenders many of whom had been sent to prison for drug-related crimes. The types of results achieved are illustrated in the two letters presented on pages 214-16 of Barrios, 1985. The first was written by a resident at Bridgeback and addressed to-whom-it-may-concern: For many years (since 1959) I had been a drug-addict. Now I'm a resident at Bridgeback. For a long time I thought there was no hope. I had been told that once a dope-fiend always a dope-fiend. Not having too much on the ball, as far as a future, I let this saying make a nest in my subconscious. Because of this I would not deal with anything. Through the years I tried several times to break the habit but each time would go back. Well, I finally gave up and said it's time to get help. I signed up for the Bridgeback Drug Program. There I thought that I could get help by just grouping [note: this is a form of encounter group therapy and has been the main form of therapy currently used by many drug rehabilitative programs] but I couldn't. So along came Dr. A.A. Barrios. He had a very unique program called SPC (selfprogram control). At first I just sat in class and didn't get involved, then he started saying things that sounded good. He said he could change a person's entire life if they got involved. I didn't believe it at first. So, I said what can I lose. I started out by using the Spiral Mind Technique. I began getting so involved, I purchased a kit. Every morning I would use it. Then it started taking effect. The next thing I know I had no desire whatsoever to use or even be around dope. Then I had this Mural to paint, 75 feet long and 25 feet high. I just knew I wouldn't finish it. So I programmed in that I would complete the Mural, and now it's one of the best in the city of L.A. and I'm always getting recognition for it. Now, still using Dr. A. A. Barrios' SPC program, I'm enjoying life in a much more rewarding way. I attend L.A. Business College where I'm studying ing. Upon completion, I hope to become an ing clerk. Next, I applied for a job for the State of California as a claim's examiner's assistant. My application was accepted. I took the test and I found it was so easy; it was as if I had taken it before. It's really something to see how these techniques work. I just know I did well on it because I got under the Spiral that morning. Oh yes, let me include this in this short story of my changed life-style. My grades in high school were C's and D's; now they are, believe it or not, A's and B's. I'm going to close with these last few words. There was this young lady that came to the program. I saw where I could help her with this new program. She was like me at first, skeptical; now she's getting involved and she's really doing fine now.

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The following letter was written to the Director of the House of Uhuru by one of the peer-counselors who had taken part in the pilot SPC study there: I am writing concerning a program I feel would be of great interest to you and which I highly recommend for incorporation into the House of Uhuru. First of all Mr. Anderson, allow me to state that this program, Self-Program Control (SPC), works! It is a truth, in that by means of it one can be in control of his life and destiny. Unhealthy habits, such as over-eating, excessive smoking and drinking, drug taking and abuse and countless others can be minimized and eventually alleviated by applying the techniques acquired and practiced until they become second nature by believing you can do it. I know this is possible because I've seen the program work not only with me but many others as well, thanks to being in the SPC class Dr. Barrios taught here this past semester. At the beginning of the class we were asked if there was anything that we wanted to focus upon within ourselves. One of the goals I set was to become adept at tension control. Before utilizing the SPC techniques I experienced headaches often, lost my temper at the drop of a hat, and underwent mood changes quite frequently (depression, despondency, self-pity, etc.). Now, as I'm sure you are aware of, my temper and mood variations have displayed positive movement toward a more balanced equilibrium, and my headaches are almost nonexistent. In March of this year my husband was incarcerated, and would be away for 18 months. As a result of this occurrence, I felt afraid and completely alone. I started drinking alcohol everyday. I'd get off from work, stop at a liquor store and after getting home, would drink myself into a stupor. During this time I had forgotten about SPC and just about everything else. Then one evening after I had taken my first drink, I ed the SPC 20 to 10 Countdown Technique for relaxation. I went through the technique twice, programmed in the goal of not having to drink to deal with my fears, insecurities, and poured the pint of bourbon down the kitchen drain. I felt and continue to feel good about myself! With the continued usage of the techniques learned through SPC, and reading excerpts from the book Psycho-Cybernetics by Maxwell Maltz, I became more confident and aware of my abilities to change and control my life as I deem fit. In regards to Self-Program Control being incorporated and implemented as an on-going therapeutic phase of the Uhuru's philosophy, I am strongly in favor of the idea. Not only have I seen the positive effects of the class on myself and the others taking it, but I have also seen that we ourselves could very easily teach it to others in turn. During the last four classes ten clients participated who were from the residential component. These ten clients were taught SPC by us without Dr. Barrios. We, the class, introduced to them a few of the SPC techniques that were ideal for tension control and relaxation. At the end of the very first session, all of the residential clients were very enthused and expressed a desire to attend and learn more from additional sessions. At the conclusion of the fourth session, clients were relating to me how they had used the Deep Breathing Technique to relax and had as a result stopped taking sinnequans, a tranquilizing medication. Also while participating in the regular intensive grouping sessions, by using the 20 to 10 Countdown Technique the clients were able to control their tempers and display a more positive attitude and behavior pattern. Many of the clients also reported that they were now able to go to sleep at night without the aid of medication simply by using the techniques learned in SPC. One client especially stated she had gotten so upset one day that

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her blood pressure went up high enough for our doctor to feel medication was necessary to restore it to normal. At this time the client went through the techniques learned in SPC, and as a result her blood pressure returned to normal without her having to be istered medication. Each day SPC is being heralded by these ten residents who were fortunate enough to be included in the SPC class, and they themselves are now teaching the techniques of SPC to new residents. These are some of the incidents that lend credence to the benefits that can be acquired through SPC. The above letter illustrates once again a major advantage of the SPC program - how easy it is to teach. Please also note the chain reaction effect. The students I taught in turn taught the program to ten other residents who in turn started teaching the program to others. Again this is all in keeping with the "demystification" approach of Ivey and Alshuler (1973) that says we don't have to be Ph.Ds or so called experts in order to help others. I believe strongly that we need this chain reaction effect if we are going to help turn this world around in time. As I alluded to in the beginning of this book, we are currently in a life or death race, “... for at the phenomenally fast rate at which technology has advanced during the past century, man now has the means to totally destroy himself, and will unless we can get to him first”. (Barrios, 1985:217)

CONCLUSIONS A significant number of benefits were derived from the theory. These include: (1) a further understanding of the hallucinogens, schizophrenia & bipolar disorder, bio, higher–order conditioning, placebos and faith-based phenomena including free will and faith healing; (2) development of more effective methods of hypnotic induction; (3) development of more effective methods of giving post-hypnotic suggestions; and (4) development of SelfProgrammed Control (SPC), a positive-oriented behavioral improvement program which provides a systematic means of achieving self-actualization. Although Maslow (1971) did an excellent job of introducing the concept, he never really developed a systematic approach to achieving self-actualization. Key factors in achieving self-actualization in the SPC program are the greater levels of self-efficacy (Bandura, 1977) and emotional intelligence (Goleman, 1995) achieved. Positive results of SPC’s application in a number of important areas were presented: education; welfare; industry; medicine; and drug rehabilitation. This emphasis on a positive psychological approach to behavioral improvement fits right in with the current positive Psychology movement (Seligman, 2005).

REFERENCES Bandura A (1977) Self-Efficacy: Toward a unifying theory of behavioral change. Psychological Review 84: 191-215. Barber TX (1969) Hypnosis: A Scientific Approach. New York: Van Nostrand Reinhold.

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Barber TX, Calverley DS (1964) Toward a Theory of “hypnotic” behavior: Effects on suggestibility of defining suggestion as easy. Journal of Abnormal and Social Psychology 68: 585- 592. Barber TX, Calverley DS (1969) Multidimensional analysis of “hypnotic” behavior. Journal of Abnormal Behavior 74: 209-220. Barber TX, Spanos NP, Chavez JF (1974) Hypnosis, Imagination, and Human Potentialities. New York: Pergamon. Barrios AA (1965) an explanation of the behavioral and therapeutic effects of the hallucinogens. International Journal of Neuropsychiatry 1: 574-92. Barrios AA (1969) Toward Understanding the Effectiveness of Hypnotherapy: A Combined Clinical, Theoretical and Experimental Approach. Doctoral dissertation, University of California at Los Angeles. Barrios AA (1970) Hypnotherapy: A Reappraisal. Psychotherapy: Theory, Research and Practice. 7: 2-7. Barrios AA (1973a) Posthypnotic suggestion as higher-order conditioning: a methodological and experimental analysis. The International Journal of Clinical and Experimental Hypnosis 21: 32-50. Barrios AA (1973b) Increasing the effectiveness of hypnotic induction. Paper presented at the VIth International Congress for Hypnosis. July 3 rd, 1973, Upsala, Sweden. Barrios AA (1973c) Self Programmed Control: A new approach to learning. Proceedings of the Sixth Annual Conference of the Western College Reading Association. (See also articles section of www.stresscards.com.) Barrios AA (1975) Self Programmed Control: Towards Greater health happiness and productivity. Recreation Management: The Journal of Employee Recreation, Health and Education, pp, 18-21.Barrios AA (1985) Towards Greater Freedom & Happiness. Los Angeles, SPC Press. Barrios AA (2001) A theory of hypnosis based on principles of conditioning and inhibition. Contemporary Hypnosis 18: 163-203. Barrios AA (2002) Science in of Religion: From the Perspective of a Behavioral Scientist. Banning, California, Cancer Federation Press. (This article can also be found in the articles section of www.stresscards.com) Barrios AA (2006) The Concentration Spiral on DVD. See additional products section, www.stresscards.com. Barrios AA (2007a) Commentary on a theory of hypnosis based on principles of conditioning and inhibition Part I: Contrasts with other perspectives and ing evidence. Contemporary Hypnosis 24: 109-122. Barrios AA (2007b) Commentary on a theory of hypnosis based on principles of conditioning and inhibition Part II: Benefits of the theory. Contemporary Hypnosis 24: 123-138. Cousins N (1989) Head First: The biology of Hope. New York: E.P. Dutton. Dorcus RM (1963). Fallacies in predictions of susceptibility to hypnosis based on personality characteristics. American Journal of Clinical Hypnosis 5: 163-70. Erickson MH, Rossi EL, Rossi SI. (1976) Hypnotic Realities: The Induction of Clinical Hypnosis and Forms of Indirect Suggestion. New York: Irvington. Friedman M, Rosenman RH (1974) Type A Behavior and Your Heart. New York: Fawcet Columbine Books.

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Gliedman LH, Gantt, WH, Teitelbaum, HA (1957) Some implications of conditional reflex studies for placebo research, American Journal of Psychiatry 113: 1103-07. Goleman D (1995) Emotional Intelligence: Why It Can Matter More Than I.Q. Bantam Books. Harlow H (1959) Learning set and error factor theory. In Koch, S (Ed.). Psychology: A Study of a Science. New York, NY: McGraw-Hill; 492-537. Hernstein R (1962) Placebo effect in the rat. Science 138: 677-8. Hilgard ER (1965) Hypnotic Susceptibility. New York: Harcourt, Brace & World. Hilgard ER (1977) Divided Consciousness: Multiple Controls in Human Thought and Action. New York: Wiley. Ivey AE, Alshuler AS (1973) An introduction to the field (Psychological Education). Personnel and Guidance Journal 51: 591-597. Kirsch I (1985) Response expectancy as a determinant of experience and behavior. American Psychologist 40: 1189-1202. Kirsch I (1997a) Response expectancy theory and application: A decennial review. Applied & Preventative Psychology 6: 69-79. Kirsch I (1997b) Suggestibility or Hypnosis: What do our scales really measure? The International Journal of Clinical and Experimental Hypnosis 45: 212-225. Kirsch I (2000) The response set theory of hypnosis. American Journal of Clinical Hypnosis 42: 274-292. Kirsch I, Lynn SJ (1998) Dissociation theories of hypnosis. Psychological Bulletin 123: 100115. Kirsch I, Wickless C, Moffit K (1999) Expectancy and suggestibility: Are the effects of environmental enhancement due to detection? The International Journal of Clinical and Experimental Hypnosis 47: 40-45 Knowles JB (1963) Conditioning and the placebo effects of decaffeinated coffee on simple reaction time in habitual coffee drinkers. Behavior Research and Therapy 1: 151-7. Kroger WS (1977) Clinical and Experimental Hypnosis. Philadelphia: J.B. Lippincott. Losak J (1972) Do remedial programs really work? Personnel and Guidance Journal 50: 383386. Lynn ST, Sherman SJ (2000) The clinical importance of sociocognitive models of hypnosis: Response set theory and Milton Erickson’s strategic interventions. American Journal of Clinical Hypnosis 43: 294-311. Maltz M (1960) Psycho-Cybernetics. Englewood Cliffs, N.J.:Prentice Hall, Inc. Maslow A (1971) The Farthest Reaches of Human Nature. New York: Viking. Montgomery GH (1995) Mechanisms of placebo analgesia: Expectancy theory and classical conditioning. Unpublished doctoral dissertation, University of Connecticut, Storrs. Mowrer OH (1960) Learning Theory and the Symbolic Processes. New York, NY: John Wiley and Sons. Orne MT (1959) The nature of hypnosis: Artifact and essence. Journal of Abnormal Psychology 58: 277-99. Osgood CE (1963) On understanding and creating sentences. American Psychologist 18: 73551. Pavlov I (1960) Conditioned Reflexes. New York, NY: Dover. Sanders RS, Rehyer J (1969) Sensory deprivation and the enhancement of hypnotic susceptibility. Journal of Abnormal Psychology 74: 375-81.

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Seligman MEP (2005) Positive psychology, positive prevention, and positive therapy. Handbook of Positive Psychology. Snyder, C.R. & Lopez, S. (Eds.) Skinner BF (1957) Verbal Behavior. New York, NY: Appleton-Century-Crofts. Spanos NP, Rivers S (1977) Experienced involuntariness in response to hypnotic suggestions. In W.E. Edmonston, Jr. (Ed.), Conceptual and investigative approaches to hypnosis and hypnotic phenomena. Annals of the New York Academy of Sciences 296: 208-216. Temoshok L, Dreher H (1993) The Type C Connection. New York: Random House. Weitzenhoffer AM (1953). Hypnotism: An Objective Study in Suggestibility. New York, N.Y.: John Wiley and Sons. Wickless C, Kirsch I (1989) Effects of verbal and experiential expectancy manipulations of hypnotic susceptibility. Journal of Personality and Social Psychology 57: 762-768. Wickramasekera I (1969) The effects of sensory restriction on susceptibility to hypnosis: A hypothesis, some preliminary data and theoretical speculation. The International Journal of Clinical and Experimental Hypnosis 17: 217-24. Wickramasekera I (1970) Effects of sensory restriction on susceptibility to hypnosis. Journal of Abnormal Psychology 76: 69-75. Wickramasekera I (1973) Effects of electromyographic on hypnotic susceptibility. Journal of Abnormal Psychology 82: 74-77. Wickramasekera I (1980) A conditioned response model of the placebo effect: Predictions from the model. Bio and Self-Regulation 5: 5-18. Wilson DL (1967) The role of confirmation of expectancies in hypnotic induction. Dissertation Abstracts International 28: 4787-B. (University Microfilms No. 66-6781) Wrenn CG, Larsen RP (1955) Studying Effectively. Stanford University Press.

In: Hypnosis: Theories, Research and Applications Editors: G. D. Koester and P. R. Delisle

ISBN 978-1-60456© 2009 Nova Science Publishers, Inc.

Chapter 2

PATTERNS OF INTERACTIONAL HARMONY: THE PHENOMENOLOGY OF HYPNOSIS INTERACTION Katalin Varga, Emese Józsa, Éva I. Bányai and Anna C. Gősi-Greguss Center for Affective Psychology, Eötvös Loránd University, Budapest, Hungary

ABSTRACT In this study we review the process of the formulation of our interactional approach to hypnosis together with the development of a new methodology through various experiments. The first interactional method developed to detect interactional synchrony between hypnotist and subject on the subjective level is the Parallel Experiential Analysis Technique (PEAT). PEAT is suitable for eliciting and simultaneously gathering free reports on the subjective experiences from both interactants that later can be parallelly processed. On the basis of four experimental series, characteristic data are shown as examples of the phenomenology of the subjective experiences of hypnotists and subjects. The free reports of hypnotists about their subjective experiences were analysed separately as well and yielded three common topics that are illustrated by verbatim quotations from the original reports. Another possibility of the interactional analysis is the use of the same paper/pencil tests for the hypnotist and subject. First we used the Phenomenology of Consciousness Inventory (PCI) for this purpose, and in several of our experiments we compared their subjective experiences along their scores on the PCI factors. Later we developed a new paper/pencil test, the Dyadic Interactional Harmony (DIH) questionnaire, for directly measuring the synchrony of an interaction. DIH was validated in a series of experiments and it is a promising measure for tapping the interactional aspects of a hypnotic relationship. We used PCI and DIH from hypnotist and subject as means of interactional analysis of subjective data along with the concept of hypnosis styles (maternal/paternal scores) in a real-simulator design. We exemplify the special possibilities of the interactional approach of phenomenological data by a recent empirical result: we

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Katalin Varga, Emese Józsa, Éva I. Bányai et al. demonstrate the very different pattern of heritability in the case of subjective data as opposed to the behavioral score of hypnosis. In our experiments, in which standardised hypnosis interactions of subjects of various kinship had been analyzed, results showed that the phenomenological experience of hypnosis is not based on genetic determination, but the way interactants evaluate the session (the interaction itself) seems to be closely related to the degree of kinship. All of these empirical results seem to add special new possibilities to the understanding of hypnosis and we encourage every researcher to follow this interactional approach and methodology.

1. INTRODUCTION Interactional Approach in Hypnosis Research As Shor noted in 1959, “the flesh and blood of hypnosis—its multidimensional clinical richness and variation—only appears when hypnosis is viewed in of the dynamic interrelationships between real people” (p. 594). This implies that we cannot really understand hypnosis on an individual basis; no matter how deeply the subject is investigated, we miss the real target. Since the early 1980s more and more theoretical and empirical work emphasize the interactional nature of hypnosis (Diamond, 1984, 1987; Fourie, 1983; Levitt and Baker, 1983; Nash and Spinler, 1989; Sheehan, 1980), and more and more theories conceptualise hypnosis as an interactional process, as a social encounter between hypnotist and subject (see, e.g., the chapters of Bányai, Lynn and Rhue, Nash and Sheehan in Lynn and Rhue, 1991). These theories place particular emphasis on “rapport”, the special relationship between the two participants. Interestingly, however, even the very interactional approaches investigate the hypnotic process from the perspective of the subject, so the hypnotist is just a participant of the subject’s hypnotic dreams (Sheehan and Dolby, 1979) or just the target of the subject’s perceptions, emotions, transference, deprived attachment needs, etc. (see Baker and Levitt, 1989; Levitt and Baker, 1983; Perry and Sheehan, 1978; Nash, 1991; Nash and Lynn, 1986; Sheehan, 1980; for a review see Diamond, 1984 or Bányai, 1991). At the same time, the social-psychobiological approach (Bányai, 1991) conceptualizes hypnosis as a unique reciprocal interaction between hypnotist and subject: instead of limiting our attention to only one of the participants of the hypnosis interaction, we investigate both of them. Experimental hypnosis has been approached by our laboratory from an interactional point of view for decades: we have been investigating both parties of a hypnosis interaction, i.e., not only the subject, but the hypnotist as well. Our empirical research in hypnotic interaction includes the attitudinal, behavioral, relational, psychophysiological and phenomenological investigation of the participants (for results on these levels see Bányai, 1985; Bányai, Mészáros and Csókay, 1982, 1985; Bányai, Gősi-Greguss, Vágó, Varga, and Horváth, 1990). We think that, as in the other measures, the phenomenological level of hypnosis also must and can be investigated in an interactional way. In this paper we summarize our steps, here providing an archival ing of our research on interactional phenomenology. That is why we present our original research data in detail, serving those who would like to study the subtleties. First we introduce our data on

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hypnotists’ phenomenology, as there is no other systematic study about experimental hypnotists’ involvement in the process. The subject’s subjective experience of hypnosis is not discussed in detail here because the subject’s phenomenology is a classical topic in the literature described by several authors (Shor, 1962; Field, 1965; Matheson, Shue and Bart, 1989; J. Hilgard, 1979; Pekala and Kumar, 1989; Fromm, 1977; Fromm, Brown, Hurt, Oberlander, Boxer and Pfeifer, 1981; Fromm, Lombard, Skinner and Kahn, 1987–88; Eisen and Fromm, 1983; Kahn, Fromm, Lombard and Sossi, 1989 and so on). Then we present our methodological development: specific techniques for gathering subjective data of both participants and specific methodology for comparing the subjective experiences of the hypnotist and that of the subject. Finally, with the help of two examples, we will show the special possibilities of phenomenological analysis within interactional framework. The details of the studies summarized in this chapter are introduced in Table 1. Table 1. Some details of the studies discussed in this paper Hypnosis scale(s) TRH (5 hypnotists) or AAH (2 hypnotists) 1st series: waking control and a hypnotic part (SHSS:B) in a counterbalanced order 2nd series: SHSS:A The participants were hypnotized twice, first with the HGSHS:A, and then later with the SHSS:C. E1: SHSS:A

Subjects

Hypnotists

Phenomenological methods Free reports (PEAT, written or audiotaped)

Reference

103 experimental hypnosis sessions

7 hypnotists (4 female and 3 male)

1st series: 12 (5 males and 7 females, 4 high, 4 medium and 4 low) 2nd series: 12 (6 males and 6 females, 4 high, 4 medium and 4 low) 104 students (52 men and 52 women)

2 hypnotists: 1st series) 1 female, 42 years old 2nd series) 1 male, 33 years old)

PEAT

5 different female experimenter hypnotists

PCI after SHSS:C

Varga, Józsa, Bányai, GősiGreguss and Kumar (2001)

232 healthy volunteer Ss (168 (=72,4%) females, 64 (=27,5%) males

PCI, DIH

Varga, Józsa, Bányai, GősiGreguss (2006)

E2: WSGC

110 healthy volunteer Ss (79 (=71,8%) females, 31(=28,2) males

18 hypnotists (in 25% of the sessions a male, in 75% female hypnotist) 3 female hypnotists

PCI, DIH

Varga, Józsa, Bányai, GősiGreguss (2006)

Varga, Bányai and GősiGreguss (1999) Varga, Bányai and GősiGreguss (1994)

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Katalin Varga, Emese Józsa, Éva I. Bányai et al. Table 1. Continued

Hypnosis scale(s) Free induction, free analgesia suggestion, tested by a standardized cold pressor test. Standardized age regression and trance-logic suggestions, free dehypnosis.

Subjects

Hypnotists

32 subjects: for each H 8 young, healthy volunteer subjects (4 females, 4 males / 2 highs, 2 mediums, 2 lows and 2 simulators), 32 subjects

4 hypnotists (2 females, 2 males)

SHSS:A

62 MZ twins, 60 DZ twins, 62 siblings, and 94 parent child pairs, altogether 278 healthy volunteer Ss

10 hypnotists

Phenomenological methods PCI, DIH, judgement of hypnosis styles

Reference

PCI, DIH

Varga, Bányai, GősiGreguss, Tauszik (n.d.)

Varga, Bányai, Józsa and Gősi-Greguss (2008)

TRH: traditional relaxational hypnosis. AAH: active alert hypnosis. PEAT: Parallel Experiential Analysis Technique. PCI: Phenomenology Consciousness Inventory (Pekala, 1982, 1991). DIH: Dyadic Interactional Harmony Questionnaire (Varga, Józsa, Bányai, Gősi-Greguss, 2006). WSGC Waterloo-Stanford Group Scale of Hypnotic Susceptibility, Form C (Bowers, K. S. 1998). HGSHS: A Harvard Group Scale of Hypnotic Susceptibility, Form A (Shor and Orne, 1962). SHSS: A or B Stanford Hypnotic Susceptibility Scale, Form A or B Weitzenhoffer and Hilgard, 1959). SHSS: C, Stanford Hypnotic Susceptibility Scale, Form C (Weitzenhoffer and Hilgard, 1962). Ss: subjects. H: Hypnotist.

2. HYPNOTISTS’ PHENOMENOLOGY In his influential paper, Orne (1959) stated that the real essence of hypnosis lies in the subjective alterations experienced by hypnotized individuals. Fromm and her colleagues have stressed that controlled assessment and description of phenomenological aspects are crucial to the understanding of the nature of hypnotic phenomena (Eisen and Fromm, 1983; Field, 1965; Fromm, Brown, Hurt, Oberlander, Boxer, and Pfeifer, 1981; Fromm, Lombard, Skinner and Kahn, 1987–88; Kahn, Fromm, Lombard and Sossi, 1989; Lombard, Kahn, and Fromm, 1990). All of these papers obviously were speaking about the hypnotized subject. But to be truly interactional, one has to investigate both partners in the hypnosis session. That is why we wanted to first test whether, if hypnotists are really involved in the process of experimental hypnosis, they would give rich and meaningful phenomenological data about their experiences. For a long time hypnotists have been almost completely neglected in hypnosis research. The question arises: why? At the beginning of the history of hypnosis, the hypnotist

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(magnetiser) was considered central in the process; later this approach was reversed, because in 1813 Abbe Faria concluded that the process was more due to the subjects. During the past decades both hypnosis research and clinical reports stressed the subjects’ skills rather than the hypnotists’ contribution to the process (see Baker, 1987; Frankel, 1987; Fromm, 1987; Gravitz, 1991; Hilgard, 1987; Lazar and Dempster, 1984). In spite of these there are excellent works regarding hypnotherapists that describe (a) their countertransference (Gill and Brenman, 1959, Brown and Fromm, 1986); (b) the phenomenon of mutual hypnosis, and the possibility of the therapists' trance state (Diamond, 1984; Tart, 1969; Scagnelli, 1980; Vas, 1993); (c) the therapist-patient relationship (Brown and Fromm, 1986; Gill and Brenman, 1959) and (d) the determinants of a successful hypnotherapist (Diamond, 1986, Lazar and Dempster, 1984). But we can find very limited information about the experimenter hypnotist: one cause of this can be their reluctance to be analysed, and to uncover their own regressive, unconscious material in a professional setting (Gill and Brenman, 1959; Lazar and Dempster, 1984). This important limiting factor raises special methodological, motivational and even ethical questions. Experimenter hypnotists are often regarded as immovable figures, functioning unflappably according to the protocol of the (standardised) experiment. There is no mention about the possibility of their emotional involvement, of real transference or countertransference, of the possibility of leaving the normal, waking state of awareness, etc. Some influential theoreticians even explicitly deny the possibility of the development of archaic involvement within an experimental context (Shor, 1962). Early research data about the hypnotists from our Budapest Hypnosis Laboratory are very important objective, empirical signs of their deep “tuning in” to the subject, the signs of interactional synchrony: hemispheric prevalence influenced by the subject's susceptibility, synchronous electromyographic activity during hypnotic suggestions (Bányai, 1985), changing the duration of the induction procedure (Bányai, Gősi-Greguss, Vágó, Varga, and Horváth, 1990), deviation from the standardised text (Bányai, Gősi-Greguss, Vágó, Varga, and Horváth, 1990; Gősi-Greguss, Bányai, Varga, and Horváth, 1992), mirroring the posture of the subject, swaying motion of the hypnotist’s body in synchrony with the subject's breathing, common breathing rhythm and heart rate concordance between hypnotist and subject (Bányai, 1991). Unfortunately, the subjective, inner feelings of the experimenter hypnotist are almost completely hidden. Even those, who stress the importance of the investigation of subjective experiences (Hilgard, 1968; Lynn and Rhue, 1991; Sheehan and McConkey, 1982) restrict themselves to the subjects’ phenomenological data, it is quite rare, that the hypnotists’ experiences were explored in detail (Bányai, 1991; Bányai, Mészáros and Csókay 1985; Varga, Bányai and Gősi-Greguss, 1991; Varga, Bányai, Gősi-Greguss, and Horváth, 1992). It is all the more surprising if we consider that Diamond (1987) emphasised that the relational dimensions of hypnosis (transference, working alliance, symbiotic/fusional alliance and realistic relationship) operate subjectively. So, before attempting to interrelate the subjective feelings of both participants of the hypnosis interaction, we should know what are their experiences at all. Free reports from hypnotists. Here we summarize our experimental data about the first step of collecting and analysing subjective experiences of experimenter hypnotists (see Table 1, for further details Varga, Bányai and Gősi-Greguss, 1999).To get a systematic view on the

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hypnotists’ phenomenology, free subjective reports have been gathered under controlled experimental setting regarding the most important contents of the subjective experiences of the experimenter-hypnotists. We were looking for the common topics in the independent reports of different hypnotists, inducing hypnosis either in a traditional way, or using activealert induction (Bányai and Hilgard, 1976), supposing that the common elements should reflect the most important points in the hypnotists' phenomenology in general. Method. Seven hypnotists' free reports were collected regarding altogether 103 experimental hypnosis sessions in which they conducted hypnosis, either by TRH (5 hypnotists) or by AAH (2 hypnotists). In all of the sessions healthy young volunteers— mostly university students—of different hypnotizability participated as subjects. The basic data of hypnotists involved in this experimental series are presented in Table 2. In the cases of TRH, the Ss were hypnotized by standardized relaxational hypnotic induction procedures and test suggestions of the Stanford Hypnotic Scales (SHSS: A, B, C, Weitzenhoffer and Hilgard, 1959, 1962) which were read verbatim. The standardized procedures of AAH sessions applied the active-alert versions of the test-suggestions (Bányai and Hilgard, 1976, Bányai, 1980). The subject and the hypnotist didn't know each other previously, and the hypnotist was blind to the subjects' susceptibility. The sessions were video recorded in full length. After the hypnotic sessions all of the hypnotists gave free reports: an encouraging instruction was given to them, stressing that all of their impressions, feelings, remarks were important, they were asked to relate anything regardless of its perceived importance. These reports were video-recorded, then contentanalysed. Here we demonstrate and discuss three important topics that are common in the reports: (1) the way the hypnotist evaluated and reflected the context (situation) of the hypnosis session, (2) the subjective feelings reflecting the hypnotist's trance-like state, and (3) the (counter)transference reactions of the hypnotist (for more detailed results see Varga, GősiGreguss and Bányai, 1999.) Table 2. Basic data of hypnotists

No.1. No.2. No.3. No.4. No.5. No.6. No.7.

Sex F M F M M F F

Age 42 33 25 30 32 49 41

Hypnotizability 0 (SHSS:B) 5 (SHSS:B) 6 (HGSHS) 1 (SHSS:B) 12 (SHSS:B) 0 (SHSS:B) 12 (SHSS:B)

Background EE C CC EE EE CC E CC CC

After the sex (F: female, M: male) the age and the hypnotizability of the hypnotists are presented according to the standardised scales (Weitzenhoffer and Hilgard, 1959, /SHSS:B Stanford Hypnotic Susceptibility Scale, Form B/ Shor and Orne, 1962, /HGSHS: Harvard Group Scale of Hypnotic Susceptibility/). Finally the orientation of the hypnotist is indicated (E: experimenter C: clinician, the number of the letters roughly represents the ratio of the involvement in these fields). The hypnotists No. 1–5 are the ones who applied traditional relaxational hypnosis, while hypnotists 6th and 7th were using active alert hypnosis.

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Verbatim quotations will serve as examples for these features. The origin of the quotations is indicated by the number of the hypnotist (H) and the subject (S) of the given session. While reading the quotations please note that the demonstrated phenomena occured independently from the hypnotizability of the hypnotist, regardless of the way the report is gathered, and regardless of the professional orientation of the hypnotist.

2.1. The Context of Hypnosis from the Viewpoint of Hypnotist The outcome of the session is determined by the expectations and beliefs regarding the nature of hypnosis. Both the subject’s (patient’s) and hypnotist’s (therapist’s) faith in the process play a major role in facilitating success (Diamond, 1986). This inevitably requires unique attitude and special mood in the hypnosis session. The context-generated expectancies and the role demands of the situations labeled “hypnosis” are central elements in the socialpsychological of hypnosis (Spanos, 1986, Coe and Sarbin, 1977; White, 1941). Research shows that the way subjects conceptualize the situation of the hypnosis session—for instance, whether they label it as “hypnosis” or as an “experiment on imagination”—has surprisingly strong influence on their (hypnotic) performance (deGroot, Gwynn and Spanos, 1988; Spanos, Gabora, Jarrett and Gwynn, 1984; Spanos, Kennedy, and Gwynn, 1989). Naturally the analysis of the same phenomenon on the part of hypnotists could be interesting: the way the hypnotist perceives the situation and interprets his/her own role may be influential on the subjects' perception, since the hypnotist directly or indirectly communicates his/her own attitude. If we have a more detailed picture about the hypnotists’ attitude it may take us closer to answering the burning question: what is the mechanism of the subjects' processing of contextual information having an impact on their performance and involvement in the situation.

About Hypnosis TRH (H3, S2) “The presence of the observer was calming, though at the beginning she was not noble enough and it didn't fit to the fineness of the situation as she turned her pages, and stirred, and kept scratching. It didn't disturb me, I just realized, that she was simply doing her job, without the feeling, that ... this is “something”, a kind of holy, having a special spirit and atmosphere (the observer’s behaviour) is so vulgar, compared to the feelings between me and the subject.. that silence and all devout attention and relationship in which all tiny hair's breadth trembling has its own significance” AAH (H6 S8/1): “...There is no doubt, the active alert hypnosis seems to change our energetic matters as well.. extreme energies are involved here.” Interactional Aspects, Togetherness, Mutual Involvement TRH (H1, S6) “…the way I say... a completely equal relationship... I mean “let's go together to this state...” AAH (H1 S8/1) “she has turned to me many times, searching for my eyes, and it disturbed me all along, that I had to look at the text. I think she experienced a kind of loneliness, and it was bad for me, as well, it has destroyed our relationship.”

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Professional Remarks TRH (H2, S5) “I feel this is very important... in the introduction as a matter of fact, we repeat the conditions: to co-operate, to concentrate, and just to listen to my voice…this is the repetition of the rapport....If she stands this without uneasiness, she will accept the situation!” AAH (H6, S2/1) “...during hypnosis you get the from the face, the posture, the spinning of the pedal...and you can feel where we are...

2.2. Signs of Alteration of State of Consciousness The concept of the hypnotized subjects’ trance state is fundamental in the neodissociation theory (Hilgard, 1976, 1977/79), and an important element in the “state” or “special process” theories either as causal variable, or just characteristic of the hypnotized person. The possibility that the other participant of the dyad—i.e. the hypnotist—may get into an altered state of awareness is well documented regarding clinical hypnosis sessions: mutual hypnosis (Tart, 1969), counter-trance (Vas, 1993), the client as hypnotist hypnotizing the therapist (Diamond, 1980) and related phenomena have both theoretical and practical significance. But these studies present this issue as specific for therapeutic sessions and suppose that it is unlikely to occur in experimental hypnosis. As “most hypnotherapist spontaneously experiences trance when hypnotizing their clients” (Diamond, 1984, p. 9.), Diamond stresses the importance of systematic research studying the hypnotherapists' trance experiences in order to move from purely speculative analysis of the nature of these phenomena (Diamond, 1984, 1987). We think and by quotations below that the characteristics of trance(like) states (Ludwig, 1972, 1983) can be documented in experimental hypnotists’ reports as well. Among others Tart (1972) and Orne (1959) stress that the subjective conviction that somebody is in an altered state of consciousness (ASC) is a crucial factor in detecting the state. This subjective element is easily available for the person so s/he can identify this state without doubt. Many theories—in spite of the methodological controversies—postulate, that the best index of an ASC is the person’s subjective experience of being in the state (Farthing, 1992; Haley, 1958; Pekala, Steinberg, and Kumar, 1986; Pekala and Kumar, 1989, Tart, 1972, etc.) TRH (H1, S10) “The rumbling in my stomach was due to relaxation ... it was extremely good, that I could relax... (...) this arose from her, because why would I relax in a situation, like this?” AAH (H6, S2/1) “When I hypnotize I am at least as hypnotized as the subject.” TRH (H1, S2) “Look, I say things like this completely out of my control... I was not aware of this at all...” AAH (H7 S1/1) “(arm rigidity suggestion) I simply had to raise up my arm, I don’t know why...(...) meanwhile once I’ve tried to let it down, but it didn’t went. I felt that this is good, so I also do together with him up to the end.” TRH (H5, S10) “It is difficult to put my experience into words, because there are mostly pictures inside me....When I entered my first impression was that this man exists just inside of his skin (...) I had an image of a man sitting cross-legged...in rather

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primitive circumstances ...the life goes on. And he is sitting there so calmly, because the inside of him is lively, colourful, joyful, changing, strange, surprising, mystic.” AAH (H6, S2/1) “When I hypnotize, at the dream suggestion, my fantasy begins to work, I start to dream...” TRH Q (H5, S9) “Sometimes I felt…that we were definitely together...feel together…maybe it was me, who felt it, but I think she also felt this kind of easiness, those kinds of effects of the suggestions that I myself felt, what I wanted to get.” AAH Q (H6, S2/1) “When I hypnotize, my arm gets heavy first…at the arm rigidity I feel that my arm is rigid and stiff, in spite of the fact that I am the one who gives the suggestion.” TRH Q (H1, S1) “At this moment I had a feeling in my body…it was a strange feeling: ‘don't go further!’... as if I entered a circle, and I felt: ‘Backward! It is too quick for her!’” AAH Q (H7 S1/1) “...I had a completely pleasant feeling... throughout from now... it was comfortable for me...it was very good for me…so it was enjoyable to read in this strange hypnosis.” TRH Q (H1, S9) “I definitely that I had something in my mind at this point, but I don't what...I have no idea.” AAH Q (H7 S1/1) “I was not sure even that he had said ‘21 years’ (actually it was half minute earlier), and it is very difficult for me to what they say…the numbers....The hypnosis is difficult at these times, surely....” The shift from the normal state of awareness on the part of the hypnotist are explained by some theories as “dependency needs (that) are revoked by the subjects’ regression” (Lazar and Dempster, 1984, p. 32) or as the hidden wish to satisfy his regressive longings (Gill and Brenman, 1959) and related dynamic/analytic concepts. The signs of ASC are possibly the natural consequences of the setting of hypnosis and the role of hypnotizing itself. Hypnotist focuses upon the subtleties of communication, because the message must have the form that would be most conductive to the subject's frame of reference or awareness (e.g., trance state) (Diamond, 1986, p.239.). The intensive concentration, the extremely detailed observation of the subject and absorbed attention are all factors that may lead to ASC, and “may evoke greater sensitivity to and feeling of intimacy” (Lazar and Dempster, 1984, p.32.) with the subject. To reach this, the hypnotist usually moves from the normal state of awareness to get closer to the subject’s state. Usually deep, physical-body involvement may help the hypnotist to bridge the gap between himself or herself and the patient (Bányai, 1991; Bányai, Gősi-Greguss, Vágó, Varga, and Horváth, 1990; Diamond, 1987). We can not forget, thought, that parallel with these alterations in cognitive functioning the hypnotist must keep control and takes responsibility of the whole process. This requirement involves dissociation on his/her part: at least one subsystem must keep the functions of reality-testing, planning and monitoring. It is needless to stress, again, that the notion of “dissociation” had been “reserved” for the subjects so far. In his writings Diamond strongly stresses (1984, 1986, 1987) the therapists’ trance as one contribution of hypnotherapists in their clinical practice. This “facilitates the ability to be empathic with and receptive to the patient” (Diamond, 1986, p. 243), which in turn facilitates the therapist’s ability to employ a “language” appropriate to the patient’s operative state of consciousness” (p.244.)

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Others (Hammond, 1991) also discuss the possibility of “going into a trance oneself, and simply ‘trusting the unconscious’ to formulate suggestions and conduct hypnotherapy” (p. 38.), Enhanced receptivity and empathy are obviously important in experimental settings as well, and the issue of “appropriate language” is especially interesting in the experimental context. The nature of the message exchanged between the hypnotist and subject is always determined in the hypnotic context (Haley, 1958), but consider, that almost all controlled experiments employ standardized, verbatim inductions and suggestions. The experimenterhypnotists' ASC may urge them to use a language according to the demands of their own trance states instead of the standard protocol. The restrictions of the standardized text may increase the inner tension (dissociation) in the hypnotists, which leads them at a certain point to break the rule. This way the amount and type of departure from the standardized text and changes in affective prosody (Gősi-Greguss, Bányai, Varga, and Horváth, 1992; GősiGreguss, Bányai and Varga, 1996; Gősi-Greguss, 2002; Gősi-Greguss, Bányai, Józsa, SuhaiHodász and Varga, 2004) may be one of the objective indices of hypnotists’ trance states.

2.3. Transference on the Part of the Hypnotist An experimental hypnosis session is a very special situation: two persons, formerly complete strangers, meet for the first time in their lives, enter an interactional process where the ways they seat themselves (proxemic), the way they communicate and distribute information-channels (one with closed eye, other influencing by mere words) is very special, they must reach a predetermined goal under limited time with special means, and the whole process is recorded under very detailed observation. The relationship between hypnotist and subject is most commonly approached by the process of transference, or archaic involvement (Horváth, Bányai, Varga, Gősi-Greguss, and Vágó, 1988; Nash, 1991, Nash and Spinler, 1989; Sheehan, 1980). In this intense, sometimes embarrassing situation it is natural to re-evoke earlier relationship-patterns and find one's way in the situation by their help. Our result showed that usually an accidental physical resemblance to some relatives or other important persons in the hypnotist’s life evokes the transferential feelings. Our material yielded rich data on this respect: TRH (H4, S9) “As she got relaxed her mouth curved down, and it made her awfully antipathetic. Her face became so aggressive. It disturbed me! She reminded me of the secretary of Dr. K.” (K: a head of another department). TRH (H5, S4) “She is a kind of woman whose eyes are worth looking into for a long... long time... yes ... The one whom you snap up into your arms willingly...her body as well... If...” (deep breath and coughing, and turning to other topic). AAH (H2 S8/1) “I like so much these type of persons... this very clever, very intelligent,… and somehow very good type of men…I really like...All in all, this Rita is a really nice girl.” AAH (H6, S2/1) “She was a sweet little girl...she stole her way into my heart, really,...I take a shine to these kind of girls...It was like playing.”

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Wachtel’s comment on transference is especially relevant here: “(transference is) a particular way of organising new stimulus input, based, but not completely unresponsive to the actual situation” (Wachtel, 1973, p.328, emphasis added). Brown and Fromm (1986) defines countertransference as a situation, where the “therapists sometimes look at patients through the distorting lenses of the past. They may feel for and about certain patients, and react to them, as if these patients were important figures from their own past” (Brown and Fromm, 1986, p. 215). These occasions are supposed to be dangerous for the success of the therapy, even the transfer of the patient to another therapist is suggested (Lazar and Dempster, 1984; Brown and Fromm, 1986). In our view, the above examples match this, and other definitions of (counter) transference: e.g. “complex mode of interpersonal relation in which the therapist (hypnotist) comes to assume a particular importance for the client (subject) that is not ed for in of normal social or psychological processes of interaction” (Sheehan and Dolby, 1979, p. 573). In this case, though, the detection of signs of countertransference in experimental hypnosis sessions has some important implications: (a) What can or must be done if experimental settings are “infected” by these transferential feelings on the part of the experimenter-hypnotist? Can we say that the experiments remained standardized, well controlled situations? What if one of the most important features of the hypnotists' involvement—that is (counter)transference—remains uncontrolled, or undetected? (b) As almost all of our experimental settings showed the signs of some types of (counter)transferential feelings, one hypothesizes that this phenomenon must be more frequent in clinical settings as well. If this is true, it is rather a natural phenomenon than an unwanted side-effect to be minimised. Close analysis of the countertransference reactions in experimental context may help to differentiate the helpful countertransference—as a way for being in tune with the various aspects of the patient's personality—from those of antitherapeutic ones (see Diamond, 1987 about this distinction). Clearly, the aim of the hypnotist is to find an appropriate position for himself or herself in the dimension from drive-organised primary process to concept-organised secondary ones (Hilgard, 1962) so as to be able to gain the most from the benefits of the functions of the dissociation (Ludwig, 1983).

3. DEVELOPMENT OF INSTRUMENTATION By demonstrating that even experimenter hypnotists have rich and important phenomenological data, we had to develop appropriate methodologies for recording phenomenological data in interactional approach. We wanted to enrich the research arsenal by methods that are suitable for both the subjects and for the hypnotists.

3.1. Parallel Experiential Analysis Technique (PEAT) Sheehan and his colleagues (Sheehan, McConkey and Cross, 1978; Sheehan and McConkey, 1982; Sheehan, 1982–83) developed the Experiential Analysis Technique (EAT)

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for gathering data on hypnotic subjects' phenomenological experiences. The essence of this technique is that the report of a hypnotic subject on his/her subjective feelings and thoughts is stimulated by the video-playback of the original hypnosis session. In this situation an independent inquirer listens to the subjects’ reports (for details of the original procedure see Sheehan and McConkey, 1982). Our interactional approach required to extend this procedure to the hypnotist. The new method, called Parallel Experiential Analysis Technique (PEAT) has been described in details in Varga, Bányai and Gősi-Greguss (1994), here we restrict ourselves to the most important methodological points, and some of the preliminary results that later proved to be relevant (see Table 1 and Figure 1).

Video Picture In the interactional modification of EAT it is important to use a video recording of the hypnosis session where both of the participants can be seen. Althought we did not compare this kind of picture systematically to a recording where only the subject is seen, we have the feeling that the “dyadic” picture elicit more comments on the partner. Unfortunately, even the most comprehensive report on EAT (Sheehan and McConkey, 1982) misses to mention who is (or who are?) seen in the video picture used (subject alone or together with the hypnotist?). Inquirers It is better to use two inquirers interviewing the subject and the hypnotist simultaneously but separately, immediately after the session: in this case both S and H can give fresh and spontaneous remarks. It would be very tiring for one inquirer to listen to the reports of both S and H one after the other, and a single inquirer may mediate between the two reports, biasing the second by losing his/her independence. The problem arises however, that the difference in the two separate inquirers' style and personality may result different influences on the reports. So we analysed the effect of different inquirers: our results showed that only one thematic category was influenced (the male inquirer elicited more negative statements than the female), but this effect was observed only in the case of subjects. Nevertheless, it is advisable to work with inquirers who share as many characteristics (age, gender, hypnotic susceptibility, and so on) as it is possible, in order to reduce the possibility of such differences seen above. Parting the Participants of Hypnotic Interaction After the hypnosis session the hypnotist briefly described the importance of the registration of subjective experiences, and reasoned that the subject would be interviewed by an independent person, whom s/he introduced by telling his/her name and affiliation, and leaved the subject alone in the chamber. The whole “parting ceremony” of hypnotist and subject was standardized. When the independent inquirer came in to interview the subject, the same instruction and procedure was applied as those used by the original EAT method (see Sheehan and McConkey, 1982). We think that the most important methodological point researchers using PEAT have to consider is the parting of the hypnotist and the subject at the end of their hypnosis interaction. This parting leads both of them to a situation where they are supposed to give honest and deep reports on their feelings. Apart from clinical evidence, experimental research (Bányai,

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1991) also shows that very strong emotional bonds may develop between hypnotist and subject, sometimes reaching the deep archaic layers of their personality. Tearing them from this relationship and asking them to report on the hypnosis session is a problematic point, even in the original form of EAT (where only the subjects are involved). That is why it is crucial that before parting, the hypnotist should put trust in the inquirer, and should briefly explain the scientific importance of the independent way of discussing subjective feelings. Furthermore this problem is connected to the hypnotizability of the subjects: the higher is the susceptibility of the S, the stronger is the observable bond to the hypnotist (Nash and Spinler, 1989): so parting with the hypnotist immediately before the (P)EAT session doesn't exert equal effect on subjects of different hypnotizability.

The Hypnotist's Report It is equally—if not more—important to make every effort to help the hypnotist too, to give a detailed report about his/her experiences. In our experiments the PEAT session with the hypnotist took place in the same or in a very similar experimental chamber, as the hypnosis session or the PEAT session with the subjects. It is of vital importance to give an encouraging instruction to the hypnotist as well. It is important to train the inquirer to acquire the appropriate attitude: helping the hypnotist to change his/her role and creating an atmosphere where self-disclosure can take place. In our experiments the hypnotists during PEAT occasionally turned to very intimate, ego-involved topics, and sometimes the report was given in a high emotional tone. It may be difficult for the inquirers to handle these situations: to be empathic, but not deeply involved, and to remain within the strict experimental conditions determined for them in this method. Data Analysis The subjective experiences related by the subjects and by the hypnotist were content analysed separately. A category system (of about 90 categories) covering the topics and features of the reports was developed to analyse the experiences. The main groups of categories were as follows: 1. 2. 3. 4. 5. 6. 7.

attitudes to and preconceptions and/or knowledge about hypnosis; situational and contextual factors; signs of alteration of consciousness; remarks on relational and emotional experiences; comparison with other states of awareness (waking, sleeping, etc.); ego-involving experiences; general evaluation of the state or of process.

One can follow several ways when comparing the independent reports of subject and hypnotist: • • •

actual thematic concordances can be looked for independent raters can judge the degree of harmony between the reports temporal changes of the dynamics of the concordances in the independent reports can be followed,

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by intercorrelating the frequency of the appearance of specific thematic categories the hypnotic interaction in general can be characterized

With the help of PEAT one can even utilize the opportunity that a video recording offers an objective time measure on the basis of which slight temporal changes can be followed: this way we can describe the dynamics of the interactional process, and discrepancies or concordances can be discovered in the timing of comparable features in the two participants' experiences.

1. Original hypnosis interaction, recorded. 2. Reports of hypnotist and subject separately, in the presence of independent inquirers (I1 and I2), stimulated by the video recordings taken in step 1. 3. Data analysis: comparing the independent reports by viewing it simultaneously on two monitors. The rater may look for thematic concordances, or judge the degree of harmony between the reports. Figure 1. Steps of PEAT.

Below three points (A, B, C) will illustrate the interactional nature of PEAT by demonstrating some connections between the subjective reports of the subject and that of the hypnotist. A. Thematic concordances: In the course of analyzing our records, we realized that if we follow the video recordings of the two reports simultaneously—for instance, on two monitors—we can detect characteristic changes in the degree of harmony between them. In some parts the hypnotist's and the subject's reports conflicted with each other, but there were points where the independent reports were in very high concordance. In these latter cases the two people commented on the events in the same way, they sometimes used the same expressions or metaphors describing their feelings and experiences, the color tone of their imagery scenes was the same, and so on. The agreement between the reports is sometimes striking. Some verbatim quotations exemplify these concordances:

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a) Commenting the same part of the session, the subject said: “...I felt that I was in a very deep hypnosis” while the hypnotist said: “I felt that he was in a deep trance” b) Subject: “at the end it would have been good to stay and continue...” Hypnotist: “I felt that he would like to go on enjoying this hypnosis.” c) Subject: “At this point there was something like sunshine, with a beautiful calm feeling” Hypnotist: “At the moment a nice warm feeling spread over my body.” It is important to underline that these points of concordance cannot be attributed to the observation of obvious behavioral features (e.g., smiling). As in PEAT the participants of the hypnosis interaction relate their experiences and feelings, and comment on the events of the hypnotic session completely independent of each other, it is very interesting to find that these independent reports still match each other. We postulated that in most of the cases the points of concordance indicate a deep attunement between the hypnotist and subject, where they have common subjective feelings and associations, and their reports indicate a very fine harmony of their experiences. This phenomenon can be considered as another sign or example of interactional synchrony, apart from those that were described in other levels of the investigation, e.g. t movements and posture mirroring in overt behavioral level, or the common breathing rhythm and parallel myographic activity at the physiological level (Bányai Mészáros and Csókay, 1982, 1985; Bányai, 1985; Bányai, 1991). B. According to our analysis of different levels of the hypnosis sessions, the nature of the hypnotists' relational and emotional involvement in hypnosis and their so called working styles were different: One of the hypnotists (1st series) relied mainly on her physical feelings, while the hypnotist in the second series remained at a more analytic, cognitive level, using his cognition instead of his body. These styles were labelled as “physical-organic” and “analytic-cognitive”, respectively. This analysis was one of the first studies where the various working styles of hypnotists have been described. Later on a detailed description and operationalization of hypnosis styles has been published (for detailed description of these styles see Bányai, Gősi-Greguss, Vágó, Varga and Horváth, 1990; Bányai, 1991; Bányai, 1998; Bányai, 2002; Varga, Bányai, Józsa and Gősi-Greguss, 2008). Analysis of the subjects’ verbal reports given by PEAT showed that the degree of the subjects' “positive relational experiences” is closely connected to these different styles: In the 1st series the “positive relational” category in the subjects' reports showed tendency to correlate positively with an interactionally synchronous physical phenomenon, with the amount of the so called “common breathing rhythm and pulsation” (r=.53, p<.10): that is, with the time ratio of the matching of breathing rhythm of the hypnotist and subject during the hypnosis session. This connection was even stronger with low hypnotizable subjects (r=.96, p<.05). In the 2nd series, however, the same category in the subjects' reports - referring to their “positive relationship” with the hypnotist - was closely connected to those contents of the hypnotist's reports, which indicate his cognitive style: these were: (1)

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Katalin Varga, Emese Józsa, Éva I. Bányai et al. the “amount of interpretation” (r=.75, p<.01), (2) the “comments on his strategy in hypnosis” (r=.65, p<.05), and (3) the “professional statements” category (r=.60, p<.05). C. The intercorrelation of the categories of hypnotists' and the subjects' subjective experiences showed the following: In the 1st series the frequency of the subjects' reports on their “positive relationship with the hypnotist” correlated positively with the hypnotist “positive emotional-relational involvement” (r=.68, p< .02), with the “total number of positive comments” of the hypnotist (r=.81, p< .01), and with the “general good feelings” of the hypnotist (r=.63, p<.05). In sharp contrast with these correlations, none of these categories of the hypnotist of 2nd series correlated significantly with the subjects above mentioned category. So, the intercorrelation of the participants' subjective experiences shows a very different pattern in the two series.

3.2. Five-score Version of the Phenomenology of Consciousness Inventory The Phenomenology of Consciousness Inventory is a paper and pencil test with 53 items, measuring the subjective alteration of consciousness on 26 dimensions (PCI, Pekala, 1980, 1982, 1991ab; Pekala, Steinberg and Kumar, 1986): Altered Experience (Body image, Time sense, Perception, Meaning), Positive Affect (Joy, Sexual Excitement, Love), Negative Affect (Anger, Sadness, Fear), Attention (Direction, Concentration), Imagery (Amount, Vividness), Self Awareness, Altered Awareness, Arousal, Rationality, Volitional Control, Memory, Internal Dialogue. PCI is suitable to map phenomenological states by having subjects complete it in reference to a preceding stimulus condition. The Hungarian version was validated by Szabó (1989; see also Szabó, 1993). As our earlier data proved that experimenter hypnotists’ free reports contain many details regarding their own alteration of state of consciousness, PCI seemed to be a good paper and pencil test to tap this aspect. Especially, as the PCI have been used in wide variety of stimulus conditions (such as progressive relaxation and deep abdominal breathing (Pekala and Forbes, 1988), out-of-the-body experience (Maitz and Pekala, 1991), drumming and trance postures (Maurer, Kumar, Pekala, and Woodside, 1997; Woodside, Kumar, and Pekala, 1997), and firewalking (Pekala and Ersek, 1992–93) it was just one step to have hypnotists complete the Phenomenology of Consciousness Inventory as well, to score their own feelings and experiences, in reference to the preceding “hypnotizing” period. But originally PCI has no final score; it gives 26 scores on the above mentioned scales and subscales. This makes it a bit difficult to use it in relation to other measures. The difficulty is even grater in the interactional approach, where the scores of both participants are taken into consideration. Kumar, Pekala and Cummings (1996) reported a five factor scoring method of PCI, where only five scores characterize the phenomenological state of a person. In our study we wanted to test via a confirmatory factor analysis (CFA) if the covariance matrix of phenomenological report during the entire SHSS:C istration in this study conforms (or fits) to that found in previous work (Kumar, Pekala and Cummings, 1996). Our results are consistent with those of Kumar, Pekala and McCloskey (1999), in that the factors of dissociative control, positive affect, and attention to internal processes were

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significantly correlated (p < .001) with the SHSS:C score, even though there were methodological differences between the two studies. That is, these results hold whether the PCI was completed by the subjects in reference to a four-minute interval embedded in the hypnosis session (as in the original application of PCI), or when the PCI was completed in reference to the entire scale (as was done in our later study). The confirmatory factor analysis on the Hungarian data revealed a reasonably good fit for the factor model found by Kumar, Pekala and Cummings (1996). This fit suggests that the five factor model of the PCI obtained earlier with the HGSHS:A might be productively extended to other scales (the SHSS:C), in a different linguistic and cultural setting (see Table 1, for further details Varga, Józsa, Bányai, Gősi-Greguss and Kumar, 2001). So, on the basis of these results we included PCI to our research arsenal. Both for hypnotists and subjects we calculate five scores, as defined below: 1. Dissociative control: Higher factor scores reflect alterations in (a) trance effects associated with altered state of awareness and altered experiences (body image, time sense, perception, visual imagery, and meaning) and (b) ego-executive functioning (Fromm, Brown, Hurt, Oberlander, Boxer and Pfeifer, 1981) and reality orientation associated with decreases in memory, rationality, volitional control, and internal dialogue (i.e., the classic suggestion effect, Weitzenhoffer, 1978; Bowers, 1981, 1992). In an earlier study, Spinhoven, Vanderlinden, Ter Kuile and Linssen (1993) had found two factors, trance and reality orientation, associated with a shortened version of the PCI istered within the context of the Stanford Hypnotic Clinical Scale (Morgan and Hilgard, 1975). According to Kumar, Pekala and Cummings (1996), the dissociated control factor combines Spinhoven et al.’s two factors into one factor. 2. Positive affect: Higher factor scores reflect more joy, more sexual excitement, more love, altered meaning, altered body image, and altered perception. 3. Negative affect: Higher factor scores reflect more anger, sadness, fear, and arousal, but low rationality. 4. Visual imagery: Higher factor scores reflect more visual imagery (amount and vividness). 5. Attention to internal processes: Higher scores reflect greater alterations in time sense and perception, greater absorption, inward directed attention, altered state of awareness, internal dialogue, and low imagery vividness.

3.3. Development, Standardization and Validation of the Dyadic Interactional Harmony (DIH) Questionnaire The next step in the formation of our interactional methodology was the development of a new paper and pencil test called the Dyadic Interactional Harmony (DIH) questionnaire (Varga, Józsa, Bányai and Gősi-Greguss, 2006; see Appendix 1). The most important characteristic of this measure is its direct focus on the interaction itself, evaluated by the participants of the interaction themselves. The main motive for the development of this questionnaire was to get a measure that is: a) short and simple; b) easily applicable for parallel processing of the data; c) not specific for

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hypnotic interactions; d) not restricted to experimental hypnosis sessions, but provides clinically meaningful data as well; e) suitable to characterize the degree and pattern of harmony between the interacting participants. DIH lists 50 items: nouns and adjectives that are characteristic of various kinds if dyadic interactions. The interactants independently fill in the questionnaire indicating how much each feature characterized their recent interaction on a Likert-type scale, from 1 (not at all) to 5 (completely). The Hungarian version of DIH was standardized in a sample of 256 subjects (Varga, Bányai, Gősi-Greguss, 1999), who were interacting in pairs in a non-hypnotic setting in a so called mutual Rorschach test situation (for the test see Engelbrecht, Arnold and Eraschky, 1987 and Loveland, Wynne and Singer, 1963). In the mutual Rorschach test situation the interacting partners should come to an agreement regarding the meaning of the ink-blots of the “classical” Rorschach-test. The standardization DIH data of Mutual Rorschach situation were factor analyzed, using iterated principle factor analysis with varimax rotation. Four factors were obtained, ing for 72% of the common variance. On the basis of these factors, four subscales were created (3 positive and 1 negative), each having good internal consistency: 1. Intimacy (items like ion, love. Cronbach alpha: 0.85), 2. Communion (items like understanding, harmony. Cronbach alpha: 0.86), 3. Playfulness (items like humour, inspiring. Cronbach alpha: 0.81), 4. Tension (items like anxiety, fear. Cronbach alpha: 0.78). The cumulative explanatory values of these factors are: 42, 58, 66 and 72% respectively. Appendix 2. shows the data of factoranalysis of DIH. Of course after standardization we applied DIH to hypnosis sessions as well. At first data were collected on 232 subjects in standardized individual (E1: Stanford Hypnotic Susceptibility Scale, Form A, SHSS: A, Weitzenhoffer and Hilgard, 1959) and 110 subjects in standardized group hypnotic sessions (E2: standardized protocol of Waterloo-Stanford Group Scale of Hypnotic Susceptibility, Form C, WSGC, Bowers, 1998), where other measures of hypnosis (e.g. hypnotic susceptibility, PCI) were applied to validate the DIH subscales on a hypnotic sample. In case of the individual sessions (E1) the measures were applied for the hypnotists (Hs) as well. The hypnotist (H) and the subject (S) completed the questionnaires independently. The four subscales had good internal consistency in this hypnotic sample as well, as their Cronbach alpha values ranged from 0.77 to 0.92. The subscales of DIH are not independent from each other (as can be seen in Table 3), as it was the case in the original standardization sample as well. Table 3. Correlations of DIH subscales (data of the subjects)

Intimacy Communion Playfulness Tension

E1 (N=231) 1,00 0.51** 0.59** 0.03

* p < .05; ** p < .01

Intimacy Communion Playfulness E2 E1+E2 E1 E2 E1+E2 E1 E2 E1+E2 (N=106) (N=337) (N=231) (N=106) (N=337) (N=231) (N=106) (N=337) 0.69** 0.57** 0.65** 0.62** -0.28** -0.06

1,00 0.53** 0.63** 0.59** 1,00 -0.29** -0.41** -0.31** -0.17** -0.43** -0.25**

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Table 4. Correlations of the DIH subscales with the other tests in E1

Tension

Intimacy

Communion

Playfulness

Tension

231 228 228 228 228 228 227 227 227 227 227

Playfulness

SHSS-A PCI DC S PCI PA S PCI NA S PCI VI S PCI IA S PCI DC H PCI PA H PCI NA H PCI VI H PCI IA H

DIH Scores of the hypnotist

Communion

N Intimacy

DIH Scores of the subject E1

0.19* 0.21** 0.48** -0.02 0.19** 0.14* 0.13 0.11 -0.04 0.14* 0.12

0.18** 0.01 0.16* -0.19** 0.11 0.11 0.00 0.00 -0.03 0.05 -0.02

0.21** 0.21** 0.32** -0.10 0.13* 0.21** 0.03 0.01 -0.08 0.06 0.04

-0.07 -0.00 0.02 0.50** -0.10 -0.00 0.13 0.05 0.01 0.00 0.14*

0.33** 0.17* 0.11 0.14* 0.06 0.09 0.50** 0.82** 0.06 0.14* 0.58**

0.30** 0.15* 0.14* 0.06 0.09 0.13* 0.29** 0.46** -0.14* 0.21** 0.34**

0.29** 0.16* 0.13* 0.01 0.08 0.13* 0.40** 0.62** -0.06 0.17* 0.45**

-0.14* -0.00 0.01 0.02 0.06 -0.04 0.27** 0.12 0.51** -0.01 0.24**

S – scores of the subject; H – scores of the hypnotist (* p < .05; ** p < .01).

Table 5. Correlations of the DIH subscales with the other tests in E2

E2

N

Intimacy

DIH Scores of the subject Communion Playfulness

Tension

WSGC PCI DC PCI PA S PCI NA S PCI VI S PCI IA S

106 106 106 106 106 106

0.29** 0.41** 0.65** -0.15 0.19* 0,19*

0.27** 0.29** 0.41** -0.27** 0.16 0.16

-0.22* -0.09 -0.22* 0.63** -0.06 -0.06

0.20* 0.26** 0.50** -0.30** 0.08 0.08

S – scores of the subject (* p < .05; ** p < .01).

Relationship of DIH with the other Measures of Hypnosis The correlation coefficients of the subscales of DIH and the other measures (SHSS: A, WSGC and the 5 factor-based scales of PCI) are presented in Tables 4 and 5. As it can be seen in Table 4 and 5, SHSS susceptibility scores of subjects have a low to moderate but significant positive correlation with their Intimacy, Communion and Playfulness DIH subscales. It means that high level of susceptibility is characterized by an intimate and playful atmosphere with better communion between H and S. Furthermore the above DIH scales of hypnotists show higher positive correlation with the SHSS values, so the perceived quality of the interaction by the hypnotists seems to be more closely related to the subjects’ hypnotizability scores than the DIH values of subjects themselves. On the basis of their susceptibility scores the subjects were arranged into three groups of “susceptibility range”: 0–4 Low susceptibility, 5–8 Medium susceptibility, 9–12 High

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susceptibility*. As there was no significant interaction of the “Experiment” and “Susceptibility ranges” we report the comparison of Lows, Mediums and Highs on DIH subscales in a pooled sample of E1+E2. In the pooled sample, a significant difference appeared in the case of the subjects' “intimacy”, “communion” and “playfulness” scores (see Table 6) as a function of hypnotic susceptibility of the subjects, due to the Low hypnotic susceptibles, who gave significantly lower “intimacy” “communion” and “playfulness” scores than the Medium or High susceptibles. Table 6. Comparing the means of the DIH subscales of the Low, Medium and High susceptible subjects DIH scores of Ss Tukey Post Hoc test High F Post Hoc df

Pooled (N=337) DIH subscale Intimacy

x= sd= x= sd= x= sd= x= sd=

Communion Playfulness Tension

Low (N=111)

Medium (N=164)

2.08 0.65 3.7 0.84 2.7 0.84 1.39 0.58

2.42 0.73 4.1 0.65 3.1 0.83 1.3 0.60

(N=62)

2.55 0.62 4.2 0.66 3.4 0.76 1.19 0.61

2,334

11.52**

L<M=H

2,334

16.35**

L<M=H

2,334

13.76**

L<M=H

2,334

2.13 n.s.

-

* p < .05; ** p < .01

Table 7. The DIH scores of hypnotists and subjects and their comparison by t-tests (in E1)

DIH SUBSCALE Intimacy Communion Playfulness Tension

x= sd= x= sd= x= sd= x= sd=

E1 (N=227) t

Ss

Hs

(N=227)

(N=227)

2.39 0.71 4.23 0.64 3.22 0.84 1.30 0.60

2.13 0.73 3.63 0.71 2.55 0.78 1.55 0.56

df

4.29**

226

10.30**

226

9.26**

226

4.67**

226

* p < .05; ** p < .01

*

Analysing the distribution of susceptibility in the two samples of E1 and E2 we decided to rise the cutting value of the range for High susceptibles, to get a more suitable range for statistical analysis. That is why we do not exactly follow the conventional ranges of 0–4 for Low, 5–7 for Medium, and 8–12 for High.

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5 4 3 2 1 0

Ss

Te ns io n

ul ne ss Pl ay f

m

un io n

Hs

Co m

In tim ac y

DIH score

Average DIH scores of Ss and Hs (E1)

DIH subscales

Figure 2. The DIH scores of hypnotists and subjects on the four subscales. In case of all the subscales the difference is significant at p < .01.

Phenomenological Data from DIH On the basis of the 227 hypnotic interactions of E1, the hypnotists’ and subjects’ DIH mean scores were calculated and compared to each other. The data of comparison of “hypnotizing” and “being a subject” in a standardized hypnosis experiment on the 4 subscales of DIH are summarized in Table 7. As it was seen, the difference between the average scores of the subjects and hypnotists is significant in case of all the subscales of DIH, but these differences are so small, that the similarity of subjects’ and hypnotists’ average scores in each DIH scale seems to be more important (see Figure 2.). It can be seen in Figure 2 that the general patterns of the average scores of hypnotists and subjects on the 4 subscales do harmonize with each other. So these types of experimental hypnotic sessions are moderately intimate and playful interactions, with high level of felt communion, and some tension—according to the subjective judgments of both H and S. As a summary we can say that the DIH questionnaire has good psychometrical features: very high internal reliabilities for the subscales in the original (Mutual Rorschach sample), and in these hypnotic samples as well. The high correlation between the factors and subscales imply that basically “one thing” is measured by DIH, i.e., the “intimacy” subscale. This strongest factor has the highest explanatory value, but the three other smaller subscales may contain important information, occasionally showing different relationships with the other variables than the strongest factor (details are shown later). Subjects of individual sessions give higher scores on DIH, especially on the “communion” scale, reflecting the fact that a dyadic situation is based more on the cooperation of the participants than the group session. The analysis of the pattern of correlations between PCI (the validating criteria ) and DIH, we can characterize the relationship between the subjective alteration in consciousness reported by the participants on PCI, and the way they characterized their interaction on DIH. The positive affects reported by the participants on PCI is strongly correlated with the way the interactants characterize the interaction itself (positive DIH scales), which is true both in the case of subjects and hypnotists. In case of subjects the positive subscales of DIH are

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moderately connected to the positive affect scale of PCI, but all the other PCI scales are almost independent from the DIH scores (significant but close to zero correlations). That is the phenomenological level of subjects’ (PCI) seems to be almost entirely independent from the way they evaluate the interaction itself (DIH). On the other hand in case of hypnotists, their own subjective consciousness alterations represented by PCI H (dissociative control, positive affect, internal attention) are moderately or highly connected to the way they judged their interaction with the subjects (DIH). So the various subjective aspects of felt trance state while hypnotizing seems to be more connected to the felt quality (especially intimacy) of the interaction, than the state of being hypnotized. The application of DIH in a hypnotic sample fulfilled the aims and requirements set at the beginning of its development: this is an easily istered, quick method which can be applied for subjects and hypnotists, both in individual and group sessions.

4. SPECIAL POSSIBILITIES OF INTERACTIONAL APPROACH OF THE PHENOMENOLOGICAL DATA Finally we present two examples to show the special possibilities of interactional phenomenological analysis. The first will be about the pattern of phenomenological and relational data in relation of hypnosis stiles (maternal and paternal), the second a twin-study on the heritability of hypnotic responsibility. In both of these cases phenomenological data, but only if approached intreactionally, could yield important empirical data, describing special phenomena that were not appearing in other measures.

4.1. Phenomenology of Hypnosis Styles During the past decades our laboratory described two characteristic hypnosis styles, the physical-organic and the analytic-cognitive styles. The most important features of these styles are summarized in Table 8. These two basic forms of involvement closely resembled the hypnosis styles described by Ferenczi (1909/1965), so we gave the same name to them: physical-organic style is now metaphorically called maternal hypnosis style, which is based on love, while analyticcognitive style as paternal hypnosis style, which is based on fear (Bányai, 2002). These names, of course, do not mean (simply) the direct reoccurrence of the appropriate parentinfant relationship patterns; the styles are only resembling them in some respects. These styles served as an appropriate basis to examine the nature of subjective experiences of the participants of the hypnosis interaction along with the hypnosis styles.

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Table 8. The most important features of the physical-organic and the analytic-cognitive hypnosis styles

Verbal behavior during rapport formation Interactional synchrony parameters during hypnosis (such as posture mirroring, simultaneous movement, breathing together) Relationship with the subject

Main characteristics during phenomenological report

Maternal (physicalorganic) style Hypnosis is built mainly on positive emotions More personal

Paternal (analytic-cognitive) style Hypnosis is built mainly on respect of authority More formal

Frequent and vigorous occurrence of interactional synchrony and eye- and proximity

Absence or rare occurence

More informal way of expressing emotions, more personal and emotionally comforting atmosphere. The hypnotist is very much with the hypnotized person. He/she mainly wants the hypnotized subject’s desires and ideas to come true, and facilitates the independent initiatives of the hypnotized person. He/she places emphasis on the current condition and wishes of the subject. Hypnotists relies on his/her bodily cues Deep involvement

Slightly inhibiting the subject’s independent initiatives and verbal behavior. The hypnotist leads and directs the hypnotized person. He/she mainly wants to realize his/her own ideas and intentions, and slightly limits independent initiatives of the hypnotized person. He/she does not place emphasis on the current condition and wishes of the subject. Mentally stimulating atmosphere Many professional remarks Interpreting and analyzing the hypnotic session

Relationship between Phenomenological Measures and Hypnosis Styles In our laboratory experiment, each of four hypnotherapists hypnotized 8 young, healthy volunteer subjects (including two simulators: subjects earlier proven to be extremely low hypnotizables were used as simulators). The session was semi-standardized: free relaxation induction followed by free analgesia suggestion was used, analgesia was tested by a standardized cold pressor test, and then standardized age regression and trance-logic suggestions were istered; the session was closed by free dehypnosis and a brief inquiry. The subjective experiences of the participants were screened with PCI and DIH questionnaires immediately after completing the session (see Table 1 for further details; Varga, Bányai, Józsa and Gősi-Greguss, 2008).

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Judgment of hypnosis styles: Four expert judges trained in psychotherapy and in hypnosis rated the 32 hypnosis sessions independently: the verbatim transcripts of the hypnosis sessions served as a basis of judgment. All indications of name, gender, and hypnotic susceptibility of the participants were eliminated from the transcripts. To assess the judges’ aggregate reliability effective reliability was calculated (Rosenthal and Rosnow, 1991). The consistency of judgments was also assessed by calculating Cronbach’s alpha coefficient (Cronbach, 1951). Reliability was considered acceptable if both measures were above .60. Correlations between hypnosis styles and measures of subjective experiences: To characterize the relationship between the hypnosis styles and the subjective experiences, intercorrelations were calculated. The results are shown both for the whole sample (N=32 interactions) and for the sample without simulators (N=24 interactions). The relationships between maternal and paternal scores and DIH scores of hypnotists and subjects are shown in Figures 3a and 3b. As it can be seen with half an eye—although the correlations themselves are moderately high and because of the low sample size they are not significant—the pattern of the results is obvious and striking. All of the correlations between maternal score and DIH scales are positive in every case both for hypnotists and subjects, while they are negative with paternal scores.

t=1.74+ t=2.36**

t=1.8+

t=2.29**

a)

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t=2.86** t=2.27*

t=2.01+

b) †

Note: In the small boxes t refers to the difference of correlations, +p< .1, *p< .05, **p< .01

Figure 3. a) Correlations between hypnosis styles and DIH scores: Results of SUBJECTS. b) Correlations between hypnosis styles and DIH scores: Results of HYPNOTISTS.

There is a noticeable difference in the results of subjects and hypnotists: in case of subjects the lowest correlations turn up between maternal-paternal scores and the DIH intimacy scale (these correlations are close to zero), while in case of hypnotists these are the highest correlations (most of them are significant). Although on the grounds of correlation we cannot conclude cause and effect, this result may imply that hypnotists tend to judge their own intimacy score in a given situation according to their judged style (i.e., in case of maternal style, they report higher intimacy scores, while in case of paternal style, they report the lack of intimacy). Subjects, on the contrary, seem to score their intimacy independently of the style of the hypnotist. It seems to be an important result that real subjects produced more obvious, stronger relationships between hypnotist styles and DIH scores. (The correlations calculated with the inclusion of the simulators are always lower than those without them in the case of the subjects, while in case of hypnotists, the situation is reversed: the correlations with the simulators are higher than those calculated without them.). Hypnotists, on the other hand, seemed to be a little “more present” in the interactions when the simulators were involved †

The difference between these correlations was calculated according to Williams’s T2 statistic that tests whether two dependent correlations (here: correlation of maternal style and a given DIH subscale and paternal style and a given DIH subscale) that share a common variable (here: the given DIH subscale) are different. This test is the one recommended by Steiger (1980) for this purpose (the same method is used in the following figures).

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than with real subjects only (even if the hypnotists were not aware of the simulators). Perhaps they showed a more prototypical variant of their style when they encountered simulators. Among the numerous indices of PCI, we will discuss only the most important from the point of view of our question: how much is the components of the altered of state of consciousness experienced in the cases of the maternal and paternal hypnosis styles, and what kinds of emotions accompany them in both participants of the hypnosis interaction. These scales are Altered Experience main scale with its component subscales (alterations in body image, time sense, perception, and meaning) and the Affect main scale with its subscales here. Figures 4a and 4b show the correlation between PCI’s Altered Experience main scale (and its subscales) and hypnosis style scores both for the subjects (a), and the hypnotists (b). The experience or the lack of experience of an altered state of consciousness of the subjects seems to be independent of the style of hypnosis (Fig. 4a). The pattern is clear: the Altered Experience of the subjects is either independent from the styles (correlations are close to zero) or shows positive correlations with both styles (except for alteration of Body Image and Meaning: they show a very moderate negative correlation with paternal style). Since the highest correlations are around 0.2 here, it can be concluded that the subjects can experience the most important components of an altered state of consciousness with either hypnosis style. No wonder, that the hypnotists scoring their own alteration of consciousness by PCI show the connection unambiguously with (their own) hypnosis style (Figure 4b). Maternal style goes hand in hand with significant positive, paternal style with significant negative correlations. The more the hypnotist was characterized by maternal style, the more Altered Experience while hypnotizing he/she reported, while the more he/she was paternal, the more he/she reported the lack of these alterations. So paternal hypnotists’ experience of body image, time sense, perception, and meaning remained similar to the reality orientation of the normal waking state. In contrast to the pattern given on DIH by the hypnotists, in this case (PCI) the presence of simulators slightly moderated this connection, as if maternal hypnotists could experience these alterations less with simulators, and paternal ones needed less to indicate the lack of alteration—in this case they tend to keep the ordinary waking experience-modes as compared to the cases of hypnotizing real subjects. As it can be seen in Figures 5a and 5b, both the Positive Affect and the Negative Affect main scales and their subscales of PCI showed the same pattern both in case of the subjects and the hypnotists: maternal hypnosis was correlated with the experience and expression of (either positive or negative) emotions, while paternal style showed a reverse relationship. The only important exception to this pattern was that the more maternal the style was, the less the hypnotist reported sexual excitement. It is interesting that no opposite pattern was found in paternal style. During the interpretation of our results it is important to emphasize again the fact that the style scores—verbatim transcripts (!) judged by independent raters—and experience data— the interactants self-reported answers on the questionnaires—originated in very different kinds of characteristics of the given interaction.

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a) t=3.19***

t=3.1***

t=1.74+ t=4.02*** t=2.26** t=2.78* t=2.0+ t=2.14* t=1.88+p

b) Note: In the small boxes t refers to the difference of correlations, +p< .1, *p< .05, **p< .01, ***p< .005. Figure 4. a) Correlations between hypnosis styles and PCI Altered Experience factor scores: Results of SUBJECTS. b) Correlations between hypnosis styles and PCI Altered Experience factor scores: Results of HYPNOTISTS.

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a)

t=1.74*

b) Note: In the small box t refers to the difference of correlations, *p< .05. Figure 5. a) Correlation between hypnosis styles and PCI affect factors: results of SUBJECTS. b) Correlation between hypnosis styles and PCI affect factors: results of HYPNOTISTs.

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The construct of “hypnosis style” has been ed by these data, as the pattern of correlations of subjective experience data and style scores are in line with our theoretical expectations. In case of maternal style, subjects can experience the alteration of consciousness while their hypnotist “follows” (or “leads”?) them into the domains of alteration independently of the level of maternality. Higher maternality accompanied by a higher intimacy-experience on the side of hypnotists, and more expressed emotions in both interactants. Maternal style is characterized by a generally more overt presence of emotions, let them be positive or negative. Paternal style also makes it possible for the subjects to experience the alteration of consciousness subjectively, but in this case, either the subjects, or the hypnotists are moderate in the experience and expression of emotions, and there is no place for togetherness, playfulness, or intimacy in the situation—as opposed to the maternal style. Looking at the results from another point of view, these results serve as validation indicators for the subjective experience tests applied in this study, since hypnosis styles can be described and confirmed with several other parameters beyond the direct judgment of style (see Bányai 1998, 2002). Our result showed that from the point of view of the alteration of consciousness of subjects, any style can be favorable; this means that the experience of alteration is not dependent on style, rather, it is probably based on some other factor (that is not analyzed here). Because PCI is a state-indicator, experience of alteration might depend on some other, trait-like parameter(s) of the subject.

4.2. Phenomenological Patterns as a Function of Kinship The second example will show the relationship of various phenomenological measures connected to hypnosis as a function of kinship. Hypnosis is unique among the ASCs because of extended research under well monitored, standardised circumstances. Since the development of standardised susceptibility scales— most of them based on the Stanford Hypnotic Scales (SHSS:A, B, C, Weitzenhoffer and Hilgard, 1959, 1962) —the induction and the test suggestions can be istered in well controlled way, making it possible to investigate hypnosis in various international and cultural circumstances. Hypnotic susceptibility, that varies from individual to individual, is a highly stable trait of a person (Piccione, Hilgard and Zimbardo, 1989). The norms of standardised susceptibility scales in various languages and samples confirmed again and again the close to normal distribution of susceptibility. The individual stability and “same-distribution” nature of hypnotic responsiveness imply that it is based on at least partly biologically determined factors with certain level of genetic contribution. Surprisingly till today only one early study (Morgan, Hilgard and Davert, 1970; Morgan, 1973) investigated directly the heritability of hypnotic ability. That research focused only on the susceptibility scores of the hypnotized subjects.

Table 9. Intraclass correlations of the twin study

SHSS:A

MZ twins DZ twins Siblings ParentChild pairs

S-S 0.22

PCI DC

S-H S-S S-H NA 0.35* -0.04

0.15 0.17 0.07

* p < .05; ** p < .01

PCI PA S-S

S-H

0.52** 0.04

PCI NA

Intraclass correlations PCI VI PCI IA

S-S

S-S

S-H

S-S

0.22

-0.03

S-H

0.36* 0.1

DIH Communion S-S S-H

DIH Playfulness S-S S-H

DIH Tension

S-H

DIH Intimacy S-S S-H

0.13

0.13

0.58** 0.03

0.55** 0.16

0.17

0.11

0.40* 0.05

0.09

0.28

0.32* 0.24

0.31*

-0.01

0.19

0.1

0.19

S-S

S-H

0.14

0.31* 0.19

0.34** 0.27

-0.04

0.34* 0.24

0.04

0.14

0.01

0.39*

0.2

0.08

-0.18

-0.06

-0.03

0.45** 0.2

0.07

0.2

-0.02

-0.01

-0.03

0.08

0.18

-0.15

0.11

0.03

-0.02

-0.06

0.12

-0.1

0.08

-0.1

-0.11

0.11

0.13

0.06

0.18

0.10

0.07

0.19

-0.09

0.04

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Our laboratory, when replied the work of Morgan (1973), extended it by (1) measuring the phenomenological aspects (apart from the behavioral scores of susceptibility) and by (2) including the investigation of hypnotist (apart from the subjects). According to our earlier results hypnotic interactions do differ in the level of concordance/accord between the subjective reports of the hypnotist and subject. Some hypnotic dyads show high agreement, and a similar pattern, while others do not match each other in the way they report their subjective feelings regarding the hypnosis session. We never tested, however, systematically the effect of kinship on this aspect. Comparing the pattern of data between the subjects and between the hypnotist and subject of various degree of kinship we wanted to learn more about the possible genetic background of hypnotic responsiveness. Apart from the basic data of hypnotic susceptibility, well established measures of hypnosis (e.g., DIH, PCI) have been used both with subjects and with hypnotists (Hs) to test the effect of kinship. Subjects (Ss) (mono- and dyzigotic twins— MZ and DZ, respectively—siblings and parent-child pairs) have been hypnotized using the standard protocol of SHSS:A (Weitzenhoffer and Hilgard, 1959). To prevent the relatives from influencing each other (e.g., by discussing their experiences) they were hypnotized at the same time in two separate experimental chambers, by two different hypnotists. Immediately after the hypnosis session the hypnotist and the subject independently completed the questionnaires (Varga, Bányai, Gősi-Greguss, Tauszik, n.d., for further details see Table 1). Here we report only the most peculiar results of our study. The relationship between the variables will be expressed in intraclass correlations (ICC)1. When the two of relatives (e.g. the two persons of a twin pair) will be compared we indicate it by “S-S”, when the subject and the hypnotist of the same session will be compared “S-H” will indicate it (see Table 9). As it can be seen all the correlations of hypnotic susceptibility are low, nonsignificant. Among the ICCs in case of PCI there are significant moderate to high correlations between the of MZ twins on dissociative control, positive and negative affect. DZ twins show moderate significant correlation on the visual imagery scale, siblings on positive affect and attention to internal processes. Considering the S-H intraclass correlation of PCI scales we see, that all of the correlations are close to zero, and nonsignificant, except for the moderate significant correlations on dissociative control, and positive affect in cases of DZ twins. On the DIH scale, where the interactants evaluate the session itself, a different pattern appears. In the case of S-S ICCs, MZ twins yield high and highly significant correlations, with the only exception of playfulness scale. Apart from this all of the correlations are close to zero, and nonsignificant. The S-H intraclass correlation of DIH scales apart from the significant moderate correlations between DZ twin and their hypnotists, all of the correlations are close to zero, and nonsignificant.

1

This type of correlation is used to determine a correlation between two variables when it is not clear which variable should be X or Y for a given row of data. There are various ways to calculate ICC, we used the fromula: ri

=

within groups.

s 2b − s 2 w s 2b + s 2 w

where sb is the variance based on between groups and sw is the variance based on

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According to our data the only moderately high significant intraclass S-S correlation on PCI is the positive affect scale in cases of MZ groups, all the others are either non-significant, or significant but moderate. This implies that the way relatives of various kinship experience the phenomenology of hypnosis do not strongly resemble to each other. As Appendix 3 shows, the average PCI scores of MZ twins are not significantly different from that of the other groups (with the only exception that MZ twins gave smaller scores on “attention to internal processes” subscale than the siblings did). On the DIH scale, however, the MZ group gave significantly higher averages than the other groups, with the only exception of “communion”, where MZ and DZ groups were similar to each other, significantly exceeding the other two groups). So, MZ of our sample gave relatively higher scores when evaluating the hypnosis interaction (on DIH), but not deviated from the other groups when their actual phenomenological experiences have been reported (PCI). It is surprising, that the way interactants evaluate their recent hypnosis interaction on DIH is very similar in cases of of MZ twins, but not in cases of any other S-S dyads (even not in cases of DZ twins)2. Comparing the highly significant correlations between the of MZ twins with the correlations between the scores of MZ subjects and their hypnotist an interesting picture emerged. The of MZ twins (but nobody else) correlate highly on DIH scores with each other (and not with their hypnotists), in spite of the fact that they interacted with two different hypnotist. They seem to evaluate the session similarly to their co-twins, and not to the person they were actually interacting. We might suppose that they bring their own „interactional model” into the hypnotic situation (Burgoon, Stern and Dillman, 1995). It is surprising, thought, that the key variable of hypnosis research, hypnotic susceptibility score does not show the same similarity in cases of MZ twins. As the scores on SHSS:A are based on behavioral manifestations, this imply that close or similar patterns of subjective evaluation of the interaction (expressed on DIH) can be connected to different behavioral scores, and vice-versa: the same behavioral score may hide divergent evaluational patterns. Behind this pattern of data two types of interactional processes could be hypothesised. MZ twins can be similar to each other while evaluating the hypnosis session because they follow the reactive interactional pattern: the environmental effects (in this case the standardised hypnosis session with two different hypnotists) might appear to them as something subjectively (almost) the same. The other possibility is that following the rules of evocative interaction the two of MZ twins evokes (almost) the same reaction from their interactional partners (in this case from their hypnotists). In this latter case the independent hypnotist hypnotizing the of MZ twins should give similar scores to each other, as the of MZ twin evoke similar reactions from them. Two test this possibility we correlated the sores of the two hypnotists who hypnotized the of the twins (or siblings or parent-child pairs). All of these H-H correlations proved to be close to zero and nonsignificant (for the details see Appendix 4). So our data seems to more the reactive interactional pattern, and not in line with the evocative interaction pattern in cases of MZ twins. 2

If we calculate the intraclass correlations only for the subgroup of the same-sex DZ twins, in cases of PCI subscales only the visual imagery subscale becomes more highly correlated (compared to the total sample of DZ twins, where we also found a significant – but moderate – correlation). In cases of DIH subscales, all the intraclass correlations remains nonsignificant, except for communion, where it becomes significant, moderately high (r= 0.41 for details see Appendix 5).

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Unfortunately, our data tell nothing about the question whether this phenomenon is hypnosis-specific, or MZ twins would give the same concordance with each other while interacting with two different partners in some non-hypnotic settings (chess, music, sex, etc.)?

5. GENERAL CONCLUSION Over the past 20 years we have collected a large amount of data about the phenomenological involvement of hypnotic interactants (our findings have been reported in detail elsewhere: Varga, Bányai, Gősi-Greguss, 1996, 1997, 1999, 2000; Varga, Józsa, Bányai, Gősi-Greguss and Suhai-Hodász, 2004; Varga, Józsa, Bányai and Gősi-Greguss, 2006; Varga, Bányai, Józsa and Gősi-Greguss, 2008). To do so, we had to develop interactional modifications of well-known “subject-centered” phenomenological measures— e.g., the “Parallel Experiential Analysis Technique” (PEAT, Varga, Bányai and GősiGreguss, 1994, based on EAT of Sheehan and McConkey, 1982); apply for the hypnotist measures designed for the subject, e.g., the Phenomenology of Consciousness Inventory (PCI) questionnaire of Pekala, Steinberg and Kumar (1986); or develop special measures to have the participants evaluate the hypnotic interaction itself, i.e., Dyadic Interactional Harmony (DIH) (Varga, Józsa, Bányai and Gősi-Greguss, 2006). In the interactional approach, rich and valuable data has been gathered from the hypnotists. Today we can describe the state and process of hypnotizing much better than some decades ago. The traditional picture presents the hypnotist as a powerful, magician-like figure who overwhelms the subject, puts him into trance, and has extraordinary power (see, e.g., Yapko, 1984). This inevitably leads the therapists to make impossible demands on themselves to get dramatic results quickly. Having a more realistic, more human picture about the hypnotist and about the process of hypnotizing seems to be crucial in educating and training would-be hypnotists. This may prevent the feeling of guilt, self-doubt, self-criticism and other negative feelings that may lead to burnout. It is especially relevant to have a closer analysis of the possibility that the trance state of the hypnotist may prevent some of the negative consequences of deep emotional involvement. As non-hypnotic therapists also report spontaneous trance states in which they are especially effective and full of healing powers (e.g., Rogers, 1979), this possibly works in their case as well. Especially interesting patterns appeared when we interrelated the phenomenological data of the subject and that of the hypnotist. According to our observation, hypnotic interactions do differ in the level of concordance/accord between the subjective reports of the hypnotist and subject. Some hypnotic dyads show high agreement and a similar pattern, while others do not match each other in the way they report their subjective feelings regarding the hypnosis session. In our view, this can be considered a sign of interactional synchrony at the phenomenological level. This level is at least as informative as the other indices analyzing the synchronous phenomena at the behavioral or electrophysiological level (e.g., t movements and posture mirroring at the overt behavioral level, or the common breathing rhythm and parallel myographic activity at the physiological level; for details see Bányai 1985, 1991, 1998).

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All of these interactional synchrony indices formed the basis of the description of “hypnosis styles” (e.g., paternal and maternal styles, Bányai, 1991, 1998, 2002ab; Varga, Gősi-Greguss, and Bányai, 1999). The main requirements of a good rapport are selectivity, reciprocity, synchrony (Bernieri, Gillis, Davis, and Grahe, 1996; Capella 1997; Tickle-Degnen and Rosenthal, 1990). In the case of hypnotic rapport, it involves sensitivity to each other, a complex emotional relationship and a special need to be directed (to direct) (Bányai, 1995). To get to a relationship of this kind in a strongly controlled standardized hypnosis session, very special processes must be activated in both partners of the interaction. The influence of working models seems to be also relevant in this respect. These models are based on early personal history—described by attachment theories (e.g., Bowlby, 1980)—and determine the person’s feelings in his adult relationships as well, for instance, when entering a hypnotic interaction. There is a sharp difference between individuals with, e.g., secure or avoidant attachment styles (Ainsworth, Blehar, Waters, and Wall, 1978). Many theories of intimacy predict that some people feel comfortable with closeness and intimacy, and are willing to rely on others when needed. Others report being very uncomfortable getting close to and depending on others (see, e.g., Argyle and Dean, 1965 or Patterson, 1976). The explanatory value of these aspects in the process of interactional adaptation need much further research (Burgoon, Stern, and Dillman, 1995). The DIH questionnaire is a promising tool to understand better the way people enter into important human interactions, as it is not specific to hypnosis, and can easily be applied to any other human interactions. Hypnosis styles are related to the hypnotists’ overt behavioral parameters—e.g., smiling, touch, eye , words used, calling the subjects by their first name (for more details see e.g., Bányai, 2002b). During a hypnosis session these underlying characteristics might mediate to the subject what kind of hypnosis can he/she expect with the given hypnotist. This may “inform” the subject regarding what kind of relationship patterns should he/she mobilize (recollect or fantasize) along which he/she can organize his/her interactional expectations or experiences—probably at a non-conscious level—in connection with the actual hypnosis. According to our results, we assume that the development of a given hypnosis style is not a unidirectional process going from the hypnotist to the subject. It is more probably construed along constant “message-exchanges” between subject and hypnotist. Presumably a kind of typical pattern is formulated in the harmony of their subjective experiences (e.g., regarding mutuality) develops, if the participants come to an understanding in this “style-bargain”. If this bargain remains one-sided, then one of the participants cannot enforce his/her stable or momentary needs for relationship patterns (Bowlby, 1980), so we will find higher disharmony in the experiences, and there will be no “clear” experience-patterns of mutual attunement. The results of our twin study showed that the phenomenologically experience of hypnosis is not based on genetic determination, but the way interactants evaluate the session (the interaction itself) seems to be closely related to the degree of kinship. MZ twins—most probably on the basis of reactive interactional pattern—evaluate the hypnotic interaction very similarly to each other, possibly by activating early relational patterns. This was not true for their behavioral responses to hypnosis (SHSS: A), or the phenomenological aspects of the state (PCI). These findings can well be interpreted using the concepts of working models and early interactional patterns, within the sociopsychobiological model of hypnosis. According to our

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results, the influence of early models may be so strong that MZ twins are not really “disturbed” by the actual hypnosis situation. This could be considered a clear example of the proposal that the hypnotic situation serves as a possibility to activate this early-based model, proposed by the sociopsychobiological model (Bányai 1998, 2002ab). We are far from fully understanding the hypnotic interaction, but the interactional approach to hypnosis and the detailed analysis of phenomenological data of both participants seem to be a promising way to discover the real essence of hypnosis.

APPENDIX 1. DYADIC INTERACTIONAL HARMONY QUESTIONNAIRE Date:

Name: Please consider your recent interaction. Please indicate how much the following features characterized your recent interaction. Circle the corresponding number 1. meaning: not at all 5. meaning: completely The numbers in between indicate gradual steps between the two extremes.

2. SYMPATHY.........................

1-2-3-4-5

SELF-DISCLOSURE....

1-2-3-4-5

2. COOPERATION...................

1-2-3-4-5

4. TENSION..................

1-2-3-4-5

4. ANXIETY.............................

1-2-3-4-5

3. OPENNESS..............

1-2-3-4-5

2. MUTUAL CONFIDENCE… 1 - 2 - 3 - 4 - 5

DOMINANCE.............

1-2-3-4-5

4. CONSTRAINED...................

1-2-3-4-5

1. TENDERNESS.........

1-2-3-4-5

2. ATTUNEMENT.................... 1 - 2 - 3 - 4 - 5

2. HARMONY..............

1-2-3-4-5

2. UNDERSTANDING…….....

1-2-3-4-5

RIGOUR......................

1-2-3-4-5

SUBORDINATION..................

1-2-3-4-5

3. HUMOUR................

1-2-3-4-5

1. LIKING.................................

1-2-3-4-5

1. INTIMACY................

1-2-3-4-5

2. PATIENCE...........................

1-2-3-4-5

CLUMSINESS...............

1-2-3-4-5

4. RELAXED............................

1-2-3-4-5

EXCITEMENT..............

1-2-3-4-5

COMPETITION........................

1-2-3-4-5

3. PLAYFULNESS..........

1-2-3-4-5

BOREDOM...............................

1-2-3-4-5

2. ACCORD / CONSONANCE

1-2-3-4-5

1. CORDIAL.............................

1-2-3-4-5

1. INTIMATE................

1-2-3-4-5

RESERVE.................................

1-2-3-4-5

1-2-3-4-5

1. EROTICISM/SENSUALITY 1 - 2 - 3 - 4 - 5

4. DEFENSELESSNESS.... SHALLOWNESS..........

1. HAPPINESS.........................

1-2-3-4-5

1. WARMTH..................

1-2-3-4-5

2. MUTUAL ATTENTION…..

1-2-3-4-5

3. INSPIRING.................

1-2-3-4-5

1-2-3-4-5

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APPENDIX 1. (CONTINUED) SINCERITY............................. 1 - 2 - 3 - 4 - 5 2. MUTUALITY..................

1-2-3-4-5

REJECTION............................

1 - 2 - 3 - 4 - 5 ABANDONED.....................

1-2-3-4-5

INFORMALITY.....................

1 - 2 - 3 - 4 - 5 3. AGITATING....................

1-2-3-4-5

1. LOVE.................................. 4. FEAR...................................

1 - 2 - 3 - 4 - 5 3,4 EASY-FLOWING.......... 1 - 2 - 3 - 4 - 5 1 - 2 - 3 - 4 - 5 1. ION.......................... 1 - 2 - 3 - 4 - 5

3. FREEDOM..........................

1 - 2 - 3 - 4 - 5 DISTANCE..........................

1-2-3-4-5

PERSONAL............................

1 - 2 - 3 - 4 - 5 CLOSENESS.......................

1-2-3-4-5

Is there any other feature that is not present here, but is important to characterize your recent interaction? (You can write more than one): Note: “Easy-flowing” item scores inversely in the “Tension” scale. The numbers before the items indicate the subscale to which the item belongs (1. Intimacy, 2. Communion, 3. Playfulness, 4. Tension). Items without number do not belong to any subscale, as their factor values were too small.

APPENDIX 2. DATA OF FACTORANALYSIS OF DIH IN THE MUTUAL RORSCHACH SITUATION Factor 1 2 3 4 5

Variance explained 10,5645 4,0842 2,0519 1,6142 1,0997

Cummulative variance in the data in the factor space 0,4173 0,5442 0,5786 0,7545 0,6596 0,8602 0,7234 0,9434 0,7668 1,0000

Cronbach alfa 0,9715

Rotated, sorted factor values (Mutual Rorschach situation) ITEMS ION INTIMACY INTIMATE WARMTH EROTICISM/SENSUALITY TENDERNESS LOVE HAPPINESS CORDIAL LIKING ACCORD / CONSONANCE

FACTOR1 0,665 0,656 0,626 0,618 0,614 0,609 0,585 0,545 0,534 0,453 0,000

FACTOR2 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,253 0,332 0,643

FACTOR3 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,380 0,000 0,000 0,000

FACTOR4 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000

Patterns of Interactional Harmony UNDERSTANDING 0,000 0,620 HARMONY 0,270 0,588 MUTUAL ATTENTION 0,000 0,580 MUTUALITY 0,000 0,565 ATTUNEMENT 0,000 0,537 COOPERATION 0,000 0,535 SYMPATHY 0,324 0,472 MUTUAL CONFIDENCE 0,258 0,493 PATIENCE 0,000 0,474 OPENNESS 0,000 0,319 HUMOUR 0,000 0,000 INSPIRING 0,363 0,000 PLAYFULNESS 0,000 0,000 FREEDOM 0,000 0,000 AGITATING 0,375 0,000 EASY-FLOWING 0,000 0,000 TENSION 0,000 0,000 ANXIETY 0,000 0,000 FEAR 0,000 0,000 RELAXED 0,000 0,000 CONSTRAINED 0,000 0,000 DEFENSELESSNESS 0,000 0,000 4,845 4,379 Eigen Value 0,85 0,86 Cronbach-alfa Note: “RELAXED” item scores inversely in the “Tension” scale.

89 0,000 0,000 0,260 0,296 0,000 0,000 0,000 0,000 0,000 0,582 0,565 0,554 0,551 0,480 0,496 0,511 0,000 0,000 0,000 0,000 0,000 0,000 4,062 0,81

0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000 -0,430 0,000 -0,513 0,644 0,599 0,588 -0,553 0,455 0,461 3,416 0,78

APPENDIX 3. COMPARISON OF THE MEANS OF THE PCI AND DIH SUBSCALES OF THE GROUPS (* p < 0,05; ** p < 0,01)

PCI subscale Dissociative control Positive affect Negative affect Visual Imagery Attention to internal processes

x= sd= x= sd= x= sd= x= sd= x= sd=

PCI averages of Ss MZ DZ SIBL. twins twins -0.00 0.46 1.14 3.47 3.76 3.28 0.14 -0.41 0.34 2.08 1.89 2.21 0.09 -0.18 -0.12 2.02 1.68 1.38 0.15 0.00 0.18 1.24 1.43 1.47

PARCHILD 0.19 3.19 -0.44 2.06 -0.25 1.28 0.04 1.32

-0.11 1.32

0.12 1.32

0.25 1.59

0.68 1.30

df

Tukey Post Hoc test F Post Hoc

3,273

1.37

3,273

2.52

3,273

0.62

3,273

0.24

3,273

3.64*

MZ = DZ = SB= PC MZ = DZ = SB= PC MZ = DZ = SB= PC MZ = DZ = SB= PC MZ < SB

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APPENDIX 4. INTRACLASS CORRELATIONS OF HYPNOTISTS HYPNOTIZING THE TWO OF TWINS, ON THE SUBSCALES OF PCI AND DIH (* p < 0,05; ** p < 0,01) H-H Intraclass correlation PCI Monozygotic twins Dizygotic twins Siblings Parent-Child pairs

Dissociative control

Positive affect

Negative affect

Visual imagery

Attention to internal processes

0.07

-0.05

0.06

0.08

0.08

0.02

0.1

-0.22

0.02

0.01

0.06 -0.11

-0.13 -0.18

-0.06 0.00

-0.06 0.1

0.15 -0.23

H-H Intraclass correlations DIH Monozygotic twins Dizygotic twins Siblings Parent-Child pairs

Intimacy

Communion

Playfulness

Tension

-0.11 0.15 -0.4 -0.05

0.01 0.02 0.06 -0.05

-0.02 0.23 0.00 -0.08

-0.08 -0.36 0.08 -0.18

APPENDIX 5. INTRACLASS CORRELATIONS OF THE SAME-SEX DZ TWINS ON THE SUBSCALES OF PCI AND DIH (For the Data of other groups see Table 9 in the text). (* p < 0,05; ** p < 0,01) S-S Intraclass correlation PCI Same-sex dizygotic twins (N=22)

Dissociative Control

Positive affect

Negative affect

Visual imagery

Attention to internal processes

0.31

0.27

0.28

0.54**

0.23

S-S Intraclass correlations DIH Same-sex dizygotic twins (N=22)

Intimacy

Communion

Playfulness

Tension

0.27

0.41**

0.16

0.05

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ACKNOWLEDGMENT Some charts and tables of this chapter are republished here by the permission of Contemporary Hypnosis.

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Matheson, G., Shue, K.L. and Bart, C. (1989) A validation study of a short-form hypnoticexperience questionnaire and its relationship to hypnotizability, American Journal of Clinical Hypnosis, 32, 17-26. Maurer, R. L., Sr., Kumar, V. K., Woodside, L., and Pekala, R. J. (1997). Phenomenological experience in response to drumming and hypnotizability. American Journal of Clinical Hypnosis, 40, 130-144. Morgan, A. H. (1973) The Heritability of Hypnotic Susceptibility in Twins. Journal of Abnormal Psychology, 82, 55-61. Morgan, A. H., and Hilgard, J. R. (1975). Stanford Hypnotic Clinical Scale. In E. R Hilgard and J. R. Hilgard (Eds.) Hypnosis in the Relief of Pain (Appendix A, pp. 209-221). Los Altos, CA: William Kaufmann. Morgan, A. H., Hilgard, E. R., and Davert, E. C. (1970) The Heritability of Hypnotic Susceptibility of Twins: A Preliminary Report. Behavioral Genetics, 1(3/4):213-223. Nash, M. R. (1991) Hypnosis as a Special Case of Psychological Regression. In S. J. Lynn, and J. W. Rhue (Eds.): Theories of Hypnosis: Current Models and Perspectives (pp. 171194). New York, London: The Guilford Press. Nash, M. R. and Lynn, S. J. (1986) Child Abuse and Hypnotic Ability. Imagery, Cognition and Personality, 5, 211-218. Nash, M. R., and Spinler, D. (1989) Hypnosis and Transference: A Measure of Archaic Involvement. International Journal of Clinical and Experimental Hypnosis, 37, 129-143. Orne, M.T. (1959) The Nature of Hypnosis: Artifact and Essence. Journal of Abnormal and Social Psychology, 58, 277-299. Patterson, M.L. (1976) An Arousal Model of Interpersonal Intimacy. Psychological Review, 83(3), 235-245. Pekala, R. J. (1980). An Empirical-Phenomenological Approach for Mapping Consciousness and Its Various “States.” Unpublished doctoral dissertation, Michigan state University (University Microfilm No. 82-02, 489). Pekala, R. J. (1982). The Phenomenology of Consciousness Inventory. Thorndale, PA: Psychophenomenological Concepts (Now published by the Mid-Atlantic Educational Institute. see 1991a). Pekala, R. J. (1991a). The Phenomenology of Consciousness Inventory. Thorndale, PA: West Chester, PA: Mid-Atlantic Educational Institute. Pekala, R. J. (1991b). Quantifying Consciousness: An Empirical Approach. New York: Plenum. Pekala, R. J., and Ersek, B. (1992-93). Firewalking Versus Hypnosis: A Preliminary Study Concerning Consciousness, Attention, and Fire Immunity. Imagination, Cognition, and Personality, 12, 284-293. Pekala, R. J., and Forbes, E. J. (1988). Hypnoidal Effects Associated with Several Stress Management Techniques. Australian Journal of Clinical and Experimental Hypnosis, 16, 121-132. Pekala, R. J., and Kumar, V. K. (1989). Phenomenological Patterns of Consciousness During Hypnosis: Relevance to Cognition and Individual Differences. Australian Journal of Clinical and Experimental Hypnosis, 17, 1-20. Pekala, R. J., Steinberg, J. and Kumar, V. K. (1986). Measurement of Phenomenological Experience: Phenomenology of Consciousness Inventory. Perceptual and Motor Skills, 63, 983-989.

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Perry, C.W. and Sheehan, P.W. (1978) Aptitude for Trance and Situational Effects of Varying the Interpersonal Nature of the Hypnosis Setting. American Journal of Clinical Hypnosis, 20(4), 256-262. Piccione, C., Hilgard, E. R., and Zimbardo, P. G. (1989). On the Stability of Measured Hypnotizability Over a 25 Year Period. Journal of Personality and Social Psychology Review, 57, 289-295. Rogers, C.R. (1979) The Foundation of the Person-Centered Approach. Manuscript. Rosenthal, R., and Rosnow, R. L. (1991). Essentials of Behavioral Research: Methods and Data Analysis. New York: McGraw-Hill. Scagnelli, J. (1980) Hypnotherapy With Psychotic and Borderline Patient: The Use of Trance by Patient and Therapist. American Journal of Clinical Hypnosis, 22(3), 164-169. Sheehan, P. W. (1980) Factors Influencing Rapport in Hypnosis. Journal of Abnormal Psychology, 89, 263-281. Sheehan, P. W. (1982-83) Imaginative Consciousness - Function, Process and Method. Imagination, Cognition and Personality, 2, 177-194. Sheehan, P. W. (1991). Hypnosis, Context, and Commitment. In S. J. Lynn, and J. W. Rhue (eds) Theories of Hypnosis: Current Models and Perspectives (pp. 520-541). New York, London: The Guilford Press. Sheehan, P.W. and Dolby, R.M. (1979) Motivated Involvement in Hypnosis: The Illustration of Clinical Rapport Through Hypnotic Dream. Journal of Abnormal Psychology, 88(5), 573-583. Sheehan, P. W., and McConkey, K. M. (1982) Hypnosis and Experience: The Exploration of Phenomena and Process. Hillsdale, New Jersey: Lawrence Erlbaum. Sheehan, P.W., McConkey, K.M., and Cross, D.(1978) Experiential Analysis of Hypnosis: Some New Observations on Hypnotic Phenomena. Journal of Abnormal Psychology, 87, 570-575. Shor, R. E. (1959) Hypnosis and the concept of the generalized reality-orientation. American Journal of Psychotherapy, 13, 582-602. Shor, R. E. (1962) Three Dimensions of Hypnotic Depth. International Journal of Clinical and Experimental Hypnosis, 10, 23-38. Shor, R. E., and Orne, E. C. (1963). Norms on the Harvard Group Scale of Hypnotic Susceptibility, Form A. International Journal of Clinical and Experimental Hypnosis, 11, 39-47. Spanos, N.P. (1986). Hypnosis and the Modification of Hypnotic Susceptibility: A Social Psychological Perspective. In P. Naish (Ed.) What is Hypnosis? (pp. 85-120). London: Open University Press. Spanos, N. P., Gabora, N. J.,Jarrett, L. E., and Gwynn, M. I.(1989) Contextual Determinants of Hypnotizability and of Relationships Between Hypnotizability Scales. Journal of Personality and Social Psychology, 57(2):271-278. Spanos, N. P., Kennedy, S. K., and Gwynn, M. I. (1984) Moderating Effects of Contextual Variables on the Relationship Between Hypnotic Susceptibility and Suggested Analgesia. Journal of Abnormal Psychology, 93(3):285-294. Spinhoven, P., Vanderlinden, J., Ter Kuile, M. M., and Linssen, C. G. (1993). Assessment of Hypnotic Processes and Responsiveness in a Clinical Context. International Journal of Clinical and Experimental Hypnosis, 41, 210-223.

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Steiger, J. H. (1980). Tests for Comparing Elements of a Correlation Matrix. Psychological Bulletin, 87, 245–251. Szabó, Cs. (1989). Szubjektív élmények különböző indukciós technikákkal létrehozott hipnózisokban [Subjective experiences induced by various hypnosis techniques]. Unpublished doctoral dissertation, Kossuth Lajos University, Debrecen, Hungary. Szabó, Cs. (1993). The Phenomenology of the Experiences and the Depth of Hypnosis: Comparison of Direct and Indirect Induction Techniques. International Journal of Experimental and Clinical Hypnosis, 41, 225-233. Tart, C. T. (1969) Psychedelic Experiences Associated With a Novel Hypnotic Procedure, Mutual Hypnosis. In C. T. Tart (ed.) Altered States of Consciousness (pp. 291-308). New York: Wiley. Tart, C. T. (1972). Altered States of Consciousness. New York: Anchor Book Doubleday and Company Inc. Tickle-Degnen, L., and Rosenthal, R. (1990) The Nature of Rapport and Its Nonverbal Correlates. Psychological Inquiery, 1(4): 285-293 and 324-329. Varga, K., Bányai, É. I. and Gősi-Greguss, A. C. (1991) Investigating the Phenomenological Level of Hypnosis Within the Social Psychobiological Model of Hypnotic Interaction. Abstract. In Abstracts of the Second European Congress of Psychology, Budapest, Hungary, July 8–12, 1991, Vol. II. 120. Varga, K., Bányai, É. I., and Gősi-Greguss, A. C. (1994) Parallel Application of the Experiential Analysis Technique with Subject and Hypnotist: A New Possibility for Measuring Interactional Synchrony. International Journal of Clinical and Experimental Hypnosis, 42(1): 130–139. Varga, K., Bányai, É. I., Gősi-Greguss, A. C. (1996) Harmony in Phenomenology: A New Way to Measure Interactional Synchrony. 7th European Congress of Hypnosis, Budapest, Hungary, August 17-23. Book of Abstracts, 147. Varga, K. Bányai, É. I., Gősi-Greguss, A.C. (1997) New Ways of Characterizing the Phenomenological Aspect of Rapport. 14th International Congress of Hypnosis, San Diego, California, United States of America, June, 21-27, Scientific Presentation Abstracts, 64-65. Varga, K., Bányai É. I., Gősi-Greguss, A: C. (1999) Hypnotists’ Phenomenology: Toward the Understanding of Hypnotic Interactions. Hypnos, 26(4): 181-193. Varga K., Bányai É.I., Gősi-Greguss A. C. (2000) Transference and Countertransference in Experimental Hypnotic Settings. 15. International Congress of Hypnosis, München, 2-7. October 2000., Book of Abstracts, 128. Varga, K., Bányai, É. I., Gősi-Greguss, A. C., and Horváth, R. J. (1992) Interactional Application of Experiential Analysis Technique. Abstract. In Book of Abstracts of the 12th International Congress of Hypnosis. Jerusalem. Israel. July 25–31, 38. Varga, K., Bányai, É. I., Gősi-Greguss, A.C., and Tauszik, K. (n.d.) : Phenomenological Aspects of Hypnotic Interactions: The Effect of Kinship. Paper to be submitted to International Journal of Clinical and Experimental Hypnosis. Varga, K., Bányai, É.I., Józsa, E. and Gősi-Greguss, A.C. (2008): Interactional Phenomenology of Maternal and Paternal Hypnosis Styles. Contemporary Hypnosis, 25(1), 14-28.

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Varga K., Józsa E., Bányai I. É., Gősi-Greguss A. C. (2006) A New Way of Characterizing Hypnotic Interactions: Dyadic Interactional Harmony (DIH) Quastionnaire. Contemporary Hypnosis, 24 (4), 151-166. Varga, K., Józsa, E., Bányai, É. I., Gősi-Greguss A. C., and Kumar, V. K. (2001) Phenomenological Experiences Associated With Hypnotic Susceptibility. International Journal of Clinical and Experimental Hypnosis, 49(1): 19-29. Varga, K., Józsa, E., Bányai, É. I., Gősi-Greguss, A. C., Suhai-Hodász, G., (2004) Hypnosis Interaction from an Evolutionary Perspective: the Patterns of Harmony in Phenomenology. Paper presented at the 16th International Congress of Hypnosis Singapore, October 17–22, 2004. Book of Abstracts, 17. Vas, J. (1993) The “Counter-Trance” Concept: Pulling Psychotic Patients Out Of the Well of Pathological Regression. Hypnos, 20(2):94-99. Wachtel, P. L. (1973) Psychodinamics, Behavior Therapy, and the Implacable Experimenter: An Inquiry Into the Consistency of Personality. Journal of Abnormal Psychology, 82, 324-334. Weitzenhoffer, A. M. (1978). Hypnotism and Altered States of Consciousness. In A. Sugarman and R. E. Tarter (Eds.) Expanding Dimensions of Consciousness (pp. 183225). New York: Springer. Weitzenhoffer, A. M., and Hilgard, E. R. (1959) Stanford Hypnotic Susceptibility Scale, Forms A and B. Palo Alto, California: Consulting Psychologists Press. Weitzenhoffer, A. M., and Hilgard, E. R. (1962) Stanford Hypnotic Susceptibility Scale, Forms C. Palo Alto, California: Consulting Psychologists Press. White, R. W. (1941) A Preface to the Theory of Hypnosis. Journal of Abnormal and Social Psychology, 36, 477-505. Woodside, L. N., Kumar, V. K., and Pekala, R. J. (1997). Monotonous Percussion Drumming and Trance Postures: A Controlled Evaluation of Phenomenological Effects. Anthropology of Consciousness, 8(2-3), 69-87. Yapko, M. A. (1984) Implications of the Ericksonian and Neurolinguistic Programming Approaches for Responsibility of Therapeutic Outcomes. American Journal of Clinical Hypnosis, 27(2):137-143. Reviewed by Professor John Gruzelier, Department of Psychology, Goldsmiths College, London UK, and by Professor Michael Nash, University of Tennessee, Knoxwille, USA.

In: Hypnosis: Theories, Research and Applications Editors: G. D. Koester and P. R. Delisle

ISBN 978-1-60456© 2009 Nova Science Publishers, Inc.

Chapter 3

APPLICATIONS OF WAKING HYPNOSIS TO DIFFICULT CASES AND EMERGENCIES

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Carlos Lopes-Pires1,3, M. Elena Mendoza2,3, and Antonio Capafons2 1

University of Coimbra, Portugal 2 University of Valencia, Spain 3 Private practice

ABSTRACT In this chapter, we describe the use of this approach for difficult cases and/or emergencies based on the Valencia Model, albeit introducing substantial modifications to adapt it to the specific characteristics of the intervention in these cases. Difficult cases and/or emergencies are defined as follows: 1) people who have gone through a number of treatments without receiving significant benefits, and, consequently, they have fewer therapeutic options; 2) people in despair (for several reasons); 3) people whose problem needs to be solved or improved immediately; 4) people in shock; 5) people who, due to their poor clinical condition, are not amenable to starting a treatment using the choice techniques for their problem, such as exposure, behavioral activation, etc. As a result, our approach puts forth three intervention models for difficult cases and/or emergencies, which correspond to the different types of cases that have been considered the most relevant according to our clinical experience.

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Illustrations by João Pires.

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INTRODUCTION For years now, there has been an attempt to validate empirically psychological therapies (Chambless and Ollendick, 2001). This is an initiative of the American Psychological Association that has been extended internationally (Woody, Weisz, and McLean, 2005). Despite the advantages of this initiative, some problems arise when these therapies have to be adjusted to the clinical setting. An obvious problem is the difference found when comparing the clinical work aimed at research with the private practice. In the first case, all of the experimental variables are intended to be controlled as much as possible, in a way that all patients receive the same therapy. On the contrary, in private practice, the approach is that the therapy is adjusted to take into the patient’s individual characteristics so that the treatment can be more efficient. These differences are even more noticeable regarding difficult cases or emergencies. In fact, to the best of our knowledge, there is no empirically validated research devoted to these kinds of cases. Moreover, the complexity of these cases makes it difficult, if not unfeasible, to carry out the so-called empirical research. However, as we will explain in the course of this chapter, these cases are very relevant in private practice. The first author has a wide experience in this type of patient and has been interested in the development of systematic psychological interventions to treat these patients maximizing the benefits. Hence, he has recently developed some intervention models specific to difficult cases and emergencies based on the Valencia Model of Waking Hypnosis (VMWH) (Alarcón and Capafons, 2006; Capafons, 2001; 2004a; 2004b). These models can be included in a stream of psychological approaches put forth to provide psychologists with a feasible alternative for treating people in these cases. Also, these interventions are probably more beneficial than pharmacological treatments, which very often lead to the development and chronicity of emotional problems. This is because they do not use a self-regulatory perspective; in other words, medicines do not foster the development of coping strategies for the patient’s problems.

DEFINITION AND CONTEXTUALIZATION OF DIFFICULT CASES AND EMERGENCIES One reason that these sorts of cases are unsuitable for evidence-based therapies (EBT), at least in their first stage, is the existence of some very specific and varied particularities. But, what are difficult cases and emergencies? Overall, these are cases with the following characteristics: 1) People who have gone through a number of treatments without receiving significant benefits, and, consequently, have fewer therapeutic options; 2) People in despair (for several reasons); 3) People whose problem needs to be solved or improved immediately; 4) People in shock;

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5) People who, due to their poor clinical condition, are not amenable to starting a treatment using the choice techniques for their problem, such as exposure, behavioral activation, etc. Since we are talking about real people with real problems, there will be a wide variety of characteristics at the starting point. For example, a person who has been suffering from a panic disorder for many years can also be in shock at the same time. In this way, this person has simultaneously the above-mentioned five characteristics. Nevertheless, it is worthy to describe these characteristics separately. Patients classified in points 1 and 5 are considered difficult cases, whereas those in points 2, 3, and 4 are considered emergencies. This classification does not imply that emergencies are not difficult, too, but that the former share a common condition that distinguishes them from the latter—namely, emergencies cannot wait weeks or months to obtain the benefits of a therapeutic approach of whatever kind it may be. These people need immediate relief from the distress they are suffering. In the next paragraphs we will describe in detail these characteristics.

1. People who have Received a Number of Treatments either without Obtaining Significant Benefits or Worsening their Condition The most common cases we see in our private practice are patients that have already gone through several treatments for a number of years with poor advances or none. Often times, they suffer from iatrogenic problems, above all, caused by pharmacological treatments. These patients show a variety of characteristics that differs whether they have been taking treatments including drugs or not. Some of these characteristics are the following: a) hopelessness, since they were told that the pharmacological approach is the only treatment and it has failed; b) holding the belief of having structural and functional problems in the brain (e.g., a problem in the neurotransmitters), in which drugs are the choice treatment; since in their case drugs have failed, they develop negative expectancies toward a possible psychological approach; c) problems caused by medicine withdrawal, not only the uncomfortable symptoms directly derived from the withdrawal, but also the psychological impact that makes the patients feel vulnerable because of the decrease or withdrawal of the medicine. Obviously, this problem tends to be worsened when there is polymedication. As a consequence, it is common that patients searching for psychological counseling on their own initiative establish an ambivalent relationship with that possible help. That is, they can think of it as their last chance, while at the same time doubt and, sometimes, even resist to the concretization of that help. In fact, these patients are a professional challenge from a psychological perspective. Therefore, besides the necessity of correcting beliefs and expectancies related to the nature of the psychological treatments as well as the psychological disorders, it is necessary the immediate implementation of psychological means that help change the patient’s psychological dynamics. An important issue to consider is the tendency of psychologists, at least in Europe, to ignore the problems caused by medications, which are crucial in this kind of patients. First, because the medication becomes a part of the problem (it generates new symptoms of distress and disturbance), second, because the patient has already attempted to quit the medication and

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has experienced negative consequences, which also reinforces the conviction that the medication is the only way of feeling a little better1. Moreover, withdrawal symptoms are an additional target of the intervention in our approach (it may have the same characteristics of an emergency, but we will discuss it further in point 4).

2. People in Despair These patients, whether have gone through previous treatments or not, have suffered from a disorder for many years, or in case the disorder is relatively recent, it has had a strong impact in patients’ well-being. From a psychological point of view, patients find themselves cornered and feel like they had reached a dead end. Therefore, the cases included in this category are patients suffering from phobias, mood disorders, affective problems (couple problems), conflicts, etc. All of them show a high degree of disorientation, anxiety and discourage, overall as a result of a prolonged emotional suffering. It is important the fact that this state prevents patients from, or makes difficult, the implementation of an intervention based on an EBT, even though, according to the diagnosis, it is clear the indication of a particular treatment. In other words, before thinking of implementing any specific treatment, the therapist have to use a previous procedure in order to decrease anxiety, improve the mood, or create a minimal emotional stability that allows to proceed with the intervention.

3. People whose Problem Needs to be Solved or Improved Immediately This category refers to people who, for instance, suffer severe or chronic insomnia. It would be the case of a person who has been days or weeks sleeping only in a residual way, or that since several years ago only sleeps regularly 2 or 3 hours per night. In all these cases, the sleeping time is perceived as insufficient, which generates disturbance (tiredness, difficulties with concentration, reasoning, and memory, anxiety, irritability, and discourage, among others). Also belonging to this category are those cases of sudden situations with severe consequences, such as a child who in response to a fright quits ingesting solid food. Therefore, we are referring to cases in which the immediate improvement is needed to avoid severe or unwanted consequences. Other cases that can be classified here are those people who are in a situation of strong suicidal ideation. It is not only that these patients are in despair –like in point 2- but above all that they are in need of finding or at least discover a way out of the situation, a solution to the suffering they are going through. It is worth mentioning that the usual approach to these patients is considering them as in urgent need of taking medication arguing that a psychological approach is too slow. This is a point of view without any scientific in regard to the pharmacological action, and it does not take into those cases in which 1

Insofar as this chapter does not intend to discuss specific aspects relative to the use of drugs in psychological treatments and its consequences (positive and negative), authors do not detail this matter further. However, it is worth pointing out the confusion between relapse and withdrawal that both physicians and psychologists show very often. It is because of this confusion that patients keep on taking harmful medications that make their disorders become chronic.

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the medication causes either the induction or exacerbation of the suicidal ideation (Healy, 2004). Additionally, a psychological approach should be incisive enough to be able to take into pieces the intricate affective-cognitive conflict in which the person is involved, and that is a goal that may be achieved quickly. In other words, probably the idea that psychological treatments are very slow was brought about by preconceptions derived from the long time that Psychoanalysis led the American and European cultural perspective.

4. People in Shock A general characteristic of emergencies is the presence of agitation (mental, motor or both). It does not allow the establishment of the necessary steps to implement the therapeutic procedure (e.g. relaxation, exposure, cognitive restructuring) indicated to a given disorder. It is common that a person in shock goes to an emergency room where the most common procedure is the use of short-acting benzodiazepines (such as sublingual ethyl loflazepate, or intravenous diazepam) or an intravenous neuroleptic. Clinical situations considered in this category are people with panic attacks, in sudden grief2, suffering trauma3, etc. In addition, cases of delirium or cuasi-delirium caused by stress4 can be also included. In the latter, it is evident the existence of a severe agitation and anxiety, and also it is possible to hear voices, symptom that traditionally has had as a first-choice treatment the prescription of antipsychotic drugs. According to our experience, it would be indicated in these cases an efficacious psychological management of these symptoms using hypnosis. This point even relies on evidence about the phenomenological and epidemiological nature of these disorders (Barlow, 2002; Bentall, 2007).

5. People who Are not Amenable to Start a Treatment It is not rare to find people who despite being very motivated for starting a non pharmacological treatment, present major difficulties to actually initiate such treatment. This is often the case of treatments using techniques such as exposure whether exteroceptive or interoceptive5. In fact, the most usual problem in practice is that the recommended procedures in these cases are the ones causing more resistance in the patients because of the strong discomfort they produce. Therefore, the dropout from the psychological treatment in this stage is a possibility. Additionally, people with moderate-severe depression present some important obstacles at the beginning of the treatment. For instance, how to start behavioral activation with somebody who feels apathetic, weak, without energy? It is as if the person was overwhelmed by an immense burden that prevents his/her from cooperating. Hypnosis is a very beneficial strategy. It helps pre-activate the patient (e.g., active-alert hypnosis procedure), or simply induces expectancies for change. 2

The grief can be the consequence of an actual loss of a beloved one, or an affective loss such as a relationship breakup. 3 For instance, in the course of an accident, an assault, a rape, etc. 4 There has been recognized in the DSM-IV a category called “Delirium Disorders”. 5 It is included the exposure in imagination.

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Furthermore, people suffering from an obsessive-compulsive disorder can be included in this group. These patients are so much confused and agitated after weeks or months experiencing intense compulsive anxiety that they are not amenable to initiate the appropriate treatment (i.e., exposure and response prevention). They need a previous emotional stabilization. People under medication constitute another group of cases, unfortunately very numerous. Even though we have already mentioned these cases in point 1, the perspective here is a different one. Indeed, patients who would be amenable and show positive psychological treatment expectancies cannot benefit of such treatment since they are under the effect of drugs that have a pernicious action over the implementation of a psychological intervention. This entails the following: 1) the medication has not helped the patient; 2) the psychological treatment is not compatible with the medication; 3) it would be desirable to discontinue the medication, however, the patient will suffer from withdrawal symptoms. The most adequate option seems to be the slow reduction of medication along with counseling and the introduction of psychological procedures aimed to reduce the withdrawal symptoms. Hypnotic techniques appear to be interesting in these cases.

GENERAL APPROACH FOR DIFFICULT CASES AND EMERGENCIES BASED ON THE VALENCIA MODEL OF WAKING HYPNOSIS (VMWH) First of all, our view is that there are two essential assumptions that simultaneously base and limit the use of hypnotic procedures in general and the VMWH in particular6. For one, when using hypnotic techniques, the psychologist keeps the same frame of mind than when using any other psychological procedure (since hypnosis is also a psychological procedure). In other words, the psychologist utilizes hypnotic techniques to modify expectancies, establish beneficial conditionings, generate favorable conditions to the modification of competences, and to teach new healthy competences7. On the other hand, the patient has to have an adequate level of suggestibility, or at least, to be willing to develop this quality. This means that not everybody can benefit right away of these procedures. Nevertheless, an interesting fact is that the most of these patients tend to be very suggestible. It is our view that, to some extent, their problems have been brought about by the spontaneous use of dysfunctional self-suggestions. In any case, these assumptions and limitations should be borne in mind so that the approach can be serious from a scientific and clinical point of view. From our perspective, there exist several fundamental therapeutic elements to take into in the psychological approach of these cases, which, in fact, our interest in the VMWH. First of all, it is important the establishment of the perception of safety and surprise. According to our clinical experience, a positive surprise for the person is therapeutic on its own, because it helps be open to novelty, change, and perhaps hope. On the other hand, 6

To be precise, in our opinion based on clinical experience, the VMWH has fewer limitations as the reader will notice. 7 An important line of research by Kirsch (2007) on the role of expectancies in human behavior, and particularly, in hypnosis, found that there is no doubt that there is an essential and deliberate utilization of expectancies for therapeutic purposes.

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the perception of safety allows establishing a therapeutic relationship of trust that will provide the patient with subsequent therapeutic benefits. Additionally, in the moment of attending an emergency or approaching a person in a difficult clinical situation, this perception of safety is essential for achieving emotional stabilization, and creating a “soothing” effect, as we will detail further in the presentation of clinical cases. Another important aspect is regarding to intrinsic characteristics of the VMWH, namely, the fact that this approach is focused on the implementation of self-control and is very structured in a very understandable and practical way for the patient. A description of the main elements of the VMWH will help the reader comprehend better these and other characteristics that make this model be an innovative approach. The VMWH, based on the socio-cognitive or cognitive-behavioral paradigm of hypnosis, includes three procedures to establish good rapport: the cognitive-behavioral presentation of hypnosis, clinical assessment of hypnotic suggestibility, and a didactic metaphor about hypnosis. Two methods of waking hypnosis are used along with these procedures, namely, Rapid Self-Hypnosis (RSH) and (hetero) Waking-Alert Hypnosis, being the former the core of the method (Capafons, 1998b). Even though it is very structured, its sequence is flexible. The cognitive-behavioral presentation of hypnosis illustrates its association with everyday life situations. Corrections to the popular misconceptions about hypnosis are provided, such as that hypnosis is a safe technique for hypnotized individuals or that it does not involve an altered state of consciousness in which a person can become “trapped”. Furthermore, this presentation conceptualizes hypnosis as a means of gaining self-control, which also reduces any fear of loosing control that the patient may hold. In this context, the patient is willing and ready to move on to the assessment of suggestibility, that is conducted without previous hypnotic induction and using classic hypnosis exercises with a different meaning. The purpose of these exercises is to assess patients’ collaboration with, and confidence in, the therapist and their attitudes toward hypnosis. The exercises are: postural sway, falling back, and hand clasping. After this, the patients are taught the rapid self-hypnosis method, which once learned, can be performed very quickly, with eyes open and in a disguised fashion (Figure 1)8. This induction method is closely linked to the hypnotic suggestibility exercises, namely, falling backwards and hand clasping, and a third one is added that involves a challenge suggestion (exercise of “confirmation”) (a detailed description of this method can be found in Capafons, 1998a; 1998b).

8

As shown in this figure, patients using Rapid Self-hypnosis may be in a public situation and doing other things while giving themselves the therapeutic suggestions. For instance, in this case, this man is smoking while hypnotized and he might be suggesting himself to feel satisfied right after starting to smoke that cigarette and feel like throwing it away, or to be calm in that situation without needing a cigarette. All this would go unnoticed by other people around him.

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Figure 1.

Once the patient has experienced hypnosis, a metaphor is used to convey the following ideas: hypnosis is not dangerous, it does not imply a lack of effort or perseverance to change behaviors, and it is an important instrument, albeit only as a helpful agent in the treatment to be implemented (since hypnosis is an adjunctive to the psychological intervention). This exercise is conducted while the patient is self-hypnotized and consists in asking the patient to imagine his/herself facing a series of fictitious difficulties (surviving in a jungle) that s/he solves successfully thanks to his/her effort and the correct use of a machete that represents hypnosis (for a detailed description of the metaphor, see Capafons, Alarcón and Hemmings, 1999). Finally, it is worth mentioning that all these methods of suggestion management has been described by patients as pleasant, enjoyable, and useful, whereas they keep the efficacy attributed to other forms of hypnotic suggestion management and have even sured other methods. Likewise, all the procedures included in the VMWH have been empirically validated (Capafons, 2004a).

REVIEW OF RESEARCH OF APPLICATIONS OF HYPNOSIS IN DIFFICULT CASES AND EMERGENCIES As mentioned before, hypnosis is an essential component of the VMWH. According to the literature, the application of hypnosis to difficult cases and/or emergencies has been mainly focused on patients in need of relief of the acute pain and/or anxiety suffered either in accidents or in peri-surgical procedures. Likewise, there exist studies carried out to assess the efficacy of hypnosis in patients suffering from chronic disorders whose symptoms do not respond to the conventional medical treatment for that problem. The first kind of patients corresponds to points 2 and 3 of the classification of cases mentioned above, that is, people in despair and people who need an immediate improvement, respectively. Studies found in the literature are mainly relative to burn patients and to patients undergoing surgery. Hypnosis has been successfully used in cases of burn-injury patients to

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manage anxiety and pain while they go through dressing changes and wound debridement. Results indicate that patients treated with hypnosis as an adjunct obtained significant pain reductions relative to pretreatment baseline or control groups and needed less medication (de Jong, Middelkoop, Faber and Van Loey, 2007; Patterson, Everett, Burns and Marvin, 1992; Patterson and Ptacek, 1997; Patterson, Wiechman, Jensen and Sharar, 2006). Additionally, hypnosis has shown to be efficacious in managing the anxiety and reducing the pain associated to dressing changes (Frenay, Faymonville, Devlieger, Albert and Vanderkelen, 2001; Patterson, Questad and de Lateur, 1989). Relative to studies with patients who have to go through surgery, hypnosis has been used as an adjunct to psychological interventions for reducing anxiety, as an adjunct to pharmacological analgesia and to teach patients strategies to cope with peri-surgical procedures. In addition, it has been utilized to reduce the pain medication needed before and after surgery, the bleeding, and the hospital stay, as well as to facilitate post-operative recovery (Pinnell and Covino, 2000). There is a great deal of research whose results the efficacy of hypnosis in this area (e.g., Blankfield, 1991; Faymonville, Meurisse and Fissette, 1999; Lang et al., 2000, 2006; Lang et al., 2006). Furthermore, it is important to take into the meta-analysis performed by Montgomery, David, Winkel, Silverstein and Bovbjerg (2002) in which it was found that 89% of surgical patients benefitted from interventions with hypnosis compared with to patients in control conditions. This was revealed both in self-report measures and in objective measures, which suggests that hypnosis used as an adjunctive procedure helped most patients reduce the adverse consequences of surgical interventions. The second kind of patients mentioned are those with a chronic disorder that does not respond to the medical conservative treatment and correspond to point 1 of the classification. Among the studies that have addressed this kind of cases, those conducted on two particular areas are relevant for the low efficacy of the conservative medical treatments in contrast with the success of hypnosis. The first area concerns the incorporation of hypnosis as an adjunct to cognitivebehavioral therapy in the treatment of irritable bowel syndrome (IBS). This disorder leads to considerable emotional and physical suffering, quality of life impairment, and disability for many patients. Conventional medical treatments for IBS are unsatisfactory for more than half of all patients, leaving them with significant chronic symptoms. There are two structured protocols for the application of hypnosis in the treatment of IBS. One has been developed in the University of Manchester (UK) (Gonsalkorale, 2006; Whorwell, 2006). The other one is the North Carolina Protocol, a seven-session hypnosis-treatment, unique because the entire course of treatment is designed for verbatim delivery. Research has shown that this protocol benefit more than 80% of patients (Palsson, 2006). Both protocols have proven that the treatment with hypnosis has an important impact that is well maintained for most patients for years after the end of treatment. Gains of intervention include changes in colonic motility and rectal sensitivity, as well as changes in central processing, psychological effects and improvement of quality of life, even in patients that do not respond to conventional medical treatments (Gonsalkorale, Houghton and Whorwell, 2002; Gonsalkorale and Whorwell, 2005; Whitehead, 2006; Whorwell, 2006). The second area of study is focused on patients suffering chronic pain caused by temporomandibular disorders. It is estimated that 23% of patients do not respond to conservative treatments involving a dental and physical medicine approach (Clark, Lanham

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and Flack, 1988). According to Simon and Lewis’ study (2000), the use of hypnosis as an adjunct to cognitive-behavioral treatment in these patients is promising. After the treatment, patients of this study reported a significant decrease in pain frequency, duration, and intensity, as well as, in medical use. Likewise, participants showed and increase in daily functioning, and their treatment gains were maintained for six months after hypnosis treatment (Simon and Lewis, 2000). Besides this research, which is focused on cases sharing some of the characteristics of the cases we consider as difficult or emergencies, to the best of our knowledge, there are no published studies about the use of hypnosis in the kind of cases we describe in this chapter. Therefore, it is important to point out that this work is pioneer in two aspects: first, the application of hypnosis to cases that psychologists can find in their everyday private practice (differing from those mentioned before that can be often found in hospital practice), and whose characteristics make them difficult and in need of a special approach to achieve a quick improvement; second in the use of the waking version of hypnosis and in particular the therapeutic procedures of the VMWH adapted to these cases.

THE THREE MODELS OF INTERVENTION DERIVED FROM THE VALENCIA MODEL OF WAKING HYPNOSIS This approach results from the experience with some hundreds of difficult cases and emergencies that led the first author to develop different models of hypnotic intervention based on the VMWH. The approach is ed by three models of intervention (Pires, 2008) intending to respond to the clinical diversity of difficult cases and emergencies. The models are simply called model 1, 2, and 3. Before further describing each model, it will be helpful to review the general frame of these models concerning their psychological origins. First of all, the two aspects already mentioned are very important, namely, safety and surprise. However, in a strict sense, the establishment of safety and use of surprise are inherent conditions to any profession in which there is a relationship of help. On the other hand, to create safety in an approach as specific and incisive as the one we set forth is crucial and can not be postponed until the safety is established throughout several sessions. In fact, these two elements can be viewed as essential in the establishment of this approach. Another aspect that we consider important to explain is the assessment of hypnotic suggestibility, above all, the possible use of psychometric instruments. In our approach, whether the cases are difficult and/or emergencies or not, the hypnotic suggestibility is not assessed, since, according to our clinical experience, there are several limitations or determining factors that make it not useful9. They are as follows: •

9

Assessment procedures do not predict clinically the therapeutic benefits. Indeed, the different items used to assess the suggestibility are not related to the clinical and therapeutic response. Beliefs and attitudes toward hypnosis are more interesting factors (Capafons, 2001), but they are not relevant in our approach as we will explain further on.

This opinion has been also advocated by others (for a review on this topic, see Weitzenhoffer, 2000).

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•

•

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They are very extensive and take time, and consequently they are not suitable for the kind of clinical situations that we are describing here. In emergencies especially it is pursued an immediate therapeutic impact. The assessment procedures can foster a traditional perspective of hypnosis in people that hold these beliefs, since the exercises can familiar scenes of hypnosis (it is important to take into that when these items are introduced to patients, they are also told that their purpose is the assessment of the hypnotic suggestibility). There is a high risk of spoiling effects that could be used for the patients’ benefit, given that the first with hypnosis is through the items (which are actually induction procedures). The surprise factor, that is a very important condition for this approach, is completely lost. Often times, we have found that patients that responded very well to the items, at the time of using hypnosis with therapeutic purposes, ended up resisting or rejecting its use, maybe because their misconceptions about hypnosis.

The main characteristic of our approach is the development of brief procedures taking the psychological, technical, and philosophical assumptions of the VMWH as a starting point. The resulting models can be called Very Brief Models. In the following diagram the models can be compared to each other. Thus, comparing the two figures the following differences can be easily noticed: 1. 2.

3. 4.

5.

There is not a presentation of hypnosis. The clinical approach begins with an induction procedure. That is, besides the lack of a presentation of hypnosis, the clinical assessment of the hypnotic suggestibility is transformed into a hypnotic induction procedure. The hypnotic induction is directed in the sense of its maximization in an only session. That is the reason why the patient is immediately trained in rapid hypnosis.10 As soon as the patient has some experience in the benefits of hypnosis, the “presentation of hypnosis” is carried out. This would be what in the VMWH corresponds to the stage “Practice and training suggestions” or later. The reason is obvious: when patients have already felt benefits and have personally experienced what hypnosis is, they are more receptive and willing to comprehend, accept, and implement the wide range of hypnotic procedures. The “didactic metaphor” is taken off since this approach aims to be as quick as possible. However, this does not mean that it can not be used subsequently, after the beginning (rapid hypnosis)11.

To sum up, the VMWH is adapted to the clinical circumstances and characteristics of these patients. In table 1 is shown the logic that directs these models, that is, kind of a line of reasoning for decision-making concerning whether or not using hypnotic techniques.

10

Notice that in some cases, the approach is directed immediately in of “self-hypnosis”. This will be better understood when each model be explained. 11 Except for when in the development of our approach (in subsequent sessions), the format is already set according to the usual VMWH, after the patient’s emotional stabilization.

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Diagram 1. Comparison of Valencia Model of Waking Hypnosis and Very Brief Model (Taken from Alarcón & Capafons, 2006).

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The discussion of the first three points is framed in of the so-called difficult cases and emergencies above-mentioned. In point 4 of difficult cases the goal is to know, according to the clinical history, context, and clinical characteristics, whether the use of hypnosis is possible. For instance, only counseling could be more feasible and have more benefits. Relative to the point 4 of emergencies, in may be the case that the person is not in conditions to pay attention12. Point 5 in both situations consists in the implementation of the approach through one of the models. The models are explained in the next section.

Model 1 There is not any preparation or mention to hypnotic suggestions. After listening to the patient’s complaints, asking ourselves the questions of the table 1, and establishing the rapport with the patient, we implement the Model 1. This protocol was put forth with the goal of causing surprise, and the first exercise was selected due to its similarity to tests used in neurology. Table 1. Line of reasoning for decision-making concerning whether or not using hypnotic techniques 1. Is this a difficult case? 2. Have there been previous treatments? Were these treatments the most adequate? 3. If the treatments were adequate, but they failed, something different should be done, although taking as a reference the previous treatments. If they were not adequate, the focus would be a therapeutic adaptation. 4. Conclusion: Is hypnosis a feasible alternative? 5. Procedure (one of the models) ----------------------1. Is this an emergency? 2. Is the suffering unbearable? 3. Is there a strong pressure to get the problem solved immediately? 4. Conclusion: Is the use of hypnosis feasible? 5. Procedure (one of the models)

Postural Sway The patient is asked to stand up and stand facing the wall with his/her feet together and his/her arms and hands stretched out beside his/her body (see Figure 2A). The patient is also asked to fix his/her eyes on a spot and after that to close his/her eyes (Figure 2B). After 5 or 10 seconds the patient will be asked to open again his/her eyes. This position in itself produces swaying. When the patient has opened his/her eyes s/he is asked the question: “what

12

The first author has already had the experience of an emergency in which the patient was under the effect of an antidepressant (a substance called escitalopram, that she had taken for 5 days), which produced her to suffer from vertigo and to be unable to keep a hardly coherent dialogue. Two days later, after suspending the drug, it was possible to initiate an approach including hypnosis.

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did you feel in your body?” Most patients answer that they felt like swaying13. Then, the protocol goes on with the next exercise: falling back.

Figure 2A.

Figure 2B.

13

Some people, especially very hypnotizable people, may feel a little dizzy.

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Figure 3.

Figure 4.

Falling Back The patient remains in the same position and the therapist places him/herself behind the patient, asking him/her to fall backwards, and assuring the patient that s/he is safe since s/he is going to fall into the ing hands of the therapist (Figure 3). This exercise is carried out several times. It is worth noting that this exercise not only pursues to help develop

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confidence in the therapist, but also to create a setting of surprise (“what are these exercises for?”). After repeating the exercise follows the same one but adding the use of suggestion.

Falling back Using Suggestion As in Figure 2A, the patient is asked to fix his/her eyes on a spot and to stay put. The therapist warns the patient that s/he is going to place him/herself behind his/her and put his/her hand in a way s/he can hold the patient when s/he falls. After that, the therapist says something like the following: “Please, imagine that my hands are powerful magnets that are attracting you backwards. Attracting you…Attracting you…Attracting you backwards…More and more….” (Figure 4). In our approach, it is not so important that the person falls backwards. The goal is to involve the patient in a setting of surprise that will lead him/her to the main exercise (the last one of this Model). The next exercise used in this Model is a simple exercise of suggestion that appears in many scales to assess suggestibility, namely, hands attracting to each other. Hands Attracting to Each other The patient is asked to stand up, put his/her arms parallel to each other (Figure 5A), and close his/her eyes, while imagining that his/her hands (separated 15-20cm) are getting closer to each other, more and more until eventually they touch (Figure 5B). The underlying idea of this exercise is, once again, the development and increase of the surprise. It is thought that this exercise leads to an increase of the involvement in a suggestive activity as well as causes surprise. It also prepares the patient for the next exercise that is actually the one to use in a therapeutic way: side arm lift (levitation).

Figure 5A.

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Figure 5B.

Side Arm Lift (Levitation) The patient is in a standing position (this time his/her feet are separated so that s/he does not sway too much)14, and right after the previous exercise, the therapist says the following: “In this exercise, after asking you to close your eyes, I am going to take your right (or left) hand by the wrist and push it upwards. I would like you to feel your arm lifting, to feel its movement. This movement will be repeated several times.” It is obvious that this exercise is intended to be used as a hypnotic induction, by means of creating a movement perceived as involuntary. In fact, most people quickly experience this involuntary arm movement. The therapist says something like the following: “Notice how interesting… your arm lifting on its own… and notice that it is not only interesting but also gives you a pleasant feeling of relaxation. Now, pay attention to what is going on… the left arm also lets go and begins to lift…and both arms lift…lift…they go up until a certain moment comes when they no longer lift but go down.” At this point, there are several alternatives, depending on the clinical case and the goals intended to achieve through this intervention. From our point of view, there are two major alternatives considered especially helpful to attain emotional stabilization and step back from conflicts: a) Suggesting to the patient to feel as if s/he was a stone statue placed in a garden, knowing that statues do not suffer, do not think, do not move, they just observe the world movement, the of the year seasons, the rain, the sun, the clouds, the birds that come and 14

Obviously, all these exercises can be performed while the patient is sat. This would be the case of either temporarily or permanently disabled patients. In the “falling back” exercise, the starting position may be with the patient sat as close to the edge of his/her wheelchair or the chair as possible, and then proceeding like in the standing version of the exercise, but substituting the suggestion for feeling that the therapist’s hands attract him/her to fall backwards with the suggestion of the same effect but produced by the back of the chair.

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the birds that go away. Even it may be suggested that the person mentally leaves the statue and sits in a bench in the garden observing with serenity the events. In a second alternative (b) it can be suggested to the patient to listen to the sound of the road, the cars, the leafs of the trees, going further every time and very relaxed, calm, and appreciating how big things are small, and small things are big, depending on the perspective and importance that we give to them... Some people do not move their arm (even when the therapist is pushing). These people tend to do catalepsy, leaving their arm extremely rigid. Others simply leave their arm flaccid, but do not experience the sensation of involuntariness. Relative to the case of catalepsy, an alternative to the side arm lift (levitation) can be the suggestion of feeling as being a stone statue (according to the mentioned scenery). In regard to the second case, we have noticed that most of these patients tend to sway more or less slightly when they are in a standing position, even when keeping their feet separated from each other. Therefore, an alternative to the side arm lift (levitation) is the watch pendulum. The wording for the watch pendulum may be as follows: “Now, if you pay close attention, you will notice a very interesting thing: your body is swaying…swaying as if it was a watch pendulum…The pendulum of a very big and antique watch, but the pendulum is fixed in the base…Swaying…Swaying...Insofar as it sways…” And it continues with those suggestions thought as the most appropriate for the case. It is worth pointing out that there are some other possible variants, regarding induction techniques derived from this initial exercise of arm lift. The first variant consists in proceeding with the same procedure with the other arm, such as shown in Figure 6A. In this case the wording may be something like the following: “If you wish, in a moment may happen something very interesting: when I touch you with my finger in your arm (e.g., the left arm), you will see that it will let go and will start lifting like happened with your other arm…” This way of proceeding results in hypnosis deepening.

Figure 6A.

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Figure 6B.

Another variant, this one more complex but also very interesting in of the suggestive-therapeutic possibilities, is shown in Figure 6B. In this case, after the right arm has lift, suggestions for the arm to descend are given (for example by saying: in a moment I am going to touch your right shoulder with my finger and then I am going to go down touching your forearm, arm, hand, and fingers, and you will be able to feel this arm going down until it touches your body. Your arm will no longer be rigid and hard as if it was a rock). Once the arm is in the initial position it may be suggested that at any time the right hand and arm will move. Often times, we use the following procedure in which a metaphor about “unconscious processes” is included (it can be used any other metaphor that is appropriate for the goals): “Well, I know you are listening to me and you are going to find this very interesting and amazing. I think you will enjoy being even more surprised. Listen to a very important thing I am going to tell you… Everybody has conscious and unconscious activities, and because of that, sometimes we do not know why we do this or that. The learning of better regulating that unconscious activities will be very important in order to change difficulties, either emotional or any others. An interesting way of letting these unconscious processes show themselves is by means of the movement of the left arm. Thus, when I say “now”, you will be able to feel some changes in your right arm and hand, then a time will come in which your right hand is going to move to a part of your head… I do not know where it will go; you do not know either... Will it go to your face, to your nose, to one of your ears, to your forehead, to your hair, to your mouth, to your chin? I do not know, you do not know either... Notice those small and very subtle movements inside your hand, little by little moving, moving... etc. The movement involuntariness is reinforced constantly and, at the same time, its relationship with something pleasant (as your hand and arm raise you feel more confident, calm, hypnotized…). Perhaps, this is the more complex procedure and the most productive, and it can be used subsequently. Finally, there are some aspects to emphasize: 1) The patient is ready for rapid hypnosis through several inductions that will prepare the next stage; 2) At the end, it is explained to the

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patient how hypnosis can be incorporated in a therapeutic plan in order to help him/her, and misconceptions or negative attitudes toward hypnosis are clarified in a conversation. Everything is ready for preparing the next session.

Model 2 By and large, this model is the most appropriate for emergencies, since it is much more direct, brief, and incisive. Likewise, it is worth pointing out that, from the start, this second model uses waking hypnosis and is adapted to a self-hypnosis format. Overall, this model has two stages and both of them are intended to cause surprise. As mentioned, the final goal is to deal with the patient’s emotional agitation and activated state. The first stage involves, above all, the development of patient’s absorption in his/her inner processes that will be the target of the therapist’s intervention. We use a combination of several items belonging to the VMWH, in particular, the sensations of heaviness/lightness in the arms, which subsequently can be associated with other elements leading the patient, in a gradual way, to understand that his/her emotions are determined by his/her thoughts, in other words, by his/her “mind”15. The following paragraphs detail the procedure. LIGHT/HEAVY ARMS FOR EMOTIONAL EQUIVALENCE. For this exercise the patient is comfortably sat. The therapist asks the patient to keep his/her eyes open and talk whenever s/he asks him/her something. However, the patient may choose to keep his/her eyes closed if s/he feels more comfortable this way. It is explained that the important thing is to “let him/herself go”, that is, not to make efforts to produce the sensations that the therapist will refer. The kind of speech and suggestions given can be as follows: I am going to ask you to sit as much comfortable as possible (Figure 7). Often times, we only realize the presence of certain sensations when we pay close attention to them. For example, I am going to ask you to pay attention to your hand and tell your brain or simply let it know that feeling your right hand is not the same than feeling your left hand. Give that information to your brain and wait… Wait to see what happens and let me know… (Pause for some seconds. Most people tend to report an increase of heaviness or lightness in their hands.) If the patient does not report anything, the therapist may go on as follows: Most of people notice that one hand turns a little heavier and the other a little lighter. Please, pay attention to check if something like that happens to you. It is almost sure that the patient will notice changes. Probably, the hand and arms will lift (Figure 6B). Moreover, there are alternatives to the heaviness/lightness sensations, such as hot/cold or simply the immobility of one or both hands.

15

In our opinion, this is one of the most interesting aspects of the VMWH. It makes it immediately appealing for those who has private practice and many times need to make the patients understand that the way they think or interpret the situations (internal or external) has a strong influence over their dysfunctional emotions.

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Figure 7.

The important thing is the occurrence of those alterations, which will be associated subsequently to wanted emotional aspects, as it is carried out in the VMWH. For example: Please, now tell your brain that to the extent that your right hand and arm lift, you relax yourself… You start feeling a sensation of calmness… Observe how interesting and pleasant this is… Notice that you are starting to learn to regulate better your emotions and that it will have many benefits for you. The second stage may simply consist in keeping this script, deepening above all selfhypnosis, or moving on to another script that can be started in the same session or in the following one. This decision will depend on the clinical assessment of the patient at that moment. The other script is the hands attracting each other, that is performed over the therapist’s table (Figure 8A), or, alternatively, with the patient’s hands over his/her thighs (Figure 8B). It makes no difference, although we recommend for the homework to use the latter position. Hands attracting to each other. As is shown in Figure 8A, the patient is sat with his/her arms over the table in parallel from the elbows. The separation between the hands should be about 20 cm, not too much since it is more difficult the movement over a surface than, for example, over the thighs. Additionally, as it can be done with other kind of inductions, if the hands do not move, different suggestions can be employed (“Your hands can not move... they are immobile… more and more immobile”, etc.). Actually, the important thing is the rapid induction of (self) hypnosis, as well as the association of the movement of the hands approaching to each other (Figure 8B) with a desirable psychological effect. For instance: “As your hands move approaching to each other, you feel more relaxed, safer, calmer…” In our clinical practice, this induction procedure is very efficient and pleasant for the patients. First, because it is very quick, and second because it causes a noticeable surprise effect, and at the same time a quick stabilizing emotional effect (brought about by the suggestions given in order to achieve relaxation, serenity, and confidence, among others).

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Figure 8A.

Figure 8B.

Model 3 This model is mainly used when the patient has already achieved an adequate emotional stabilization. Indeed, it is a result of the previous model and, overall, it is developed in of the VMWH, as it was described in the beginning of the chapter. Nevertheless, it can be more beneficial for the patient to go on working with the approach explained in the Model 2, but including new clinically and therapeutically relevant aspects. It is worth mentioning that according to our clinical experience, many emergencies do not need a transition to this Model, because patients improve or solve their difficulties in a satisfactory level.

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What does the Model 3 consist in? Actually, this Model develops the VMWH in a slower way, breaking it in stages, and lengthening the hypnotic procedures16. For example, let us suppose that a patient comes in a situation of panic attack without agoraphobia, and having been suffering repeatedly from crises in the last days. After a minimal emotional stabilization is achieved through the Model 2, the intervention may proceed as follows and according to this rationale: 1) The interoceptive exposure is the choice treatment for this disorder (Craske and Barlow, 2007); 2) The patient is asked to hypnotize him/herself and is trained in producing alternatively relaxation/calm and anxiety/fear, while giving him/herself suggestions of safety and confidence. This training will allow the patient to understand two important theoretical facts of the panic disorder, first, that it is the patient him/herself who, paradoxically, produces the panic attack; and second, that it is done by increasing his/her respiratory rate. When the patient is in self-hypnosis, it can be emphasized what happens in the breathing cycle, that leads him/her to produce an increase in anxiety/fear, namely, there is an increase of the respiratory rate, along with the obvious reduction of oxygen and increase of carbon dioxide in blood, which leads to the conditions for the development of the panic attack (Barlow, 2002). Specific induction techniques will not be presented for this Model, since they are the same than for the two previous Modes (above all Model 2), or any other of those included in the VMWH (Capafons, 2001; Capafons, 2004a; 2004b). The techniques included in the latter are all aimed to achieve Rapid Self-Hypnosis. In order to understand and illustrate the clinical applications of these Models, in the next section we will introduce a variety of clinical cases.

CLINICAL CASES Case A. (Delirious Agitation, Anxiety) The first case is an emergency. A. is a high school arts teacher who had a position in the South of Portugal (Algarve) during the past academic year. When he came back home (Center of Portugal, in a city named Leiria), in July 2007 the event that led him to our office took place. The patient, a 30-year-old man, was always a person showing a high social anxiety and obvious interpersonal difficulties. During the past academic year, A. tried to fit in with his colleagues, what led him to drink and consume marihuana. The latter caused him to start having some persecutory ideas as well as hearing voices. Perhaps related to this somehow delirious activity, A. initiated a relationship with one of his colleagues, which he regarded as a romantic relationship. However, at the end of the academic year, he confirmed that he was mistaken, and it was only an illusion of his own mind. In this emotional condition he came back to his family home (his brother and his mother, his father ed away many years ago). It is A.’s mother who ed us. She was in despair and worried since in the last days A. had done unpredictable things, such as going to see some friends, giving them the keys of 16

Clearly, the aim is not using the VMWH as it is established, since that would be going backwards, which is not possible. However, some of the essential elements of the VMWH can be used working with them in more detail (thus, according to the assumptions of the VMWH). For example, the therapist may spend more time explaining and training in the influence that thoughts and interpretations have on what we feel.

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his car stating that he was not going to need them anymore, and then being found in the beach trying to go out of sea. Furthermore, some nights he slept inside his car or outside in the beach, he used to talk to himself as if there were somebody else, and was very agitated without being able to sleep. This information given by phone was enough to realize that this could be a case of psychotic agitation (delirious disorder). A.’s mother preferred that we assess his son first, rather than proceeding directly to his hospitalization in Psychiatry. A. was received the same day in the evening (A.’s mother called at midday). He appeared to be a very anxious person, agitated, and with difficulties to explain what happened to him. Even so, it was possible to clarify the events he told us as well as the impact they had had on him. It was immediately clear that he was emotionally destabilized and to help stabilize him was considered as the main and immediate goal of the intervention. The Model 1 was applied with the arm lift procedure. Taking into that A. responded very well, the variant of the hand and arm going up to a specific place of the head was used. Suggestions of calming down, safety, and tranquility were given. The response was excellent. The patient practiced at home during the following three days and then came back. At that point, he showed to be calm and ready to use the procedure in self-hypnosis (without knowing anything about that). He was able to achieve what he called “meditation”. A. came back to the office after two weeks and one month and he kept his positive progress. In these two sessions the work with him was focused on problem solving, including the hearing voices. He considered being able to proceed on his own in this matter17. Some months later he ed us again to improve some interpersonal aspects (related to social skills), and after several weeks he had gained good results. Previous to introduce this case in the chapter, we ed A. again and he confirmed to be very well18.

Case B. (Traumatic Stress) This case is an emergency too. B. is a 41 years old male who was referred by a colleague, after it was verified that he was in a trauma. Five days before, the patient along with four of his friends (among them there was a cousin of him that he considered as a brother) were hunting, a hobby all of them had some years ago. In the way back home they were involved in a serious car accident, as a result of which the patient’s cousin ed away. One of the things that most impacted B. was to see part of the brain of his cousin spread on the ground, with his head opened. From that day on, B. hardly slept and experienced permanent and intrusive flashbacks about the accident. He also reported to suffer a high level of emotional/physiological activation (heart rate and breathing cycle accelerated), anxiety, anguish, and sadness. He had difficulties to concentrate in his job as a business man. Relative to his family his own children reminded him his cousin’s children, now without his father, and his own wife reminded him his cousin’s wife, now a widow…

17

An interesting aspect is that the patient went on hearing “voices”, generally neutral or even positive ones. The patient was able to live with those voices without any problem. 18 The total therapeutic process (including the first session) took place between July and October, 2007.

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The rationale of the intervention, after talking with the patient about the therapeutic goals, was, first of all, to reduce his state of high emotional activation. To this end, the technique of breathing control was used (see Craske and Barlow, 2007). It consists in breathing in a controlled way during about 15-20 seconds (more than 12 seconds), paying close attention to the exhaling. The objective is to change the pectoral breathing into a diaphragmatic breathing. This helps reestablish an adequate balance of brain oxygenation and helps decrease the symptoms causing anxiety. The patient was trained in this procedure in the first session, and was asked to repeat it at home several times during the day. He came back two days later for the next session. The second session was intended to deal with the link that people tend to do after the death of a close person, namely, a process of guilt that, as the time es, fades away. We proposed B. the use of waking hypnosis to be able to proceed to vanish this process. We implemented specifically the Model 2, using the second stage (hands attracting each other) to give temporal distancing suggestions (and in this way, achieving a decrease of negative emotions): “Tell your brain that as your hands approach attracted by each other, you feel that the accident took place long time ago, long time ago... it did not happen one month ago nor a year ago... it happened long, long ago... and this is why you feel that your distress, anxiety, anguish are vanishing and decreasing...” Most part of this session was devoted to implement this procedure, first in hetero-hypnosis and then in self-hypnosis. The patient felt very relieved and showed to have good ability to use self-hypnosis. There was another session four days after this one, in which B. was told to practice several times per day this procedure (at least once in the morning, afternoon, and night). The next sessions were one and two weeks later respectively. That is, second session four days after the first one; third session seven days after the second; and fourth session, 14 days after the third session. It is worth pointing out that this kind of emergencies is, by nature, acute and its treatment has preventive characteristics. For example, in this case, everything indicated that the patient would be vulnerable to develop post-traumatic stress. However, since the intervention worked out successfully, several days after the trauma, that development never reached to an end. Indeed, an unpublished recent exploratory study conducted by one of the authors (Pires and Peralta, 2008) suggests that the cognitive involvement subsequent to the exposure to unpleasant scenes increases drastically the dysphoria, above all depressive feelings, decreasing the appreciation of neutral or positive scenes. Therefore, by “withdrawing” the patient from the cognitive involvement in the traumatic event, as well as allowing him/her to feel safe, may be very relevant in order to the post-traumatic stress does not develop further.

Case N. (Panic Disorder with Agoraphobia) The patient is a 30-year-old male that had been suffering from panic disorder with agoraphobia since he was 17 years old and had always been under pharmacological treatment. The treatment lasted 6 months and it revealed to be a very complicated case. The patient not only was completely limited (he did not go anywhere alone or too far away from his home), but he also was under much medication (two antidepressants, two benzodiazepines,

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propanolol, and a mood stabilizer). For that reason, the first months the intervention was focused on reducing gradually the medication19. As it is known, the choice treatment for panic disorder is conducted through the implementation of exposure variants, such as in vivo exposure (agoraphobic aspects), and interoceptive exposure (inner/somatic aspect of panic). Even so, many patients are reluctant to go through such procedures, above all to the interoceptive exposure. This patient was not an exception to these cases. After a negotiation process with the patient, we agreed to proceed with gradual in vivo exposure. At this time the patient was no longer taking medication20. Just as we expected, there were substantial difficulties and resistance. N. itted to be a “coward”: he did not bear to cope with agoraphobic situations. In this context, the use of hypnosis was put forth as an alternative. The Model 1 was applied and the statue scene was used to generate in the patient a feeling of distancing regarding the fear, and to suggest courage by means of some coping scenes of hard adversities in a mountain area. The important goal here was to elicit his feeling of courage and associate it to the word “courage”, in a way that he would be able to use it subsequently during the exposure. Then this situation was trained in vivo while in waking hypnosis. Therefore, these were the first steps to work with the exteroceptive exposure. The procedure was repeated several times, whenever it was necessary to “unblock” the agoraphobic coping. Meanwhile, it was possible to initiate interoceptive exposure that the patient accepted this time. It is important to emphasize that even though he exposure has been the basis of the treatment, the use of hypnotic techniques was essential for the effective treatment implementation. Hypnosis allowed overcoming the patient’s difficulties to cope with phobic situations.

Case T. (Phobia to Eat) The patient is an 11 years old male child who quitted eating solid food, taking only liquids after the death for asphyxia of a neighbor child. The latter21 was alone at home and tried to swallow a too big amount of food without chewing, and ended up asphyxiating herself. The patient’s parents realized what was happening to the child several weeks after the problem was already consolidated and started by asking for help to the Pediatrician. Due to they did not obtain any result, they turned to a Psychologist, also without any result. Then they looked for another Pediatrician who referred the case to us. Meanwhile, several months had ed. In this way, the case became a complicated case at the same time that was an emergency because the problem was already causing an impact on the child’s health. As a general rule, in cases involving children a simple approach of the Model 2 has shown to be useful. Inasmuch as children tend to be very suggestible, the exercise of the hands attracting to each other is applied without too many details. Additionally, according to 19

We counted on a physician’s collaboration. Even though from a clinical perspective, the patient did not have at this time any improvement, he considered that the medication, after all those years, had not solved his problem and had caused him several problems (“side effects”). 21 This child had trisomy 21. 20

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our experience, children like to keep their eyes opened. The intervention in this case was conducted in several stages that where established in accordance with the goals estimated as necessary at each moment. First, it was thought helpful to proceed to a sort of “oblivion” of the event that brought about the phobic situation, in order to facilitate the ingestion of solid and harder food in his mouth. During the exercise of “hands attracting each other” it was suggested that as his hands approached to each other, the above-mentioned event would turn distant, more and more distant, further in time until it had completely disappeared. After this procedure, there was a break to assure that the oblivion was working. As soon as it had worked it appeared helpful to produce in the patient the sensation of hunger in a way that he could eat a bite of a sandwich that his mother had brought. The procedure was the same one with the hands trying to cause sensations of hunger. The suggestions resorted to a detailed description of the somatic and cognitive signs of hunger, and to the anticipation of the pleasure of satisfying the hunger, producing salivation. In this stage, the psychologist’s intervention (hetero-hypnosis) was alternated with the performance of the child (selfhypnosis). The instruction was: “Tell your brain…” Before terminating, and in order to prepare for future sessions, it was suggested to T. that the exercise of the hands attracting to each other would be helpful to make changes in the brain so that the food turned tastier…22 Also, T. was told that this training is called self-hypnosis. After finishing hypnosis, the patient said that he had a stomachache that felt like... hunger. He ate in a natural way, to his mother astonishment, as if he had never had such a problem. The following sessions took place every other day during a week in which we went to his house at dinner time. T. stayed alone with us while his parents went to the living room. The first few minutes were spent in ing the good flavors of food, the advantages of eating well to obtain energy to be able to jump and study. Right after this, the mentioned exercise “to turn food tastier” was utilized. T. was told the following: “Very well, now you are in self-hypnosis and are going to eat until you do not feel like eating more. You will be able to move, to watch TV, to drink water, etc. You will remain alone. When you are finished, call me. See you later.” Two weeks later we went to the patient’s house again to observe his progresses and reinforce the procedure. Everything was going well. In the next few months a follow-up by phone was performed. More than three years has ed and there has not come up any problem.

Case C. (Depression, Pharmacological Iatrogeny) This case is framed in what we consider as “difficult cases”. Indeed, in our clinical practice a kind of case very common is chronic depression. To be precise, they are depressed patients who initiated a pharmacological treatment many years ago, and with the ing of the years, not only do not improve the initial clinical situation, but also present clear symptoms of emotional, cognitive, and behavioral deterioration, most of all as a result of the own treatment iatrogeny. As a rule, they are people without motivation and hopeless, with 22

This procedure was necessary to avoid the contradiction created by doing something with the goal that he eats, whereas it has been suggested oblivion… Subsequently, his mother confirmed that when she asked him the reason to do that exercise, he replied: “it is for improving my appetite. The food I ate before was not so tasty”.

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severe difficulties in their jobs (they are on sick leave many times or retired). Despite all this, they are not able to leave the medication since those times they have tried, they go through strong withdrawal syndrome and their physicians reject such a possibility. In this way, the situation becomes very complicated and the first objective is the relief of the side effects of the medication. This may take a more or less long period of time. During this time, a detailed intervention is carried out. That is, education, restructuring of the psychological components essentials for a comprehensive and in-depth psychological treatment. From our approach, hypnotic techniques can be useful in different points. Let us proceed explaining these points with this illustrative case. The patient is a 41 years old woman who has been depressed for nearly 6 years. She is married and has two children. She has many difficulties in her job as a lawyer, since she has reasoning and memory problems and repeated work absences. She is on psychiatric pharmacological treatment since the start of the problem, namely, an antipsychotic (risperidone), two antidepressants (fluoxetine and fluvoxamine), and two benzodiazepines (alprazolam and triazolam). This prescription is the most recent from a very long list. Building of a context of hope. It consists in creating positive and favorable expectancies toward this new process of help23. We turn to the Model 1. After proceeding as it was described above, we can to the following scenario: “Now, you can be in any place. Do you like going to the beach in a summer’s evening where there are few people and the sea is very calm? If so, imagine yourself walking by the seashore, walking on the wet sand. You know that the sand is wet because you are walking barefoot. Turn to face the sea. Today the sea is very calm and smooth. The seagulls fly along with the air current. In the background, some ships hardly move on the horizon. You are happy and satisfied. Actually, a few months have ed since your health improved and you feel better. Smile… Smile while looking at the sea and the seagulls, while thinking that all the efforts are really worthy. At the beginning everything seemed to be impossible, but then, little by little you overcame all the difficulties. You have become a better person. Take a deep breath… notice the smell of the sea… You are satisfied… Now, you know that, in life, there are good things and not as good things, and the latter are difficulties, obstacles that can be overcome. This kind of scenario was repeated with some variants during the first weeks in order to reinforce and develop positive expectancies in a way that the therapeutic process became more feasible. Hypnosis and withdrawal. In this case hypnosis was also used to cope with withdrawal symptoms that the patient reported to be the most distressful, that is, pain and anxiety. This procedure had to be repeated inasmuch as all the medications dosage reduction had effects of withdrawal of variable intensity. The period in which the withdrawal of the medication took place lasted about two months. Just before the complete withdrawal the patient was ready and felt like starting with behavioral activation. Actually, there were few things left to do after this. The same rationale was applied and usual elements of cognitive-behavioral therapy for depression were used, such as behavioral activation and correction of dysfunctional cognitions, and benefitting from

23

Sometimes, the patients are so medicated that it is necessary to wait a few weeks of medication reduction to be able to conduct what is going to be described. In this case, it is important to take into the pathological role of the own medication in the patient’s current state, trying to know in details the relationship between the drugs and the complaints. For example, many patients complain about being always sleepy and with the necessity of lying down but they still take the drugs that have those same effects…

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a self-help book wrote by the first author (Pires, 2004), which helped the patient to follow the psychologists indications.

DISCUSSION AND CONCLUSIONS This chapter describes and illustrates the use of waking hypnosis based on the Valencia Model and applied to clinical cases considered difficult and/or emergencies. Due to their nature, these cases represent a major challenge for professionals. As we have pointed out, the application of hypnotic techniques and procedures may be an important instrument to help these patients. Notwithstanding, the aim is not to apply techniques on their own without the of a planned psychological intervention. On the contrary, according to our point of view, hypnotic techniques are, above all, psychological procedures based on psychological variables and fitting into a set of therapeutic procedures that psychologists can use. Waking hypnosis has a great advantage compared with the so-called traditional approach: It does not put forth the existence of a mental or cognitive discontinuity between a normal consciousness and an altered state of consciousness. Therefore, it allows an easier approach in which there is no need for giving explanations to the patient24. In point of fact, hypnotic techniques can be integrated easily in the intervention and, overall, patients are not afraid of losing control over themselves or being in a trance state. In the case of the VMWH, there are some additional advantages: It is standardized in a protocol of procedures established in stages, and these stages are so clear and simple that its use becomes very appealing for those using it in their clinical work. It was from the clinical experience with the model that its application to difficult cases and emergencies arose. In these kind of cases, the VMWH cannot be used as it was initially put forth and described, but it is still possible to apply and adjust its principles and its philosophy, in a way that some appealing and elegant intervention models can be obtained and offered to those patients in need of help. The resulting models are specific versions of the VMWH for very specific cases. From a clinical/therapeutic point of view, what are the most interesting aspects of the models described in this chapter that could be emphasized? Most of all, their parsimony and simplicity are very important. The intervention is focused directly on the clinical aspects using hypnotic procedures that are simple, interesting, and, oftentimes, surprising for the patients. Another characteristic is that the models are quick. The VMWH itself is quick, but the variants presented here are even faster in responding to the demands of these kinds of cases. Likewise, our view is that this rapidity is an element of the surprise itself. On the whole, the quick involvement of patients in the rapid inductions of these models lead also to quick changes in the patients’ psychological state in a positive way (helping to produce calm, motivation, hope, courage, etc.). Another interesting aspect is the easy integration of the logic of these models in a cognitive-behavioral psychological approach. It allows, for one, that the therapist can work these aspects integrated into his/her usual professional work insofar as it is not necessary to resort to concepts that, at least for the patients, could appear as mysterious (such as the idea of trance); on the other hand, it allows the patients to integrate more easily what they are

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learning from a self-regulatory or a self-control point of view. Likewise, this is also one of the essential aspects of the VMWH. Obviously, the cases described here are only illustrative, since these models can be applied to the majority of psychological disorders encountered in the clinical practice. Together with the therapeutic arsenal that psychological therapies represent nowadays, hypnotic techniques and, in particular, those characterizing waking hypnosis according to the Valencia Model, constitute another instrument that can be very useful to help patients. Empirical evidence ing these models is recently increasing, along with the evidence coming from clinical practice (Ludeña and Pires, in press). We consider that the dissemination of these techniques, more modern and psychologically integrated, will constitute in future a relevant research field and an important set of clinical interventions (Agostinho, in press).

REFERENCES Agostinho, M. (In press). (Re)Definindo a Perturbação de Stresse Pós-Traumático: Revisão da literatura sobre Avaliação, Diagnóstico, Tratamento Psicológico e tendências actuais incluindo o uso de hipnose. (Redefining Post-Traumatic Stress Disorder: Review of the literature on assessment, diagnosis, and psychological treatment, and current tendencies, including the use of hypnosis.) Psychologica. Alarcón, A., & Capafons, A. (2006). El modelo de Valencia de hipnosis despierta: ¿técnicas nuevas o técnicas innovadoras? (The Valencia Model of Waking Hypnosis. Are these new or innovative techniques?) Papeles del Psicólogo, 27, 70-78. Barlow, D.H. (2002). Fear, Anxiety, and Theories of Emotion. In D.H. Barlow (Ed.). Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.). New York: Guilford Press. Bentall, R. (2007). Halucinatory experiences, In Cardeña, E., Lynn, S. & Kripper, S. (Eds.). Varieties of anomalous experiencies: Examining the scientific evidence, 4ª edition. Waschington, DC: American Psycological Association. Blankfield, R.P. (1991). Suggestion, relaxation, and hypnosis as adjuncts in the care of surgery patients: A review of the literature. American Journal of Clinical Hypnosis, 33, 1782-1786. Capafons, A. (1998a). Hipnosis clínica: una visión cognitivo-comportamental (Clinical hypnosis: A cognitive-behavioral perspective). Papeles del Psicólogo, 69, 71-88. Capafons, A. (1998b). Rapid self-hypnosis: A suggestion method for self-control. Psicothema, 571-581. Capafons, A. (2001). Hipnosis (Hypnosis). Madrid, Spain: Síntesis. Capafons, A. (2004a). Clinical applications of “waking” hypnosis from a cognitivebehavioural perspective: From efficacy to efficiency. Contemporary Hypnosis, 21, 187201. Capafons, A. (2004b). Waking hypnosis for waking people: Why from Valencia? Contemporary Hypnosis, 21, 136-145. 24

The referred explanations are, above all, those related to popular beliefs and misconceptions about hypnosis.

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Capafons, A., Alarcón, A., & Hemmings, M. (1999). A metaphor for hypnosis. Australian Journal of Clinical and Experimental Hypnosis, 27, 158-172. Chambless, D. & Ollendick, T. (2001). Empirically ed Psychological Interventions: Controversies and Evidence. Annual Review of Psychology. 52, 685–716. Craske, M. & Barlow, D. (2007). Mastery of your anxiety and panic: therapist guide. New York: Oxford University Press. De Jong, A.E., Middelkoop, E., Faber, A.W., & Van Loey, N.E. (2007). Nonpharmacological nursing interventions for procedural pain relief in adults with burns: a systematic literature review. Burns, 33, 811-827. Faymonville, M.E., Meurisse, M., & Fissette, J. (1999). Hypnosedation: A valuable alternative to traditional anaesthetic techniques. Acta Chirurgica Belgica, 99, 141–146. Frenay, M.C., Faymonville, M.E., Devlieger, S., Albert, A., & Vanderkelen, A. (2001). Psychological approaches during dressing changes of burned patients: a prospective randomised study comparing hypnosis against stress reducing strategy. Burns, 27, 793799. Gonsalkorale, W.M. (2006). Gut-directed hypnotherapy: the Manchester approach for treatment of irritable bowel syndrome. International Journal of Clinical and Experimental Hypnosis, 54, 27-50. Gonsalkorale W.M., Houghton, L.A., & Whorwell, P.J. (2002). Hypnotherapy in irritable bowel syndrome: A large-scale audit of a clinical service with examination of factors influencing responsiveness. American Journal of Gastroenterology, 97, 954-61. Gonsalkorale, W.M. & Whorwell, P.J. (2005). Hypnotherapy in the treatment of irritable bowel syndrome. European Journal of Gastroenterology and Hepatology, 17, 15-20. Healy, D. (2004). Psychiatric drugs explained (4rd Ed.). London, UK: Churchill Livingstone. Kirsch, I. (2007, November). The Placebo Effect and the Power of Belief. Oral presentation at I Simpósio Ibérico de Hipnose Experimental e Clínica, Coimbra, Portugal. Lang, E.V., Benotsch, E.G., Fick, L.J., Lutgendorf, S., Berbaum, M.L., Berbaum, K.S., Logan, H., & Spiegel, D. (2000). Adjunctive non-pharmacological analgesia for invasive medical procedures: A randomised trial. Lancet, 355, 1486–1490. Lang, E.V., Berbaum, K.S., Faintuch, S., Hatsiopoulou, O., Halsey, N., Li, X., Berbaum, M.L., Laser, E., & Baum, J. (2006). Adjunctive self-hypnotic relaxation for outpatient medical procedures: A prospective randomized trial with women undergoing large core breast biopsy. Pain, 126, 3–4. Ludeña, M. & Pires, C.L. (In press). A inclusão de hipnose nas terapias psicológicas (Hypnosis in psychological therapies). Psychologica. Montgomery, G.H., David, D., Winkel, G., Silverstein, J., & Bovbjerg, D. (2002). The effectiveness of adjunctive hypnosis with surgical patients: A meta-analysis. Anesthesia and Analgesia, 94, 1639-1645. Palsson, O.S. (2006). Standardized hypnosis treatment for irritable bowel syndrome: the North Carolina protocol. International Journal of Clinical and Experimental Hypnosis, 54, 51-64. Patterson, D.R., Everett, J.J., Burns, G.L., & Marvin, J.A. (1992). Hypnosis for the treatment of burn pain. Journal of Consulting and Clinical Psychology, 60, 713-717. Patterson, D.R. & Ptacek, J.T. (1997). Baseline pain as a of hypnotic analgesia for burn injury treatment. Journal of Consulting and Clinical Psychology, 65, 60-67.

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Patterson, D.R., Questad, K.A., & de Lateur, B.J. (1989). Hypnotherapy as an adjunct to narcotic analgesia for the treatment of pain for burn debridement. American Journal of Clinical Hypnosis, 31, 156-163. Patterson, D.R., Wiechman, S.A., Jensen, M., & Sharar, S.R. (2006). Hypnosis delivered through immersive virtual reality for burn pain: A clinical case series. International Journal of Clinical and Experimental Hypnosis, 54, 130-142. Pinnell, C.M. & Covino, N.A. (2000) Empirical findings on the use of hypnosis in medicine: A critical review. International Journal of Clinical and Experimental Hypnosis, 48, 170194. Pires, C.L. (2004). A depressão e o seu tratamento psicológico: Guia de auto-ajuda (Depression and its psychological treatment: Self-help guide). Leiria: Editorial Diferença. Pires, C.L. (2008, April). El uso de la hipnosis en casos difíciles y/o urgentes (Use of hypnosis in difficult cases and/or emergencies). Invited oral presentation for the School of Psychology, University of Valencia, Spain. Pires, C.L. & Peralta, C. (2008, June). Estudo experimental exploratório do impacto de imagens muito desagradáveis na memória emocional mediada por retenção cognitive. (Experimental exploratory study on the impact of highly stressful images over the emotional memory modulated by cognitive retention.) Oral presentation at XIII Congress of the School of Education of the University of Coimbra: Current tendencies in Education and Psychology. Coimbra, Portugal. Weitzenhoffer, A. (2000). The practice of hypnotism, Vol. 1, New York: John Wiley & Sons. Woody, S.R., Weisz, J. & McLean, C. (2005). Empirically ed Treatments: 10 Years Later. Clinical Psychologist, 58, 5-11.

In: Hypnosis: Theories, Research and Applications Editors: G. D. Koester and P. R. Delisle

ISBN 978-1-60456© 2009 Nova Science Publishers, Inc.

Chapter 4

LANGUAGE, METAPHOR AND NEUROSCIENCE: SCIENTIFIC EXPLANATION AND PRAGMATIC RULES FOR EFFECTIVE COMMUNICATION IN HYPNOSIS Renzo Balugani1,* and Giuseppe Ducci2,† 1 2

Società Italiana di Ipnosi, Via Tagliamento 25, 00198 Rome, Italy Società Italiana di Ipnosi, Via Tagliamento 25, 00198 Rome, Italy

ABSTRACT Neuroscience, in particular thanks to imaging techniques, now makes it possible to express the embodied, sensorimotor nature of many cognitive domains including action perception, simulation and imagery. There is also growing neurophysiological evidence regarding the sensorimotor basis of language and concept formation, as previously theorized by cognitive linguistics. The role of metaphor posited by Lakoff and Johnson in the construction of the thought and abstract thinking is described. Conceptual metaphors and their use in everyday language are discussed, emphasizing both their universality and their variations in specific pathological populations. Arguments about the close link between hypnosis and metaphor are given; the opportunity of a finely graded assessment of the particular use of metaphors in any particular patient is suggested in order to build up a more effective intervention in the practice of Ericksonian psychotherapy.

INTRODUCTION In recent years, the discovery of new classes of neurons has allowed behavioural scientists to build on more solid foundations the origin of some peculiar features of the human brain. In a previous contribution we reviewed the implications of mirror neuron functions in * †

: [email protected]

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the practice of psychotherapy (Balugani, 2008; Balugani and Ducci, 2007). These neurons, rather than simply monitoring action execution, also fire during the observation of the same action performed by someone else. The embodied simulation (Gallese, 2007) is the postulated mechanism of resonance emerging from their functioning: this preconscious, automatic mechanism would also allow many fundamental abilities of the mind, such as the imitative learning, the comprehension of fine actions performed by another and the inference of the purposes of such actions, as well as the agent’s intentions (Iacoboni, Molnar-Szakacs, Gallese, Buccino, Mazziotta and Rizzolatti, 2005). A central role of mirror neurons has also been postulated in the ability to create an inner representation of the other’s mind state (including perceptual, affective and emotional features), the ability commonly addressed as “theory of mind”. Thanks to the encoding of the observed experience in the observer’s physiological parameters, this automatic and preconscious process would predispose the adult human being to empathy (Gallese et al., 2004; Gallese, 2007): in the authors’ hypothesis, through the process of internally simulating the other person’s goals, one comes to infer and represent the other’s mental state as well as anticipate the actions these intentional mind states are likely to cause. This involves mentally inducing the internal subjective states of the other in ourselves by imitation, identification or, lately, through neural resonance evoked by the automatic activation of our brain’s mirror neuron system during the observation of the other person’s behaviour (Gallese et al., 2004; Gallese, 2007). This radical view - a mirror system allowing action understanding by mean of an inner simulation mechanism - has been recently criticised by research from other fields of study (Fonagy, Gergely, & Target, 2007). Firstly, developmental research has found in infants as young as six months old the activation areas lacking in motor properties (such as the superior temporal sulcus [STS]) during the observation of actions for which they still don’t have motor schemes (Kamerawi, Kato, Kanda, Ishiguro and Hiraki, 2005; Luo and Baillargeon, 2005; Wagner and Carey, 2005). Secondarily, by using neuro-imaging techniques with very accurate experimental designs, other researchers have found a wider activation pattern, rather than solely localized to the mirror neuron system: the activation involves brain areas, such as the above-mentioned superior temporal sulcus (STS), the temporo-parietal junction (TPJ) and the anterior fronto-median cortex), which have no mirror properties and which are typically involved in mentalisation and belief attribution tasks (Grezes, Frith and ingham, 2004; Saxe and Kanwisher, 2003; Saxe and Wexler, 2005). Lastly, an fMRI study used the ingenious method of “rubber hand illusion” in order to determine whether the brain attributed the same observed action to the self versus to another agent: the authors concluded that, in contrast to the radical “shared representation” model of self–other understanding, “the motor system…includes representations of other agents as qualitatively different from the self” (Schütz-Bosbach, Mancini, Aglioti and Haggard, 2006). Even considering the criticisms raised against the hypothesis of a unique, sensory-motor mechanism able to manage the attribution of meaning to human experience, we are not prone to abandon the importance given to embodied processes. As we described in a previous work (Balugani, 2008; Balugani and Ducci, 2007), there are other features of brain function that highlight the existence of such a mechanism, mental imagery being one of these. The ability to autonomously activate representations of fine-graded, same-as-real sceneries in the absence of the actual perceptive and motor input and output is a quite different kind of simulation: if compared to the embodied one described by Gallese and colleagues, mental imagery is

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deliberated, conscious and controlled. In spite of that, neurophysiologic registration as well as neuroimaging studies show that it can elicit the activation of a great part of the very same cortical and sub-cortical structures involved in actual perception and movements (Jeannerod, 2001). This is to say that a certain part of understanding and reasoning skills rely on the activation of processes primarily involved in perception and action: that is, an embodied simulation process is implicated. Similar characteristics are traceable in another cardinal cognitive domain: language. In the present work, we would like to analyse concept formation, categorization and reasoning and their correlations with embodied mechanisms. After that, we would like to discuss some important implications in the psychotherapeutic process in general, and in hypnotic therapy in particular. As we pointed out previously (Balugani, 2008; Balugani and Ducci, 2007), we consider hypnosis embodied in nature per se. Our aim is to ascribe the linguistic features of hypnosis (such as the use of metaphors) an effectiveness descending from the sensory-motor computational level they work at.

CONCRETE CONCEPTS: CATEGORIES AND BODY A vast, seminal work of review by Gallese and Lakoff has recently highlighted the role of the cognitive linguistics in the comprehension of concept formation and managing (Gallese and Lakoff, 2005; Gallese, 2003). They begin with a firm critique of the classical theories of language, for which concepts were conceived as abstract, amodal, and arbitrary, made up of symbols and having the properties of productivity and compositionality, among others. In Fodor’s theory (see Fodor, 1975), the purported amodal (or supra-modal) nature of concepts would be implemented in putative brain structures, endowed with characteristics and rules totally independent from those governing the input/output modules. Cognitive linguistics, in contrast, ascribes the inferential structure of concepts to the web-like structure of the brain as well as its organisation in functional clusters. The human brain can generate and use concepts owing to the previous experiences of interaction with the phenomenic world, and to the development of perceptual and motor processes in charge of regulating these interactions. From this position, the theory of the “grandmother cell” is refuted: a neuron codifying for the “grandmother” meaning, the loss of which would cause the loss of its semantic counterpart, doesn’t exist. Contrarily, concepts are embedded in a web of connections, with the functional clusters governing the sensory motor experience (Lakoff and Johnson, 1998) at the most basic level. At least, in this regard, concepts are primarily embodied. Accordingly, language is inherently multimodal in this sense: it uses many modalities linked together, i.e., sight, hearing, touch, motor actions, and so on. Language exploits the pre-existing multimodal character of the sensory-motor system. If this is true, it follows that there is no single “module” for language1. But let us look in detail at the arguments regarding the categorisation and concept formation.

1

In the words of Gallese and Lakoff, “It is important to distinguish multimodality from what has been called ‘supramodality’. The term ‘supramodality’ is generally (though not always) used in the following way: It is assumed that there are distinct modalities characterised separately in different parts of the brain and that these can only be brought together via ‘association areas’ that somehow integrate the information from the distinct modalities” (Gallese, & Lakoff, 2005).

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The classic theory of categorisation assumed that categories formed a hierarchy—bottom to top—and that there was nothing special about those categories in the middle. This view was challenged by the research by Rosch and her co-workers, who found that in the hierarchies continuum, such as “vehicle–car–sports car”, the one in the middle is special: Rosch called it the “basic-level” category (Rosch, 1973; 1978). One can get a mental image of a car but not of a vehicle in general: we have motor programmes for interacting with cars, but not with vehicles in general (a bicycle requires very different motor skills of those involved in the driving of an articulated lorry)2. The basic level is the highest level at which this is true. Moreover, words for basic-level categories tend to be recognisable via gestalt perception, learned earlier, to be shorter (e.g., car vs. vehicle), to be more frequent, to be ed more easily, and so on. Rosch observed that the basic level is the level at which we interact optimally in the world with our bodies. The consequence is that categorisation is embodied—given by our interactions, not just by objective properties of objects in the world, as a long philosophical tradition had assumed. We can here argue the importance in the phylogenesis of such an experience-dependent concept formation: what would happen to a man interacting with a tiger using the same lovely behavioural repertoire used with a cat (cat and tiger being two very different basic level categories, both part of the same, more general “feline”). He just didn’t have the time to transmit his genes to the descendants! This way, it is easier to consider the actual brain organisation as a consequence of our evolutionary history, which is the way in which our brain and the brains of our evolutionary ancestors have been shaped by bodily interactions in the world. It is now simpler to hypothesize a body-based comprehension: according to Gallese and Lakoff, understanding requires simulation, as they argue about the concept of grasp. A growing body of neurophysiological evidence confirms that it is true for concrete concepts, such as physical actions and physical objects. An fMRI study by Tettamanti and colleagues (2005) shows that listening to action-related sentences activates a left fronto-parieto-temporal network that includes the pars opercularis of the inferior frontal gyrus (Broca’s area), those sectors of the premotor cortex where the actions described are motorically coded, as well as the inferior parietal lobule, the intraparietal sulcus, and the posterior middle temporal gyrus. These data provide direct evidence that listening to sentences that describe actions engages the visuomotor circuits, which subserve action execution and observation. Two research studies, one (Hauk, Johnsrude and Pulvermuller, 2004) using fMRI and one (Buccino et al., 2005) using motor-evoked potentials (MEP) and transcranial magnetic stimulation (TMS), pointed out that processing verbally-presented actions (related to mouth, hand and foot) activates the specific motor system involved. This is coherent with the hypothesis that concept understanding involves sensory-motor mechanisms (the embodied simulation postulated by Gallese). In particular, the results obtained with TMS and MEP recordings show that when the response to the behavioural task is given with the hand, reaction times are slower during listening to hand-action-related sentences (Buccino et al., 2005), indicating a facilitation due to a sub-threshold activation.

2

Furthermore, what is true for the basic level category is also applicable for the more particular ones: with few variants, the drive programmes of a sports car and a runabout are the same.

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A more recent study using fMRI technique confirms the key role of the pars opercularis in the embodied simulation engaged during the comprehension of sentences describing goaloriented hand actions (Baumgaertner, Buccino, Lange, McNamara and Binfofski, 2007). Nowadays, any traditional theory that claims that concrete concepts are modality-neutral and disembodied encounters great difficulties. The modality-neutral structure is just not needed, and if it exists, it would be a useless duplication, contravening Occam’s argument. On the contrary, these results taken together give us a confirmation of the thesis of embodied semantics. It holds that conceptual representations accessed during linguistic processing are, in part, equivalent to the sensory-motor representations required for the enactment of the concepts described (Aziz-Zadeh, Wilson, Rizzolatti and Iacoboni, 2006).

ABSTRACT CONCEPTS: METAPHORS AND BODY As everyone knows, human language and thought don’t operate just on concrete concepts: many facts of interest can appear to the consciousness without any impact on our sensory filters. Abstract concepts such as feelings, moral values and spiritual ideals, before being something the human being is prone to live and die for, are daily matters to deal with; furthermore, we make daily efforts to share them with others. The roots of social network (the formal institution as well as the informal bonds) rely on the ability of men and women to think about such concepts, talk about them and regulate their behaviours by virtue of them. How can the human brain build a stable representation of the concepts of freedom, morality and causality, since it has no senses to catch them in a perceptual-like fashion? How can it operate on them the necessary transformations requested by the domain of abstract thinking, in such a flexible way that allows it to cope with a permanently changing reality? By a dodge. Every natural language, in the course of cultural evolution, has selected a rich repertoire of metaphors used as equivalences. In order to catch and manipulate an abstract concept, its principal characteristics are compared to those of another concrete, wellknown concept that will work as a prototype. As it is customary to interact with the latter, so will it be with the former. The cognitive linguistic calls these metaphors “conceptual”: the abstract concept requiring explanation (the explanandum) is mapped on an image-schemata (the explanans), which is a neural representation whose origin lies in the experiential, sensory-motor domain. In such a way, the knowledge accumulated during the sensory-motor interactions with the physical world—real sensations and actions with real objects—are projected by analogy to the explanandum, allowing a fictitious—abstractly and no more concretely—but effective interaction with it. Following Lakoff (1987), metaphor is not just a matter of rhetoric, but a way we think, through a systematic projection from a source domain to a target one. In Lakoff and Johnson’s words: “Metaphor is pervasive in everyday life, not just in language but in thought and action. Our ordinary conceptual system, in of which we both think and act, is fundamentally metaphorical in nature” (Lakoff and Johnson, 1980). Let’s look at an example: How do we reason and talk about the concept of time? Through a limited number of metaphors, “time is moving objects” being one of these. In some common utterance like “Christmas is arriving” or “the summertime has gone away” we can easily recognise a precise mapping of the abstract concept and its features (e.g., time and its

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discrete moments) on the image-schema of the source domain (moving objects). This way, any discrete future moment is intended as a concrete object moving from a perceptual-like horizon toward a fixed observer, the speed of its movement being the same as that of the time flow. Another frequent metaphor is the seemingly different one of “time is a fix field which the observer moves on”. In this case, the observer moves along a field punctuated of discrete objects representing the discrete moments: Think about the expressions “We’ll arrive at the date without finishing the job” or “I’d like to come back to my childhood time”. Time is seen here as a fix background where the observer can move forward (future) or backward (past). Lakoff and Johnson (1998, 1999) give us a full, rich description of the primary imageschemas we use everyday in thought and in language, often in a preconscious, automatic way. Some of the prominent primary schemas are the following: Intimacy is closeness (e.g., We have a close relationship). Difficulties are burdens (e.g., She’s weighed down by responsibilities). Affection is warmth (e.g., They greeted me warmly). Importance is big (e.g., Tomorrow is a big day). More is up (e.g., Prices are high). Similarity is closeness (e.g., Those colors aren’t the same, but they’re close). Organization is physical structure (e.g., How do pieces of the theory fit together?). Help is (e.g., your local charities). Time is motion (e.g., Time flies). States are locations (e.g., I’m close to being in a depression). Change is motion (e.g., My car has gone from bad to worse). Purposes are destinations (e.g., He’ll be successful, but isn’t there yet). Causes are physical forces (e.g., They push the bill through Congress). Knowing is seeing (e.g., I see what you mean). Understanding is grasping (e.g., I’ve never been able to grasp transfinite numbers). A key note: Because they originate in the kinaesthetic possibilities that our body has to interact with the physical world, the most basic of these schemas are limited in number. Anyway, the use we make of them in understanding and talking about abstract concepts such as love, causality and time - is ubiquitous in our everyday lives. When the source domain is suitably basic, such as when it deals with human kinaesthetic experience or knowledge of the properties of physical objects, then we are no longer just talking about metaphor, but rather about a system for the embodiment of human cognition. This step is very close to the concept of embodied simulation (Gallese, 2004). Embodiment is sometimes also referred to as semantic or symbol grounding, by which is meant a process for asg meaning to an arbitrary symbol. The image-schemas consist of basic level kinaesthetic programmes (Johnson, 1987), the kinds of sensorimotor experiences that begin at the earliest age and involve the most central objects and actions in our lives. “Basic-level” is meant in the tradition of Rosch, as that level of interaction with the external environment at which people function most effectively and accurately. This basic level is characterized by gestalt perception (the whole is more than its parts), mental imagery, and motor movements and our proprioceptive perception of those movements. As everyone can note, in natural language we use a number of conceptual metaphors larger than that permitted by the primary mappings listed above. A “compound” or “complex”

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metaphor is a self-consistent metaphorical complex composed of more than one primitive. Complex metaphors are created by blending primary metaphors and thereby fitting together small metaphorical pieces into larger metaphorical wholes. For instance, consider the following three primitive metaphors: “persisting is remaining erect”, “structure is physical structure”, and “interrelated is interwoven”. These three primitives can be combined in different ways to give rise to compound metaphors that have traditionally been seen as conceptual metaphors. But the combination of these primitives allows for metaphorical concepts without gaps. Thus, combining “persisting is remaining erect” with “structure is physical structure” provides for a compound “theories are building” that nicely motivates the metaphorical inferences that theories need and can collapse, etc., without any mappings such as “theories need windows”. Given the complexity which compound metaphors can reach, it seems likely that a part of the cerebral circuitry in charge of the processing of the most abstract concepts rely in areas relatively segregated from their primitive sensory-motor precursors: they could emerge from the differentiation of secondary areas whose roots lay in the primary, sensory-motor ones. On the base of connectionist models (Narayanan, 1999), Lakoff offers the hypothesis that the most abstract concepts, such as metaphoric ones and those belonging to grammar in any natural language, are coded in secondary areas, not directly involved in the action/perception information processing (Gallese and Lakoff, 2005). Thanks to the latest results of neuroscience we already accepted that linguistic processing of concrete concept is possible through the involvement of part of the very same brain structures implicated in perception and action. Let’s now see how cognitive neuroscience help us to understand the way our brain process metaphors. Linguistic analysis as well as psychological studies indicate an embodiment of metaphor. Human brain creates, manages and talks about conceptual metaphors through the very same parameters emerged during the development of sensory-motor skills. The way people comprehend and explain to other the abstract properties of a concept is strictly correlated to (and precisely mirrors) the embodied comprehension they have in the sensory-motor areas about the physical event used as image-schema. Gibbs and co-workers give us a convicting description of the physical momentum / representational momentum matching, on which are built a number of daily used metaphors, as in the expressions: “I was bowled over by that idea”; “I got carried away by what I was doing”; “You had better stop the argument now before it picks up too much momentum and we can’t stop it”, and so on (Gibbs, Costa Limab and Francozo, 2004). Seitz (2005) accurately reviewed some major strand of scientific evidence (evolutionary, developmental, neuropsychological and cognitive): he suggests that humans recognise and create basic metaphoric associations across disparate domains of experience partly because they are pre-wired to make these linkages. These basic metaphoric equivalences operates largely outside of conscious awareness, and include perceptual-perceptual, movementmovement, cross-modal (synesthetic), and perceptual-affective relations demonstrated to be uniquely mapped onto brain networks (Seitz, 2005). In accordance with Gallese and Lakoff (2005) and Gibbs and colleagues (2004), moreover, he posits that linkages belonging to a complex, secondary metaphor is a self-consistent amalgam of more than one primitive, partially losing the involvement of sensory-motor areas. Indirect evidence of the link between metaphorical generation and manipulation skills and the embodied simulation system is given by the neuropsychology of patients suffering

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from autism: they can not make any use of metaphorical images, being their language strictly literal. The evidence relies in their recently recognised deficit of such fronto-parietal circuitry having mirror properties (Oberman, Hubbard, McCleery, Altschuler, Ramachandran, & Pineda, 2005).

ERICKSONIAN PSYCHOTHERAPY: THE EMBODIMENT AT WORK IN HYPNOSIS Some authors found enlightening implications of the mirror system in elucidating hypnotic induction, rapport and many of the classical phenomena of suggestion: action/perception matching mechanism and empathy would play a key role in creating a rapport zone mediating between consciousness and the brain plasticity, at the root of the implicit acquisition of new, adaptive skills (Rossi and Rossi, 2006). Moreover, from our point of view, hypnotic psychotherapy is a very advantageous one by virtue of its embodied nature, as well as its possibility to directly modify the basic computational level of the patient, the sensory-motor one (Balugani, 2008; Balugani and Ducci, 2007). Is it possible to extend the same advantages to the linguistic domain of the patienttherapist relationship? We often refer to the right hemisphere (RH) as the (largely unconscious) container where the personality draws the necessary skills to explore new experiences and meanings in order to get a creative change in the personality. Neuropsychophysiologic theory of hypnosis postulates that during this altered state of consciousness the aware, logic, controlling role of left hemisphere (LH) is reduced, in favour of RH holistic, analogical processes (Gruzelier, 1998; 2006). Neurophysiologic researches about the skill of use and comprehension of metaphors permit us to ascribe to metaphorical language a key role in the course of a therapy based on hypnosis. The comprehension of new, unconventional metaphors is processed in the Wernicke homologue area, in the posterior superior temporal sulcus (STS), in the inferior frontal gyrus (IFG) of the RH; in contrast, the processing of semantically correlated concepts inside salient and conventional verbal expressions relies in the LH functioning. Moreover, the results previous researches indicating that during word recognition, the RH activates a broader range of related meanings than the LH, including novel, nonsalient meanings (Mashal, Faust and Hendler, 2005; Faust and Mashal, 2007). These data suggest a close, functional link between metaphors and hypnosis. In every linguistic transaction we can make two kind of use of metaphors: the first and more obvious is the rhetoric one, in which a metaphorical image is explicitly sorted out by the speaker in order to pict out a nonliteral meaning. For example, a patient feeling having not enough resources to fly up in his/her existential journey could say “I have loosen my wings”, we could refer to an impulsive patient by saying “He doesn’t let the grass grow under his feet”, and so on. The second use we can make of metaphors is the one described above: the metaphor gives us a mapping by which we can operate on abstract concepts as they were concrete entities, having recourse to the experiential repertoire about our previous interactions with the

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physical world. In the utterance “anger urged me to react that way”, a patient could select a particular case of the conceptual metaphor “emotions are forces”, by which showing the impotence and ivity he/she felt. While the first kind of metaphors is conscious and arbitrary (often a matter of eloquence), the second one is pre-reflexive, unaware and largely universal for the speakers a specific idiom. Even universal, some variant can be more frequent in specific conditions, such as in mutually segregated cultural contexts.3 Psychotherapeutic relationship is not an exception, conceptual metaphors being real organizational principles allowing the building and sharing of shared narrations between therapist and patient (Casonato, 1994). Rapport is the name given to the intense cognitive, emotional, and behavioural attunement existing between patient and hypnotist: thanks to this attunement, the both become more and more mutually responsive. Among the most frequent techniques used to empower rapport, as described in any Ericksonian psychotherapy handbook, ‘pacing’ implies the acceptance and utilization by the therapist of the spontaneous characteristics of a patient’s language (Bandler and Grinder, 1975; 1976; 1977). The same use of predicates (nouns describing action or events, verbs and their modifiers) allows the therapist to tailor a finer graded intervention following the patient’s existential point of view (Gordon and MeyersAnderson, 1984). Pacing facilitates rapport in the fact that the therapist is in the patient’s (linguistic) shoes. In agreement with the primary embodied nature of language (as discussed above), we record the conceptual metaphors used by the patient for the same reason we observe and collect all the elements needed to build our ‘hypnotic diagnosis’ (Lankton, Gilligan and Zeig, 1991; Zeig, 1984; Zeig, 1982; Gilligan, 1982). If the patient says “I can’t catch the meaning, I can’t see any association between my problem and your solution” we first categorise him/her as visually/kinaesthetically inclined; then we can think about the specific use of the conceptual metaphors “grasping is understanding”, “seeing is knowing”: not just as a technical imperative, but in order to encode his/her very specific phenomenological horizon in his/her own sensory-motor parameters. Using the same metaphors will allow us to better attune with him/her. A second argument in favour of including the metaphoric expressions in our hypnotic diagnosis, is the known existence of variants in their use among different psychopathological conditions. In fact, research studies show evidence that conceptual metaphors like “time is moving objects” declines in very different ways if the patient suffers from hypomania or from depression (Casonato, 2004). When the excited patient says “Events run over me” or “The present rapidly runs away”, he/she uses the metaphor in a particular way: the observer is oriented toward the future, and time runs away in a fast, elusive way. On the other hand, depressed patients who say “When I realize that time goes on, it’s already gone”, “I live in an eternal present”, or “I can’t go on” mean that they are turned to the past, time has stopped its flow, and their movement toward future events is impossible. If we are able to catch these detailed “minimal cues” we will better attune, empathize and understand our patients’ phenomenological experience. Once a good rapport is built and every useful detail is recorded in our hypnotic diagnosis, we have to meet another principle of Ericksonian therapy: utilization. It means that we have 3

See a French work discussing the conceptual metaphor “body as container”, and its variants in fields as clinical psychopathology, Freudian and Ericksonian psychotherapy, and poetry (Santarpia, Blanchet, Cavallo and Raynaud, 2006)

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to start our intervention from the frame given by that patient, from the lenses he/she uses to look at the reality, in order to allow him/her to build new narratives, new associations, new evocations (Casilli and Ducci, 2002). It is absolutely necessary that utilization include the metaphorical repertoire of the patient, both the rhetoric and the conceptual ones. Utilization will mean using that repertoire in a strategic way, contemporarily making him/her feel accepted and authentically understood: at the same time, we then tell a story, a metaphor or an anecdote using his/her very same idiom but also promoting the therapeutic change. Casula argues that “metaphor allows therapists to send messages resulting from a combination of scientific reasoning and therapeutic intuition” (2005). In fact, the largest part of Ericksonian tools plays its role in that middle ground with on one side the literal language and on the other side the bodily action: that middle ground is metaphor. First of all, the embodied parameters of patient and therapist (Balugani and Ducci, 2007; Balugani, 2008) remind us that “Ericksonian hypnosis is characterised by the use of indirect suggestions grounded on linguistic metaphors of the body […] indicating conceptual metaphors of the body” (Santarpia, Blanchet, Venturini, Cavall and Raynaud, 2006). Taking into a hypnotic diagnosis that includes all of the communicative aspects (beyond the cognitive and the behavioural ones usually considered), we will have more chances to tailor an effective treatment: we will build interventions at a level of information processing largely unperceived by the patient, grounding its root in his/her sensory-motor code. Following Haley, analogical and metaphoric techniques are particularly effective with resistant subjects, based on the fact that they cannot resist a suggestion that they are unaware of receiving (Haley, 1973): in order to raise the effectiveness of our intervention, then, we will enrich a metaphor of such sensory-motor features belonging to the real action involved as if it were real. If a ruminating patient complains about the difficulty of making a decision and says “I can’t come to the point”, our purpose will be to virtually imagine walking toward a well-described point in a field of grass, getting over any obstacle. Our language will be as concrete, clear and easy as possible: such is the language used by the right hemisphere (Gruzelier, 1998). For the same reason, our images would be chosen from the basic level categories in order to allow the patient more rapid access as well as a more salient representation. The following is the case of Franco, a young patient who has discovered he is HIV positive only five months ago. The illness is being managed well and he doesn’t need to take medication. But his partner is trying to leave him, denying that the reason is the risk of infection. Franco is very depressed, and the actual situation reactivates old feelings of being inadequate and a loser. During the therapy, the hypnotist suggests, as a personal experience, to give attention to some little and usual experiences, like lying on the grass looking to the sky with some rapidly moving clouds and the leaves of a cottonwood moved by a gentle wind, or the sweet sound of little waves on a beach and the smell of the sea in a night lighted by the moon, or the smell of the wet ground after a summer rain, and how all these usual experiences come together to bring about the comfortable feeling of being alive. The repetition of these suggestions, at the same time, evokes the strength and the stability during the time (in the past, in the present and, above all, in the future) of the cottonwood, of the beach, and of the ground, giving the opportunity for the subject to identify himself in these features. It wouldn’t be the same if we just suggested Franco to feel comfortable and confident with his own body and sensations: the richness of the description proposed is

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intended to bring about the desired representation in a way that is mostly outside of the field of consciousness and intentionality. In this regard, there are numerous works indicating lists of therapeutic metaphors (Barker, 1987; Casula, 2004). Often, nevertheless, the easiest way to find a good one is to accurately listen to our patients. This is the case of Gianluca, whose feelings of emptiness and demotivation to meet the challenges of everyday life are described, in his words, as “being barren, dried, with not energy enough inside of me”. The therapist, identifying these details as a part of the metaphor “interior life as soil”, directs the patient to “watch the field and the aqueduct in charge of carrying the water; then, patiently go back along the aqueduct and find out the exact point where an amalgam of withered leaves and dead branches obstructs the water flow. Once found, accurately clean up the conduit with your own hands (and ideo-motor actions by the hand can be suggested to enrich the proprioception) and see the water starting to flow again in the right way. Back to the soil, look at the slow but inexorable impregnation as the ground becomes soaked and fertile. Then it can be just a matter of time to discover the moment in which the first little plant emerges into the sun and starts growing in a progressive, confident way”. Another delicious example of the Ericksonian approach is offered by Roffman, as a part of an insightful article explaning how metaphor works in psychotherapy. He depicts the case of a nine-year-old child suffering from encopresis (Roffman, 2008). When the excited boy narrates in detail his uncle operating with excavators and bulldozers, the therapist follows him, transforming that casual description in an effective therapeutic metaphor, asking him what these machines do with the dirt they pick up. Boy: Therapist: B.: T.: B.: T.: B.: T.: B.:

They dump it into the dumptrucks. Then what happens? The dumptrucks take it to the place, the dump or whatever, and drop it off. They dump it? Yeah, what else should they do with it? Quite right. But how do they know where to dump it and when? They just know. They’re not stupid. You mean they know where to dump it. They don’t just dump it wherever or whenever? They do it in the right place at the right time? Of course, what do you think?

We would like to conclude with a consideration evoked by the nature of Batesonian’s syllogism in grass (grass dies, men die, men are grass), as discussed in Roffman (2008). In metaphors as well as in psychotherapy, we operate in a domain where associations are right if and when they work: consistence or logical are often question of no importance. This is why a humble attitude is cardinal among therapists: they offer, don’t force. The utilisation on one side and the use of evocative suggestions on the other allow our patients to mobilize their own internal resources and to be the protagonist of their changes.

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Gordon D., Meyers-Anderson M. (1981). Phoenix – Therapeutic Patterns of Milton H. Erickson. Cupertino, CA: Meta Publications. Grezes J., Frith C.D., & ingham R.E. (2004). Inferring false beliefs from the actions of oneself and others: An fMRI study. NeuroImage, 21: 744–750. Gruzelier, J.H. (2006). Frontal functions, connectivity and neural efficiency underpinning hypnosis and hypnotic susceptibility. Contemporary Hypnosis, 23: 15-32. Gruzelier, J.H. (1998). A working model of neurophysiology of hypnosis: a review of the evidence. Contemporary Hypnosis, 15: 3-21. Haley J. (1973). Uncommon Therapy: The Psychiatric Techniques of Milton H. Erickson, M.D. New York: Basic. Hauk O., Johnsrude I., Pulvermuller F. (2004). Somatotopic representation of action words in human motor premotor cortex. Neuron, 41: 301-307. Jeannerod M. (2001). Neural simulation of action: a unifying mechanism for motor cognition. NeuroImage, 14: 103-109. Johnson M. (1987). The body in the mind: The bodily basis of meaning, imagination and reason. Chicago: University of Chicago Press. Kamerawi K., Kato M., Kanda T., Ishiguro H., & Hiraki K. (2005). Six-and-a-half-month-old children positively attribute goals to human action and to humanoid-robot motion. Cognitive Development, 20: 303–320. Lankton, S. R., Gilligan, S. G., & Zeig, J. K. (Eds.) (1991). Ericksonian monographs, number 8: Views on Ericksonian brief therapy, process and action. New York: Brunner/Mazel. Lakoff G. (1987).Women, fire, and dangerous things: What categories reveal about the mind. Chicago: University of Chicago Press. Lakoff G., & Johnson M. (1980). Metaphors we live by. Chicago, IL: University of Chicago Press. Luo Y., & Baillargeon R. (2005). Can a self-propelled box have a goal? Psychological reasoning in 5-month old infants. Psychological Science, 16: 601–608. Mashal N., Faust M., & Hendler T. (2005). The role of right hemisphere in processing nonsalient metaphorical meanings: application of principal component analysis to fMRI data. Neuropsychologia, 43: 2084-2100. Narayanan, S. (1999). Moving right along: a computational model of metaphoric reasoning about events. Proceedings of the National Conference on Artificial Intelligence, AAAI-99, from: http://www.icsi.berkeley.edu/~snarayanan/met.ps. Oberman L.M., Hubbard E.M., McCleery J.P., Altschuler E.L., Ramachandran V.S., & Pineda J.A. (2005). EEG evidence for mirror neuron dysfunction in autism spectrum disorder. Cognitive Brain Research, 24: 180-198. Pulvermueller, F. (2002). The neuroscience of language. Cambridge, UK: Cambridge University Press. Rizzolatti G., & Arbib M.A. (1998). Language within our grasp. Trends in Neurosciences, 21: 188-194. Rizzolatti G., Craighero L. (2004). The mirror neuron system. Annual Review of NeuroScience, 27: 169–192. Roffman A. (2008). Men are grass: Bateson, Erickson, utilization and metaphor. American Journal of Clinical Hypnosis, 50(3): 247-257. Rosch E. (1978). Principles of categorization. In: E. Rosch, B.B. Lloyd (Eds.), Cognition and categorization, 27-48. Hillsdale, NJ: Laurence Erlbaum Associates Inc.

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Rosch E. (1973). On the internal structure of perceptual and semantic categories. In: T.E. Moore (Ed.), Cognitive development and the acquisition of language. New York: Academic Press. Rossi E.L., & Rossi K.L. (2006). The neuroscience of observing consciousness & mirror neurons in therapeutic hypnosis. American Journal of Clinical Hypnosis, 48(4): 263-278. Santarpia A., Blanchet A., Cavallo M., & Raynaud S. (2006). Categorization of conceptual metaphors of the body. Annales Medico Psychologiques, 164: 476-485. Saxe R., & Kanwisher N. (2003). People thinking about thinking people. The role of the temporo-parietal junction in ‘theory of mind’. NeuroImage, 19: 1835–1842. Saxe R., & Wexler A. (2005). Making sense of another mind: The role of the right temporoparietal junction. Neuropsychologia, 43: 1391–1399. Schütz-Bosbach S., Mancini B., Aglioti S.M., and Haggard P. (2006). Self and other in the human motor system. Current Biology, 16: 1830–1834. Sitz, J.A. (2005). The neural, evolutionary, developmental, and bodily basis of metaphor. New Ideas in Psychology, 23: 74-95. Tettamanti M., Buccino G., Saccuman M.C., Gallese V., Danna M., Scifo P., Fazio F., Rizzolatti G., Cappa S.F., and Perani D. (2005). Listening to Action-related Sentences Activates Fronto-parietal Motor Circuits. Journal of Cognitive Neuroscience, 17(2): 273– 281. Wagner L., & Carey S. (2005). 12-month-old infants represent probable ending of motion events. Infancy, 7: 73–83. Zeig J.K. (1984) La diagnosi ipnotica. In: E.Del Castello, M.La Manna, C. Loriedo (Eds.), Ipnosi. Seminari di Jeffrey Zeig. Napoli: L’Antologia. Zeig J.K. (1982). Ericksonian Approaches to Hypnosis and Psychotherapy. New York: Brunner/Mazel.

In: Hypnosis: Theories, Research and Applications Editors: G. D. Koester and P. R. Delisle

ISBN 978-1-60456© 2009 Nova Science Publishers, Inc.

Chapter 5

THE RELATIONAL (INTERSUBJECTIVE) APPROACH TO HYPNOSIS Udi Bonshtein Child & Family Guidance Unit, Western Galilee Hospital, Nahariya, Israel and The psychotherapy study program, Zefat, Israel

ABSTRACT The main aim of the present paper is to discuss how intersubjectivity can be applied to hypnosis. Intersubjectivity is the sharing of subjective states by two or more individuals. This is a major perspective in psychoanalysis. Adopting an intersubjective perspective in psychoanalysis means, above all, abandons the myth of the isolated mind. First, the paper reviews the relationship between hypnosis and psychoanalysis. Three splits are described: a) psychoanalysis splits off from brain science; b) psychoanalysis splits off from hypnosis and c) splits occur within psychoanalysis. I discuss how these splits can be healed, so that hypnosis can be considered a two-person rather than a one person process. Next, the paper presents the main assumptions of the intersubjective approach and how it is used in hypnosis, through case stories. The assumptions are based on theoretical and empirical from neuroscience.

It could be interesting to look backward…, Where things had begun…

HISTORICAL VIEW Psychoanalysis and Hypnosis Psychoanalysis was born out of hypnosis. Sigmund Freud, the Viennese physician who founded Psychoanalysis, arrived on a fellowship at Jean Martin Charcot's hospital,

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Salpetrie`re, in late 1885. Freud had previously acquired an interest in hypnosis as a medical student, and engaged in some clinical applications. He had originally intended to study neuropathology in Paris, but because of his personal bonding with Charcot (the mentor he called his ‘‘great teacher’’; Freud, 1914/1957, p. 13), his special interest soon shifted to the psychopathology of hysteria. His meeting with Josef Breuer, a prominent Viennese physician who was 14 years Freud’s senior, led to their co-authored essay, "Studies in hysteria" (Breuer and Freud, 1895), which is generally considered as the formation point of psychoanalysis, although it was actually a book about hypnosis. Let us take now a careful look at that time. The development of psychoanalysis since Breuer and Freud's pioneering work reveals three main split offs. Two of them are externals - the split between psychoanalysis and brain science and the split between psychoanalysis and hypnosis. The third was an internal split (actually, many splits) within psychoanalysis; dividing it into many divisions and schools. We can begin our journey by reviewing each of those splits.

Psychoanalysis Splits off from Brain Science I believe that Freud consciously chose to move away from neurology and found a new discipline. He abandoned brain research in favor of the subjective point of view establishing psychoanalysis. Due to the lack of effective research methods at that time, he chose a different method of learning about human subjectivity. Freud saw this split as temporary, until science would be able to investigate the mind. Another reason for Freud's choice to found a new discipline was the sociopolitical atmosphere in Vienna. As a Jew who spoke about sexuality as the main inner motivator of children and adults – he was isolated from the mainstream of psychiatry. He worked on his own at first, gradually winning over colleagues (Gay, 1988).

Psychoanalysis Splits off from Hypnosis The official explanation Freud gave for abandon hypnosis was that he wanted to work with defense mechanisms and encourage the emergence of transference. He preferred to do this by using free associations. One can ask if lying on a couch and offering free associations is not a variation of hypnosis. One can ask the same thing about transference, since transference emerges very powerfully during hypnosis. Freud was not sure about his qualifications as a hypnotist, which was another reason for abandoning this method in favor of psychoanalysis. This is surprising, since Freud seems to have been a creative therapist who was very successful in hypnotizing his hysteria patients. As I see it, Freud never abandoned hypnosis, but only its authoritative style, replacing it with a more permissive form of hypnosis, which he called psychoanalysis. Despite his announced abandonment of hypnosis as a clinical technique in 1896, Freud maintained an interest it throughout his career (Gravitz, 1991; Gravitz & Gerton, 1984). Hypnosis was both mysterious and personally unsettling for him. In fact, hypnosis and psychoanalysis have more similarities then differences. Psychoanalysis is saturated with suggestive processes, including free-association, therapeutic setting (lying on the couch, therapist's tone of voice, routine of time) and suggestivity of

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psychoanalytic theories (Bonshtein, 2003). Moreover, the theory and practice of hypnosis developed in parallel with psychoanalysis, using psychoanalytic conceptualizations such as transference, objection, defense mechanisms and the like, which are important to every hypnotists' training and daily work. This split, like the previous one, served the developmental and consolidation of psychoanalysis as an independent discipline. Freud owed a great debt to the hypnotherapists of his time, mainly Charcot and Janet. Pierre Janet was a pioneering French psychiatrist and philosopher in the field of dissociation and traumatic memory. He was one of the first people to draw a connection between events of the subject's early life and his or her present-day trauma, and he coined the words ‘dissociation’ and ‘subconscious’. He studied under Charcot and managed Charcot's Psychological Laboratory while Freud was there. Despite the similarities of some of his ideas to those of Freud (some consider him the true founder of psychoanalysis, as he preceded Sigmund Freud in some ways), Freud hardly mentions him (Breuer is the one who gave credit for some of Janet's contributions in "Studies in Hysteria"). It is unlikely that Freud did not know about Janet's contribution, but this is not the place to discuss this issue. In essence, according to Freud, the hypnotic subject played a ive dependent role. In 1890 he compared hypnosis to the relationship between parent and child (Freud, 1890/1953). It was, he said, these attributes that facilitated the subject's acceptance of the therapist's suggestions. He further maintained that hypnosis is a manifestation of libidinal regression in which the patient undergoes temporal regression to an infantile dependent relationship (Freud, 1905/1953). For Freud (1921/1922), then, the effects of hypnosis derived from the overarching construct that they were basically transferential phenomenon. ‘‘Transference . . . can give you the key to an understanding of hypnotic suggestion’’ (Freud, 1910/ 1957, p. 51).

Splits within Psychoanalysis The many splits within psychoanalysis occurred because different practitioners defined the borders of the field differently. These splits served a necessary developmental function. Even in the Bible, in Genesis creation occurs trough separation (or splits): God divided the light from the darkness, the upper waters from the lowers waters, the day from the night, men from women and the like. I will focus on one of the main lines of development in psychoanalysis: the shift from an intrapersonal ("one-person") psychology to interpersonal ("two-person") psychology (Berman, 1997). During the past 15 years, there has been a vast change in psychoanalysis. It takes the form of a broad movement away from classical psychoanalytic theorizing grounded in Freud's drive theory, toward models of mind and development grounded in object relations. In clinical practice, there has been a corresponding movement away from the classical principles of neutrality, abstinence and anonymity toward an interactive vision of the analytic situation that places the analytic relationship, with its powerful, reciprocal affective currents, in the foreground. While the goal of psychoanalysis in Freud's day was rational understanding and control (secondary processes) over fantasy-driven, conflictual impulses (primary processes), the goal of psychoanalysis in our day is most often described as the establishment of a richer, more

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authentic sense of identity (Mitchell, 1993). What the patient needs, according to Mitchell, is not clarification or insight so much as a sustained experience of being seen, personally engaged, and, basically, valued and cared about. What today's analysis provides is the opportunity to freely discover and playfully explore one's own subjectivity, one's own imagination.

And now, in your pace… Easily, safety and softly… You can come to here and now… Healing the Splits Psychoanalysis and brain science are meeting again those days. We can see the subjective and objective points of view together in the inter-disciplinary field called neuropsychoanalysis. Brain researchers uses psychoanalytic concepts to investigate human subjectivity, and psychotherapists uses empirical findings to advance theoretical and clinical work. The split between hypnosis and psychoanalysis has not healed yet, but it is beginning to do so. Over the years, psychoanalysts have become more antagonistic towards hypnosis, but hypnotists have become more favorably disposed to psychoanalysis. In fact, the essential developmental pathways of psychoanalysis are reflected in the theory hypnosis and its clinical implications. The professional hypnosis literature contains many interpersonal and intersubjective considerations, of "hard" psychoanalytic concepts are used (as in the HypnoAnalytic approach). Present psychoanalytic objectives seems to fit in with modern approaches to hypnosis. The healing of the rift in psychoanalysis was achieved by adopting a meta-theoretical point of view, which combines interpersonal and intrapersonal psychologies. In fact, this is happening right now. Theory is no longer a truth on its own, but more like an organizer of human experience, allowing us to make more flexible use of it. Integrating these paths into hypnosis will rely on new evidence about the neurological basis of hypnosis and seeing hypnosis as a mutual occurring process between two subjects: the hypnotized person and the hypnotist. More detailed information on this topic can be found in Balugani (2008) and Jamieson (2007). Here I focus on one of the new and most promising discovery of recent years: mirror neurons. A mirror neuron is a neuron which "mirrors" the behavior of another animal or human, by firing both when the animal (or human) itself acts and when it observes the same action performed by another. These neurons were first discovered by Giacomo Rizzolatti and his research team in Italy in the early 1990s, while investigating primate motor cortex (see Rizzolatti et al., 1996; Rizzolati & Craighero, 2004). In the human brain, mirror neurons have been found in the premotor cortex and the inferior parietal cortex. Some scientists believe that mirror neurons might be very important in imitation and language acquisition. It is generally accepted that no single neuron can be responsible for any phenomenon. Rather, a whole network of neurons (neuronal assembly) is activated when an action is observed. These neurons may be important for understanding the

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actions of other people, and contribute to our Theory of Mind (ToM) skills. The term "theory of mind" refers to the ability to represent mental states of others or one self, including their beliefs, feelings, intentions or knowledge, and for their behavior. Some preliminary evidence connects ToM and hypnosis demonstrating that the same brain regions and modules are involved in both (Bonshtein, in preparation). Rossi and Rossi (2006) proposed that mirror neurons may function as an interface mediating among the observing consciousness, the gene expression/protein synthesis cycle, and brain plasticity in therapeutic hypnosis and psychosomatic medicine. Linking absorption, empathic, introspective, and reflective functions to hypnosis leads us closer to the relational perspective on hypnosis. Hypnosis, in this view, is a process involving two active partners, like the theoretic assumption in the psychoanalytic relational field. We begin with a short review of the relational approach and then examine its implications for hypnosis.

THE RELATIONAL APPROACH Adopting a relational (intersubjective) perspective in psychoanalysis means giving up what Stolorow and Atwood (1992) call “the myth of the isolated mind”. Intersubjectivity is the sharing of subjective states by two or more individuals. It is very close to my view of hypnosis as a shared subjective state and to Winnicott's potential space, which I consider in more detail in below. Relational psychoanalysis began in the 1980s as an attempt to integrate the detailed exploration of interpersonal interactions and the notion of ideas about the psychological importance of internalized relationships with other people. Relationalists argue that personality emerges out of the matrix of early formative relationships with parents and other figures. While in traditional psychoanalytic thought (such as Freudian theory) human beings are motivated by sexual and aggressive drives, relationalists argue that the primary motivation of the psyche is to be in relationships with others. As a consequence early relationships, usually with primary caregivers, shape one's expectations about the way in which one's needs are met.

Figure 1. A dwarf saxophone player or a female face? Therefore, motivation is determined by the systemic interaction of a person with his or her relational world. Individuals attempt to re-create these early learned relationships in ongoing relationships that may have little or nothing in common with those early

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relationships. This re-creation of relational patterns serves to satisfy the individual's needs in a way that conforms with what was learned as an infant. This re-creation is called enactment. For relational analysts, psychotherapy works best when the therapist focuses on establishing a healing relationship with the patient, in addition to focusing on facilitating insight. They believe that this helps the patient break out of the repetitive patterns of relating to others that maintain psychopathology. In the treatment room there are two subjects, the patient and the therapist, each of whom bring his unconscious to the situation, with mutual (but not symmetric) relations. The therapist's subjectivity and specific encounter with the patient's subjectivity is crucial in that view. In the post-modern age there is no place for one and only one truth (e.g., the unconscious drive that is seen by the therapist as is hiding from the patient's consciousness). Truth is relational and context-dependent, as demonstrated in figure 1: One can see a dwarf saxophone player or a female face at any time. Both are possible. The primary significance of those theories is that the therapist's subjectivity is important as a diagnostic or theraputic tool. Some basic concepts that can be used in relational hypnosis are projective identification, containment, attunement, enactment, transitional space and selfdisclosure. Projective Identification Melanie Klein (1946), who first introduced the term, considered it as an intrapsychic phenomenon, while her followers (especially Bion) considered it as an interpersonal phenomenon. Projective identification is defined as a phenomenon in which a person projects a part of himself into another object (not onto it, as occurs in projection) in such a way that his behavior towards those onto whom he projects part of himself evokes the thoughts, feelings or behaviors projected. Consequently, projective identification brings about a change in the psychic reality of the receiver of the projection. The recipient is influenced by the projection and begins to behave as though he or she in fact actually has the projected thoughts or beliefs. This is a process that generally happens outside the awareness of both persons involved. What is projected is most often an intolerable, painful, or dangerous idea or belief about the self that the projecting person cannot accept. Projective identification is believed to be a very early or primitive psychological process and is understood to be one of the more primitive defense mechanisms. Yet it is also thought to be the basis from which more mature psychological processes like empathy and intuition are formed, and have a communicative quality. Containment In psychoanalytic theory, the term "container" is associated with the development of the concept of projective identification. When a part of the self is projected into an object, the object then becomes a container that holds what has been projected into it. In the mother-infant relationship, the infant projects into the mother parts of the self that are intolerable and suffused with anxiety. The mother constitutes a container for the projected parts of the infant. She contains what is projected. The affective and mental condition of a mother capable of taking in what has been projected and remaining with it is called 'reverie'. In the therapeutic situation the therapist serves as a container. With the development of the intersubjective approach in psychoanalysis (Berman, 1997), the can no longer be

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considered empty. The reactions of the therapist to the patient in many cases are not merely the result of the patient’s projective identification, but rather a mixture of projected parts of the patient with denied and split-off parts of the therapist. Attunement Affect Attunement is Stern's (1985) conceptualization of a sharing or alignment of internal states in the domain of intersubjective relatedness. For Stern, the subjective sense of self is something that arises about of a kind of mutual, wordless experience that he describes as attunement based on his observational work. Attunement differs from empathy in that attunement occurs largely outside of awareness and almost automatically, while aspects of empathy require conscious cognitive mediation. Both empathy and attunement share emotional resonance, but attunement takes emotional resonance and recasts it into another form of expression, sometimes even another sensory modality. It is a distinct form of affective transaction in its own right. Enactment Enactment has become a central concept in psychoanalytic understanding of the therapy process. Relational psychotherapists argue that the primary motivation of the psyche is to be in relationships with others. Early relationships, usually with primary caregivers, shape one's expectations about the way in which one's needs are met. Individuals attempt to recreate these early learned relationships in ongoing relationships that may have little or nothing to do with those early relationships. Enactment is the recreation of relational patterns serves to satisfy the individual's needs in a way that conforms to what they learned as an infant. Transitional Space The concept of ransitional space is a condensation of Winnicott's ideas of potential space and transitional phenomena (Winnicott, 1971). Potential space is the overlapping space between two individuals, neither subject nor object but some of both. In this space we find transitional objects and transitional phenomena. Hypnosis, for many reasons (as Winnicott himself thought about psychoanalysis), is a transitional phenomenon which occurs in transitional space. Self Disclosure Self-disclosure is the act of revealing more about ourselves to others: what we feel, think, imagine, dream, and the like. In psychotherapy the patient is the one who reveals his or her inner life. Freud, for example, insists that the psychoanalyst must be neutral and anonymous, but actually discloses himself to his patients to a great extent. In relational psychoanalysis, however, self-disclosure serves as a useful therapeutic tool, although still a very controversial one.

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THE RELATIONAL APPROACH TO HYPNOSIS Empirically, the intersubjective school is inspired by research on infants non-verbal communication, which in turn inspired research on the hypnotize-hypnotist dyad. Such research has been conducted by Eva Banyai and her collegous at their laboratory in Budapest. Traditional approaches focused either on the hypnotist or on the subject's hypnotic states. Historically, the hypnosis literature has concentrated either on the skill of the hypnotist (such as Mesmer or, more recently, Erickson) or on the hypnotizability of the subject (such as Charcot and the authors of the modern hypnotic susceptibility scales). Since researches focused on either the hypnotist or the subject, they attributed hypnotic effects to only one of them ("one- person hypnosis"). Banyai (1998) described this split as reflected in the fact that clinicians using hypnosis as a therapeutic tool tend to follow the mesmeric tradition, emphasizing the hypnotists' skilled and sometimes even virtuoso technical manoeuvres (Barber, 1980; Haley, 1963; Van Dyck, 1982; etc.). Experimental investigation, in contrast, has focused almost exclusively on changes occurring within the hypnotized person. Owing to the important recognition that hypnotic responsiveness – as measured by standardized scales is a stable personality trait, compelling data have been accumulated on the differences in people's susceptibility to hypnosis (Hilgard, 1986). From the relational point of view there is no need to limit ourselves by focusing attention on either the hypnotist or the subject (i.e, on only one of the individuals participating in hypnosis). Rather, we can consider hypnosis an interpersonal process ("two-person hypnosis", involving a paradigms shift equivalent to the main shift in psychoanalysis, mentioned earlier). From this point of view the two participants affect each other consciously and unconsciously, and sensitive hypnotists can gain an advantage by paying attention to their inner mental life during hypnosis. Livnay calls this the hypnotist trance (Livnay, 1995, 1996). Sandor Ferenczi (1909), who considers hypnosis in an interactional framework, hypothesized a distinction between 'maternal' and 'paternal' hypnosis. Banyai (1998) further identified two different working styles of hypnotists: one a physical-organic style characterized by proximity, warmth and being very personal with the subject, which she likened to Ferenczi's (1909) description of a maternal hypnotist, as opposed to a analyticalcognitive style, characterized by distance and reason, which she likened to Ferenczi's description of a paternal hypnotist. Case vignette 1: Ruth is a 30-year old hi-tech worker, married, with one child. She came to therapy due to a severe case of trichotillomania (compulsive hair pulling). As in the case of anxiety disorders (some consider anxiety management difficulties as the basis of trichotillomania), in the first stage of therapy I am more authoritative, didactic and serve as an information supplier, as is Ferenczi's description of paternal hypnosis. In this initial stage Ruth needed to feel that she had someone to lean on. When I became more permissive and acceptive she regressed back to her starting point, giving up all her accomplishments. Since she had already had some ineffective treatments in past, I listened very carefully to what she "said", understanding that my paternal stance had been a response to her archaic needs at that phase. I used that stage to gave her "homework", an exercises, according to the integrative hypnotic-CBT model (Bonshtein et al., 2005), which led to complete cessation of her habit. At the next stage I became more flexible, accepting and "maternal", and started to deal with more affective issues.

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In addition to the paternal and maternal styles, Banyai (2002) described two more styles of hypnosis: sibling style and lover-like style. In the sibling style hypnosis is based mainly on equality. The hypnotist almost wishes to participate in the realization of the desires and ideas of the hypnotized subject, and accepts this person's independent initiatives. The hypnotist places emphasis on togetherness. The atmosphere is an intimate one. In the lover-like style hypnosis is built mainly on erotic attraction. The feelings and emotions aroused by the hypnotized person are most important for the hypnotist. It is almost indifferent to the hypnotist if the hypnotized subject’s desires and ideas are realized or not, or if the hypnotized person has independent initiatives. The hypnotist emphasizes his/her own feelings. Banyai and her colleagues (1985, 1998) noticed that similar physiological changes seemed to appear in the hypnotist and subject and concluded that the development of hypnotic process is influenced by the personal characteristics of both the hypnotist and the subject, their relationship and their actual physiological, behavioral and subjective experiential changes during the mutual interaction between them. These findings accord with the mirror neuron hypothesis described above. The interaction synchrony appears either in overt movements (e.g. t movements of the limbs when the subject enacts motor suggestions) and postures (e.g., posture mirroring), or in covert processes (e.g. breathing and electromyographic activity). These phenomena are usually involuntary and outside of awareness. When hypnosis is sufficiently deep, a swaying motion of the hypnotist's body has been observed in synchrony with the subject's breathing. This phenomenon has been called "t rhythmic movements". Such mutual regulatory functions can be found in parent-infant interactions (e.g., Stern, 1985; Brazelton et al., 1974). There is evidence that in both animals and humans social emotions and interactions are accompanied by marked neurophysiological and hormonal changes (Reite & Field, 1985). Field states, "Attachment might . . . be viewed as a relationship that develops between two or more organisms as their behavioral and physiological systems become attuned to each other. Each partner provides meaningful stimulation for the other and has a modulating influence on the other's arousal level" (1985, p. 415). Different styles of hypnosis may help meet the subject's various needs, and, in the case of a patient, they may correct different regulatory deficiencies. Banyai and colleagues' findings indicate that these styles are not as stable as they seemed first. Hypnotists who usually use a maternal style may sometimes show signs that do not fit into this style. The same is true for paternal hypnotists (Gosi-Greguss et al., 1993). Case vignette 2: Some years ago, during an experiential intersubjective workshop under my guidance, one of the participants began to share a personal experience. I became attuned, in a trance state, absorbing unbearable feelings from her and the rest of the group (which also experienced trance a state). My emotional experience was very powerful; all the periphery of my perception field became blurry. I felt pain and sadness. My mind generated a variety of images, which I tried to integrate into communicative a domain. My experience crystallized into a song – lyrics and music. Since music has great affective and emotional qualities and can be used as a projective and expressive vehicle (or, in Winnicott's term, "potential space"), I played the song to the group at the end of the sharing, calling it a gift from me to the speaker.

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Udi Bonshtein The effect was amazing. The group was silent. People cried, indicating a powerful emotional experience and leading us to more effective work.

UTILIZING COUNTERTRAN(CE)SFERENCE While transference is the redirection of a client's feelings from a significant person to a therapist, countertransference is the redirection of a therapist's feelings toward a client, or more generally, a therapist's emotional entanglement with a client. I have coined the word "countertranceference" to describe the hypnotist's trance and subjective experience during hypnosis. Many clinicians emphasize the importance of the therapist allowing himself or herself to become more aware of his/her countertransference as well as other feelings, yet caution about the complexities and dangers of sharing them with the patient. One of the foremost figures in the research and delineation of therapist trance and the interactional aspects of the hypnotic situation has been Diamond (1980, 1983, 1984, 1987, 1988). He mentioned the hypnotherapist's need to gather up the courage to experience and tolerate the patient's unconscious affects and images within himself, including pain and uncertainty, while remaining strong and stable enough to and direct the healing journey. Case vignette 3: Jean is a 16 year-old girl whom I met while she was hospitalized. She was an attractive girl, with a complex clinical picture, including dissociative conditions and suspected psychotic states. I will describe one aspect of her treatment, with the aim of demonstrating a productive use of countertransference, although some people might consider it controversial. During a session in which she minimized her difficulties, I stated that it could be very frustrating to act as if everything is all right when you want someone to notice you are lonely, someone who can really see you. After some silence she replied, "Suppose you were a student who is really care about his grades, and suppose your grandfather is dying, Ok? What would you do if you got a zero on an exam?" I thought about it, allowing myself to become absorbed in my memories of having an ill sibling, keeping my own needs away in fronts of a "real" pain of somebody else. I said: "I am not proud of it, but I am assuming that I was not telling about my sadness to anybody". "Why you are saying you are not proud of it?" she said, and (probably due to projective identification) I felt a sudden sadness, with tears in my eyes. This authentic response of mine opened the door for Jean to progress considerably in therapy.

There is a great debate about self-disclosure and sharing the therapist's countertransference with the patient. Several writers have proposed the careful use of disclosure and sharing of countertransferential feelings with the patient (e.g. Epstein & Feiner, 1979; Gorkin, 1987; Wollstein, 1988). Here too, Ferenczi preceded his time with an open approach including disclosing the therapist's feelings and attitudes to the patient, going as far as free-associating to one's unconscious motives after making a countertransferentially based error in therapy (Gorkin, 1987). Gill (1988) emphasized the need to carefully elicit the patient's reaction discerning what it is and how he or she experiences the therapist's disclosure.

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When is Sharing and Self-disclosure Appropriate? While many clinicians gain great advantages from sharing and self-disclosure, questions have been raised about when they are appropriate. The main issues include patient's level of personality organization and who needs the self-disclosure (patient or therapist). Although disclosure of countertransference has occasionally been used with very disturbed patients (Racker, 1953; Searles, 1979), Diamond (1983) has cautioned against using it with patients with a poor level of organization. On the other hand, patients with poor personality organization can have serious difficulties accepting the therapist's subjectivity, and many find the therapist's self-disclosure insulting or even a destructive attack on their own subjectivity. On the other hand, some patients can be eager for role reversal, thriving whenever there is real, intimate sharing. Livnay (1995) found that patients with severe personality disorders are those who are most likely to put him into a trance state. These states very often bring him into with a more mothering style, in Banyai's (1992). The second issue is whether self-disclosure serves the patient or the therapist. Whenever a therapist considers sharing or disclosing, this must be done with the patient's needs in mind. Many authors have cautioned about therapists' improper use of sharing or disclosure for their own narcissistic, aggressive or dependency needs. This caution must be weighed against overintellectualization and the loss of the benefits of spontaneity. Self-disclosure must be based on a high level of maturity and self-awareness on the therapist's part, including constantly checking the basis of one's motivation for speaking and acting. Diamond (1983) stressed the need for the therapist to have reached a high level of integration. Being in supervision or therapy is recommended for enhancing awareness of the therapist's own motives and unconscious wishes and needs. Case vignette 4: Sara, a 40-year-old woman, suffered from severe social anxiety. She functioned at a very low level, trying hard to go out and work in her profession as a kindergarten art teacher. She had been previously diagnosed as having a low-borderline personality organization level. During the initial moments of the session she "got lost", having difficulty in focusing: "It takes so much time…I don’t know from where to begin…I am talking about just one activity I need to, and I have 30 more to make ready!" she terrified stated. "How can I work for just 45 minutes?" she keeps asking herself, helplessly. At the first stage I gave her a preliminary suggestion about focus and limit time investment at work, using a story and self-discloser material. Pacing and leading her through my tone of voice, slowly lowered her stress level. Her muscles seemed to be a little more relaxed and she smiled at me. In those moments I felt like a mother calming a distressed baby, by being attuned to her inner rhythms (which in turn gave me the opportunity to free-associate the story I told her). After containing her fears, I tried to serve as an organizer for her, by asking a title to the first encounter she was making. I asked for more titles. If she connects those titles between them, can she see her activity develop until a clear picture? "I feel as if you opened a curtain for me" she says gratefully. At this point I induced relaxation indirectly, playfully, encouraging her to use her imagination. After some productive work, I began to feel her twisting and fighting and myself as despairing, losing, and giving up – my hurt rate increased and I felt a great amount of anxiety. It was clear to me that my feelings were actually her feelings, so I "digest" them for her, distancing them by telling her about another person I knew who felt very distressed when

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Udi Bonshtein giving his lectures, and the way he used the imagery of the audience in their underwear, using an amusing illusion to dispel his fear. After some more organizing work, I gave her positive and reinforcing suggestions, reframing the work she already done as very successful, as well as the intended work (future projection).

SUMMARY Hypnosis can be seen as a two person phenomenon - two people who create each other continually and mutually. The view of hypnosis as a context-dependent, interpersonal phenomenon is based on well-known theoretical models, such as social role-playing or sociocognitive theory (Kirch, 1991; Spanos, 1991; Wagstaff, 1991). Today's evidence from neuroscience and experimental hypnosis the hypothesis of unconscious attunement and rhythmic resonance between hypnotists and their patients. Skilled hypnotherapists can use their mental states (such as images, mentalrepresentations, dreams, feelings and thoughts) as therapeutic and/or diagnostic tools. One of the interesting directions for further investigation is the curative aspects of attunement, empathy and precise affective recognition of the patient. The trance state, as a Winnicottian potential space, is a very powerful therapeutic tool, reminiscent of reminds the initial affective atmosphere between mother and child (as Freud himself claimed, see Freud, 1890). I can take a risk hypothesize that the infant's brain is equipped with mirror-neurons and great hypnotic susceptibility, which make it possible for him/her to respond easily to mother's rocking, voice, presence or touch, with unlimited amounts of trust.

REFERENCES Balugani, R. (2008). Embodied simulation and imagery at work in hypnosis: Ericksonian psychotherapy and its uniqueness. Contemporary-Hypnosis, 25(1): 29-38. Bányai, É.I. (1988). The interactive nature of hypnosis: Research evidence for a socialpsychobiological model. Contemporary Hypnosis, 15(1): 52-64. Bányai, É.I. (2002). Communication in different styles of hypnosis. In: C.A.L. Hoogduin, C.P.D.R. Schaap, H.A.A. de Berk, (eds) Issues on Hypnosis (p. 1–19). Nijmegen Cure & Care Publishers. Bányai, É.I., Meszaros, I., & Csokay, L. (1985). Interaction between hypnotist and subject: A social psychophysiological approach. (Preliminary report). In D. Waxman, P.C. Misra, M. Gibson, M.A. Basker (eds.): Modern Trends in Hypnosis (p. 97-108). New York, London: Plenum Press. Barber, J. (1980). Hypnosis and the unhypnotizable. American Journal of Clinical Hypnosis, 23: 4-9. Berman, E. (1997). Relational psychoanalysis: A historical background. American Journal of Psychotherapy, 51(2):185-204. Bion, W. (1962). Learning from Experience. New York: Jason Aronson.

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Bonshtein, U. (2003). The possibility chooses of knowing and the unconscious suggestion. Sihot-Dialogue, 18(1): 79-80. (Hebrew) Bonshtein, U., Shaar, I. & Golan, G. (2005). Who wants to control the habit? A multidimensional hypnotic model of smoking cessation. Contemporary Hypnosis, 22(4): 193200. Brazelton, T.B., Koslowski, B., & Main, M. (1974). The origins of reciprocity: The early mother-infant interaction. In M. Lewis & L. Rosenblum (eds.), The Effect of the Infant on its Caregiver. New York: Wiley. Breuer, J., & Freud, S. (1895/1937). Studies in hysteria. New York: Nervous and Mental Diseases Publishing. Diamond, M.J. (1984). It takes two to tango: Some thoughts on the neglected importance of the hypnotist in an interactive hypnotherapeutic relationship. American Journal of Clinical Hypnosis, 27: 13. Diamond, M.J. (1987). The interactional basis of hypnotic experience: On the relational dimensions of hypnosis. International Journal of Clinical and Experimental Hypnosis, 35: 95-115. Diamond, M.J. (1980). The client-as-hypnotist: Furthering hypnotherapeutic change. International Journal of Clinical and Experimental Hypnosis, 28: 197-207. Diamond, M.J. (1983). An hypnotic induction technique to induce therapist trance: The client-as-therapist. In J. Hariman's (Ed.), The Therapeutic Efficacy of the Major Psychotherapeutic Techniques (pp. 69-73). Springfield, IL: Charles C. Thomas. Diamond, M.J. (1988). Accessing archaic involvement: Toward unraveling the mystery of Erickson's hypnosis. International Journal of Clinical and Experimental Hypnosis, 36: 141-156. Epstein, L., & Feiner, A. H. (1988). The therapist's contribution to treatment. In B. Wolstein (Ed.), Essential papers on countertransference (pp. 282-303). New York, New York University Press. Ferenczi, S. (1909/1965). Comments on hypnosis. In: R.E. Shor, and M.T. Orne (eds), The Nature of Hypnosis: Selected Basic Readings (p. 177–178). New York: Holt, Rinehart and Winston. Freud, S. (1890/1953). Psychical (or mental) treatment. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 7, pp. 282– 302). London: Hogarth Press. Freud, S. (1905/1953). Three essays on the theory of sexuality. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 7, pp. 130–243). London: Hogarth Press. Freud, S. (1910/1957). Five lectures on psychoanalysis. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 11, pp. 9– 55). London: Hogarth Press. Freud, S. (1914/1957). On the history of the psychoanalytic movement. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 14, pp. 1–66). London: Hogarth Press. Freud, S. (1921/1922). Group psychology and the analysis of the ego. London: International Psycho-analytical Press. Gay, P. (1988). Freud: A Life for Our Time. New York: W. W. Norton & Company.

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Gill, M. M. (1988). The interpersonal paradigm and the degree of the therapist's involvement. In B. Wolstein (Ed.), Essential papers on countertransference (pp.304-338). New York, New York University Press. Gorkin, M. (1987). The uses of Countertransference. New York Jason Aronson. Gosi-Greguss, A.C., Banyai, E.I., Varga, K. (1993). Hypnotist styles as reflected in standardized hypnosis experiments. Paper presented at the 6th European Congress of Hypnosis, Vienna, Austria, 14-20 August 1993. Gravitz, M.A. (1991). Early theories of hypnosis: A clinical perspective. In S.J. Lynn & J.W. Rhue (Eds.), Theories of hypnosis: Current models and perspectives (pp. 19–42). New York: Guilford. Gravitz, M.A., & Gerton, M.I. (1984). Hypnosis in the historical development of psychoanalytic psychotherapy. In W.C. Wester & A.H. Smith (Eds.), Clinical hypnosis: A multidisciplinary approach (pp. 7–17). Philadelphia: Lippincott. Haley, J. (1963). How hypnotist and subject maneuver each other. In J. Haley (ed.): Strategies of Psychotherapy. New York: Grune and Stratton. Hilgard, E.R. (1986). Divided Consciousness: Multiple Controls in Human Thought and Action. New York: John Wiley and Sons. Jamieson, G. A. (Ed). (2007). Hypnosis and conscious states: The cognitive neuroscience perspective. New York, NY, US: Oxford University Press. Kirch, I. (1991). The social learning theory of hypnosis. In S. Lynn & J. Rhue (Eds.), Theories of hypnosis: Current models and perspectives (pp. 439-465). New York: Guilford. Klein, M. (1946). Notes on Some Schizoid Mechanisms. In Envy and Gratitude, and Other Works: 1946-1963. New York: Dell, 1977. Livnay, S. (1995). The Therapist Trance as a Generator of Associative Techniques in Therapy. In E. Bolcs, et al (Eds): Hypnosis Connecting Disciplines: Proceedings of the 6th European Congress of Hypnosis (pp. 152-155). Vienna: MedizinishPharmazeutlische Verlag. Livnay, S. (1996). When Erickson Meets Freud: The Therapist Trance and Countertransference as Resources for the Hypnotherapist. In B. Peter, et al (Eds.): Munich Lectures on Hypnosis and Psychotherapy (pp. 79-86). Munich: M.E.G. Stiftung. Mitchell, S. A. (2003). Hope and Dread in Psychoanalysis. New York: Basic Books. Racker, H. (1953). The countertransference neurosis. International Journal of Psychoanalysis, 34: 313-324. Reite M., & Field T. (eds.) (1985). The Psychobiology of Attachment and Separation. Orlando: Academic Press. Rizzolatti G., & Craighero, L. (2004). The mirror-neuron system. Annual Review of Neuroscience, 27:169-192. Rizzolatti, G., et al. (1996). Premotor cortex and the recognition of motor actions. Cognitive Brain Research, 3: 131-141. Rossi, E. L., & Rossi, K., L. (2006). The Neuroscience of Observing Consciousness & Mirror Neurons in Therapeutic Hypnosis. American Journal of Clinical Hypnosis, 48(4): 263278 Searles, H.F. (1979). Countertransference and related subjects. New York, International Universities press.

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Spanos, N. (1991). A sociocognitive approach to hypnosis. In S. Lynn & J. Rhue (Eds.), Theories of hypnosis: Current models and perspectives (pp. 324-361). New York: Guilford. Stern, D. N. (1985). The Interpersonal World of the Infant: A View from Psychoanalysis and Developmental Psychology. New York: Basic Books. Stolorow, R. D., & Atwood, G. E. (1992). Contexts of Being: The Intersubjective Foundations of Psychological Life. Hillsdale, NJ: The Analytic Press. Van Dyck, R. (1982). How to use Ericksonian approaches when you are not Milton H. Erickson. In J.K. Zeig (ed.), Ericksonian approaches to hypnosis and psychotherapy (p. 37-47). New York: Brunner Mazel. Wagstaff, G. (1991). Compliance, belief, and semantics in hypnosis: A nonstate, sociocognitive perspective. In S. Lynn & J. Rhue (Eds.), Theories of hypnosis: Current models and perspectives (pp. 362-369). New York: Guilford. Winnicott, D.W. (1971). Playing and Reality. London: Routledge. Wollstein, B.(1998). The pluralism of perspectives on countertransference. In B. Wolstein (Ed.), Essential papers on countertransference (pp. 339-354). New York, New York University Press.

In: Hypnosis: Theories, Research and Applications Editors: G. D. Koester and P. R. Delisle

ISBN 978-1-60456© 2009 Nova Science Publishers, Inc.

Chapter 6

HYPNOSIS, ABSORPTION AND THE NEUROBIOLOGY OF SELF-REGULATION Graham A. Jamieson University of New England, Australia In memory of my mother, Agnes Fraser Jamieson

ABSTRACT In hypnosis, suggested behaviours are characteristically accompanied by a diminished sense of effort and personal agency while suggested experiences, which strongly contradict objective reality, appear to be accepted without conflict. Dissociated control theory is a cognitive neuroscience of hypnosis that emphasises functional disconnections (dissociations) within the predominantly anterior brain networks, which implement cognitive control. Profound alterations in the ongoing experience of the self outside the hypnotic context (labelled by Tellegen as absorption) are a key predictor of a person’s ability to experience suggested distortions of reality. Tellegen (1981) defined the trait of absorption as arising from the interplay of two mutually inhibitory mental sets, the instrumental and the experiential mental sets. The capacity to set aside an instrumental set finds a clear counterpart in current neuroimaging and EEG studies of dissociated control in hypnosis. The consequent ability to adopt an experiential set has a clear counterpart in the recent discovery of a characteristic brain network during quiescent mental activity. Neuroimaging studies of suggestions used to induce hypnotic analgesia show strongly overlapping activations with the loci of this network which generates core aspects of internally focused self experience. Tellegen pointed to distinctive roles for the instrumental and experiential mental sets in psychophysiological self-regulation in order to explain the importance of the trait absorption in mediating the mixed pattern of results in earlier bio studies. This finds further in recent studies on the roles of these mutually inhibitory neural networks in differing patterns of regulation of peripheral physiology. These findings provide an important foundation from which to

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INTRODUCTION One of the most characteristic features of experience during hypnosis is the loss of awareness of the immediate environment and a strong focus on the communication (words) of the hypnotist and/or the experiences they suggest. This feature of hypnosis was labeled by Shor (1959) as loss of Generalized Reality Orientation (GRO) and identified as a primary dimension of hypnotic experience in his influential 3-factor theory of hypnosis. Similar observations had been made by other observers going back to the nineteenth century. Although Shor interpreted this feature of hypnosis as an expression of a loss of and concern with everyday reality (indeed with the very psychological framework required to focus on that reality) others (for example Milton Eriksen) interpreted this as the expression of the development of an intense attentional focus leading to the exclusion of otherwise distracting or irrelevant stimuli from conscious awareness. Meanwhile, following the advances in the measurement of individual differences in hypnotic ability which led to the Stanford and Harvard scales psychological researchers sought to identify the personality and ability characteristics which predisposed an individual to high (or low) hypnotizability. Despite an intensive effort from the late 1950s to the early 1970s with virtually every psychological measure available these efforts were largely fruitless (a situation which remains essentially unchanged to this day). The one notable exception to these null findings was the biographical interview work, focusing on the construct of imaginative involvement, conducted by Josephine Hilgard and her associates (Hilgard, 1974). At the same time Tellegen and Atkinson (1974) reported the development of a ‘paper and pencil’ personality scale which correlated significantly with hypnotic susceptibility. The items on this scale (developed from a series of similar early attempts) asked about the occurrence of a range of unusual or trancelike alterations in experience in daily life. Abstracting from the content of several items (and likely influenced by contemporary ideas in the hypnosis literature) Tellegen and Atkinson (1974) fatefully defined the trait measured by their scale as “absorption”. They described absorption as a state of, “total attention involving a full commitment of available perceptual, motoric, imaginative and ideational resources to a unified representation of the attentional object” (Tellegen & Atkinson, 1974, p. 274).

HYPNOSIS AND THE SUPERVISORY ATTENTIONAL SYSTEM Influenced by this lead, a number of neurophysiological researchers began to search for evidence of the involvement of the brains systems of attentional control in the various phenomena of hypnosis. The Supervisory Attentional System (SAS) model of Norman and Shallice (1986) elegantly summarises key elements of the thinking which guided these efforts. According to this model the selection of routine responses is the outcome of an automatic and unconscious competition amongst fixed action schemata (neural networks

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mapping specific inputs to specific outputs), for access to various response systems. This process, called contention scheduling is implemented predominantly in posterior cortical regions. However flexible, non-routine responses require current goals to guide the selection of task appropriate but often weak schema mappings against the competition of much stronger automatic mappings. This is implemented by the SAS which monitors the activation of task relevant schema and modulates their activation to bias the contention scheduling process in favour of the current task set. Task set representations are stored in anterior cortical regions, thus the source of top-down attentional control is activity in elements of a far frontal attentional network. These researchers therefore searched for evidence of activity within the anterior cortical networks believed to implement top-down attentional control, which would distinguish high from low hypnotically susceptible individuals particularly during hypnosis, or when responding to specific suggestions such as hypnotic analgesia. In work with the electroencephalogram (EEG) interest focused on the theta frequency band (4-7 Hz) due to the role of theta in tasks demanding mental concentration or effort (e.g., Ishii et al., 1999). Indeed over several decades a number of studies have reported evidence of a positive relationship between hypnotizability and or the hypnosis condition and increases in EEG theta power (e.g., Ray, 1997). In addition increased prefrontal cortical activation reported in PET studies of hypnotic analgesia suggestion, a phenomenon which some have considered to be a paradigm case for the role of focused attentional control in the production of hypnotic responses, have been interpreted as further for this view (e.g., Crawford et al., 2000). Woody and Bowers (1994) employed the SAS model in a very different way to understand another key aspect of hypnotic experience that of effortlessness or non volition in the generation of hypnotic responses, otherwise known as ‘the classic suggestion effect’ (Weitzenhoffer, 1953). On the Norman and Shallice a volitional response is a paradigm case of attentional control implemented by the SAS. Therefore, Woody and Bowers argued, if the experience of non volition in hypnosis is veridical it must be accompanied by a reduction, if not loss, of SAS control and a shift toward contention scheduling. At the level of cortical dynamics this corresponds to a weakening of the influence of prefrontal task set representations on more posterior cortical processing. Evidence for this model of hypnotic responding requires a decrease (not an increase) in the efficiency of selective attentional control in hypnotized high susceptibles and a corresponding decrease in functional connectivity between cortical regions responsible for implementing top-down attentional control. According to Woody and Bowers hypnosis is characterized (at least in part) by dissociation between conscious volitional control implemented by the SAS and unconscious automatic control implemented by contention scheduling. A shift from the former to the latter should be evidenced by a decrement (rather than an improvement) in performance on those very tasks which are paradigm cases of executive attentional control. The Stroop task (Stroop, 1935) is without doubt the classic selective attention task in experimental psychology and has been employed in more publications than any other paradigm in the field (MacLeod & MacDonald, 2000). In the Stroop task participants view color-name stimuli presented in an actual color, which may be congruent (e.g., the color-name “red” presented in red) or incongruent (e.g., the color-name “red” printed in green) with the color-name. Participants must respond to either the color-word or the actual color. The Stroop effect is evidenced by slower reaction times (and typically a greater error rate) when responding to incongruent than

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congruent stimuli. An important feature of the Stroop effect is that it is greater when responding to the color of the stimulus then when responding to the color-name. Current models of the Stroop effect emphasize co activation of competing responses driven by different features of the stimulus (the color-name and the color of the word, respectively). When these are congruent there is little response conflict. Likewise when the task is to respond to the color-name over learned and highly automatic word reading schema easily out compete schema activated by the color of the word in the contention scheduling process for access to motor response systems. However, when the task requires a response to the color of the word on incongruent stimuli additional top-down (SAS) control is required to bias response competition in favor of the weaker color response pathways (Botvinick, Cohen and Carter, 2004). A similar logic is employed in many Stroop type tasks subsequently developed in the experimental literature. Studies of hypnosis (without further suggestion) and hypnotic susceptibility using the Stroop task have shown that high susceptibles in the hypnosis condition show a significant decline in multiple indices of the efficiency of Stoop performance on high conflict (i.e., incongruent, color naming) trials. Sheehan, Donovan and MacLeod (1988) found an increase in Stroop color naming reaction times (although high susceptibles were better able to make use of further specific suggestions to reduce Stroop conflict). Kaiser et al. (1997) found higher errors in hypnotized participants with higher hypnotic susceptibility using a Stroop type task. Nordby, Hugdhal, Jasiukaitis and Spiegel (1999) also reported greater Stroop errors in hypnotized high susceptibles. Jamieson and Sheehan (2004) employed a classic version of the Stroop task in a very large sample, rigorously assessed for hypnotic susceptibility and found a significant interaction between hypnotic susceptibility and hypnosis condition in Stroop error rates (with errors rising specifically for high susceptibles in the hypnosis condition). Collectively this evidence points very strongly towards a decrease in the efficiency of top-down SAS control of Stroop induced response conflict in the hypnotized condition for high susceptible individuals. However Sheehan et al. (1988) found that, distinct from the effect of hypnosis per se, with specific suggestions hypnotized high susceptibles were better able to control Stroop induced response conflict than were lows. Recently Raz, Shapiro, Fan and Posner (2002) found that high susceptibles were able to eliminate the Stroop effect by means of specific hypnotic suggestions. Subsequently Raz, Kirsch, Pollard and Nitkin-Kaner (2006) also found that high susceptibles were able to use these specific suggestions to modulate Stroop interference but could do so both with and without undergoing a hypnotic induction procedure. Thus it appears that, in response to suggestion, there are effects in hypnosis which suggest enhanced control of conflicting or distracting competition for attentional resources. Earlier a series of neuropsychological studies conducted by Gruzelier and his colleagues indicated decreased performance on tasks affected by prefrontal lesions (such as letter fluency see Gruzelier and Warren, 1993) during the hypnosis condition, particularly by those higher in hypnotic susceptibility. Gruzelier (e.g., 1998) has consistently interpreted these findings as evidence for a decrease in frontal cortical activation brought about by hypnosis. Crawford and Gruzelier (1992) proposed a synthesis of their respective focused attention and frontal inhibition s of hypnosis in which the hypnotic induction first engages and directs the focus of frontally mediated attentional processes followed by a gradual inhibition of frontal activation and finally a shift to a more posterior mediated flow of mental activity. In this case focused attention becomes a prerequisite for subsequent frontal inhibition. Egner and

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Raz (2007) have also attempted a synthesis of their recent divergent Stroop and hypnosis findings by pointing to the distinction between the effects of hypnotic induction and specific hypnotic suggestions in their respective results. On their hypnosis is characterized by a disengagement of anterior mediated SAS control processes which in turn allows the development of sustained iterative processing loops in the absence of (more usual) disruption by frontal attentional control networks. In many respects this proposal by Egner and Raz may be considered as almost the inverse of that put forward by Crawford and Gruzelier 15 years earlier in that a sustained attentional focus, when it appears in hypnosis, is not underpinned by the activity of frontal attentional control networks but is enabled precisely as a consequence of the disengagement of these networks (see also Jamieson and Sheehan, 2004).

CONFLICT-MONITORING AND COGNITIVE CONTROL Despite its historical importance both to the development of cognitive neuroscience and modern hypnosis research today the SAS model fails to provide a detailed of cognitive control. For example the SAS performs both monitoring and control functions and the deficits caused by frontal lesions indicate the key role of anterior cortical networks in their implementation but beyond this the model has little to say as to where or how they are implemented in the anterior cortex or how these functions are related. While there are several leading s of cognitive control and/or the executive functions of the anterior cortex arguably the most clearly specified and empirically studied is the conflict-monitoring model developed by Cohen and associates (Cohen, Aston-Jones and Gilzenrat, 2004; Miller and Cohen, 2000). According to this model activity in task set or goal representations located in the lateral prefrontal cortex (PFC) biases competition between competing responses much as described in the SAS model. However activation in these task set representations is dynamically modulated by about the level of conflict between competing response tendencies. Specifically response conflict is monitored by the dorsal Anterior Cingulate Cortex (dACC), a deep midline anterior cortical structure. As conflict between competing response tendencies rises (indicating a greater likelihood of an incorrect response or error) so does activation in the dACC which in turn triggers an increase in control related activation in lateral PFC task set representations which then brings about a flexible adjustment of topdown attentional control of competing response processes (Botvinick, Cohen and Carter, 2004). Using this model MacDonald, Cohen, Stenger and Carter (2000) were readily able to distinguish regions of brain activation related to cognitive control from those related to conflict-monitoring using the Stroop paradigm in an fMRI scanner. They presented congruent or incongruent Stroop stimuli preceded by an instruction to name the color-word or to name the color in which the word appeared. Two different contrasts were performed. The first contrast was performed for the post instruction interval and was between the color naming instruction and the color-word naming instruction. This represented a contrast between high and low control demand conditions respectively and revealed significant activation in the left dorsolateral prefrontal cortex. The second contrast was made in the post stimulus period and was between incongruent (high response conflict) and congruent (low response conflict)

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stimulus events respectively. In this case conflict related activation occurred exclusively in the dACC. The conflict-monitoring model functionally and anatomically fractionates monitoring and control functions and clearly specifies the relationship expected between them. In addition to strong experimental from neuroimaging studies this model has largely been generated and tested around the Stroop task and similar response conflict paradigms making it an obvious choice for the further investigation of changes in cognitive control and the functional role of anterior cortical networks in hypnosis. Egner, Jamieson and Gruzelier (2005) adopted a strategy similar to that used by MacDonald et al. (2000) in order to identify the specific mechanism of the dissociation in attentional control believed to occur in hypnosis. They conducted an event related fMRI study of high and low hypnotically susceptible participants in both hypnotized and non hypnotized conditions performing a Stroop paradigm requiring color naming or color-word naming responses to congruent and incongruent Stroop stimuli. Similarly to MacDonald et al. (2000) high versus low conflict contrasts revealed significant activations in dACC and a color naming versus color-word naming contrast identified significant activation in left inferior frontal gyrus (IFG). However when activity levels were examined in conflict related regions of interest a classic interaction effect was found between hypnotic susceptibility and hypnotic condition. Conflict related activation in dACC rose in high susceptibles in hypnosis but actually dropped in low susceptibles demonstrating reduced efficiency in the control of response conflict in hypnotized highs. There was no effect present for activation in the control related region of interest for high or low susceptibles in either hypnotized or non-hypnotized conditions. This is contrary to the expected relationship between conflict and control related activations where increased conflict detection should lead to an up regulation in control related activation. The absence of a similar pattern in the control related activation strongly suggests a breakdown of functional connectivity between conflict monitoring and control processes and their respective anterior cortical regions rather than between anterior and posterior cortex as suggested in the initial formulation of dissociated control theory. In this study Egner et al. (2005) sought to directly assess functional connectivity between cortical regions through EEG coherence. We recorded EEG from the same participants performing the identical task under hypnotized and non-hypnotized conditions on a separate occasion away from the MRI scanner. We found that coherence in the gamma band (closely associated with the binding of discrete cortical processes into an integrated neural ensemble see De Pascalis, 2007) declined between recording sites reflecting activity in dACC and left IFG (electrodes Fz and F3 respectively) for high susceptibles in the hypnotized condition. No such breakdown in cortical functional connectivity was observed for low susceptibles or for the homologous right hemisphere connection between Fz and F4. A similar breakdown in EEG gamma band coherence was found by Trippe, Weiss and Miltner (2004) between motor cortex and frontal cortical sites in hypnotized high susceptibles experiencing hypnotic analgesia. By comparison high and low susceptibles generating analgesia by attentional distraction (the mechanism proposed for hypnotic analgesia by proponents of the focused attention of hypnotic phenomena) did not show this effect. Further EEG evidence (again from the high frequency gamma band) in of a functional disconnection between and within anterior cortical regions in hypnosis has been reported by Croft, Williams, Haenschel and Gruzelier (2002) who found that the correlation between ACC

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sourced gamma and subjective pain experience broke down for higher susceptible individuals in the hypnosis condition. An often overlooked finding from EEG research on cognitive control in hypnosis comes from the work of Kaiser et al. (1997) who examined averaged event related potentials (ERP’s) to error responses on their Stroop type task (see discussion of their behavioral results above). These error related ERP’s play an important role in the brains detection of and response to errors in task performance and have been the subject of intense investigation and theorizing from this perspective (Falkenstein, 2004). Kaiser et al. (1997) found that a later positive component the error related positivity or Pe, which appears to be closely related to the emotional experience of making an error (the so called “oh crap” response) and to the magnitude of subsequent behavioral corrections (Nieuwenhuis et al., 2001), is diminished in high susceptibles in hypnosis. However an earlier negative going component of the brains response to errors, the error related negativity or Ne, was not affected. In our most recent data on this topic, gathered in conjunction with Croft, Cleary, Hammond and Findlay, we have also found a significant reduction in the Pe in hypnotized highs and further a significant increase in the Ne in this same condition. Although significant we are currently extending our sample prior to a journal submission. If correct this suggests two things. Firstly the finding of an increased Ne independently s the finding of Egner et al. (2005) that hypnotized highs showed greater conflict related activation in dACC while performing the Stroop task. Both sets of results were produced from a Stroop paradigm, one utilized fMRI the other EEG, one studied correct responses the other error responses. Although controversial the of conflictmonitoring in cognitive control has recently been powerfully extended to cover electrophysiological error responses by modeling the Ne as generated by the dACC post response detection of conflict between the intended correct response and the executed incorrect response (Van Veen and Carter, 2002). Note that due to the timing of its peak, approximately 100 milliseconds post error response, the Ne cannot be generated by from the actual error response itself. If the conflict-detection is correct then the enhanced Ne in the present findings has precisely the same functional interpretation as the increased dACC activation reported by Egner et al. (2005) that is increased dACC responsiveness to the detection of response-conflict in hypnotized high susceptibles. Secondly, the earlier unconscious Ne response is generated in dACC and the later Pe more closely associated with conscious awareness of error and corrective behavioral responses) appears to be generated in rostral ACC. Meta analyses of imaging studies strongly a functional division between dorsal and rostral segments of the ACC with dorsal activations more closely associated with cognitive and behavioral tasks and rostral activations more closely associated with affective and motivational manipulations (Bush, Luu and Posner, 2000). It is likely then that functional connectivity from dorsal to rostral ACC plays a key role in the translation of detection of the likelihood of an error (arising from post error response conflict) into the mobilization of an adaptive change in top-down control to reduce the likelihood of error on subsequent trials. Consistent with the findings of Egner et al. (2005) it appears that the earlier monitoring part of this adaptive control circuit is intact (if anything it is hypersensitive) in hypnosis but that the later part of the control network is disrupted due to a dissociation between monitoring and control functions within and between key anterior cortical regions in hypnotized high susceptibles.

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TWO MODES OF SELF-REGULATION Over the last fifteen years the new discipline of cognitive neuroscience, which combines the new imaging technologies with the EEG, the rigorous experimental paradigms of cognitive psychology and the mathematical modeling of connectionism, has grown and flourished principally focusing on the issue of cognitive control. While there remains deep disagreement and controversy rapid progress has been made which no truly contemporary hypnosis researcher should ignore. For many traditional cognitive paradigms key components of the circuitry of cognitive control have been mapped along with their dynamic functional connectivity. Whist this circuitry is far from identical for disparate tasks there are common identifiable themes (sketched above) involving a dynamic interplay between dACC monitoring, prefrontal task set representations and top-down control of more posterior perceptual and motor control functions. Within this same time period the work described above has shown that, at least in part, important aspects of the change in mental organization which occurs in hypnosis can also be understood within this emerging theoretical framework, principally a breakdown in functional connectivity between monitoring (dACC) and control functions within the anterior cortex and the consequent effects of this on the integrated control of other brain-mind functions. However just as the seemingly discrete discipline of cognitive neuroscience has itself spilled over into the most recent development of cognitiveaffective-social neuroscience so to related research in hypnosis is now pointing to the necessity for a wider integration with social and affective neuroscience in the understanding of hypnosis. Conclusions from this work are necessarily more tentative but even at this point important new directions and the beginnings of new advances can be clearly identified. An early finding within imaging studies of effortful cognitive activity (the antithesis of the experience of hypnotic responding) was a ubiquitous activation within the dACC relative to various “control”conditions. However just as ubiquitous, but much less commented on, was a consistent deactivation of several other brain regions (including the rACC) in the same experimental contrasts. Subsequent meta analyses have shown that an identifiable network of (functionally connected) brain regions is more active in a variety of “resting state” control conditions than effortful cognitive processing (Raichle et al., 2001). That is just as there appears to be a broad pattern of functionally interconnected regions (with important common nodes) implementing effortful cognitive control there arguably appears to be a broad but systematic alternative pattern of brain activations and connections closely associated with effortless experience. These distinct functional networks are mutually inhibitory; implementation of one excludes implementation of the other. The dorsal and rostral divisions of the ACC are critical nodes in each network. Provocatively a previous meta analyses has also identified a mutually inhibitory relationship between activation in dorsal and rostral ACC in cognitive and affective paradigms respectively (Bush et al., 2000). I have argued above that hypnosis is closely associated with a specific type of disruption to one of these principal networks. It is plausible then that hypnosis is also associated with some form of modulation of the alternative network engaged during other forms of effortless experience. Data from PET studies of hypnosis conducted by Faymonville et al. (2003) and by Rainville et al. (2002) may provide initial evidence of this wider possibility. Faymonville et al., (2003) conducted an investigation of the functional connectivity of a dACC region in

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which activity co-varied with the analgesic effects of hypnotic suggestions to relive a positive affective experience. They conducted a Psychophysiological Interaction (PPI) analysis which found regulatory interactions with key nodes of the “resting state” network, including rACC and regions of the posterior cingulate cortex and parietal association areas. Rainville et al. (2002) used self report ratings of the experience of absorption during a hypnosis procedure to identify a network of brain regions in which activation co-varied systematically with this experience. They also reported a network which featured rACC, posterior cingulate and parietal association cortex. The consistent nodes in the activation networks related to these additional components of hypnotic experience in both studies also appear as principal nodes in the meta analyses identifying the resting state network. Unlike with cognitive control I cannot offer a systematic theory of these findings but I suggest they are closely tied to the role of hypnosis, and what are more widely known as trance states, in psychophysiological (as distinct from cognitive) self-regulation (see also Woody and Szechtman, 2007). A recent series of neuroimaging studies conducted by Critchley and colleagues (Critchley et al., 2003; Nagai et al., 2004) have identified distinct networks of brain regions (each spanning across a range of higher cortical midbrain and brain stem structures) engaged in the regulation of phasic sympathetic nervous system activity and in the regulation of tonic parasympathetic nervous system activity. Activation in each network is mutually inhibitory and the dorsal and rostral ACC play a fundamental role in each. Critchley (2005) has himself observed the likely integration of these central networks of somatic regulation and the networks regulating active cognitive processes and resting self-focused mental states respectively. Growing evidence for two functionally distinct, mutually inhibitory networks of cognitive, affective and somatic self-regulation bring us full circle to a psychobiological construct with deep roots in hypnosis research, that of absorption (Ott, Reuter, Hennig and Vaitl, 2005). Absorption has been found to play a critical role in the success of different psychological strategies for somatic self-regulation. Qualls and Sheehan (1981) attempted to understand the factors underlying the success (and failure) of bio training. Across a series of important studies they found that individuals’ level of trait absorption was a critical predictor of the success or failure of disparate self-regulation strategies. Looking at electromyograph activity (muscle tension) they found that low absorption individuals could learn to lower muscle tension through bio protocols but that when instructed to use this same approach high absorption individuals not only failed but actually increased their state of muscular tension. High absorption individuals were readily able to lower muscular tension if allowed to adopt their preferred self-regulatory style of focusing their awareness on self generated inner experiences. When instructed to adopt this approach low absorption individuals failed to lower (and actually raised) their level of muscular tension. High and low absorption ability (the ability to engage in trance like experiences in daily life) is closely related to the ease and effectiveness of two very different styles (and associated strategies) of psychological and somatic self-regulation. These findings led Tellegen (1981) away from his earlier of absorption as strongly focused attention to a fundamental redefinition of the trait. Tellegen (1981) described experience as being organized around two discrete and mutually exclusive mental sets, the instrumental-mental-set and the experiential-mental-set. He (Tellegen, 1981, p.222) describes the instrumental set as “a state of readiness to engage in active, realistic, voluntary and effortful planning, decision making and goal directed behavior”. A description which is immediately recognizable as active cognitive control implemented by the dACC, lateral PFC

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and posterior cortical networks described by cognitive neuroscience and known to be disrupted in high susceptibles during hypnosis. By contrast, Tellegen described the experiential set as “a state of receptivity or openness to experiencing whatever events, sensory or imaginal [that] may occur … a tendency to dwell on rather than go beyond the experiences …[which] have a sense of effortlessness and involuntariness” (Tellegen, 1981, p. 222). He further emphasized the role of affective processes in the experiential-mental-set. Tellegen then conceptualized absorption as a predisposition, when circumstances permit, to set aside an instrumental set and adopt instead an experiential mental set. That is, from a contemporary cognitive-affective-social neuroscience perspective, he described absorption as the predisposition and ability to inhibit or disrupt one of two major patterns of neural functional connectivity, experience and selfregulatory organization and to adopt the other, a very different mode of organization with its own characteristic patterns of functional connectivity, experience and self-regulatory mechanisms.

CONCLUSION The distinctive character of the changes in experience that accompany hypnosis (at least in high susceptibles) remain one of the most important features for hypnosis researchers to comprehensively catalogue, map and explain (Sheehan and McConkey, 1982). The mutual engagement between cognitive neuroscience and hypnosis research as outlined here has already proven most fruitful in this regard. However, the principal social role of hypnosis has always been and remains the self-regulation of psychological, psychophysiological and related somatic states. Therefore, the study of hypnosis must not only include but also extend beyond the purely psychological level of analysis. For example, recent studies have demonstrated the important role of hypnosis and hypnotic susceptibility in the self-regulation of stress-related endothelial dysfunction (Jambrik et al., 2005), ventricular arrhythmia (Taggart et al., 2005) and other elements of heart rate variability (Diamond, Davis and Howe, 2008). If continued vigor is shown by researchers and ed by funding bodies, the future collaboration of hypnosis with systems-level neuroscience research holds the great promise of uncovering the full nature of these underlying psychological, central and peripheral systems of self-regulation.

REFERENCES Botvinick, M.M., Cohen, J.D. & Carter, C.S. (2004). Conflict monitoring and anterior cingulate cortex: an update. Trends in Cognitive Science, 8, 539-546. Bush, G., Luu, P. & Posner, M. (2000). Cognitive and emotional influences in the anterior cingulate cortex. Trends in Cognitive Sciences, 4, 215-222. Cohen, J.D., Aston-Jones, G. & Gilzenrat, M.S. (2004). A systems level theory of attention and cognitive control. In MI Posner ed. Cognitive neuroscience of attention (pp. 71–90). New York: Guilford Press.

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Crawford, H.J. & Gruzelier, J.H. (1992). A midstream view of the neuropsychophysiology of hypnosis: recent research and future directions. In E Fromm and M Nash, eds. Contemporary Hypnosis Research (pp. 227-266). New York, Guilford Press. Crawford, H.J., Horton, J.E., Harrington, G.S., Hirsch-Downs, T., Fox, K,, Daugherty, S. & Downs III, J.H. (2000). Attention and disattention (hypnotic analagesia) to noxious somatosensory TENS stimuli: fMRI differences in low and highly hypnotizable individuals. NeuroImage, 11, S44. Critchley, H.D., Josephs, O., O’Doherty, J., Zanini, S., Dewar, B.-K., Mathias, C.J., Cipolotti, L., Shallice, T., & Dolan, R.J. (2003). Human cingulate cortex and autonomic cardiovascular control: converging neuroimaging and clinical evidence. Brain, 216, 2139– 2152. Croft, R.J., Williams, J.D., Haenschel, C. & Gruzelier, J.H. (2002). Pain perception, hypnosis and 40 Hz oscillations. International Journal of Psychophysiology, 46, 101-108. De Pascalis V. (2007). Phase-ordered gamma oscillations and the modulation of hypnotic experience. In G. A. Jamieson (Ed), Hypnosis and conscious states: The cognitive neuroscience perspective (pp. 67-89). New York: Oxford University Press. Diamond, S.G., Davis, O.C., & Howe, R.D. (2008). 0 Heart rate variability as a quantitative measure of hypnotic depth. International Journal of Clinical and Experimental Hypnosis, 56, 1–18. Egner, T., Jamieson, G., & Gruzelier, J. (2005). Hypnosis decouples cognitive control from conflict monitoring processes of the frontal lobes. Neuroimage, 27, 969-978. Egner, T. & Raz, A. (2007). Cognitive control processes and hypnosis. In G. A. Jamieson (Ed), Hypnosis and conscious states: The cognitive neuroscience perspective (pp. 29-50). New York: Oxford University Press. Falkenstein, M. (2004). ERP correlates of erroneous performance. In M Ullsperger and M Falkenstein, eds. Errors, Conflicts, and the Brain. Current Opinions on Performance Monitoring, pp.5-14. Leipzig, Max Planck Institute for Cognitive Neuroscience. Faymonville, M.E., Roediger, L., Del Fiore, G., Delgueldre, C., Phillips, C., Lamy, M., Luxen, A., Maquet, P. & Laureys, S. (2003). Increased cerebral functional connectivity underlying the antinociceptive effects of hypnosis. Cognitive Brain Research, 17, 255 – 262. Gruzelier, J. (1998). A working model of the neurophysiology of hypnosis: A review of evidence. Contemporary Hypnosis, 15, 5-23. Gruzelier, J. & Warren, K. (1993). Neuropsychological evidence of reductions on left frontal tests with hypnosis. Psychological Medicine, 23, 93-101. Hilgard, J.R. (1974). Imaginative involvement: Some characteristics of the highly hypnotizable and the nonhypnotisable. International Journal of Clinical and Experimental Hypnosis, 22, 138-156. Ishii, R., Shinosaki, K., Ukai, S., et al. (1999). Medial prefrontal cortex generates frontal midline theta rhythm. Neuroreport, 10, 675–679. Jambrik, Z., Sebastiani, L., Picano, E., Ghelarducci, B. & Santarcangelo, E.L. (2005). Hypnotic modulation of flow-mediated endothelial response to mental stress. International Journal of Psychophysiology, 55, 221– 227 Jamieson, G.A. & Sheehan, P.W. (2004). An empirical test of Woody and Bower’s dissociated control theory of hypnosis. International Journal of Clinical and Experimental Hypnosis, 52, 232-249.

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Kaiser, J., Barker, R., Haenschel, C., Baldeweg, T. & Gruzelier, J. H. (1997). Hypnosis and event related potential correlates of error processing in a stroop- type paradigm: A test of the frontal hypothesis. International Journal of Psychophysiology, 27, 215-222. MacLeod, C.M & MacDonald, P.A. (2000). Interdimensional interference in the Stroop effect: uncovering the cognitive and neural anatomy of attention. Trends in Cognitive Sciences, 4, 383-391. MacDonald, A.W., Cohen, J. D., Stenger, V. A. & Carter, C. S. (2000) Dissociating the role of dorso-lateral prefrontal cortex and anterior cingulate cortex in cognitive control. Science, 288, 1835-1838. Miller, E.K. & Cohen, J.D. (2001). An integrative theory of prefrontal cortex function. Annual Review of Neuroscience, 24, 167-202. Nagai, Y., Critchley, H.D., Featherstone, E., Trimble, M.R. & Dolan, R.J. (2004). Activity in ventromedial prefrontal cortex covaries with sympathetic skin conductance level: a physiological of a “default mode” of brain function. Neuroimage, 22, 243–251. Nieuwenhuis, S., Ridderinkhof, K.R., Blom, J.B., Blom, G.P. & Kok, A. (2001). Error-related brain potentials are differentially related to awareness of response errors: evidence from an antisaccade task. Psychophysiology, 38, 752-760. Nordby, H., Hugdhal, K., Jasiukaitis, P. & Spiegel, D. (1999). Effects of hypnotizability on performance of a Stroop task and event –related potentials. Perceptual and Motor Skills, 88, 819-830. Norman, D.A. & Shallice, T. (1986). Attention to action: Willed and automatic control of behaviour. In R. J. Davidson, G.E. Schwartz, & D. Shapiro (Eds.) Consciousness and self-regulation, Vol.4 (pp. 1-18). New York: Plenum Press. Ott, U., Reuter, M., Hennig, J. & Vaitl, D. (2005). Evidence for a common biological basis of the Absorption trait, hallucinogen effects, and positive symptoms: Epistasis between 5HT2a and COMT polymorphisms. American Journal of Medical Genetics (Neuropsychiatric Genetics), 137B, 29-32. Raichle, M.E., MacLeod, A.M., Snyder, A.Z., Powers, W.J., Gusnard, D.A. & Shulman, G.L. (2001). A default mode of brain function. Proceedings of the National Academy of Sciences U S A, 98, 676–682. Rainville, P., Hofbauer, R.K., Bushnell, M.C., Duncan, G.H. & Price, D.D. (2002). Hypnosis modulates activity in brain structures involved in the regulation of consciousness. Journal of Cognitive Neuroscience, 14, 887-901. Ray, W.J. (1997). EEG concomitants of hypnotic susceptibility. International Journal of Clinical and Experimental Hypnosis, 45, 301-313. Raz A, Shapiro T, Fan J and Posner MI (2002). Hypnotic suggestion and the modulation of Stroop interference. Archives of General Psychiatry, 59, 1155-1161. Raz, A., Kirsch, I., Pollard, J., & Nitkin-Kaner, Y. (2006). Suggestion Reduces the Stroop Effect. Psychological Science, 17, 91-95. Sheehan, P. W., Donovan, P. B., & MacLeod, C. M. (1988). Strategy manipulation and the stroop effect in hypnosis. Journal of Abnormal Psychology, 97, 455-460. Sheehan, P.W. & McConkey, K.M. (1982). Hypnosis and experience: the exploration of phenomena and process. Hillsdale N.J., Erlbaum. Shor, R.E. (1959). Hypnosis and the concept of generalized reality orientation. American Journal of Psychotherapy, 13, 582-602.

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Stroop, J. (1935). Studies of interference in verbal reactions. Journal of Experimental Psychology, 18, 643-661. Taggart P., Sutton, P., Redfern, C., Batchvarov, V.N., Hnatkova, K., Malik, M., James, U., & Joseph, A. (2005). The Effect of Mental Stress on the Non-Dipolar Components of the T Wave: Modulation by Hypnosis. Psychosomatic Medicine, 67, 376–383. Tellegen, A. (1981). Practicing the two disciplines for relaxation and enlightenment: Comment on ‘Role of the signal in electromyograph bio: The relevance of attention’ by Qualls and Sheehan. Journal of Experimental Psychology: General, 110, 217-226. Tellegen, A., & Atkinson, G. (1974). Openness to absorbing and self-altering experiences: Absorption, a trait related to hypnotic susceptibility. Journal of Abnormal Psychology, 83, 268-277. Trippe, R.H., Weiss, T., & Miltner, W.H.R. (2004). Hypnotisch-induzierte Analgesie Mechanismen. Anästhesiologie & Intensivmedizin, 45, 642-647. Van Veen, V. & Carter, C.S. (2002). The timing of action-monitoring processes in the anterior cingulate cortex. Journal of Cognitive Neuroscience, 14, 593-602. Weitzenhoffer, A.M. (1953). Hypnotism: An objective study in suggestibility. New York, Grune and Stratton. Woody, E. & Bowers, K. (1994). A frontal assault on dissociated control. In S. J. Lynn & J. W. Rhue (Eds.), Dissociation: Clinical and theoretical perspectives (pp. 52-79). New York: Guilford. Woody, E. & Szechtman, H. (2007). To See Feelingly: Emotion, Motivation, and Hypnosis. In G. A. Jamieson (Ed), Hypnosis and conscious states: The cognitive neuroscience perspective (pp. 241-255). New York: Oxford University Press. Reviewed by Professor Adrian P. Burgess, Department of Psychology, Aston University, Birmingham UK, and by Dr Nick Cooper, University of Essex, Colchester, UK.

In: Hypnosis: Theories, Research and Applications Editors: G. D. Koester and P. R. Delisle

ISBN 978-1-60456© 2009 Nova Science Publishers, Inc.

Chapter 7

THE NEUROPHYSIOLOGY OF HYPNOSIS IN MASS PSYCHOGENIC ILLNESS Felipe A. Tallabs G* The Free Institute of Science, osé Revueltas 2748, Col Alta Vista Sur, Monterrey, 64740México

ABSTRACT Mass Psychogenic Illness (MPI) is typically defined as the collective occurrence of a constellation of similar physical symptoms and related beliefs, for which there is no plausible pathogenic explanation, and which can be divided in two possible conditions, Mass Anxiety Hysteria and Mass Motor Hysteria. Evidence has emerged that the cultural context is of utmost importance in the mechanism of both variants of Mass Psychogenic Illness. However, there is an underestimated variable that relates both conditions even in a more meaningful manner, and this is the neurophysiology of hypnosis. This study presents evidence that the neural mechanism of hypnosis is a fundamental prerequisite for the environmental context to exert pressure and provoke the onset of MPI; the role of empathy is assessed as a part of the mechanism of suggestibility during MPI, as well as a possible mirror neuron system that could be the cornerstone of symptomatology transmission. Fundamental differences are presented from the two variants of MPI, Mass Anxiety Hysteria and Mass Motor Hysteria.

Keywords: Hypnosis, Mass Anxiety Hysteria, Mass Motor Hysteria, Empathy, Mirror neurons

*

Email: [email protected]

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INTRODUCTION Collective psychogenic illness has been reported since the Middle Ages, and such s have continued to appear all the way up to our time. Many forms of behavior had been described, ranging from general anxiety symptoms like dizziness, fainting, headaches, hyperventilation, nausea, palpitation, anxiety, abdominal pain, etc. (Bebbington et al., 1980; Colligan and Murphy, 1979; Small and Nicholi, 1982; Small and Borus, 1983; Watson and Bausher, 1983) to more specific symptoms like seizures, agitation terror (Acherman and Lee, 1978), running, laughing and twitching, reciting poetry (Dhadphale and Shaikh, 1983), trances, hallucinations, peudoparesis, anesthesia (Lee and Acherman, 1980; McEvedy and Beard, 1970), agitation, possession (Teoh and Yeoh, 1973), just to name a few. There exists no satisfactory definition of mass hysteria. A wide variety of crazes, panic and abnormal group beliefs have been labeled as mass hysteria. However, these epidemics, while definitely of a pathological order are certainly psychosocial phenomena rather than manifestation of individual mental Illness. A detailed assessment of modern mass hysteria symptoms suggests that two broad groups may be identified. The first consists of episodes featuring some or all the symptoms of acute anxiety. The second group consists of episodes involving symptoms more recognizable as hysterical in nature, demonstrating alterations in motor function, such as pseudo seizures, pseudo paresis and all sorts of pseudoneurological phenomena. However there are cases in which both sets of phenomena are present, anxiety and pseudoneurological (Ali Gombe et al., 1996). It has been argued that in cases where anxiety-like symptoms (mass anxiety hysteria) are predominant, there was almost no history of previous prolonged stress or tension, which is always present in the cases where hysteria symptoms are predominant (Wessely, 1987). But whatever the form of the specific case, there is always a “mythical” belief on a source that causes the phenomena, could be a mysterious gas (Wong et al., 1982), an insect plague (Bartholomew, 1994), even demons (Huxley, 1952) or any other belief. The difference is that in Mass Anxiety Hysteria (MAH), the belief is created at the same time that the first symptoms appear in the case 0 or first subject, whereas in Mass Motor Hysteria (MMH) there is a previous belief in the cause. It is relevant also that MAH lasts only for hours whilst MMH can last from weeks to years. Interesting to note is the fact that this time difference is similar to the difference found between hypnotic paralysis and conversion paralysis. (This will be explained further in section 3.) Another common feature of MMH and MAH with conversion and hypnotic paralysis is the fact that MMH is the result of a long exposure to stress that could not be avoided (Knight et al., 1965; Tan, 1963; Teoh et al., 1975; Colligan et al., 1982; Kerchkoff and Back, 1965; Stahl and Lebedun, 1974; Ikeda, 1966) whilst MAH seems to be the result of momentary suggestibility triggered by a situation where attention is focalized (contracted) into a perceived danger, which in turn raises the level of anxiety. Regarding the nature of the perceived danger, Wessely comments: “The common feature of the stressors underlying outbreaks of mass motor hysteria is an inability on the part of the subject either to comprehend the true nature of the threat or have the ability to avoid it” (Wessely, 1987). This inability to comprehend the nature of the stressor mentioned by Wessely is the cause of the cultural interpretation of the stressor into a

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comprehensible, culturally manufactured danger. This particular danger provides the features of the condition itself (symptoms). The unitary approach to group behavior started with LeBon (1895) who saw crowd behavior as more than the sum of single behaviors. He suggested the existence of a “complexity” in crowd psychology that provoked emergent behaviors observable only in groups. It has been proposed that group reality replaces external reality, and such isolations prevents adequate verification of perceived threats (Festinger, 1950; Gruenberg, 1957). Theories of mass hysteria spreading mechanisms have also involved the analogy between the spread of mass hysteria and the spread of an infectious disease. According to Penrose (1952) also Back (1971), those who accepted the fantasy idea will succumb to the epidemic, those who reject it will be resistant, and those who ignore it will be immune. Theoretical models of group behavior have been designed to be applied to all forms of group behavior. It is this universality that prevents such models from becoming complete explanations, specifically when observing the difference of spread that occurs in MAH and MMH. In Mass Anxiety Hysteria, transmission of the outbreak is commonly along a “line of sight”, those who do not witness the outbreak are never affected. The spread of Mass Motor Hysteria however, depends upon social interaction occurring between the initial case preceding the outbreak and the rest of the group. If a belief is to be propagated and sustained over a prolonged period of time, it must be relevant to the group and all involved in the epidemics should be able to identify with the initial case or subject 0’s behavior. This is only possible if the subject 0 has high status in the group. In experimental settings, subjects with high prestige were found to be the most effective models of contagion (Bartholomew and Wessely, 2002). What is evident is that in MMH, social networks facilitate the spread of the symptoms.

STRESS AND HYPNOTIC TRANCE In 1924 some of Ivan Pavlov’s dogs accidentally became trapped in their cages when the Nerva River flooded St Petersburg. The water entered Pavlov’s laboratory and reached nearly to the top of the cages containing the dogs. Towards the end, when they were swimming around the very tops of their cages, they were dramatically rescued by a laboratory attendant who brought the dogs out under the water to safety. All the dogs had met the frightening experience with initial fear and excitement. But after their rescue, some were in a state of severe inhibition, stupor and collapse. The strain on the nervous system had been so intense that the fearful excitement aroused had resulted in a final emotional collapse. Pavlov was most excited when he found that in all those dogs which had experienced the collapse, all the recently implanted conditioned reflexes had been abolished. “it was as if the recently printed brain-slate had been suddenly wiped clean. Pavlov was able to imprint on them new patterns of behavior” (Sargant, 1974). One of Pavlov’s most important findings (Pavlov, 1941) describes what happens to the conditioned behavior when the brain is “Transmarginally” stimulated by aggression or fear beyond its capacity for showing its habitual response. He called this state “rupture in higher nervous activity”. After the onset of this rupture a state of transmarginal inhibition is set.

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According to Pavlov, this state of brain activity is similar to that seen in human hysteria. This can cause a great increase in suggestibility. The individual suddenly takes notice of events and influences around him to which he would normally have paid little or no attention. In this “hypnoid” state of brain activity, people become open to the uncritical adoption of thoughts and behavior patterns present in their environment, which normally would not have influenced them emotionally or intellectually. The individual becomes susceptible to influences in the environment to which he was formerly immune. Evidence of the relationship between severe traumatic events and development of dissociative symptomatology is considerable (Spiegel, 1984, 1988; Frankel, 1990; Marmar et al., 1994; Koopman et al., 1995) However little empirical evidence existed that could relate hypnotic susceptibility to conversion (Frischolz et al., 1992) until Roelofs et al. (2002) provided hard evidence of this by comparing several conversion patients with control subjects on measures of hypnotic susceptibility, cognitive dissociation and somatoform dissociation. Conversion patients were significantly more responsive to hypnotic suggestion than controls; however this important result awaits independent replication. Hypnosis can be explained as a controlled and structured dissociation (Kaplan, 1985) with a state of excessive focal concentration and relative suspension of peripheral awareness (absorption) and suspension of critical contextual evaluation (suggestibility) (Spiegel and Cardena, 1990). Absorption is a state of highly focused attention with a total involvement in a single dimension of experience, like perception, memory or ideation (Tellegen and Atkinson, 1974; Spiegel, 1992). This focalization excludes other experiences that should normally be present in conscious awareness. Janet (1907) described this as a ‘retraction in the field of consciousnesses. This retraction requires the relegation of material to the periphery of consciousness where it no longer impinges on awareness. This aspect of hypnosis is considered a dissociation of content (Spiegel, 1990; Butler et al., 1996). Suggestibility is an increased responsiveness to environmental cues (real or perceived) and is a main characteristic of hypnosis, and is thought to result from the heightened focal awareness through absorption. A person under instructions of hypnosis ‘is fully absorbed in only one or two aspects of awareness, and therefore is less likely to critically judge or evaluate the meaning of the experience’ (Spiegel, 1992). The narrowing of attention results in a diminution of higher order critical capacities; therefore a proneness to be influenced by suggestion develops.

THE ROLE OF EMPATHY IN MASS ANXIETY HYSTERIA Empathy defined as the ability to perceive accurately another person’s feelings, is a fundamental part of the social fabric of emotion, providing a bridge between one person’s feelings and those of another. The notion that empathy between two people is related to a state of shared physiology is not new, however most of the literature generated by the study of empathy is taken from a single person perspective, and although it has generated physiological measurements (Di Mascio et al, 1955; Malmo et al, 1957; Kaplan and Bloom, 1960), they came from either the observing person or the observed one, but never both of them.

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Physiology has always been perceived as something private. However, the essence of empathy is interpersonal, and during the experiencing of empathy, the physiological response of an individual can be understood in of basic social processes (Cacioppo and Petty, 1983) and even the physiological response of two people can evidence a considerable relatedness and linkage (Levenson and Ruef, 1992). This is evidence that observing the emotional display of another person can result in similar emotional displays, as well as autonomic arousal on the part of the observer (Dimberg, 1982; Lanzetta and Englis, 1989; McHugo et al, 1985; Vaughan and Lanzetta, 1980). We can then reformulate the definition of empathy as: The ability to detect emotional information, and thus physiological information transmitted by another person’s behavior. From this definition we can also define a level of empathy as: The level of accuracy to perceive and reproduce another person’s physiological state related to emotions. As I mention in the introduction, most Mass Psychogenic Illness studies consider that the symptoms begin spreading from high status students (Bartholomew and Wessely, 2002). This is evidence of the direct relationship between empathy and MPI. High status students provoke higher levels of empathy in their schoolmates. However let’s describe a possible scenario in order to clarify the role of empathy in a real life scenario of MPI epidemics. Consider the following scenario of an MPI epidemic, specifically a Mass Anxiety Hysteria fast spreading epidemic. There is a belief in an urban area Middle school that a nearby industrial complex releases fumes into the air that might be toxic. A high status student is under stress because of an impending math test the following day. Stress and lack of proper sleep cause the student to feel sick, developing dizziness and nausea. He finally throws up in front of the class and complains of difficulty breathing. Earlier that morning the stench of the nearby factory fumes had reached the school, the teacher nervously comments to her class that the student’s condition must be a result of the morning fumes. The observation of the sick student’s behavior provides to the class a confirmation that the teacher’s belief might be a reality. At the same time empathy gives them a physiological model of the first case or student 0 feelings, thus the cognitive experience and the physiological experience are now coupled, at this moment the stress rises (the class was already under stress because of the future test). If the level of empathy with the student 0 is high enough, then the reality of that person becomes consensual reality. In this moment, where single reality becomes consensual reality the mechanism of hypnosis is fundamental. As mentioned earlier, suggestibility is defined as the suspension of critical contextual evaluation, and can only be possible when attention is focalized, such focalization can be produced by the continuous perception of certain danger (real or not). In the previous scenario it was a possible toxic gas threat, however such absorption of attention was also “catalyzed” by an unavoidable future of a mathematics test, which caused an above normal level of stress. Once absorption of attention is present, the physiological response caused by an empathic observation of the student 0, triggers a suspension of critical contextual evaluation, thus, a state of suggestibility develops. Orne (1959) defined suggestibility as an increased responsiveness to social (environmental) cues, real or perceived. That is exactly what happens during MPI. However the role of empathy in MPI is still a theoretical formulation since no studies to date have thoroughly assessed it. Nevertheless, it seems feasible that the physiological response triggered by empathy, must be a fundamental element for the development of suggestibility during MPI epidemics.

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MMH AND MAH, SIMILARITIES WITH CONVERSION AND HYPNOTIC PARALYSIS All forms of Mass Psychogenic Illness may be considered an interaction between the individual and its social group. However, the nature of this interaction differs between MAH and MMH. This difference provides different characteristics to the onset of both conditions. See Table 1. Based upon Wessely (1987). Table 1. MAH Symptomatology Initial case Duration Spread Preexisting tension Age-Group

MMH Acute anxiety Rarely identified Hours(may be repeated) Rapid, line of sight Absent Under 18

Changes in motor function Usually identified Weeks to years slow present Any age

It is interesting to note the similarities that exist between Mass Motor Hysteria and Conversion paralysis as well as with Mass Anxiety Hysteria and hypnotic induced paralysis respectively. I speculated elsewhere (Tallabs, 2005) that in hypnotizable subjects the amygdalaanteriorcingulate cortex-orbitofrontal cortex connections were enhanced by a trauma-induced long-term potentiation (LTP) in the circuit between the affective subdivisions of ACC and OFC and the amygdala. Such enhancement could certainly obstruct effective functioning of the cognitive subdivisions which are suddenly disregarded by this pathological circuit, leading to a dysfunctional processing of motor behaviors (among others) that finally provokes the onset of the symptoms of conversion paralysis. Also during MAH, there are similarities with hypnotic-induced conditions like induced anesthesia; however, there is no stress during hypnotically induced conditions, which seems to be fundamental in MAH. As I have mentioned earlier there is no evidence of a previous stressing environment in MAH cases, however, there is stress in the beginning of the event, which triggers the onset of the symptoms. Stress seems to be fundamental for the suggestibility state to develop during MAH. Another fundamental difference between MAH and induced conditions is precisely the fact that MAH is environmentally shaped rather than induced. Nevertheless, recent data obtained by the author in questionnaires applied to a government elementary school district in an urban area of the city of Monterrey in northeast Mexico (yet to be published) provide evidence that some teachers were prone to experience MAH cases with regularity. Most of such cases were mild, involving few students, but very repetitive. These results evidence the fact that certain personality traits in teachers might induce episodes of MAH. Teachers that experience episodes of MAH regularly complained of being unable to control the discipline in their classrooms. This led to the “Insecure Teacher Inducer Hypothesis”. According to this hypothesis, a factor related to behaviors of insecurity in the teacher during a stressful situation, must be leading to the induction of the onset of the symptoms.

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When a teacher complains about the discipline in his/her classroom, the teacher is failing as a leader, leaving a void of an adult figure in the classroom. A teacher should be most of all a problem solver for the children. This sort of teacher is not really in control of the children’s behavior, and this can be expressed not only in words but in facial and body expressions. Once children feel the insecurity of the adult figure, many students may experience a sense of indefensibility. This stress is different to that of repressive environments so common during MMH. This is a stress of being unprotected, a feeling that anything might happen, a state of unsafeness. Such state of unsafeness is an excellent condition to produce suggestibility. If you add to this, a teacher’s comment like the one in the proposed scenario “must be the result of the morning fumes” then you have all the elements for the beginning of a MAH epidemic. So according to this hypothesis, MAH onset might benefit from an indirect inducer person. This would mean that MAH could be in certain occasions an induced condition, like induced pseudoneurological syndromes in experimental conditions.

RESONANCE BEHAVIORS AND SYMPTOM TRANSMISSION IN MMH At the end of the last century, a group of Italian neuroscientists headed by Giacomo Rizzolati and Luciano Fadiga made a transcendental discovery for the neurosciences. They discovered a system of neurons that behave like a mirror (Rizzolati et al, 1988), this “mirror” neurons were found to represent observed actions, as if made by subjects watching the action. They refer to these behaviors as “resonance behaviors”. In this type of behavior, an individual repeats overtly in a quasi automatic way a movement made by another individual (in this chapter I will only deal with this sort of behavior, not more complex types of resonance). The most typical example of resonance behavior is found in the imitative behavior observed in different species of animals. A thoroughly studied example is displayed by shore birds when alarmed. Typically one or a few birds start wing flapping, then others repeat the action and eventually the entire flock begins flight (Thorpe W H, 1953; Tinbergen N, 1953). This “contagious” behavior does not require necessarily an understanding of the action, what is of utmost importance in this case is that the action emitted by one or two birds can act as a release signal (Rizzolati, et al., 1999). Resonance behaviors appear to be present in humans also. In infants, for example, they play a fundamental role in establishing communication with adults. An example of this is the capacity of young children to imitate mouth and manual gestures (Meltzoff and Moore, 1977). It is hard to believe that at such an early age there is understanding of the meaning of the observed gestures or conscious desire to repeat them. These sorts of behaviors can also be observed in adult humans. Actions that seem to be related to some degree of empathy can be contagious; smiling produces a tendency to respond with smiling, laughing is well known to be contagious. The most usual response to the sight of someone yawning is to yawn. For all these actions there is no need to postulate a comprehension of the observed actions, such actions simply releases in the observers the seen action. The term “response facilitation” was proposed to describe this kind of behavior (Byrne, 1995). I believe that this “response facilitation” is just an element of the mechanism of empathy. This type of response provides an adaptational advantage to the individual

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inserted in a society, just like the contagious wing flapping (escape) mechanism to a bird flock. However, the behaviors observed during MMH epidemics are far from being a regular occurrence of human societies. So how do the behaviors observed during MMH come to be “contagious”. In 2001 it was discovered that there was a modulation of spinal excitability during observation of actions in humans. This modulation, however, was opposite to that occurring when the recorded muscles were actually executing the observed action (Lemon et al., 1995) such modulation replicated the observed movements (Fadiga et al., 1995) but in an “inverted mirror” fashion, thus it was speculated as a mechanism to prevent the overt replica of an observed action (Baldissera et al., 2001). In contrast with the behaviors previously mentioned: laughing, smiling and yawning, which are strongly related to empathy and do not suffer from such type of “inhibition” modulation because they are dependent on cranial nerves not spinal nerves, the behaviors observed in MMH are limb related and thus must be dependent on a mechanism to overcome such “inhibition”. This would mean that during MMH, such inhibition can be overriden, and behaviors become quite involuntary, like a yawning “infection”. Now, let’s look at the mechanism that facilitates the overriding of the inhibition. It is logical to speculate that the “inverted mirror” spinal inhibition is originated in the motor cortex, otherwise, it would not be easily overridden; because of the psychological stress present in MMH, it could not be the case if it was a purely spinal condition. My hypothesis is that such inhibition is the result of hypnotic-like suggestion. It is known that the Orbitofrontal Cortex (OFC) of the brain controls adequate responses to environmental stimuli (Kolb and Whishaw, 1998; Damasio, 1999). OFC is also implicated in action, emotion and motor inhibition of spontaneous movements (Kaada, 1969; Ludens et al., 1995). Suggestibility, as mentioned in the introduction, is an increased responsiveness to environmental cues, which is a main characteristic of hypnosis. I have speculated elsewhere (Tallabs, 2005) that OFC is an area that is responsible for suggestibility; nevertheless, further research is required to dilucidate the exact range of its functional characteristics. It is then hypothesizable that OFC is in charge of this “spinal inhibitory modulation”. So it makes sense to speculate that during suggestibility, the OFC could override any inhibition in order to correspond to the irregular level of empathy required by the situation during MMH. This would allow then for the motor system to physically reproduce the information of the observed action by the influence of the corresponding mirror system.

CONCLUSION There are two different neuropsychological mechanisms that correspond to Mass Anxiety Hysteria and Mass Motor Hysteria, and although they are closely related, they also differ in fundamental aspects. But whatever the differences, these models are only a variation of the same phenomenon, which is the neurophysiology of hypnosis. In MAH, a belief is introduced by a third party, i.e. a teacher; the reality of such belief is confirmed by empathic observation of a defined symptomatology, and if the level of empathy with the first case is high enough, then, one person’s reality becomes consensual (group) reality, thus, attention is focalized in the condition of the first person to become sick. This

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triggers a suspension of critical evaluation, in other words, a suggestion. We can speculate that such group suggestion is the cause of the communicated symptomatology. During MMH, there is a long history of a stressful environment in the group, most of the time related to a repressive environment within the group, i.e. a strict school discipline. Similar to MAH, there is an empathic response to a first case; however, there is not any environmental suggestion present. Stress focalizes attention in the empathic response to the observed behavior. Such focalization causes a suggestion and the override of the spinal “motor inhibition” in order to respond to a level of empathy required by this extraordinary situation. This allows the corresponding mirror system to exert a direct influence in motor areas otherwise blocked to its influence. What is definitely behind both variations of Mass Psychogenic Illness is the engagement of frontal brain cortex areas, specifically the Anterior Cingulate Cortex (ACC) and the Orbitofrontal Cortex (OFC). ACC has been found to be selective of attentional demands (Posner et al., 1988; Pardo et al., 1990) and it is in charge of attention focalization. OFC as mentioned earlier is in charge of suspension of critical evaluation as well as motor inhibition. These two areas are fundamental elements for the mechanism of hypnosis. It is then likely that ACC and OFC are areas strongly involved during MMH and MAH. The mechanism seen in MMH is rather similar to the one observed during conversion paralysis, however, the mechanism observed in MAH although similar to hypnotic paralysis, does not involve motor behavior. Extensive research on the neural correlates of MAH will have to be undertaken.

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Byrne R (1995) The Thinking Ape: Evolutionary Origins of Intelligence. Oxford University Press. Cacciopo T J, Petty R E (1983) Social psychophysiology: A source-book. New York: Guildford Press. Colligan M, Murphy L R (1979) Mass Psychogenic Illness in organizations. Journal of Occupational Psychology 52, 77-90. Colligan M, Pennebaker J, Murphy L (1982) Mass psychogenic illness: A Social Psychological Analysis. Lawrence Erlbaum: Hilsdale, New Jersey Dadphale M, Shaikh S (1983) The mysterious madness of Mwinilunga. British Journal of Psychiatry 142, 85-88. DiMascio A, Boyd R, Greenblatt M, Solomon H C (1955) The psychiatric interview: A sociophysiologic study. Diseases of the nervous system 16, 4-9. Dimberg U (1982) Facial reactions to facial expressions. Physchophysiology 19, 643-647. Festinger L (1950) Informal social communication. Psychological Review 57, 271-282. Frankel F H (1990) Hypnotizability and dissociation. American Journal of Psychiatry 147, 823-829. Frischholz E J, Lipman L S, Braun B G, Sachs R G (1992) Psychopathology, hypnotizability and dissociation. American Journal of Psychiatry 149, 1521-1525. Gruenberg E M (1957) Socially shared psychopathology. In: Exploration in Social Psychiatry (ed. A. H. Leighton, J. A. Clausen, R. N. Wilson) pp 201-299. Travistock Publication: London. Huxley A (1952) The demons of Loudun. Harper and Brothers, New York. Ikeda Y (1966) An epidemic of emotional disturbance among leprosarium nurses. Psychiatry 23, 152-164. Jeanet P (1907) The Major Symptoms of Hysteria. London: MacMillan. Kaada B R (1960) Cingulate, posterior orbital, anterior insular and temporal pole cortex. In: J Field (ed.) Handbook of Physiology. Baltimore, M D: Williams and Wilkins, vol 2. Kaplan H I (1985) Dissociative disorders. In: H I Kaplan, B J Sadocks (eds) Comprehensive Textbook of Psychiatry. Baltimore, MD: Williams and Wilkins, 942-957. Kerckhoff AC, Back K W, Miller N (1965) Sociometric patterns in hysterical contagion. Sociometry 28, 2-15. Knight J A, Friedman T I, Sulianti J (1965) Epidemic hysteria: a field study. American Journal of Public Health 55. 858-865. Kolb B, Whishaw I Q (1998) Fundamentals of Human Neuropsychology. New York: W H Freeman and Company. Koopman C, Classen C, Cardena E, Spiegel D (1995) When disaster strikes, acute stress disorder may follow. Journal of Trauma and Stress 8, 29-46 Lanzetta J T, Englis B G (1989) Expectations of cooperation and competition and their effects in observers` vicarious emotional responses. Journal of Personality and Social Psychology 56, 543-554. Le Bon G (1895) The Crowd. Reprinted (1960). Viking: New York. Lee R L, Ackerman S (1980) The sociocultural dynamics of mss hysteria. Psychiatry 43, 7888. Lemon R N, Johansson R S, Westling G (1995) Corticospinal control during reach, gasp and precision lift in man. Journal of Neuroscience 15, 6145-6156.

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Levenson R W, Ruef A M (1992) Empathy: A Physiological Substrate. Journal of Personality and Social Psychology 63 (2) 234-246. Luders H O, Dinner D S, Morris H H, Wyllie E, Comair Y G (1995) Cortical electrical stimulation in humans: the negative motor areas. Advances in Neurology 67:115-119. Malmo R B, Boag T J, Smith A A (1957) Physiological study of personal interaction. Psychosomatic Medicne 19, 105-119. Marmar C R, Weiss D S, Schlenger W E, Fairbank J A, Jorda B K, Kulka R A, Hough R L (1994) Peritraumatic dissociation and post-traumatic stress in male Vietnam theatre veterans. American Journal of Psychiatry 151, 907-909. McEvedy C P, Beard A W (1970) Royal Free epidemic: a reconsideration. British Medical journal. i, 7-11. McHugo G J, Lanzetta J T, Sullivan D G, Masters R D, Englis B G (1985) Emotional reactions to a political leader’s expressive displays. Journal of Personality and Social Psychology 49, 1513-1529. Meltzoff A N, Moore M K (1977) Imitation of facial gestures by human neonates. Science 198, 75-78. Orne M T (1959) The nature of hypnosis: artifact and essence. Journal of Abnormal Social Psychology 58: 277-299. Pardo J, Pardo P, Janer K, Raichle M E (1990) the anterior cingulated cortex mediates processing selection in stroop attentional conflict paradigm. Proceedings of the National Academy of Science, USA 87: 256-259. Pavlov I P (1941) Lectures on conditioned reflexes, Vol 2, Lawrence and Wishart: London. Penrose L S, (1952) On the objective study of crowd behavior. H Lewis: London. Posner M I, Petersen S E, Fox P T, Raichle M E (1988) Localization of cognitive operations in the human brain. Science 240: 1627-1631. Rizzolati G, Camarda R, Fogassi L, Gentilucci M, Luppino G, Mantelli M (1988) Functional organization of inferior area 6 in the macaque monkey: II. Area F5 and the control of distal movements. Experimental Brain Research 71, 491-507. Rizzolati G, Fadiga L, Fogassi L, Gallese V (1999) Resonance behaviors and mirror neurons. Archives Italiennes de Biologie 137, 85-100. Roelofs K, van Galen G P, Keijsers G P J, Naring G, Moene F, Sandijk P (2002) Hypnotic susceptibility in patients with conversion disorder. Journal of Abnormal psychology 111 (2) 390-395. Sargant W (1994) The mind possessed: A physiology of possession, mysticism and faith healing. The Lippincott Company: New York. Small G, Borus J (1983) Outbreak of Illness: mass hysteria or toxic poisoning? New England Journal of Medicine 308, 632-635. Small G, Nicholis A (1982) Mass Hysteria among School children. Archives of General Psychiatry 39, 721-724. Spiegel D (1984) Multiple personality as a post-traumatic stress disorder. Psychiatric Clinics of North America 7, 101-110. Spiegel D (1990) Hypnosis, dissociation and trauma: hidden and overt observers in repression and dissociations. In: JL Singer (ed.) Repression and Dissociation: Implications for Personality Theory, Psychopathology, and Health. Chicago IL: University of Chicago Press, 121-142.

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Spiegel D (1992) The use of hypnosis in the treatment of PTSD. Psychiatry Medicine 10, 2130. Spiegel D (1992) The use of hypnosis in the treatment of PTSD. Psychiatry Medicine 10, 2130. Spiegel D, Cardena E (1990) New uses of hypnosis in treatment of post-traumatic stress disorder. Journal of Clinical Psychiatry (October supplement): 39-43. Spiegel D, Hunt T, Dondershine H E (1988) Dissociation and hypnotizability in posttraumatic stress disorder. American Journal of Psychiatry 145, 301-305. Stahl S M, Lebedun M J, (1974) Mystery gases. Journal of Health and Social Behavior. 15, 44-50. Tallabs F (2005) Functional correlates of hypnotic and conversion paralysis: A neurophysiological hypothesis. Contemporary Hypnosis 22 (4) 184-192. Tan E S (1963) Epidemic hysteria. Medical journal of Malaya 18, 72-76. Tellegen A, Atkinson G (1974) Openness to absorbing and self-altering experience (absorption) a trait related to hypnotic susceptibility. Journal of Abnormal Psychology 83: 268-277. Teoh J, Soewondo S, Sidharta M (1975) Epidemic hysteria in Malaya. Psychiatry 38 258-267. Teoh J, Yeoh K (1973) Cultural conflict and transition: epidemic hysteria and social sanction. Australian and New Zealand Journal of Psychiatry 7, 283-295. Thorpe W H, (1953) Learning and Instincts in Animals (2nd Ed) London. Methuen and Co. Ltd. Tinbergen N (1953) Social Behavior in Animals. London. Methuen and Co. Ltd. Vaughan K B, Lanzetta J T (1980) Vicarious instigation and conditioning of facial expressive and autonomic responses to a model’s expressive display of pain. Journal of Personality and Social Psychology. 38, 909-923. Watson N (1982) An outbreak of hysterical paraplegia. Paraplegia 3, 154-157. Wessely (1987) Mass Hysteria: Two syndromes? Psychological Medicine 17, 109-120. Wong S W, Kwong B, Tam Y K, Tsoi M M (1982) Psychological epidemic in Hong Kong I: Epidemiological study. Acta Psychiatrica Scandinavia 65, 421-436. Reviewed by: Prof Anarbol Lopez, Center for Applied Psychology Address: Espinoza 854 Pte, Monterrey N.L. México.

In: Hypnosis: Theories, Research and Applications Editors: G. D. Koester and P. R. Delisle

ISBN 978-1-60456© 2009 Nova Science Publishers, Inc.

Chapter 8

RELAXATION, MEDITATION, AND HYPNOSIS FOR SKIN DISORDERS AND PROCEDURES* Philip D. Shenefelt Department of Dermatology and Cutaneous Surgery University of South Florida, Tampa, Florida, USA

ABSTRACT Relaxation, meditation, and hypnosis can help calm and rebalance the inflammatory immune response, which in turn can ameliorate inflammatory skin disorders. The relaxation response has been shown to help rebalance immune functioning. Mindfulness meditation has been shown to enhance the response of psoriasis to ultraviolet light treatments. Hypnosis has been shown to decrease inflammation and discomfort in a number of skin disorders and to improve the patient's attitude about having the condition. Hypnosis has also been shown to be more effective than relaxation alone in alleviating inflammatory skin disorders. Psychocutaneous hypnoanalysis permits diagnostic evaluation as to whether psychosomatic issues are initiating or exacerbating specific skin disorders. If psychosomatic issues are present, hypnoanalysis also permits treatment by reframing the initiating event in a way that defuses the negative emotional charge associated with it. Rapid induction hypnosis followed by deepening and then self-guided imagery has also been effective in alleviating anxiety and discomfort associated with dermatologic procedures.

*

A version of this book was also published as a chapter in Mind-Body and Relaxation Research Focus, edited by Bernardo N. De Luca, published by Nova Science Publishers, Inc. It was submitted for appropriate modifications in an effort to encourage wider dissemination of research.

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INTRODUCTION Our skin provides extensive with and protection from the outside world. The skin and the nervous system develop side by side in the ectoderm of the fetus and remain intimately interconnected throughout life. Cutaneous sensory nerves provide the largest sense organ of the body and are also vital to skin protection and health. There is a significant psychosomatic or behavioral component to many skin disorders. This interaction permits interventions such as relaxation, meditation, and hypnosis to have positive impacts on many cutaneous diseases. Stress is epidemic in modern life. According to an Associated Press poll conducted in November 2006 (Lester 2006), roughly 75 percent of people in the United States, Australia, Canada, , , Italy, South Korea, and the United Kingdom said that they experience stress daily. See Table 1. In modern industrial societies, factors increasing stress included multiple jobs, long commutes, and increasingly complex technology, both at work and at home. The tense or anxious feelings often associated with having too much to do, too many bills to pay, not enough time, not enough money, health concerns, or family life situations were commonplace. Those earning higher incomes frequently cited their jobs as the leading stress factor, while for those earning lower incomes it was most commonly finances. With an increased emphasis on consumerism and easy credit in the United States, finances were most commonly named as the most frequent stress factor. Our current culture has many other stressful aspects, such as information overload and encouragement of activity overload. In less stressed Spain 61 percent experienced daily stress, while in even more laid back Mexico less than 50 percent experienced daily stress. Table 1. Most important cause of stress in person’s life in percent (sample of about 1000 in each country, margin of error 3%, “other” and “not sure” omitted) modified from Associated Press poll (Lester 2006) Job Finances Health Family life Australia 35 27 14 24 Canada 32 28 19 13 30 30 20 13 37 18 25 15 Italy 33 19 20 13 Mexico 20 38 15 12 South Korea 33 28 13 12 Spain 34 15 23 19 United Kingdom 26 32 15 19 United States 26 34 15 16 Stress can trigger or aggravate many inflammatory skin diseases (See Table 2) and by adding to suppression of the immune response, chronic stress can increase susceptibility to skin cancer (Saul, Oberyszyn, Daugherty et al 2005). Stress and anxiety or anger can feed on each other in a harmful positive loop of increasing distress. The skin serves as a massive sensory organ intimately connected with the nervous system. In addition, neuropeptides released by the sensory nerve fibers activate neuropeptide receptors on skin

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cells to induce inflammatory activities. Cholinergic sympathetic fibers innervate the eccrine sweat glands and control sweating. Thermal sweating occurs globally in the skin, while emotional sweating is accentuated on the forehead, palms, soles, and axillae. Sweating can be measured by galvanic skin resistance (GSR). Adrenergic and cholinergic fibers innervate the arrector pili muscles, causing hairs to stand up. This occurs both with exposure to cold and with a strong sudden emotional fear reaction. Adrenergic fibers innervate the cutaneous blood vessels. Alpha adrenergic receptors mediate vasoconstriction, while beta adrenergic receptors mediate vasodilitation, controlling cutaneous blood flow. Emotional embarrassment can cause facial blushing, while fear can cause facial pallor. Skin temperature is related to cutaneous blood flow (Chu, Haake, Holbrook et al, 2003). Table 2. Emotional Triggering of Dermatoses in 4576 Patients Diagnosis Hyperhidrosis Lichen simplex chronicus Neurotic excoriations Alopecia areata Warts, multiple & spreading Rosacea Pruritus Lichen planus Dyshidrotic hand dermatitis Atopic dermatitis Factitial dermatosis Urticaria Psoriasis Traumatic dermatitis Dermatitis not otherwise specified Acne vulgaris Telogen effluvium Nummular dermatitis Seborrheic dermatitis Herpes simplex / zoster Vitiligo Pyoderma / bacterial infection Nail dystrophy Cysts Warts, single / multiple dermatitis Fungal infections Basal cell carcinoma Keratoses Nevi

% Triggered 100.0 98.5 97.5 96.4 94.9 94.1 85.7 81.8 75.8 70.2 69.2 68.1 62.3 55.6 55.6 55.3 54.7 51.8 40.6 35.7 33.3 29.1 28.5 27.0 17.4 15.3 8.7 0 0 0

Modified from Shenefelt: Arch Dermatol 2000; 136: 393-399, Table 1, p. 394

Time Sec d-2 wk Sec 2 wk days 2d Sec d-2 wk 2d Sec Sec Min d-2 wk Sec days 2d 2-3 wk days d-2 wk days 2-3 wk days 2-3 wk 2-3 wk days 2d d-2 wk N/A N/A N/A

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The central nervous system (CNS) also mediates hormone release through the hypothalamus with its actions on the pituitary and other endocrine glands. Skin and hair are influenced by thyroid and sex hormones. Melanocytes are stimulated by melanocytestimulating hormone to produce more melanin. Stress hormones influence the immune system, affecting inflammatory processes in the skin. Many inflammatory skin diseases such as acne, alopecia areata, aphthous stomatitis, atopic dermatitis, herpes simplex recurrences, lichen planus, rosacea, psoriasis, seborrheic dermatitis, telogen effluvium, vitiligo, and others are exacerbated by excessive stress (Zane 2003). The interactions of the CNS and the immune system were well reviewed by Kiecolt-Glaser et al (Kiecolt-Glaser, McGuire, Robles et al 2002). Habits (CNS conditioned responses) can be influenced by stress and determine skin exposure to environmental hazards such as ultraviolet light, chemicals, physical injury, and temperature extremes. Manipulation of normal or diseased skin can result in excoriations (damage from scratching), lichenification (thickening in response to rubbing), factitial (intentional) trauma, aggravation of existing skin conditions, and subsequent dyspigmentation or scarring. Conversely, the appearance of the skin and hair can have a significant impact on self image (in the CNS) and social interactions, leading to stress. Skin diseases also can affect self image, social interactions, and behavior. Chronic skin disorders such as acne, alopecia areata, atopic dermatitis, or psoriasis can induce or aggravate depression in susceptible individuals (Gupta and Gupta 2003). Reducing acute and especially chronic stress through nonpharmacologic methods can help calm inflammatory skin disorders and rebalance the immune response. The stress reducing techniques can be divided into primarily physical and primarily mental (Smith 2005). See Table 3. Table 3. Deep Relaxation Categories of Methods Primarily Physical • Breathing • Progressive muscle relaxation • Yoga stretching • Bio—requires equipment Primarily Mental • Autogenic suggestion---a special sequence of self-hypnosis • Hypnosis and self-hypnosis • Imagery and relaxing self-talk • Meditation ƒ Concentrative—one simple stimulus or mantra ƒ Mindfulness---quiet observation with detachment

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RELAXATION Breath relaxation has been practiced for centuries. It has been an aspect of some yoga traditions and has been used in the Lamaze method of natural childbirth. The basic method is to focus on the breath and to intentionally slow and deepen breathing, shifting from more shallow and rapid chest centered breathing to deeper and slower diaphragmatic abdominal breathing. Breath relaxation can induce trance. It is more commonly used to induce meditative trance but also can be used as a hypnotic induction. The resulting calming effect can improve the psychosomatic aspects of skin disorders. Progressive muscular relaxation was developed by Edmund Jacobson (1929). He showed using bio instrumentation that excess muscular tension was present in many psychosomatic disorders. Intentionally tensing and then relaxing the muscles decreased emotional distress and the resulting calmness and relaxation reduced psychosomatic symptoms. The basic method is to be in a seated or recumbent position and start at the hands, head, or toes with intentional muscle tensing followed by relaxation. The adjacent body part muscles are then tensed and relaxed, followed by those of the next adjacent body area until all areas of the body have been covered. Progressive muscular relaxation can be used by itself for treatment and prophylaxis of psychosomatic components of skin disorders. It may induce a hypnotic or meditative trance and is one of the methods of hypnotic trance induction. The relaxation should be maintained for 5 to 25 minutes for optimal benefit. The sitting position is preferred if the patient desires to realert after the progressive muscular relaxation, while the recumbent position is preferred if the patient desires to drift off to sleep for a nap or at bedtime. Bio of muscle tension via EMG can enhance teaching of relaxation. Bio assisted relaxation can have a positive effect on inflammatory and emotionally triggered skin conditions such as acne, atopic dermatitis, dyshidrotic dermatitis (Koldys and Meyer 1979), hyperhidrosis (Duller and Gentry 1980), lichen planus, neurodermatitis, psoriasis (Benoit and Harrell 1980) and urticaria. The most common mechanism is through influencing immunoreactivity (Tausk 1998). Patients who have low hypnotic ability may be especially suitable for this type of relaxation training utilizing EMG bio.

MEDITATION Various forms of meditation have been used since antiquity. They are an efficient and effective means of reducing stress. The various types of meditation may broadly be divided into concentrative meditation where the focus is on one object such as a candle flame or mandala, image, sound, word, or mantra and mindfulness meditation where the focus is on emotional nonattachment but broad awareness of many objects, sounds, other sensations, or thoughts. Both may involve entering a trance. The concentrative trance reduces external awareness, while the mindfulness trance maintains external awareness while remaining calmly centered. There are parallels of concentrative meditation to internally focused hypnotic trance and of mindfulness meditation to alert awake hypnotic trance. The western paradigm for healing tends to look at the “how” of disease, examining the subsystems involved and the means to repair and cure or control the problem with a short

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term focus, while the eastern paradigm for healing tends to look at the “what” of disease, examining the systems and supersystems involved and the means to restore or rebalance the system with a long term focus (Otani 2003). Hypnosis arose in the western cultural milieu while meditation arose in the eastern cultural milieu. They both use the trance phenomena but with different conceptual approaches and different types of emphasis. One form of generic concentrative meditation was introduced by Herbert Benson (1975) to induce what he termed the relaxation response. It involves sitting in a quiet place, closing your eyes, letting your muscles loosen and relax, starting at your feet and working upward (progressive muscular relaxation trance induction), breathing evenly through your nose and becoming aware of the breath (breath relaxation trance induction). With each exhalation, say the word “one” to yourself (concentrative mantra meditation trance induction). Maintain a ive attitude. Let any distracting thoughts or sensations drift away ignored like clouds in the sky. Maintain the concentrative meditation for 10 to 15 minutes. When you finish, remain sitting quietly for a few minutes, first with your eyes closed, then with your eyes open. The health benefits of the relaxation response have been extensive researched with positive results in areas such as cardiovascular health. Mindfulness meditation has also been used extensively for stress reduction. Originally associated with Buddhism and in particular Zen, it has been adapted for medical use. Jon Kabat-Zinn (1991, 1994) has been a major proponent of this methodology, employing mindfulness mediation and hatha yoga. He developed the Mindfulness-Based Stress Reduction program. The 8 week course had weekly 2 hour classes where techniques of breath, awareness of body sensations, and stretching yoga combined with at half day of meditation and daily homework of 45 minutes taped guided meditation or 30 minutes of meditation on their own helped them to develop nonjudgmental, moment to moment awareness, attention monitoring, and acceptance. He also performed a study (Kabat-Zinn 1998) with randomization of psoriasis patients undergoing ultraviolet B (UVB) or psoralen plus ultraviolet A (PUVA) light treatments into two groups, those listening to mindfulness meditation tapes and those who were controls. Patients in the mindfulness meditation tape group reached the halfway point in clearing and the clearing point significantly more rapidly than the controls for both UVB and PUVA treatments.

HYPNOSIS Hypnosis is a tool with many useful dermatologic applications, including stress reduction. It involves guiding the patient into a trance state for a specific purpose such as relaxation, pain or pruritus reduction, or habit modification. Hypnosis may improve or clear numerous skin disorders. Examples include acne excoriée, alopecia areata, atopic dermatitis, congenital ichthyosiform erythroderma, dyshidrotic dermatitis, erythromelalgia, furuncles, glossodynia, herpes simplex, hyperhidrosis, ichthyosis vulgaris, lichen planus, neurodermatitis, nummular dermatitis, post-herpetic neuralgia, pruritus, psoriasis, rosacea, trichotillomania, urticaria, verruca vulgaris, and vitiligo (Shenefelt 2000). Hypnosis can also reduce stress, anxiety and pain associated with dermatologic procedures. See Table 4. We all experience spontaneous mild trances daily while absorbed in watching television or a movie, reading a book or magazine, or other focused activity. After appropriate training,

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we may intensify this trance state and use this heightened focus to induce mind-body interactions that help to alleviate suffering or to promote healing. We may induce the trance state using guided imagery, relaxation, deep breathing, meditation techniques, self-hypnosis, or hypnosis induction techniques. Table 4. Skin disorders reported responsive to hypnosis. Randomized Control Trials (representing strong evidence of effectiveness) o Hypnotic relaxation during procedures o Verruca vulgaris o Psoriasis Nonrandomized Control Trials o Atopic dermatitis Case Series o Alopecia areata o Urticaria Single or Few Case Reports (representing weak evidence of effectiveness) o Acne excoriée o Congenital ichthyosiform erythroderma o Dyshidrotic dermatitis o Erythromelalgia o Furuncles o Glossodynia o Herpes simplex o Hyperhidrosis o Ichthyosis vulgaris o Lichen planus o Neurodermatitis o Nummular dermatitis o Post-herpetic neuralgia o Pruritus o Rosacea o Trichotillomania o Vitiligo

Hypnosis is the intentional induction, deepening, maintenance, and termination of the trance state for a specific purpose. Trance has been used since antiquity to assist the healing process. The purpose of medical hypnotherapy is to reduce suffering, to promote healing, or to help the person alter a destructive behavior. Some people are more highly hypnotizable, others less so, but most can obtain some benefit from hypnosis. Low hypnotizability is to a large extent hard-wired into individuals' brains and tends to be consistent over time as measured by the Hypnotic Induction Profile (Spiegel and Spiegel 2004). One biological factor that has been associated with degree of hypnotizability is the catechol-o-methyl-transferase gene. At position 148 in this enzyme, gene coding for the amino acid valine on both alleles

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(homozygous) is associated with a four times more rapid degradation of dopamine and lower hypnotizability compared with gene coding for methionine on both alleles (homozygous) with slower degradation of dopamine and medium hypnotizability. Heterozygous coding for valine and methionine is associated with medium to high hypnotizability (Lichtenberg, BachnerMelman R, Gritsenko et al, 2000). Hypnosis can hasten the resolution of some skin diseases, including verruca vulgaris (warts). Hypnosis may also help to reduce stress, skin pain, pruritus, or psychosomatic aspects of skin diseases. Suggestion without formal trance induction may be sufficient in some cases. Bloch (1927) and Sulzberger (1934) used suggestion to treat verrucae successfully. The precise definition of hypnosis is still somewhat controversial. Marmer (1959) defined hypnosis as a psychophysiological tetrad of altered consciousness consisting of narrowed awareness, restricted and focused attentiveness, selective wakefulness, and heightened suggestibility. Further discussions of the definitions of hypnosis are available in Crasilneck and Hall (1985) or Barabasz andWatkins (2005). There are many myths about hypnosis that distort, overrate, or underrate the true capabilities of hypnosis. Recent evidence from EEG studies and positron emission tomography (PET) studies comparing brain activity in the same individual when alert and when in trance lend to the theory that hypnosis is a describable altered state of consciousness rather than simply a social compliance with expectations. Quantitative EEG findings by Freeman et al (Freeman, Barabasz, Barabasz et all 2000) in a study of hypnosis versus distraction effects on cold pressor pain showed significantly greater high theta (5.5-7.5 Hz) activity for high hypnotizables (based on Stanford Hypnotic Susceptibility Scale, Form C, or SHSS:C scores ) compared with low hypnotizables at parietal and occipital sites during hypnosis and also during waking relaxation. PET subtraction studies by Faymonville et al (Faymonville, Laurys, Degueldre et al 2000) demonstrated specific areas of the cerebral cortex with higher bloodflow during hypnosis and others with lower bloodflow, presumably related to cerebral activity. In their study, pain reduction mediated by hypnosis localized to the mid anterior cingulate cortex. The mechanisms by which hypnosis produces improvement in symptoms and in skin lesions are not fully understood. Hypnosis can help regulate bloodflow and other autonomic functions not usually under conscious control. Stress reduction through the relaxation response that accompanies hypnosis alters the neurohormonal systems that in turn regulate many body functions. (Tausk 1998) For skin disorders, hypnosis may be used to help control stress exacerbated harmful habits such as scratching. It can also be used to provide immediate and long term analgesia, reduce symptoms such as pruritus, improve recovery from surgery, and facilitate the mindbody connection to promote healing. Skin diseases responsive to hypnosis are described in the relatively old book by Scott (1960) and in the chapter on the use of hypnosis in dermatological problems in Crasilneck and Hall (1985). Koblenzer (1987) also mentions some of the uses of hypnosis in common dermatologic problems. Grossbart and Sherman (1992) include hypnosis as recommended therapy for a number of skin conditions in an excellent resource book for patients. Skin disorders that have responded to hypnotherapy are discussed below.

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MEDICAL HYPNOTHERAPY Hypnosis can be used to reduce stress and psychological or behavioral impediments to healing. Hypnosis facilitates ive therapies (ego-strengthening), direct suggestion, symptom substitution, and hypnoanalysis (Scott 1960; Scott 1963; Scott 1964; Hartland 1969). See Table 5. Mentioning hypnosis to patients will allow the practitioner to gauge the patient's receptiveness to this treatment modality. The time needed to screen patients, educate them about realistic expectations for results from hypnosis, and actually perform the hypnotherapy are similar to or less than those for screening, preparing, and educating patients about cutaneous surgery and then actually performing the surgery. Practitioners who prefer to refer patients to hypnotherapists or who desire further information about training in hypnotherapy may obtain referrals or training information from the American Society of Clinical Hypnosis or similar professional organizations. Table 5. Hypnotic trance sequence during medical hypnotherapy. Trance induction Rapid- -Eyeroll Slow- -Progressive relaxation or other method Trance deepening Trance work (one or more) Ego strengthening Direct suggestion Indirect suggestion Hypnoanalysis Relaxation for procedures Trance termination Some advantages of medical hypnotherapy for skin diseases include nontoxicity, costeffectiveness, ability to obtain a response where other treatment modalities have failed, and ability of patients to self-treat and gain a sense of control when taught self-hypnosis reinforced by using audiotapes or mp3s. Disadvantages include the practitioner training required, the low hypnotizability of some patients, the negative social attitudes still prevalent about hypnosis, and the lower reimbursement rates for cognitive therapies such as hypnosis when compared with procedural therapies such as cutaneous surgery. Patient selection is an important aspect of successful medical hypnotherapy. With proper selection of disease process, patient, and provider, hypnosis can decrease suffering and morbidity from skin disorders with minimal side effects. Induction of the hypnotic state in adults is achieved by methods that focus attention, soothe, and/or produce monotony or confusion (Crasilneck and Hall 1985; Barabasz and Watkins 2005). The hypnotic state may be induced in children by having the child makebelieve that he or she is watching television, a movie, or a play or by using some other distractive process that employs the imagination (Olness 1986). ive (ego-strengthening) therapies include positive suggestions and posthypnotic suggestions for self-worth and effectiveness. Reinforcement can be achieved by recording an

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audiocassette tape or mp3 that the patient can use subsequently for repeated self-hypnosis. The strengthened ego is better able to deal with psychological elements that inhibit healing. Direct suggestion during hypnosis may be used to decrease stress, skin discomfort from pain, pruritus, burning sensations, anxiety, and insomnia. Posthypnotic suggestion and repeated use of an audiocassette tape or mp3 by the patient for self-hypnosis helps to reinforce the effectiveness of direct suggestion. In highly hypnotizable individuals, direct suggestion may produce sufficiently deep anesthesia to permit cutaneous surgery. Direct suggestion can also reduce compulsive acts of skin scratching or picking, nail biting or manipulating, and hair pulling or twisting (Scott 1960). Autonomic responses in hyperhidrosis, blushing, and some forms of urticaria can also be controlled by direct suggestion. Verrucae can be induced to resolve using direct suggestion (see below). Symptom substitution replaces a negative habit pattern with a more constructive one (Scott 1960). For example, another physical activity, such as grasping something and holding it so tightly for a half minute that it almost hurts, can be substituted for scratching. Other activities that can be substituted for scratching include athletics, artwork, verbal expression of feelings, or meditation. Hypnoanalysis may help patients with skin disorders unresponsive to other simpler approaches. Using hypnoanalysis, results may also occur much more quickly than with standard psychoanalysis (Scott 1960). The C.O.M.P.A.S.S. method of identifying seven trigger or exacerbating psychosomatic root causes is slightly modified from the method well described in Ewin and Eimer (2006). See Table 6. Uncovering the trigger or exacerbating factors and neutralizing the associated negatively charged emotion often leads to the resolution of the psychosomatic aspects of the problem. One of my patients who had persistent erythema nodosum for 9 years with no apparent physical trigger factors had resolution of the lesions after hypnoanalysis (Shenefelt 2007). Table 6. C.O.M.P.A.S.S. method of hypnoanalysis for root causes • • • • • • •

Conflict Organ language Motivation Past experiences Active identification Self punishment Suggestion

MEDICAL HYPNOTHERAPY FOR TREATING SPECIFIC SKIN DISORDERS Until recently, reports of the effectiveness of hypnosis on specific dermatologic conditions were mostly based on one or a few uncontrolled cases. Since the validity of such findings await further confirmation, "may" is used below to qualify recommendations that are based on weak evidence. The trend toward more controlled trials has produced more reliable

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information (Kaschel, Revenstorf and Wörz 1991), although randomized controlled trial results are still not available for most skin disorders. The list of responsive skin conditions below is not all-inclusive. Posthypnotic suggestion was successful in reducing or stopping the picking associated with acne excoriée in two reported cases (Hollander 1959). One patient was instructed to the word "scar" whenever she wanted to pick her face and to refrain from picking by saying "scar" instead. I have had similar success in one case (Shenefelt 2004). Hypnosis may be an appropriate treatment for the picking habit aspect of acne excoriée in conjunction with standard treatments for the acne itself. In a small clinical trial of medical hypnotherapy with five patients having extensive alopecia areata, only one patient showed significant increase in hair growth. Although three patients had only slight increase in hair growth and one had no change, hypnosis did improve stress and psychological parameters in these five patients (Harrison PV, Stepanek 1991). In a larger clinical trial (Willemsen, Vanderlinden, Deconinck et al 2006), all 21 patients with severe alopecia areata had improvement of anxiety and depression with hypnotherapy. Nine patients had total regrowth of scalp hair, and another 3 patients had better than 75 percent regrowth. Hypnosis may be appropriate as a complementary ive treatment for the psychological impact of having alopecia areata, and may sometimes have an effect on the condition itself. A number of case reports describe improvement of atopic dermatitis in both children and adults as a result of hypnotherapy (Twerski and Naar 1974). Stress plays a significant role in the exacerbation of atopic dermatitis. In a nonrandomized controlled clinical trial. Stewart and Thomas (1995) treated 18 adults with extensive atopic dermatitis who had been resistant to conventional treatment with hypnotherapy that included relaxation, stress management, direct suggestion for non-scratching behavior, direct suggestion for skin comfort and coolness, ego strengthening, posthypnotic suggestions, and instruction in self-hypnosis. The results were statistically significant (p < 0.01) for reduction in itch, scratching, sleep disturbance, and tension. Patient use of topical corticosteroid decreased by 40% at 4 weeks, 50% at 8 weeks, and 60% at 16 weeks. For atopic dermatitis, hypnosis can be a very useful complementary therapy that can decrease the needed amount of other treatments. Remarkable clearing of congenital ichthyosiform erythroderma of Brocq in a 16 year old boy was reported following direct suggestion for clearing under hypnosis (Mason 1952). Similar though less spectacular results were confirmed with two sisters aged eight and six (Wink 1961), with a 20 year old woman (Schneck 1966), and with 34 year old father and his four year old son (Kidd 1966). Based on these case reports, hypnosis may be potentially very useful as a complementary therapy in addition to emollients. Reduction in severity of dyshidrotic dermatitis has been reported with using hypnosis as a complementary treatment (Tobia 1982). Stress is a known common trigger factor for dyshydrotic dermatitis, to the point where some individuals can use the flaring of their dyshidrotic dermatitis as a barometer of their stress levels. There is one case report of successful treatment of erythromelalgia in an 18 year old woman using hypnosis alone followed by self-hypnosis (Chakravarty, Pharoah, Scott et al 1992). Permanent resolution occurred. A 33 year old man with a negative self image and recurrent multiple Staphylococcus aureus containing furuncles since age 17 was unresponsive to multiple treatment modalities. Hypnosis and self-hypnosis with imagined sensations of warmth, cold, tingling, and

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heaviness brought about dramatic improvement over 5 weeks with full resolution of the recurrent furuncles (Jabush 1969). The patient also improved substantially from a mental standpoint. Conventional antibiotic therapy is the first line of treatment for furuncles, but in unusually resistant cases with significant psychosomatic overlay, complementary use of hypnosis may help to end the chronic susceptibility to recurrent infection. Oral pain such as glossodynia may respond well to hypnosis as a primary treatment if there is a significant psychological component (Golan 1997). With organic disease, hypnosis may give temporary relief from pain. Discomfort relief from herpes simplex is similar to that for postherpetic neuralgia (see below). A reduction in the frequency of recurrences of herpes simplex following hypnosis has also been reported (Bertolino 1983). In cases with an apparent emotional stress trigger factor, hypnotic suggestion may be useful as a complementary therapy for reducing the frequency of recurrence. Hypnosis or autogenic training may be useful as adjunctive therapy for hyperhidrosis (Hölzle 1994). Stress is a common trigger or exacerbator of hyperhidrosis. A 33 year old man with ichthyosis vulgaris which was better in summer and worse in winter began hypnotic suggestion therapy in the summer and was able to maintain the summer improvement throughout the fall, winter, and spring (Schneck 1954). Pruritus and lesions of lichen planus may be reduced in selected cases using hypnosis (Scott 1960; Tobia 1982). Stress is a definite exacerbating factor in lichen planus. Some cases of neurodermatitis have resolved and stayed resolved with up to 4 years of followup using hypnosis as an alternative therapy (Kline 1953; Sacerdote 1965; Collison 1972; Lehman 1978). Stress is a major factor in increasing scratching or picking in these patients. Reduction of pruritus and resolution of lesions of nummular dermatitis has been reported with use of hypnotic suggestion (Scott 1960; Tobia 1982). Pain from herpes zoster and post-herpetic neuralgia can be reduced by hypnosis (Scott 1960; Tobia 1982). Hypnosis may be useful as a complementary therapy for postherpetic neuralgia. Hypnosis may modify and lessen the intensity of pruritus (Scott 1960). A man with chronic myelogenous leukemia had intractable pruritus that was much improved with hypnotic suggestion (Ament and Milgram 1967). Itching typically increases with stress. Stress is a common exacerbating factor in psoriasis. Hypnosis and suggestion have been demonstrated to have a positive effect on psoriasis (Kantor 1990; Winchell and Watts 1988; Zachariae, Oster, Bjerring et al 1996). A 75 percent clearing of psoriasis was reported in one case using a hypnotic sensory-imagery technique (Kline 1954). In another case of extensive severe psoriasis of 20 years duration marked improvement occurred using sensory imagery to replicate the feelings in the patient's skin that he had experienced during sunbathing (Frankel and Misch 1973). Another case of severe psoriasis of 20 years duration resolved fully with a hypnoanalytic technique (Waxman 1973). Tausk and Whitmore (1999) performed a small randomized double-blind controlled trial using hypnosis as adjunctive therapy in psoriasis with significant improvement only in the highly hypnotizable subjects and not in the moderately hypnotizable subjects. Hypnosis can be quite useful as a complementary therapy for resistant psoriasis, especially if there is a significant emotional factor in the triggering of the psoriasis. The vascular blush component of rosacea has been reported to improve in selected cases

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of resistant rosacea where hypnosis has been added as complementary therapy (Scott 1960; Tobia 1982). Stress can increase blushing. Several reports of successful adjunctive treatment of trichotillomania have been published (Galski 1981; Rowen 1981; Barabasz 1987). Stress is an exacerbating factor. Hypnosis may be a useful complementary therapy for trichotillomania. Two cases of urticaria responded to hypnotic suggestion in one study. Stress was a trigger factor. An 11 year old boy had an urticarial reaction to chocolate that could be blocked by hypnotic suggestion so that hives appeared on one side of his face but not the other in response to hypnotic suggestion (Perloff and Spiegelman 1973). In 15 patients with chronic urticaria of 7.8 years average duration, hypnosis with relaxation therapy resulted within 14 months in 6 patients being cleared and another 8 patients improved, with decreased medication requirements reported by 80 percent of the subjects (Shertzer and Lookingbill 1987). Hypnosis may be useful as complementary or even alternative therapy for selected cases of chronic urticaria. Reports by Bloch (1927) and Sulzberger (1934) on the efficacy of suggestion in treating verruca vulgaris have since been confirmed numerous times to a greater or lesser degree (Obermayer and Greenson 1949; Ullman 1959; Dudek 1967; Sheehan 1978) and failed to be confirmed in a few studies (Clarke 1965; Stankler 1967). A recent study that showed negative results was criticized for using a negative suggestion of not feeding the warts rather than a positive suggestion about having the warts resolve (Felt, Hall and Olness 1998). Many reports confirm the efficacy of hypnosis in treating warts (McDowell 1949; Ullman and Dudek 1960; Vickers 1961; Surman, Gottlieb and Hackett 1972; Ewin 1974; Clawson and Swade 1975; Tasini and Hackett 1977; Johnson and Barber 1978; Dreaper 1978; Straatmeyer and Rhodes 1983; Morris 1985; Spanos, Stenstrom and Johnston 1988; Noll 1988; Spanos, Williams and Gwynn 1990; Ewin 1992; Noll 1994). One study (Tenzel and Taylor 1969) that tried to replicate the remarkable success reported in Lancet (Sinclair-Gieben and Chalmers 1959) of using hypnotic suggestion to cause warts to disappear from one hand but not the other in persons with bilateral hand warts was unsuccessful. A well conducted randomized control study resulted in 53 percent of the experimental group having improvement of their warts three months after the first of five hypnotherapy sessions, while none of the control group had improvement (Surman, Gottlieb, and Hackett 1973). Hypnosis has been proved to be helpful as a complementary or alternative therapy for warts. Vitiligo has improved using hypnotic suggestion as complementary therapy (Scott 1960; Tobia 1982), but it is unclear whether the recovery was simply spontaneous. Hypnosis may be appropriate as a complementary ive treatment for the psychological impact of having vitiligo.

MEDICAL HYPNOTHERAPY FOR REDUCING PROCEDURE STRESS AND ANXIETY Hypnosis can reduce stress, anxiety, needle phobia, and pain during cutaneous surgery, as well as reducing postoperative discomfort. Fick et al (Fick, Lang, Logan et al 1999) used selfguided imagery content during nonpharmacologic analgesia on 56 nonselected patients referred for percutaneous interventional procedures in the radiology procedure suite. A

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standardized protocol and script was used to guide patients into a state of self-hypnotic relaxation. All 56 patients developed an imaginary scenario. The imagery they chose was highly individualistic. They concluded that average patients can engage in imagery, but topics chosen are highly individualistic, making prerecorded tapes or provider directed imagery likely to be less effective than self-directed imagery. I have used this technique with good success in dermatology patients (Shenefelt 2003). Lang et al (Lang, Benotsch, Fick et al, 2000) conducted a larger randomized trial of adjunctive non-pharmacologic analgesia for invasive radiologic procedures consisting of three groups: percutaneous vascular radiologic intraoperative standard care (control group), structured attention, and self-hypnotic relaxation. Pain increased linearly with time in the standard and the attention group, but remained flat in the hypnosis group. Anxiety decreased over time in all three groups, but more so with hypnosis. Drug use was significantly higher in the standard group than in the structured attention and self-hypnosis groups. The hemodynamic stability was significantly higher in the hypnosis group than in the attention and standard groups. Procedure times were significantly shorter in the hypnosis group than in the standard group, with the attention group intermediate. Cost analysis of this study (Lang and Rosen 2002) showed that the cost associated with standard conscious sedation averaged $638 per case while the cost for sedation with adjunct hypnosis was $300 per case, making the latter considerably more cost-effective. A meta-analysis of hypnotically induced analgesia found that hypnosis has been demonstrated to relieve pain in patients with headache, burn injury, heart disease, cancer, dental problems, eczema, and chronic back problems (Montgomery, DuHamel, and Redd 2000). For most purposes light and medium trance is sufficient, but deep trance is required for hypnotic anesthesia for surgery (Barabasz and Watkins 2005). Pain reduction mediated by hypnosis localized to the mid anterior cingulate cortex in a study (Faymonville, Laureys, Degueldre et al 2000) using a positron emission tomography (PET). For hypnosis to be of benefit, patients must be mentally intact, not psychotic nor intoxicated; motivated, not resistant, and preferably medium or high hypnotizable as rated by the Hypnotic Induction Profile (Spiegel and Spiegel 2004) or Stanford Hypnotic Susceptibility Scale and its variants. However, for self-guided imagery a moderate or high degree of hypnotizability is not critical to success. Letting the patient choose his or her own self-guided imagery allows most individuals to reach a state of relaxation during procedures.

REFERENCES Ament P, Milgram H. Effects of suggestion on pruritus with cutaneous lesions in chronic myelogenous leukemia. N Y State J Med 1967; 67:833-835. Barabasz A and Watkins JG: Hypnotherapeutic Techniques. 2nd ed. New York, New York, Brunner-Routledge 2005. Barabasz M. Trichotillomania: a new treatment. Int J Clin Exp Hypn 1987; 35:146-154. Benoit J and Harrell EH. Bio and control of skin cell proliferation in psoriasis. Psychol Reports 1980; 831-839. Benson H. The Relaxation Response. New York, New York, Morrow 1975. Bertolino R. L'ipnosi in dermatologia. Minerva Medica 1983; 74:2969-2973.

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Bloch B. Über die heilung der warzen durch suggestion. Klin Wchnschr 1927; 6:2271-2275; 6:2320-2325. Chakravarty K, Pharoah PDP, Scott DGI, Barker S. Erythromelalgia--the role of hypnotherapy. Postgrad Med J 1992; 68:44-46. Chu D H, Haake A R, Holbrook K, Loomis C A: The structure and development of skin. In Freedberg, I M, Eisen AZ, Wolff K, Austen K F, Goldsmith L A, Katz S I editors, Fitzpatrick's Dermatology in General Medicine sixth edition, New York, New York, McGraw-Hill, 2003 pp58-88. Clarke GHV. The charming of warts. J Invest Dermatol 1965; 45:15-21. Clawson TA, Swade RH. The hypnotic control of blood flow and pain: the cure of warts and the potential for the use of hypnosis in the treatment of cancer. Am J Clin Hypn 1975; 17:160-169. Collison DR. Medical Hypnotherapy. Med J Austr 1972; 1:643-649. Crasilneck HB, Hall JA. Clinical Hypnosis, 2nd ed, Orlando, Florida, Grune & Stratton, 1985. Dreaper R. Recalcitrant warts on the hand cured by hypnosis. Practitioner 1978; 220:305310. Dudek SZ. Suggestion and play therapy in the cure of warts in children: a pilot study. J Nerv Ment Dis 1967; 145:37-42. Duller P and Gentry WD. Use of bio in treating chronic hyperhidrosis: a preliminary report. Br J Dermatol 1980; 103:143-146. Ewin D. Condyloma acuminatum: successful treatment of four cases by hypnosis. Am J Clin Hypn 1974; 17:73-78. Ewin DM. Hypnotherapy for warts (verruca vulgaris): 41 consecutive cases with 33 cures. Am J Clin Hypn 1992; 35:1-10. Ewin DM, Eimer BN; Ideomotor Signals for Rapid Hypnoanalysis: a How-To Manual. Springfield, Illinois, Charles C. Thomas, 2006. Faymonville ME, Laurys S, Degueldre C, DelFiore G, Luxen A, Franck G, Lamy M, Maquet P. Neural mechanisms of antinociceptive effects of hypnosis. Anesthesiol 2000; 92:12571267. Felt BT, Hall H, Olness K, Schmidt W, Kohen D, Berman BD et al. Wart regression in children: comparison of relaxation-imagery to topical treatment and equal time interventions. Am J Clin Hypn 1998; 41:130-138. Fick LJ, Lang EV, Logan HL, Lutgendorf S, Benotsch EG. Imagery content during nonpharmacologic analgesia in the procedure suite: where your patients would rather be. Acad Radiol 1999; 6:457-463. Frankel FH, Misch RC. Hypnosis in a case of long-standing psoriasis in a person with character problems. Int J Clin Exp Hypn 1973; 21:212-130. Freeman R, Barabasz A, Barabasz M, Warner D. Hypnosis and distraction differ in their effects on cold pressor pain. Am J Clin Hypnosis 2000; 43:137-148. Galski TJ. The adjunctive use of hypnosis in the treatment of trichotillomania: a case report. Am J Clin Hypn 1981; 23:198-201. Golan HP. The use of hypnosis in the treatment of psychogenic oral pain. Am J Clin Hypn 1997; 40:89-96. Grossbart TA, Sherman C. Skin Deep: A Mind/Body Program for Healthy Skin, Revised ed. Santa Fe, New Mexico, Health Press, 1992.

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Lichtenberg P, Bachner-Melman R, Gritsenko I,Ebstein RP. Exploratory association study between catechol-o-methyltransferase (COMT) high/low enzyme activity polymorphism and hypnotizability. Am J Med Genetics 2000; 96(6):771-774. Marmer MJ. Hypnosis in Anesthesiology. Springfield, Illinois, Charles C. Thomas, 1959. Mason AA. A case of congenital ichthyosiform erythroderma of Brocq treated by hypnosis. Br Med J 1952; 2:422-423. McDowell M. Juvenile warts removed with the use of hypnotic suggestion. Bull Menninger Clin 1949; 13:124-126. Montgomery GH, DuHamel KN, Redd WH. A meta-analysis of hypnotically induced analgesia: how effective is hypnosis? Int J Clin Exp Hypn 2000; 48: 138-153. Morris BAP. Hypnotherapy of warts using the Simonton visualization technique: a case report. Am J Clin Hypn 1985; 27:237-240. Noll RB. Hypnotherapy of a child with warts. J Dev Behav Pediatr 1988; 9:89-91. Noll RB. Hypnotherapy for warts in children and adolescents. J Dev Behav Pediatr 1994; 15:170-173. Obermayer ME, Greenson RR. Treatment by suggestion of verrucae planae of the face. Psychosom Med 1949; 11:163-164. Olness KN. Hypnotherapy in children. Postgraduate Medicine 1986; 79(4):95-100,105. Otani A. Eastern meditative techniques and hypnosis: a new synthesis. Am J Clin Hypn 2003; 46:97-108. Perloff MM, Spiegelman J. Hypnosis in the treatment of a child's allergy to dogs. Am J Clin Hypn 1973; 15:269-272. Rowen R. Hypnotic age regression in the treatment of a self-destructive habit: trichotillomania. Am J Clin Hypn 1981;23:195-197. Sacerdote P. Hypnotherapy in neurodermatitis: a case report. Am J Clin Hypn 1965; 7:249253. Saul A N, Oberyszyn T M, Daugherty C, et al, Chronic stress and susceptibility to skin cancer. J Natl Cancer Inst 2005; 97:1760-1767. Schneck JM. Ichthyosis treated with hypnosis. Dis Nerv Syst 1954; 15:211-214. Schneck JM. Hypnotherapy for ichthyosis. Psychosomatics 1966; 7:233-235. Scott MJ. Hypnosis in skin and allergic diseases. Springfield, Illinois, Charles C. Thomas, 1960. Scott MJ. Hypnosis in dermatology. In Schneck JM (ed): Hypnosis in Modern Medicine, 3rd ed. Springfield, Illinois, Charles C. Thomas, 1963, pp 122-142. Scott MJ. Hypnosis in dermatologic therapy. Psychosomatics 1964; 5:365-368. Sheehan DV. Influence of psychosocial factors on wart remission. Am J Clin Hypn 1978; 20:160-164. Shenefelt PD, Hypnosis in dermatology. Arch Dermatol 2000; 136: 393-399. Shenefelt PD. Hypnosis-facilitated relaxation during self-guided imagery during dermatologic procedures. Am J Clin Hypn 2003; 45:225-232. Shenefelt PD. Using hypnosis to facilitate resolution of psychogenic excoriations in acne excoriée. Am J Clin Hypn 2004; 46:239-245. Shenefelt PD. Psychocutaneous hypnoanalysis: detection and deactivation of emotional and mental root factors in psychosomatic skin disorders. Am J Clin Hypn 2007; 50:131-136. Shertzer CL, Lookingbill DP. Effects of relaxation therapy and hypnotizability in chronic urticaria. Arch Dermatol 1987; 123:913-916.

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In: Hypnosis: Theories, Research and Applications Editors: G. D. Koester and P. R. Delisle

ISBN 978-1-60456© 2009 Nova Science Publishers, Inc.

Chapter 9

HYPNOSIS AND CANCER: A DEAD-END STORY?* Fabrice Kwiatkowski1, Nancy Uhrhammer2, Yves-Jean Bignon2 and Alain Blanchet3 1 2

Bio-statistics unit, Centre Jean Perrin and University Paris-8 (Saint-Denis), Laboratory of Molecular Oncology, Centre Jean Perrin, Clermont-Ferrand, 3 Department of Psychology, University Paris-8 (Saint-Denis),

ABSTRACT Oncology is a domain where hypnosis has a role to play, since medical treatments are still not sufficient. Although the impact of many types of psychosocial intervention have been tested in cancer patients with disappointing results on survival, hypnosis has not yet been assessed using appropriate methodology. Surveys testing hypnosis that include survival as an end-point need still to be performed. On the other hand, the impact of hypnosis on patients’ well-being has been well studied, and appears to be very useful against depression, pain, treatment side-effects and other symptoms. It can now be proposed to children or adults, and has proven to be a great help to terminally ill cancer patients. It can also prevent distress during invasive medical procedures. In most trials, hypnosis appears to be superior to standard educational and/or cognitive-behavioral interventions. Sometimes sessions can be performed by nurses and physicians having followed a short course in the technique, although for prospective trials testing wider endpoints, we suggest that well-trained hypnotists participate, preferably practitioners trained in psychology. These trials should explore various dimensions of the patient’s psyche, examine the impact of the alleviating past trauma, promote behaviors known to reduce the risk of relapse, including physical activity, diet, and biological rhythms. The effect of hypnosis on immunity should also be evaluated since some authors have shown a positive impact on natural killer cell count and activity. For research purposes, measures *

A version of this book was also published as a chapter in Progress in Circadian Rhythm Research, edited by AnneLaure Léglise, published by Nova Science Publishers, Inc. It was submitted for appropriate modifications in an effort to encourage wider dissemination of research.

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Fabrice Kwiatkowski, Nancy Uhrhammer, Yves-Jean Bignon et al. concerning susceptibility to hypnosis should be collected and new indicators developed in order to facilitate future progress. Oncology is only just beginning to take advantage of the diverse possibilities of hypnotism.

INTRODUCTION Thanks to Milton Erickson’s considerable work during the 20th century, hypnosis is currently viewed as an acceptable practice by western medicine [Pirotta, 2000; Gray, 2002]. Of course, this does not mean it is considered a standard medical treatment: hypnosis does not “work” in the way that chemical drugs do. However, neuroscience is advancing so rapidly that we may be at a turning point in our understanding of brain function, and may soon understand why hypnosis appears to be so efficient in comparison to other psychosocial interventions1. For example, the discovery that memories are not recorded once forever, but may evolve each time they are evoked, sheds new light on the “rebuilding” of the past, as illustrated by Erickson in the “February man” [1989]. Hypnotism today cannot be rejected as mesmerism was in the 19th century when many physicians were involved in this practice, with often surprising and reproducible results [Méheust, 1999; Quinn SO, 2007]. One of the lessons of this era is that stage practice (public demonstrations) must be separated from clinical practice: an other refers to certain topics that the association with charlatanism has unfortunately rendered off-limits to legitimate investigation. Last but not least, methodology in psychosocial sciences has made tremendous progress, and the “hard science” approach using statistics and objective outcomes can now be applied to measure the efficiency of any intervention, even when the underlying mechanisms are unknown. This makes it possible to compare the impact of different psychological approaches on particular psychopathologies. The subjective nature of psychological interventions and objectives, however, make it difficult to bring this science fully into the realm of “hard” science. There may in fact be no difference between a real psychological change and belief in that change. One of the best ways to show the impact of psychosocial intervention is to test it on somatic disease. Investigators do not need to know the mechanisms by which the interventions work, nor what happens in the patients’ minds. Focusing on measurable symptoms is an appropriate strategy to study the effect of a psychosocial intervention like hypnosis. Indeed, biology is a convenient context to measure changes, and to evaluate protocols regardless of content. The “patient + hypnotist” couple can be treated as a blackbox by the researcher, and its influence on biology can easily be studied. Traditional clinical research methods, including standard prospective randomized trials, can be used. This approach, with statistical analysis of the data and sample numbers appropriate to measure the expected variability of the parameters, brings hypnosis into the realm of standard scientific investigation. This first step, if the results are positive, may eventually be followed by an analysis of what occurs in the black-box, using specific tools, protocols, trials, and experts. Many authors have conducted serious investigations at the frontier of psychology and medicine, especially in the domain of cancer, where physicians facing major treatment 1

The contrary is also true: it is very likely that hypnosis will help neurosciences to understand brain functionning.

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difficulties may be more open-minded to look for resources out of their usual domain of competence. This article will focus on these experiments. The medical literature on hypnosis these past decades, and notably that concerning cancer (Medline or CancerLit index), shows a slowdown of research in this area through the 1980’s and 1990’s, followed by a resurgence in the new century (Fig 1, blue columns). A flatter but similar trend appears with the more specialized PsychInfo index (Fig 1, violet columns).

Number of articles

80 70

Medline - CancerLit PsychInfo

60

Trials (not review)

50 40 30 20 10

-09 05 20

20

00

-04

-99 95 19

-94 90 19

-89 85 19

19

80

-84

0

Time : 5 year periods Figure 1: Evolution since 1980 of the number of articles indexed in Medline/CancerLit and PsychInfo with the keywords “cancer” and “hypnosis”. Last column counts the number of articles from Medline where the “publication type” is “trial” but excludes reviews. Most articles found in PsychInfo are also referenced in Medline, except for book chapters that appear only in PsychInfo.

Special attention should be paid to prospective randomized trials: when they respect the methodological guidelines of evidence-based medicine, they are considered the most reliable type of proof [Guyatt, 1992; Cook, 1995]. Since 1980, new trials have been published at an average of almost one per year (right columns in Fig.1), representing 8 % of the literature on the topic “hypnosis and cancer”. The other 92 % includes case reports, hypnosis management, expert opinions and reviews. Very often the content of these latter [Wild, 2004; Rajasekaran, 2005; Tsao, 2005; Ladas, 2006; Rogovick, 2007] either analyze children and adults separately or consider only one population. In this chapter, since biological, clinical and psychosocial factors are evoked, we propose a different approach and to successively analyze: -

Research investigating the effect of hypnosis on clinical or biological parameters.

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-

Research into the impact of hypnosis on the patients’ well-being, including quality of life, anxiety and depression, pain management and the prevention of treatment side effects. Technical aspects of research on hypnosis with the following main topics : o o

o

What kind of hypnosis has or should be proposed to patients How biological hypotheses on the etiology of cancer and its evolution may modulate the types of suggestions made during the therapy, and what target the hypnosis sessions should address Beyond biological parameters, what to measure when hypnosis is used in a trial.

RESEARCH INVESTIGATING THE IMPACT OF HYPNOSIS ON CANCER ITSELF Results of trials including hypnosis Impact on overall survival As in many prospective trials in cancer, the main clinical end-point is overall survival2. This is the parameter of choice, since the patients are followed all during their disease and long after, even if they are in remission. It is also considered unbiased if two conditions are respected : -

no selection is made between causes of death less than 5% of the patients are lost to follow-up, and any lost patients are equally distributed in the different arms of the trial.

In phase III trials, overall survival is preferred to disease-free survival, since the latter may not coincide with overall survival and thus cannot be considered a surrogate end-point. For example, the treatment of breast cancer has improved to the point where second or third line treatments offer significant chances of survival even for metastatic patients. Although of poor prognosis, recurrence is no longer synonymous with death from cancer; therefore, overall survival has almost been the sole clinical factor tested in studies of psychosocial interventions in cancer. Prospective trials on psychosocial interventions are scarce. This is even truer for those that use hypnosis. The first reference of a trial using hypnosis as a complementary treatment for cancer concerned overall survival [Newton, 1983]. Unfortunately, its design was inappropriate: it was not a randomized trial, and the statistical analysis separated patients receiving a minimum of ten 1-hour hypnosis sessions within 3 months, from patients who received less that ten but at least three sessions. It is likely that the subjects who died shortly after enrolment in the study did not have time to receive the threshold number of ten sessions,

2

Overall survival is the interval between a starting point (date of disease diagnosis, first treatment…) and the date of death or last follow-up. Statistical methods (Kaplan-Meier, actuarial) are used to analyse these intervals.

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and this selection may for the difference in survival. In spite of these flaws, this trial launched a long series of prospective research on psychosocial interventions. Aside from Newton’s trial, only one study testing hypnosis as the main psychological intervention in cancer patients (Hodgkin’s and non Hodgkin’s lymphoma) has been published [Walker, 2000]. This second trial was also not randomized, and the slightly significant results in favor of hypnosis have to be questioned. The impact of hypnosis alone on the survival of cancer patients is thus a question that has not been yet tested with appropriate methodology. Spiegel’s well-known article in the Lancet involved a moderate number of patients (n = 86), but was the first description of a significant impact of a psychosocial intervention on the survival of women with metastatic breast cancer: mean survival time after randomization was more than 17 months longer in the intervention group versus the control group [Spiegel, 1989]. In the intervention group, self-hypnosis was taught for pain control, and patients were encouraged to discuss strategies for coping with cancer, but were not led to believe that participation would affect the course of their lives. This came to be known as “iveexpressive group therapy” [Goodwin, 2005]. To date, hypnosis has mostly been used in association with other educational and/or ive interventions (mainly group therapy), and only as a supplementary method to help patients handle pain or anxiety. Spiegel [1989, 2000] initiated this kind of protocol, and several prospective trials using hypnosis in cancer patients follow the same model. Although these studies did not use standard hypnosis, but instead taught patients how to practice selfhypnosis, for this chapter we will consider the results of these trials as representative of hypnosis impact. Even so, just four prospective trials can be selected from the literature (Fig. 2). All four studies concern metastatic breast cancer patients, and use the same psychosocial protocol established by Spiegel.

favorable

Spiegel (1989) Goodwin (2001) Kissane (2007) Spiegel (2007)

unfavorable

0.76

n = 86

1.06

n = 235 0.92

n = 227

0.93

n = 122

0.96

Total n = 670

0

1 Cox hazard ratios

2

3

Figure 2: Impact on survival of self-hypnosis as a auxiliary treatment (hazard ratios are represented by the circles, 95% confidence intervals are drawn with horizontal lines). (which one is the imagery study?)

At the end of the 20th century, it has become obvious that the early enthousiasm could not be sustained by the results. More recent publications confirm the failure of psychosocial 3

Relative-risk (RR) is the ratio of the frequency of a particular sign or disease in a group over the same frequency in a reference group. Odds-ratio (OR) applies to case-control studies, and differs from RR in the way it is calculated: if the occurrence of the sign or the disease is less than 20 %, these figures are comparable. Hazardratio (HR) is similar to RR except it applies to survival, it integrates the survival delay and is calculated using Cox's regression model.

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intervention including self-hypnosis to significantly improve survival [Spiegel, 2007; Kissane, 2007]. The conclusion of this brief review of trials “using hypnosis” does not differ from Smedslund’s meta-analysis of psychosocial interventions [Smedslund, 2004] where the authors found no significant advantage of these interventions on overall survival of cancer patients. But two remarks should be noted : -

hypnosis was not the main psychological lever in the ive-expressive group therapy, but a minor one and it consisted in self-hypnosis. An interesting finding of Smedslund’s meta-analysis is that individual treatments seemed to have a stronger impact on survival than group treatments. The hazard ratio associated with a subset of three trials testing individual interventions was 0.55 [0.43, 0.70] while the global estimate of the impact of the complementary subset (i.e. nine group treatments) was 0.97 [0.73, 1.27]. This means that individual management seemed to reduce the risk of death by half.

Thus a first global conclusion: hypnosis as the main psychological treatment has never been tested against survival in cancer patients with appropriate prospective methodology. Many types of psychosocial interventions have been investigated, but not hypnosis. Moreover, going along with Smedslung suggestions, it is likely that individual sessions of hypnosis will do much better than group training.

Impact on the response to chemotherapy Most of the time, the response to treatment is correlated to overall survival. Recently, a prospective trial in England tested a technique similar to hypnosis to enhance the response to neoadjuvant chemotherapy in breast cancer [Walker, 1998]. This idea is attractive, since for most types of cancer, data on treatment response is usually obtained routinely, and also because it is obtained more quickly than overall survival data. The psychological intervention consisted of relaxation training and guided imagery. Before the first cycle of chemotherapy, patients were taught “progressive muscular relaxation and cue-controlled relaxation” [Hutchings, 1980]. An audiotape was supplied with instructions for relaxation and patients were given a portfolio cartoons to help them visualize their host defenses destroying the cancer cells. Patients kept a diary in order to evaluate their daily practice duration. Ninety six patients were accrued, 48 in each arm. After completion of chemotherapy, no significant difference in pathological or clinical responses was found, although a weak association in the relaxation arm was found between the rating of imagery vividness and clinical tumor regression. A lack of statistical power may have been responsible for the non significance of the main outcomes, and a larger trial may show a positive response. The main interest of this study is the originality of the protocol, focusing on the response to treatment. Impact on immunity Although many authors underline the importance of immune functions in the evolution of cancer [Kiecolt-Glaser, 1999; Temoshok, 2002; Kwiatkowski, 2007a], very few trials include end-points concerning immunity. There may be at least two reasons for this dearth of information:

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the main reason is that initial expectations were too high (especially after Spiegel’s positive results), and a significant gain in survival was naturally targeted. Second, immunity is a very large and intricate set of biological processes that interfere with the whole metabolism. It appears difficult to choose the relevant parameters for cancer: number of natural killer (NK)-cells, their cytotoxic potential, cytokines (IL-2, IL-6, IL-15), hormones (melatonin, cortisol, leptin) that inhibit or activate NK activity, or other nonspecific markers of activation of cellular immunity, such as E2-microglobulin [Sabbioni, 2000] ? Immunity is a chain of biological processes, and as a chain, it has the strength of its weakest link. Testing immunity in a trial on hypnosis therefore needs to include the measure of a large set of biological parameters (Kwiatkowski, 2007b). The disadvantage of increasing the number of factors studied is the risk of falsepositive conclusions (i.e. the risk of finding a parameter significant when only chance is at work). The Bonferroni correction for multiple testing can be used to counter this effect [Bland, 1995], but it dramatically increases the population size necessary to reach sufficient statistical power, and as a consequence may make the trial unfeasible because of the associated costs.

The first study of immunological parameters in a trial tested an “early structured psychiatric intervention” (including relaxation training but not hypnosis) in patients with malignant melanoma. This intervention had a positive and significant effect on the NK lymphoid cell system and found that affective changes but not coping measures showed some significant correlation with immune cell changes [Fawzy, 1990]. The first trial using hypnosis-like approaches used a longitudinal design where patients were their own controls [Bakke et al., 2002]. This kind of design causes problems, since it is impossible to guarantee that the parameters followed through time change due to the psychological intervention or to some other uncontrolled cause. Standard methodology requires a control arm and the randomized allocation of patients to ensure that no selection and/or confusion bias will interfere with the outcome. Nevertheless, the study is interesting. For 25 stage I-II breast cancer patients, NK cell count and cytotoxicity were measured at base line, at 8 weeks and at 3 months. Hypnotic guided imagery followed the methods of Simonton [1980]. Each patient received 8 individual weekly imagery training sessions and were encouraged to practice 3 times a week. They also received relaxation training based on the Jacobson method [Jacobson, 1938]. The NK lymphocyte fraction increased with improvements in mood on different subscales of the POMS questionnaire: confusion (p = 0.004), tension (p = 0.017), anger (p = 0.015) and depression (p = 0.013). NK counts rose significantly after 8 weeks (p = 0.03) but this response was not sustained at the 3-month follow-up. No change in NK cytotoxicity was observed. Lengacher et al. [2008] recently performed a second pilot study using the same pretestposttest kind of design, but with a control arm. As in Bakke et al, breast cancer at stages 0 to 2 was targeted, while 28 patients were included (14 per arm) and relaxation with guided imagery was employed as the psychological intervention. The immunological parameter measured was IL-2-activated NK cell activity in blood samples obtained prior to surgery and

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four weeks post-surgery. Significant p-values between 0.01 and 0.05 characterized differences in NK-cell cytotoxicity between the trial arms. These two reports are coherent. Although both used small sample sizes, significant objective effects of “hypnosis” on NK cells were observed concerning one of the key immune parameters in cancer. This is not proof of any effect on disease progression or overall survival, but suggests a direction of research, in particular for those concerned by psychoneuroimmunology. Moreover, these trials show the feasibility of small studies of psychosocial intervention and sound immunological end-points. Because longitudinal studies of biological parameters are quantitative and most inter-individual variability does not interfere thanks to paired statistical tests, surveys using small sample numbers still have adequate statistical power.

Impact on circadian biological functions If instantaneous values of biological parameters are relevant as secondary objectives in prospective cancer trials testing hypnosis or other psychosocial interventions, their circadian rhythms (principally the amplitude of rhythms) give a better point of view on metabolism homeostasy: this includes major hormones (melatonin, cortisol) that rule main immune functions, temperature and rest/activity cycles. Indeed, circadian rhythms appeared to be a significant prognostic factor for overall survival in metastatic colorectal cancer patients [Mormont, 2000]. The main clock hormones, melatonin and cortisol, can easily be sampled in saliva at different times of the day, making them suitable candidates for kinetic studies. An other hormon, leptin, has recently gain importance in this type of studies, because of its crossactivity between adipocytes and immune cells. Finally, blood oxygen saturation (SPO²) could be of interest since it was shown that tumors could be very dependent on the quantity of oxygen available to them from the circulation. Cellular responses to hypoxia may explain neoangiogenesis, the spread of malignant cells, and a portion of the resistance to chemotherapy [Brahimi-Horn, 2007]. SPO² is relatively easy to measure, using a non invasive infrared electronic device at the surface of the skin. For more detail, the circadian rhythm of SPO² could be also studied with a portable device recording continuously over a couple of days. Up to now, no published research has tested the effect of hypnosis on circadian fluctuation in biological functions. The authors of the present article are undertaking one such trial [Kwiatkowski, 2007a, b], with intermediate results expected in 2010.

IMPACT OF HYPNOSIS ON PATIENTS’ “WELL-BEING” Patients’ well-being is an imprecise notion which covers a wide range of aspects, including “quality of life” (QOL), depression, anxiety, mood, etc. Although QOL is well-correlated to other psychological dimensions4, the need for more precise scales can occur, especially when testing psychosocial interventions. For example, 4

Correlations between QOL and dimensions like depression are easy to understand : depression damages self esteem and social relationships; it is often associated with poor sleep, fatigue, etc. In QOL questionnaires, each of these characteristics are probed by a few specific questions that combine to give a global estimate of

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such intervention may be of more benefit for distressed patients [Sheard, 1999; Goodwin, 2005], since most trials have shown a significant rise in mood scores in distressed cancer patients, and also since the level of depression has been found to correlate with worse treatment responses [Walker, 1999]. QOL questionnaires are not always sufficient to study this, because they are intended to illustrate a global perception of life, and thus merge together different effect sources and sacrifice accuracy on individual points. Specialized evaluation tools act as a magnifying glass: they focus on one dimension and thus reduce statistical variability. But they only focus on one topic.

Quality of life QOL is now very standardized, and internationally validated questionnaires, including SF36 [Wade, 1992] and EORTC QLQ-C30 [Aaronson, 1993], facilitate correct investigation of this domain. Since some dimensions of these questionnaires are often correlated to more targeted scales (anxiety, depression, mood, coping, pain...), many clinical studies use only a QOL questionnaire. The purpose of this choice is twofold: first, investigators want to limit the number of questionnaires that patients have to answer. This is justified, since filling out dozens of pages often represents a burden to patients already very tired and distressed because of their cancer and treatments. Second, most clinical trials give priority to biological endpoints directly related to the medical treatment. Usually in such cases, the endpoints are survival, response to treatment, and/or toxicity. Although attitudes are changing, considerations of other aspects of patients’ lives are frequently considered secondary, and psychosocial investigations are reduced to a single QOL enquiry. QOL questionnaires are not all alike. Most of the validated ones concern patients that are in rather good shape and can still do (or hope to do) the things healthy persons can do. To assess QOL in elderly or terminally ill patients, more specific questionnaires are required [Mystakidou, 2005]. For example, feelings concerning approaching death or other spiritualexistential questions are not evaluated by standard QOL questionnaires. More recent tools have been developed, such as the MVQOLI [Biock, 1998] or the Qual-E [Steinha, 2002, 2004], that may offer better evaluation of the impact of hypnosis for terminal phase cancer or palliative treatments. Unfortunately, these are only validated in certain languages, and their validation in non anglo-saxon cultures may be negative since some questions may be too direct to be acceptable in different cultures. Other aspects of emotional adjustment, measured by mood, positive/negative affect and/or coping scales, are usually correlated to global quality of life, and to depression and anxiety levels. Specific questionnaires may be necessary if the goal of hypnosis is to enhance a particular aspect of adjustment. Else, the use of such questionnaires in trials seems redundant to a QOL questionnaire. Liossi and White [2001] tested the efficacy of four weekly sessions of hypnosis compared to a cognitive-existential management among 50 terminally ill cancer patients in palliative treatment in Greece. Patients in the hypnosis group had significantly higher overall something called quality of life. QOL appears as a result of different influences: a same decrease of QOL index can come from depression itself but also from a severe wound or a life threatening sickness. QOL does not help much to discriminate between possible causes.

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QOL scores, with lower depression and anxiety scores. Although, as the authors noted, the Rotterdam Symptom Checklist [de Haes, 1990] questionnaire employed was not optimal5, the conclusions are likely valid. If we retain a strict definition of QOL, very few trials of psychosocial interventions have effectively tested QOL among cancer patients. Several studies have measured specific psychological dimensions (emotional functioning, pain, anxiety, depression, etc) but did not take global QOL into . As Ross et al. [2002] reviewed, only 8 of 38 randomized trials (21%) included a QOL survey. Uitterhoeve et al. [2004] selected 13 trials focusing on QOL, of which 3 (23%) evaluated QOL with validated instruments while the others estimated QOL on scales concerning limited domains of QOL, such as the POMS mood scale, or the HADS anxiety-depression scale. Their findings coincide with Liossi’s, although very few of the selected trials used self-hypnosis (Spiegel et al., Goodwin et al. listed in Fig.2). To conclude, although QOL has not been often tested in the context of hypnosis and cancer, it seems to be improved significantly. Hypnosis appears to be a valuable approach with terminally ill patients, where options beyond pain management are often limited.

Managing Anxiety and Depression with Hypnosis Depression may be both a cause and consequence of cancer. It has been suggested that chronic depression could favor the development of cancer. Dalton’s review [2002] showed a moderate relationship between depression and cancer. The global odds-ratio was around 1.2, with a trend toward greater risk when depression was major or chronic: for instance, in Penninx [1998], the odds-ratio was close to 1.9 in a survey of the elderly. On the other hand, cancer may favor depression. In a study of 250 patients with various disease locations, 50% of them presented adjustment disorders, and among these, 20% had major depressive episodes [Derogatis, 1983]. Similar statistics were reported among breast cancer patients Morasso et al [2001], and a prospective study, found an increase of 25 to 33% of affective and anxiety disorders when compared to the general population [Harter, 2001]. According to Ronson [2005], “the vast majority of patients receiving a diagnosis of adjustment disorder actually suffer from either sub-threshold depression or from full or partial presentation of post-traumatic stress disorder... The very fact that an average of 10% of cancer patients have been shown to meet criteria for PTSD might suggest the existence of a specific trauma stress adaptation process in this particular patient population”. Since depression has been found to be correlated to immune response for some cancer types [Lutgendorf, 2008; Steel J, 2007], and to prognosis [Watson, 1999; Hjerl, 2003], it might be important to manage depression in cancer patients. Depression frequently has been suggested to reduce survival because it encourages poor treatment compliance, resulting in disease progression, and also because of it favors a higher rate of suicide [Reich, 2007]. The association between depression, NK count/activity and prognosis suggests that depression could also shorten survival because of weaker immune defenses [Steel, 2007]. Spiegel and 5

This self-report questionnaire comprises four dimensions : physical symptom distress (23 items), psychological distress (7 items: irritability, worrying, depressed mood, nervousness, hopelessness, tension and anxiety), activity impairments (personal and social) and a global verbally labelled 7-point Likert scale about their quality of life ranging from “excellent” to “extremely poor”.

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Giese-Davis [2003] conclude in a similar manner: “there is growing evidence of a relationship between depression and cancer incidence and progression. Depression complicates not only coping with cancer and adherence to medical treatment but also affects aspects of endocrine and immune function that plausibly affect resistance to tumor progression... Further exploration of possible effects of depression and its treatment on endocrine and immune function on cancer progression itself represents an exciting research and clinical opportunity.” In Ross’s review of 38 surveys on psychosocial interventions among cancer patients [Ross, 2002], 24 trials included evaluation of anxiety and 21 evaluation of depression. Among these, 46% showed a favorable impact of psychosocial interventions on anxiety and 52% on depression. Of the 4 trials including self-hypnosis cited in Figure 2, all reported a positive impact of the interventions on anxiety and/or depression. These findings are consistent with the hypothesis that psychosocial interventions may be more helpful to distressed patients than to others. In contrast, a recent study investigating whether highly distressed patients were more likely to benefit from ive-expressive group therapy did not conclude positively: patients with different distress levels seemed to benefit similarly from psychological [Classen et al. 2008]. What about hypnosis and depression? The previous paragraphs suggest that self-hypnosis may have more impact on anxiety and depression than other psychosocial interventions, although this has never been rigorously investigated (i.e. in a randomized prospective trial). The only clinical hypnosis trial in the literature is that of Liossi and White [2001] cited previously. For terminally ill cancer patients, personal hypnosis sessions resulted in significant decreases (p < 0.01) in both depression and anxiety, in comparison to the cognitive-existential control group. Cancer survivors may also be concerned by depression. One trial of 61 women with a history of breast cancer but no detectable disease randomized the women between a hypnosis arm (5 weekly sessions plus self-hypnosis training) and a no intervention arm. Measures were taken at inclusion and after five weeks. Although 15% of the subjects were lost to follow-up or withdrew, significantly decreased depression and anxiety scores were observed in the hypnosis arm [Elkins et al., 2008]. The effect of clinical hypnosis on depressed patients without cancer, however, has been more thoroughly studied. “Cognitive hypnotherapy” was compared to standard cognitivebehavioral therapy, with changes over time measured using Beck’s depression inventory, anxiety inventory and hopelessness scale. The three scores decreased by 5%, 6% and 8%, respectively, and were maintained after 6 and 12-months [Alladin, 2007]. These figures did not reach significance, but they show that hypnosis may represent an alternative to conventional psychotherapy against depression. A study investigating the effect against long-term depressed mood of two strategies: meditation with yoga, versus group therapy with hypnosis (group hypnosis and self-hypnosis training), plus a control group found that 77% and 62% of the meditation and hypnosis groups, respectively, had no depressive symptoms at the end of the follow-up, versus 36% for the control group [Butler et al. 2008]. These results are comparable to the 73% remission rate reported for a combination of antidepressants and psychotherapy [Kocsis, 2000], suggesting that hypnosis could be an approach of choice to manage depression and anxiety for the half of

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cancer patients who suffer from depression. As stated previously, protocols including personal hypnosis sessions should also be tested, with perhaps even better outcomes.

Hypnosis and Pain One of the first reports concerning the use of hypnosis against pain in cancer patients described three cases where the treatment was effective [Milton H Erickson, 1959]. Since its invention, hypnosis has been used to ameliorate pain because this approach was one of the few available. But pain is not a simple symptom. As Kupers et al. [2005] report, “there is compelling evidence that there is a poor relationship between the incoming sensory input and the resulting pain sensation”. Cognitive processes may significantly influence this sensation. This “physical symptom” often requires more than a single pharmacologic medication to resolve, although considerable progress have recently been made in that domain. According to one review of pain and cancer [Zaza, 2002], very often pain has a psychosocial dimension that reflects both social loneliness and psychological distress. Cultural environment also plays a role in the representation of pain and its acceptance, especially today in western countries where it is often easier to be heard by the medical staff if the complaint concerns aches rather than distress. Analgesic drugs have proven to be efficient against most acute pain, especially that related to surgery, but two main domains are left for which complementary means can be required : -

short term pain during invasive medical procedures for both children or adults to reduce pain and anxiety. chronic pain during palliative treatments where pain does not respond to pharmacologic medications without high risk side-effects (for example respiratory complications from morphine derivatives).

Hypnosis to manage pain during invasive medical procedures Children are less able than adults to rationalize about a given medical procedure, or to correctly anticipate the time it will take and the amount of discomfort that it will generate. When children have had a preliminary experience of pain for a type of procedure, their distress can exaggerate negative memories, which in turn increases distress and fear for the procedure [Butler, 2005]. Children also respond better to hypnotherapy: unlike adults, they are less burdened with cognitive stereotypes, and their boundaries between imagination and reality appear less substantial. Their limit consists rather in their ability to understand what hypnotherapist says, making hypnotherapy inappropriate for children under three years. Children often fidget under trance, while adults stay motionless [Rogovik, 2007]. In their review of the few pediatric controlled trials performed using adequate methodology, Wild and Espie found the results inconsistent, but there were no conclusions of an adverse effect of hypnosis [2004]. In two tests of hypnosis in children and adolescents with cancer undergoing either bone marrow aspiration or lumbar puncture, hypnosis was significantly superior to behavioral techniques to reduce anxiety and pain during the procedure [Zelter, 1982; Katz et al., 1987]. A third study ed these results, with a significant reduction of pain and anxiety in response to either direct or indirect suggestions,

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and observing that the level of hypnotizability was correlated to the magnitude of the outcome [Hawkins, 1998]. In a protocol in which children and their parents were trained to use both distraction and hypnosis, some patients were highly hypnotizable while others not. Easily hypnotized children showed a significant decrease in pain, anxiety and distress scores with hypnosis; for those not easily hypnotized, distraction significantly reduced observer-rated distress scores [Smith, 1996]. Additional techniques have been studied, with cognitivebehavioral coping skills training (CBCST) giving results nearly as positive as those of hypnosis for 30 pediatric cancer patients undergoing bone marrow aspiration [Liossi, 1999], and attention control doing as well as hypnosis for pain, anxiety and distress in 80 patients undergoing lumbar puncture, although the effect diminished when the patients were switched to self-hypnosis. Lastly, in a trial of pediatric non-cancer patients undergoing voiding cysto-urethrography (VCUG), 44 children who had already had difficulty with at least one VCUG were randomized to routine care or hypnosis. A one hour training session in imaginative selfhypnosis was given to parents and children, which they were asked to practice several times the day before the VCUG. The levels of distress, anxiety and pain were significantly lowered in the hypnosis arm, as was the total procedural time and thus overall costs [Butler et al., 2005]. In adults, relatively few controlled clinical trials have tested the efficacy of hypnosis to reduce pain [Liossi, 2006], perhaps because adults seem more able to face temporary pain related to medical procedures. Nevertheless, fear and discomfort may result in poor cooperation during procedures, leading to usually unnecessary amounts of analgesic and sedatives [Deng, 2005]. A small sample size randomized trial (n = 20) was performed in 2002 by Montgomery et al. on women undergoing breast biopsy. Hypnosis was reported to reduce pain and distress while the effect seemed to be mediated by the pre-surgery expectations of patients [Montgomery, 2002]. The consensus that comes from studies is that hypnosis is a convenient method to reduce pain, anxiety and distress generated by invasive medical procedures, especially when patients and in particular children undergo such procedures several times. The mechanism may be partly indirect, by changing expectations and by permitting the patients (and their parents) not to focus on previous negative experiences. The susceptibility of patients to hypnosis may be a limiting factor, which confirms the standard recommendation to test hypnotizability before including patients in protocols. Not surprisingly, self-hypnosis appears to be less efficient than hypnosis sessions with a therapist. For pediatric trials, measures aimed at reducing the parents’ anxiety are probably also relevant, as the anxiety of children and parents may be correlated. The large variation of hypnotic procedures used has been criticized [Wild and Espie, 2004], but this variety is unavoidable as long as there is no consensus as to the best procedure, if indeed there is one. Meanwhile, the use of treatment manuals to standardize procedures in a trial is recommended, and meets the criteria of the American Psychological Association’s division 12 Task Force for an intervention to qualify as empirically ed therapy. Finally, it is worth noting that although most of these trials involved small samples, usually a stumbling block in clinical research, they achieved their goals and reached significance. This means that the effects were large enough to be reliably measured with a few dozen people, which is not the case for all endpoints.

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Hypnosis for chronic or persistent pain Most cancer pain is caused by tumor invasion or its pressure on nerves. Medical, radiological or surgical treatments of the underlying lesions are necessary to prevent further damage, and this often controls pain. For various reasons in such cases, complementary therapies are not indicated, and acute pain generally requires analgesics. Long-term use of analgesics, however has many side-effects, whose negative impact increases over time [Deng, 2005]. Patients who develop tolerance to opiates require higher doses and frequent drug rotation. Respiratory side-effects may become a limiting factor. Chronic constipation may lead to laxative abuse and further difficulties with bowel management. Gastrointestinal bleeding may result from the chronic use of non-steroidal anti-inflammatory drugs. Depression is associated with chronic pain and use of opiates. Hypnosis and complementary medicine (such as acupuncture, massage, or herbal therapy) may be good alternatives to increasing drug doses. Hypnosis may also be useful to manage pain generated by long term treatments, especially in cancer patients where treatments are particularly aggressive and last for months. Self-hypnosis training plus group therapy significantly reduced pain in patients with metastatic breast cancer, even more so than group therapy alone [Spiegel, 1983]. Since this initial study, others have confirmed that hypnosis, either alone or in combination with other techniques, can reduce pain. For example, hypnosis was more effective than cognitivebehavioral coping skills training, or attention control in alleviating persistent pain following bone marrow transplantation (BMT) [Syrjala, 1992]. A continuing study of BMT patients confirmed this result while adapting the content (i.e. relaxation training, imagery and/or suggestions) of the individual hypnosis sessions to the patients’ health and desire, although the hypothesis that cognitive-behavioral skills training would boost the effect of hypnosis was not confirmed [Syrjala, 1995]. Both these latter trials observed a non-significant decrease in opiate use. Hypnosis may also alleviate chronic pain in children. One study showed improvement in 80% of children with various pulmonary symptoms (asthma, chest pain/pressure, habit cough, hyperventilation...) including some who had remained symptomatic despite extensive medical treatments. This study did not include a no-treatment arm. Various subjects were worked with the patients who could identify personal objectives they wanted to address, such as school or athletic performance, and specific symptoms to alleviate, including non-pulmonary symptoms such as abdominal pain, headaches and insomnia. Neuropathic pain responds less to analgesics than nociceptive pain, and many patients continue to suffer in spite of medication. Because of the weakness of medical means against neuropathic pain, 60% to 80% of cancer patients in chronic pain seek alternative therapies on their own, with the risk of being taken into scam operations and harmful practices [Deng, 2005]. The efficacy of hypnosis against more temporary pain has been demonstrated, and suggests it may also be effective against chronic neuropathic pain. Clinical trials addressing this issue, however, are lacking. There are several negative consequences of chronic pain. First, it often provokes depression in patients, as well as in their caregivers. Second, there is some evidence that pain inhibits the immune system, which leaves patients more vulnerable to infection and possibly to the cancer itself. Third, the lack of success in pain management may damage the confidence that patients have in their medical treatments, thus lowering their compliance with treatment and in turn reducing its efficacy. We anticipate that in the near future, evidence-

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based guidelines on the use of hypnotism for pain management will be available to both patients and clinicians. Long-term follow-up after hypnosis treatment as well as the effect of hypnosis used over longer intervals should also be addressed in clinical trials [Elkins, 2007].

Hypnosis and Treatment Side-Effects As stated previously, pain is one of the major side-effects of cancer treatments, in particular with advanced cancer, where drastic measures need to be taken. In fact, the goal of the great majority of clinical investigations is to define the optimal balance between antitumor efficacy and toxicity. Typically, to be efficient, drugs have to be toxic, surgery invasive, and radiotherapy cannot avoid irradiating normal tissues. The development of targeted treatments, such as monoclonal antibodies, stereotactically guided radiotherapy and perhaps immunotherapy, is beginning to change this situation. Considerable progress has been done to prevent side-effects; for example, potent anti-emetic medications (5-HT3 receptor antagonists in association with dexamethason) enable patients to better cope with chemotherapy and radiation. Patient management including hematological follow-up helps avoid major sepsis. The major remaining side effects are pain (see previous section), nausea and vomiting, hot flushes, neuropathy, fatigue, and psychological problems more or less related to these symptoms. These symptoms are not without consequence, since they interfere with treatment (by requiring dose reductions, or delaying schedules) and compromise the patient’s therapeutic alliance with his physician.

Nausea and vomiting Although anti-emetic medications are widely used, chimiotherapy-induced nausea and vomiting still represent a significant problem for cancer patients [Koeller, 2002]. A universally effective anti-emetic regime is still elusive and the extent of this side-effect varies according to the cytotoxic agent used against cancer. Anticipatory symptoms cannot neither be treated by such medications. The use of hypnosis against nausea and vomiting is quite old. In a study of chemotherapy-related effects, patients practicing relaxation and guided imagery experienced significantly less anxiety, nausea, and depression than patients ed by a therapist or the control group [Lyles et al., 1982], a result that carried over into the follow-up period. Richardson et al. conducted a meta-analysis on this subject in 2007. They could only find four trials satisfying their selection criterias [Zelter, 1991; Syrjala, 1992; Jacknow, 1994; Hawkins, 1995]. Outcomes varied since trials addressed sometimes anticipatory symptoms and some others chemotherapy-induced ones. Among the four trials, three tested the impact of self-hypnosis and Zelter’s one tailored hypnosis. Three of them concerned pediatric cancer patients, except in Syrjala. All trials presented methodological weaknesses, mainly reduced sample sizes, which made a meta-analysis pertinent. Richardson et al. concluded that hypnotherapy lessened nausea and vomiting, but the effect size was not associated to any probability. A reduction of the amount of anti-emetic medication was also reported in Jacknow but this last outcome was questionnable since delivery conditions of anti-emetic drugs were not at patient’s request in both arms. In spite of Richardson’s conclusion, we agree with Genuis when he stated in 1995 that the consensus is that hypnosis to manage

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nausea and vomiting in cancer patients shows encouraging results but yet not compelling evidence [Genuis, 1995].

Hot flushes Hypnosis has begun to be used to treat hot flushes in breast cancer patients, an often underestimated symptom that affects up to 78% of female chemotherapy recipients and 72% of hormonotherapy recipients. [Carpenter, 2001]. Hot flushes concern patients and survivors of various types of cancer, and are associated with many physical symptoms (headaches, palpitations, paresthesia, insomnia...) and psychological troubles (irritation, embarrassment, sense of loss of control...), making their control of general interest [Elkins et al., 2004]. Hot flushes were the main end-point of a study previously cited for its findings on depression: a 68% reduction in the frequency and intensity of hot flushes was observed in the hypnosis group [Elkins et al., 2008]. This reduction had an overall impact on, or was synchronous with patients’ well-being, as shown by the significant improvement of mood scores and sleep quality. Fatigue The effect of hypnosis on fatigue has not been well studied. In one pilot study of cognitive-behavioral therapy plus hypnosis (CBT+H). fatigue was evaluated weekly on a subscale of the FACIT questionnaire (Functional Assessment of Chronic Illness Therapy) and daily on a visual analogue scale. Trend analysis was statistically significant despite the small sample size, showing that fatigue remained unchanged in the CBT+H arm, whereas fatigue increased linearly in the control group [Montgomery et al., 2009]. Hypnosis thus seems to be useful at different moments of cancer management: before, during and after treatments. This is to say: always. Although trials often target specific endpoints, case studies exhibit a much wider range of difficulties that hypnosis may help with. Hypnosis may be of some assistance when medical treatments fail. We agree with Liossi’s conclusion: “hypnosis can be generalized to many circumstances. The persons who learn hypnosis for management of pain or nausea and vomiting may apply their skills to lessen the distress of insomnia and anxiety, to address dysphagia for pills or to enhance their performance in their favourite sport. For clinician, hypnosis is an opportunity to be inventive, spontaneous and playful and to build a stronger therapeutic relationship with a patient while providing symptom relief” [Liossi, 2006].

TECHNICAL ASPECTS OF STUDIES USING HYPNOSIS ON CANCER PATIENTS We have reviewed most researches investing the impact of hypnosis on either biological or psychological end-points. Results are encouraging. But hypnosis includes a large range of practices. Besides, it can be used by varied professionnals, sometimes shortly trained, and in trials, the competences of theses persons can influence outcomes and issues addressed during sessions. Finally, different measures can be taken that qualify the trance, the relation between hypnotist and patient. These can later appear of importance if significant results are obtained

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on the disease itself. We suggest here different directions to facilitate researches on hypnosis with cancer patients.

What Kind of Hypnosis Should be Proposed? Ericksonian hypnosis: what else ? Setting aside mesmerism, two main historical periods apply to hypnotism: before Erickson and after. Before Erickson, the use of “classical” hypnosis consisted of mastering a subject’s will through vigorous induction using direct suggestions of sleep and surrender. Freud’s initial interest in hypnotism under Charcot’s teaching is an example of such an approach. One of the problems they faced was the low proportion of people able or accepting to enter a trance (less than 50%). Moreover, the results obtained were not lasting, since the patients’ acceptance was not achieved, or even sought. Freud presented this as the reason why he searched for a new approach and created psychoanalysis. Erickson’s renewal of hypnotism overcame this difficulty. Because of the effort made to meet patients’ goals and adapt to their cognitive patterns, Ericksonian hypnotism is often described as a sort of guided self-hypnosis, though it is not this simple. Erickson’s approach is so widely used today that it is no longer necessary to distinguish between practices: every hypnotist employs more or less Ericksonian hypnosis and there is no need to use the adjective “Ericksonian”. Sorry Milton ! Erickson also showed that a very deep trance was rarely necessary: most desired effects could be obtained with a light trance, as long as no unconscious resistance inteferes with explicit goals. Inductions thus do not need to be very technical. Usually, a good relaxing approach is sufficient for appropriate suggestions to take effect. For this reason, relaxation with guided imagery is usually considered a form of hypnosis, as we have done here. Since the goal is to increase the suggestibility of patients without no large alteration of the state of consciousness, other practices also probably meet this condition, including sophrology [Caycedo, 1964], meditation [Biegler, 2009], bio, and perhaps prayer, all of which induce specific kinds of trance and quite often use suggestions (positive thinking, creative imagination, etc). Many different techniques may be appropriate to address a narrowly defined goal: for example, yoga plus meditation was as efficient as hypnosis in ameliorating chronic depression [Butler, 2008]. For more complex goals addressing the past or the personality of patients, more sophisticated approaches and deeper trances are often necessary. Psychologist or not ? With cancer patients, the expectations are usually simple to formulate, and the aims of therapy rather straightforward: ameliorate pain, side-effects, depression, etc. Does this mean that hypnotists who manage cancer patients need not be competent in psychology? Two situations can be distinguished: if the intervention is limited (for example, a single session to reduce anxiety before an invasive medical procedure), induction and suggestions can probably be made by a nurse or physician with limited training in hypnosis. A study of chronic pain management [Anbar, 2002], involving more extensive interventions and with

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some components left to the physicians’ discretion, obtained significant results in spite of the pulmonologists having undergone a single 20-hour training workshop. When taking care of chronic or terminally ill patients, the situation is not the same. More training is useful when the interventions are more extended and varied. As discussed in section 2.3, pain may reflect psychosocial difficulties that the patient is unable or unwilling to express: the skills of a psychologist are necessary here to seek for the underlying cause of the pain. The end of life is also a time when essential questions are addressed, and even psychologists may need special training to be able to help patients with these issues. Psychologists and psychiatrists are also the only persons with the expertise to care for depression. Physicians and nurses trained in other specialties often do not appropriately manage the emotional crises that frequently occur in depressed cancer patients, or help patients reduce their distress level. Medical research may require hypnotists that are psychologists, depending on the legislation or regulation of the country where the research takes place, the requirements of the local ethics committee, and on the type of intervention described in the trial protocol. No special skill may be required if the intervention concerns a limited aspect of patient management, using a standardized technique and a predetermined set of suggestions. But if investigation is not so limited and may concern various aspects of the patient’s psyche or behavior, then formal training in psychology is necessary. In particular, cancer can temporarily mask deep psychosocial problems. Psychologists are the best equipped to face these situations. The hypnotist needs to be trained to listen to the patient, as well as to propose suitable directions that the patient will be able to follow and develop.

Individual or group sessions ? Several trials observed better results with individual rather than with group sessions, as summed up by Smedlungs [2004] in his meta-analysis on psychosocial interventions and survival of cancer patients. But we have found no trial testing individual versus group approaches specifically using hypnosis. Here again, there might not be a single ‘best’ method, but methods more or less appropriate to the type of investigation. Group training sessions, however, seem less well adapted to studies were personal needs and demands are to be taken into . Although personal topics may appear unrelated to the pathology, gains or improvements in these areas may indirectly help patients improve their quality of life and reinforce the progress made on pain or anxiety. Individual session are thus more suitable when the suggestions are made to fit patients’ personal difficulties or wishes, or when allegories need to be personalized. This is only possible when the patient’s current context, culture and background can be taken into . We recommend that hypnosis in group sessions be limited to the teaching of selfhypnosis. Group sessions favor the expression of practical difficulties, and the sharing of problems encountered by the participants may help others address similar problems later in personal practice. In practical , group sessions may be more difficult to organize, especially if groups are large and patients come from outside of the hospital. This simple consideration may itself determine what type of session to use, although a combination of both types may be the best solution for some trials: for example, group sessions to teach self-hypnosis plus individual sessions to address personal needs. The number of practitioners available may also be a limiting factor that favors group sessions.

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Tailored hypnosis or self-hypnosis ? Self-hypnosis can be taught to patients quite easily, in either individual or group sessions. Chronic pain is a good indication for self-hypnosis training, where patients can develop skills to manage their symptoms ad libitum. One study of children, however, reported an advantage of personal sessions, but the benefit was lost when patients were switched to self-hypnosis [Liossi, 2003], highlighting the difficulty of ensuring compliance of patients. In spite of audiotapes that could facilitate the exercises, it is difficult to obtain regular practice from subjects. Although the hypnotist should give post-hypnotic suggestions to favor effective self-practice, the quality of trance and the power of suggestions may also diminish greatly with self-hypnosis. Finally, the therapeutic alliance, i.e. the quality of the affective relationship established between the patient and his therapist, has proven to be one of the most important factors in the success of psychotherapy [Crits-Christoph, 2006]. This is very important if patient faces irrational fears [Burish, 1983], or is blocked by severe defenses that prevent access to past distress or trauma. Fawzy [1990] confirmed that affective changes had more impact on the immune system than coping management. The therapist who can enhance these affective patterns, is able to solve more painful problems: his propose alternatives will appear more secure. The absence of the therapeutic alliance makes self-hypnosis more limited and less effective.

How Theories of Cancer May Modulate the Suggestions Made During Hypnotherapy It is common sense to state that the ideas people have of cancer, its causes and probable development, will influence the way hypnotists manage their sessions. Whether these ideas correspond to scientific truths or not is not relevant to the therapy, as long as these ideas do not drive patients to dangerous experimentation or acts. The therapist may even share some of these opinions with his patients. Many of these beliefs may shape the expectations of both patient and therapist, and thus modify the outcome, or the perceived outcome, of the intervention [Montgomery, 2001; Roscoe, 2006]. For example, some chemotherapeutic drugs produce nausea and vomiting in many patients. Symptoms may appear as early as the first cycle. Surprisingly, in the following cycles it is not rare to discover that these symptoms begin as soon as patients arrive at the hospital, and not, as expected, once their chemotherapy has started. There are several different strategies that can be used to prevent symptoms, but the therapist should first make sure that his patient does not believe that the efficacy of his chemotherapy is not proportional to the severity of his symptoms [Roscoe, 2006]. In a randomized prospective trial (i.e. with a control group) where the endpoint is survival and the impact of a short series of personal hypnosis sessions is being tested, what domain should hypnotic investigations and/or suggestions cover? One could legitimately argue that such an enquiry is nonsense since what should be covered is only what patients ask for. This is relevant, but in the practice of hypnotherapyas in any other kind of psychotherapy, the therapist should be prepared to explore areas not immediately identified by the patient. There are several points of view to consider:

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Fabrice Kwiatkowski, Nancy Uhrhammer, Yves-Jean Bignon et al. 1. Most practitioners favor a neutral attitude. The primary goal, following the requests of patients, is controlling the symptoms of disease and improving patients’ wellbeing. This attitude appear rather safe, in terminally ill patients, where the objective can be limited to the quality of end of life. In an example of this strategy, a 4-stage hypnotic intervention that fits Kubler-Ross’ analysis of terminally ill patients (initial crisis, transition/rebellion, acceptance and preparation for death), the aim was to facilitate patients’ coping in their last moments [Marcus, 2003]. 2. Hypnosis may also be directed toward behavior modification : if a patient’s habits include behaviors that increase the risk of relapse or aggravation (smoking, disturbed circadian rhythms, eating disorders, reduced physical activity, etc), why not use suggestions to ameliorate their behavior? Group educational sessions are partly efficient here. Complementary work under hypnosis may be useful in facilitating such changes, especially when they are multifactorial. Behavioral changes in activity and diet may yield significant gains in survival. For example, physical activity after breast cancer was found to improve survival, in particular through the coordinate lowering of cardiovascular mortality [McNeely et al., 2006]. Breast cancer survival improved more significantly when activity was coupled to dietary modifications (higher vegetable-fruit consumption) [Pierce, 2007]. A same strategy could be used to reinforce circadian rhythm [Rossi, 2002 ; Moser, 2006]. The human “ultradian” cycle (of about 90 minutes) is of particular interest. Every cycle, we have a small period of inattention, and if we do not try to work through to the next cycle, but accept to stop our activity and empty our mind, this may reinforce the circadian activity/rest cycle as well as numerous metabolic functions, including immunity. Why not use that moment for a few minutes of selfhypnosis or relaxation? This strategy may be the last that remains, when patients are too ill to leave their bed.If we pay attention, there are many domains that could benefit from sessions targeting behavioral changes. It might be effective to focus on positive behaviors, which will bring satisfaction and in turn reinforce the patient’s will to manage other domains of his life. 3. The positive imagery approach stems from psycho-neuro-immunology theory, mainly the idea that immune cells may be boosted by suitable imagery, this being more effective if the patient is temporarily relaxed and disconnected from his surrounding [Strosberg, 1989]. The strategy requires good familiarity with the patient in order to choose appropriate allegories. Although examples of remission have been attributed to this approach, it has not proven efficient in well-designed randomized trials measuring survival. 4. Changing beliefs and/or expectations. Between 20% and 50% of therapeutic efficacy is often attributed to the placebo effect itself, that is the beliefs and expectations of patients concerning their treatment. In oncology, the placebo effect is usually considered ineffective against the disease, but to our mind, this is questionnable. Generating a placebo effect is equivalent to changing beliefs and/or expectations. With many cancer patients, this is a very delicate point: when the prognosis is very pejorative, one cannot let the patient believe he will get cured. This risks placing him in a very distressing situation when he realizes he was misled. Perhaps, ethically, the least that can be done is to weaken the patient’s certainty of not having time to live, since this often prevent him from maintaining projects, even very short term ones. Alternative projects may be suggested as for example, the surprise to obtain new insights on his personality or reducing anxiety for death. On the other hand, not to

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use the powerfully therapeutic lever of new beliefs/expectations would be regrettable. Metaphors can be used to replace an unethical message of excessive hope by a story presenting positive unexpected change. 5. It has been suggested that traumatic events in the patient’s history may be psychological risk factors for cancer (Fig. 3) [Duijts, 2003; Lillberg, 2003]. favorable

unfavorable 1.77

Traumatic events Death of the spouse Death of child, parent, friend... Personal health difficulties Health difficulties of relatives Divorce, separation Financial changes Environmental changes

1.37 1.35 1.17 0.92 0.88 0.90 1.02

0

1 Odds-ratios

2

Figure 3. Breast cancer risk in relation to life events in the six months before diagnosis [Duijts, 2003].

It is possible too that persistent psychological trauma can lower the overall health of an individual, in particular the ability of the organism to fight disease. The hypotheses behind this proposal are a bit audacious, suggesting that psychological patterns can durably depress the immune system, and that resolving past trauma can relieve this depression. There is evidence that the immune system can suppress cancer cells in the absence of treatment : once cancer appears, its development does not follow the exponential growth predicted from in-vitro cell culture models [Horii, 2005]. In many cases, the biological environment of the tumor plays an important role, both favorable (neo-vascularization of the tumor bed) and unfavorable (activation of immune defenses). Spontaneous recoveries from usually aggressive tumors have been documented: melanoma may be eliminated by the immune system [Wagner, 1998; Curiel-Lewandrowski, 2002], and leukocyte infiltration of tumors is common. These discoveries do not indicate that cancer is curable, but create opportunities for new strategies based on enhancing immunity, and here with the help of hypnosis. The success of these new strategies will naturally depend on numerous clinical, biological or genetic factors, whether the tumor is hormonedependent, and the state of the disease. The known link between immunity and the psyche suggests that the resolution of past psychic trauma with hypnosis could be useful, and should be tested in cancer patients

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Beyond Clinical and Biological Parameters, What to Measure When Hypnosis is Used in a Trial ? Hypnosis differs largely from other types of psychotherapy. In contrast to psychoanalysis, hypnotherapy does not require years of treatment. Unlike other cognitivebehavioral therapies, it provides indicators that researchers can use, in order to assess a posteriori if the outcomes are correlated to the strategy employed. In this last chapter, we present some of the possible indicators. 1. Hypnotisability, or susceptibility to hypnosis [Smith, 1996; Hawkins, 1998]. Several studies indicate that the results may depend on the level of hypnotisability of the patients. Although Erickson claimed that “non-hypnotisable persons do not exist; there are only bad hypnotists”, the power of suggestions may vary with the subject’s sensitivity to hypnotic induction. According to a large meta-analysis of 57 trials comparing hypnosis to a control group, the hypnotic suggestibility was responsible for 19% of the treatment outcomes6 [Flammer, 2003]. This means that 80% of hypnosis efficacy depend on other parameters. Several tools have been developed to measure hypnotisability: o

o

o

o

the Stanford Hypnotic Susceptibility Scale (SHSS) developed in 1965 has been widely used and often treated as a gold standard (but arguably, according to Benham [2002]). After a very short induction, individuals are tested for certain hypnotic behaviors. The test can be istered and graded by a hypnotist in about a quarter of an hour. The Creative Imagination Scale [Barber, 1978] uses a short hypnotic session including 10 experiences, after which the subject answers questions about his feelings in each experience. This scale was tested against the SHSS and shown to have a weak predictive power [Kurtz et al., 1996]. The Hypnotic Induction Profile [Speigel, 1976]. Also known as the eye roll test, the person is asked to roll his eyes upward, and the size of the visible iris and cornea is measured. The smaller this part of the eye is, the more hypnotically susceptible the person is supposed to be. The results correlate poorly with other hypnotic scales [Orne, 1979] and this scale is no longer used. Other scales can reflect hypnotic susceptibility, such as the TAS (Tellegen Absorption Scale), a self-questionnaire of 34 items. In a multidimensional analysis, Crawford [1982] showed a good correlation between SHSS and TAS. The TAS may be a good alternative to the SHSS for prospective trials where patients need to be tested at inclusion but not be hypnotized.

2. Trance depth may be a useful factor to measure, even during each session. Physiological characteristics will eventually become the best means to evaluate the quality of trance. Bio- techniques can play a role in this direction. Heart-rate 6

In this study, six randomized study reported numerical values for the correlation between hypnotisability scores and treatment outcomes, with a correlation coefficient r = 0.44. Hence, r² = 0.19, which means that 19% of the outcomes variation is due to the variation of hypnotic suggestibility.

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variability (HRV) may be one such parameter, as it has been linked to self-rated hypnotic depth evaluation, possibly through the parasympathetic branch of the autonomic nervous system [Diamond et al., 2008]. Trance depth may also be evaluated by the subject and/or by the hypnotist, as is done for pain with visual analogue scales. Such measures may not be as accurate and reliable as physiologic measures. SHSS relies on the same kind of evaluations through its referenced hypnotic behaviors which can be observed by the hypnotist during a session. 3. Other variables can probably also be scored: for example, the therapeutic alliance. Despite the subjectivity of such an evaluation, it could be evaluated by the therapist with a visual analogue scale . This may appear surprising, but the “patient-therapist” couple also influences the therapist, with a very well-known symptom known in psychoanalysis as “counter-transferance”. Why not use this particular feeling as a measure? The statistical analysis of such an indicator should be stratified by therapist if more than one therapist is employed. Various qualitative and quantitative elements could facilitate the evaluation of hypnotic sessions. These are of little interest in common practice, but when a research protocol tries to evaluate the impact of hypnosis on clinical outcomes, it might be a useful to have some standardized indicators that, later, will help understand what works and what does not. Small portable devices may soon be available to measure different physiological parameters in realtime, and enable better control of the sessions of hypnosis. We stand once again at the crossroad of hypnosis, biology and neurosciences.

CONCLUSION Most studies of the use of hypnosis with cancer patients indicate that this approach is very helpful when facing “psychosomatic” or “psychological” symptoms (pain, side effects of treatments, quality of life, anxiety, depression...) but the effect on the prognosis itself is still controversial. Some authors are pessimistic about ive-expressive group therapy and self-hypnosis training having any effect on survival [Speigel, 2007; Kissane, 2007]. One could thus decide to abandon research in this domain, but the impact of clinical hypnosis on survival, immunology or chronobiology has not been rigorously tested in cancer patients. We believe that biological endpoints such as immunity and response to treatment should not be neglected, as new experimental designs have emerged showing that hypnosis may improve the efficacy of standard treatments. The success of hypnosis in enhancing well-being confirms its place in the management of cancer patients, regardless of the stage of the disease or the age of the patient. Trials with small sample sizes offer good perspectives if targets are precise enough and longitudinal statistics are used to measure the impact of the interventions. Simple biological hypotheses can then be addressed in trials that are far less expensive than those testing new molecules or monoclonal antibodies. Other major advantages are that hypnosis is harmless and non toxic, in contrast to products from the pharmaceutical industry. Moreover, since no medical solution can be

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proposed to cancer patients in palliative care, this population seems very appropriate to test new hypotheses. To paraphrase Goodwin [2005], the least we can offer them is to live better, if not longer ! Although there is a need for standardized procedures, hypnosis sessions should not be too strictly predetermined. Patients differ: sessions must differ. What should be practiced is not some special set of suggestions, always delivered in a same manner, but the global management of patient in which hypnosis is a better way to facilitate personal adjustment and learning. Cancer deprives of life: let’s reintroduce life, flexibility and spontaneity. And if in some sub-group, an effect can be established, it will be time to focus on the matter and develop new directions for new studies using randomized prospective trials. This methodology is no longer the privilege of selected research teams. With the dissemination and sharing of knowledge and expertise in clinical research and statistics now so largely spread by accessible major medical reviews, it is possible to perform clinical studies in most hospitals. This is particularly true for specialized cancer centers, where areas of expertise are already shared by groups of physicians. The limiting factor today is not means, but ideas and priorities. A large amount of data on psychosocial intervention has accumulated, and iveexpressive group therapy has not been found to increase the survival chances of patients. Our intent was not to replace a disappointed hope by another labeled “hypnosis”. Our purpose was to show that clinical hypnosis is still promising, while most of other types of psychological approach have failed to meet the great expectations of the last three decades. If we consider the constant development of new classes of ever more efficient psychotropic drugs, the decline of the psychiatric use of psychotherapy [Mojtabai, 2008] in favor of pharmacotherapy, and the progress of neuroscience, perhaps new research into hypnosis is our last chance to promote a more human paradigm of medicine, rather than a short-sighted mechanical symptom-pill attitude that gives full latitude to industry and leaves patient with more dependencies. Clinical hypnosis and the teaching of self-hypnosis to patients constitute an attempt to give him back power over his sickness and over his own life. It helps patients to handle the major side-effects of cancer and its treatments, notably pain. It spares place for living. Evidence is lacking for any improvement in survival, but well-being is not without value. We have no doubt that the gains in quality of life will eventually translate to a significant impact on the disease itself. As beliefs about hypnosis progress, expectations change, leading to new data that may change beliefs. And so on, and so forth ! Didn’t Benham [2002] show that in western countries, hypnotic susceptibility scores were increasing?

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patients’ response expectancies in side effect development and control. Curr Probl Cancer; 30(2): 40-98 Ross L, Boesen EH, Dalton SO, Johansen C (2002) Mind and Cancer: do psychosocial intervention improve survival and psychological well-being ? European journal of cancer 38 : 1447-1457 Rossi EL (2002) Psychobiologie de la guérison. Edition "Le souffle d'or", Barret-sur-Méouge, . Original edition (1993) WW Norton & Company Inc. New-york Sabbioni M, Siegrist HP, Bacchi M, Bernhard J, Castiglione M, Thurlimann B, Bonnefoi H, Perey L, Herrmann R, Goldhirsch A, Hurny C (2000) Association between immunity and prognostic factors in early breast cancer patients before adjuvant treatment. Breast Cancer Res Treat; 59: 279-287 Sheart T, Maguire P (1999) The effect of psychosocial interventions on anxiety and depression in cancer patients : results of two meta-analyses. Br J Cancer 80 : 1770-80 Simonton OC, Matthews-Simonton S, Sparks TF (1980) Psychological intervention in the treatment of cancer. Psychosomatics; 21(3): 226-7, 231-3 Smedslund G, Ringdal GI (2004) Meta-analysis of the effect of psychosocial interventions on survival time in cancer patients. J Psychosom Res;57: 123-31 Smith JT, Barabasz A, Barabasz M (1996) omparison of hypnosis and distraction in severely ill children undergoing painful medical procedures. J Couns Psychol; 43:187-95 Spiegel D, Bloom JR, (1983) Group therapy and hypnosis reduce metastatic breast carcinoma pain. Psychosom Med; 45: 333-39 Spiegel D, Bloom JR, Kraemer HC, Gottheil E (1989) Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet 2 : 211-22 Spiegel D, Classen D (2000) Group therapy for cancer patients: a research-based handbook of psychosocial care. New-York: Basic Books Spiegel D, Giese-Davis J (2003) Depression and cancer: mechanisms and disease progression. Biol Psychiatry; 54: 269-282 Spiegel D, Butler L, Giese-Davis J, Koopman C, Miller E, DiMiceli S, Classen C, Fobair P, Carlson R, Kraemer H (2007) Effects of ive-expressive group therapy on survival of patients with metastatic breast cancer. Cancer, 11(5) : 1130-8 Spiegel H, Aronson M, Fleiss JL, Haber J (1976) Psychometric analysis if the Hypnotic Induction Profile. Int J Clin Exp Hypn; 24(3): 300-15 Steel J, Geller D, Gamblin TC, Olek MC, Carr B (2007) Depression, immunity and survival in patients with hepatobiliary carcinoma. J Clin Oncol;25(17): 2397-404 Steinha KE, Bosworth HB, Clipp EC, McNeilly M, Christakis NA, Parker J, Tulsky JA (2002) Initial assessment of a new instrument to measure quality of life at the end of life. J Palliative Medicine; 5(6): 829-41 Steinha KE, Bosworth HB, Clipp EC, McNeilly M, Christakis NA, Parker J, Tulsky JA (2004) Measuring quality of life at the end of life: Validation of the QUAL-E. Palliative and ive care; 2: 3-14 Strosberg IM (1989) Hypnosis techniques. Int J Psychosom; 36(1-4): 90-2 Syrjala KL, Cummings C, Donaldson GW (1992) Hypnosis or cognitive behavioral training for the reduction of pain and nausea during cancer treatment: a controlled clinical trial. Pain; 48: 137-46 Syrjala KL, Donaldson GW, Davis MW, Kippes ME, Cart JE (1995) Relaxation and imagery and cognitive-behavioral training reduce pain during cancer treatment: a controlled clinical trial. Pain; 63: 189-98 Temoshok LR, Wald RL (2002) Change is complex: rethinking research on psychosocial intervention in cancer. Integr Cancer Ther; 1(2): 135-45 Tsao JC, Zelter LK (2005) Complementary and alternative medicine approaches for pediatric

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In: Hypnosis: Theories, Research and Applications Editors: G. D. Koester and P. R. Delisle

ISBN 978-1-60456© 2009 Nova Science Publishers, Inc.

Chapter 10

THE VALENCIA MODEL OF WAKING HYPNOSIS AND ITS CLINICAL APPLICATIONS Antonio Capafonsa and M. Elena Mendozaa, b a

b

University of Valencia, Spain; Private Practice, Sta. Cruz de Tenerife (Spain)

ABSTRACT In this chapter, authors describe in detail the Valencia Model of Waking Hypnosis. The concept of waking hypnosis, originally introduced by Wells in 1924, was developed in Spain, and several standardized methods were generated shaping this Model. It is based on the socio-cognitive or cognitive-behavioral paradigm of hypnosis, and represents the first approach to waking hypnosis that disregards the concept of trance. Rather it advocates the continuity between hypnotic and everyday life behaviors, and is focused on variables such as expectations, motivation, attitudes, beliefs, etc. The model consists of a number of efficient methods intending to be straightforward and pleasant for the patient as well as quick to learn and to apply. The procedures implemented as part of the model in order to achieve good rapport with clients are the following: a cognitive-behavioral introduction to hypnosis, a clinical assessment of hypnotic suggestibility, and a metaphor for hypnosis. Furthermore, two induction methods of waking hypnosis are added to these procedures, namely, Rapid Self-Hypnosis and Waking-Alert Hypnosis, the latter also known as Alert-Hand Hypnosis. During the intervention, hypnosis is used in combination with motivational questions to help clients understand the relevance of their thoughts in the maintenance of their problems and the usefulness of hypnosis in changing them. The sequence is structured while flexible to be adapted to the intervention. Thus, the ultimate aim is to enable patients to activate therapeutic suggestions in those everyday situations in which they need them. Some of the advantages of waking hypnosis are the following: clients show less fear of losing control; it usually takes less time to obtain results; clients can remain selfhypnotized with eyes open while engaged in other activities, which enables them to give themselves therapeutic self-suggestions that can go unnoticed when the problem occurs

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in public situations; it is easy to generalize to everyday life; it is versatile and efficient; and it is easily convertible into a general coping and self-control set of skills. Therefore, due to its versatility, the Valencia Model of Waking Hypnosis presents many clinical applications. An illustrative case of the clinical application of this model is described in this chapter.

WHAT IS WAKING HYPNOSIS? The term of waking hypnosis was used by Wells (1924) to designate a form of hypnosis in which the person does not receive a formal method of hypnotic induction including suggestions for drowsiness or relaxation. This way of using hypnosis is more parsimonious and the person is not as afraid of losing control over him/herself as in traditional hypnosis. Likewise, waking hypnosis, due to its characteristics, presents a great deal of practical possibilities and is accessible for more people than traditional hypnosis. Waking hypnosis cannot be considered as merely waking suggestion, since the latter can be used without any induction ritual, whereas waking hypnosis counts with a set of hypnotic induction rituals. The Valencia Model of Waking Hypnosis (VMWH) was developed on the basis of the socio-cognitive or cognitive-behavioral paradigm of hypnosis (Capafons, 2001), and is considered as a therapeutic model embracing a variety of methods combined to change attitudes and use suggestions maximizing their effects. The main characteristics of the VMWH are as follows: • • • • •

There are not suggestions of drowsiness, restriction of the attention, or relaxation. People are asked to keep their eyes open, to expand their attention, to be mentally and physically activated, with increased sensation of self-control. The hypnotized person can speak fluently, walk, and perform almost any of his/her everyday tasks, while experiencing the hypnotic suggestions. Hypnotic suggestions are, essentially, direct and permissive. Hypnosis is introduced as a coping skill avoiding allusions to trance or altered states of consciousness.

EXPERIMENTAL AND THEORETICAL BASES OF THE VALENCIA MODEL OF WAKING HYPNOSIS Suggestion and other related variables, such as beliefs, expectancies, imagination, and so on, have been considered for many years components of the hypnotic experience. For instance, authors like Bernheim (1884), Wundt (1882), and Hull (1933) advocated for these ideas on the base of their experimental studies of hypnosis. Nevertheless, until the 1960s, hypnosis was associated with the methods based on Braid (1843) or Charcot (1882) views, in which relaxation, drowsiness, trance, and eye closure were suggested. Additionally, the used to designate hypnotic reactions were taken from psychopathology and some of them still remain, such as, hallucinations, catalepsies, regression, etc.

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Subsequently, studies conducted by T.X. Barber and his colleagues (Calverley, Wilson, Spanos, and Chaves, among others) in the 1960s questioned the necessity of the concept of hypnotic trance itself, as well as the methods utilized to achieve it in promoting exceptional responses (Spanos & Barber, 1976). In this way, alternative methods were developed to bring about responses to the suggestions. Thus, T.X. Barber proved that the subjective experience of “involuntarity”, besides the objective response to the hypnotic suggestions, could be achieved by using task motivating or think-with instructions (Barber & Calverley, 1965; Wilson & Barber, 1978). Later in the 1970s, in Hilgard’s laboratory, active-alert hypnosis was created by making up different methods of inducing hypnosis formally opposed to the traditional ones (Bányai & Hilgard, 1976). Other authors, like Kratochvil (1970), and Wark (1998), ruled out the concepts of drowsiness and focus on a narrow range of stimuli, proposing methods of alert hypnosis [such as hyperempiria (Gibbons, 1979)], or started to use hypnosis without a formal induction (Kuhner, 1962). On the other hand, Ericksonian authors quit traditional hypnosis and focused on communication and social influence, emphasizing permissive and indirect suggestions in a hypnotic setting away from the usual one (use of analogies, metaphors, etc.) (Hawkins, 1998; Matthews, Conti, & Starr, 1998). Finally, recently, Iglesias and Iglesias (2005) used waking/alert hypnosis from a dynamic perspective to treat panic attacks and other disorders. Another questioned concept was the trait-like quality of hypnotic suggestibility. Several methods were developed to increase it, and experimental research proved the possibility of increasing hypnotic suggestibility (Diamond, 1974; Gorassini & Spanos, 1986; Sachs & Anderson, 1967). There were even procedures proposed from a behavioral perspective resorting to basic principles of Functional Behavior Analysis (Pascal & Salzberg, 1959), in which differential reinforcement of successive approximations or the use of instigators helped more people use hypnosis, thus increasing hypnosis efficiency. On the basis of this theoretical background, the Valencia Model of Waking Hypnosis was developed in an attempt to meet the following criteria: • • • • •

The procedures should be pleasant and acceptable for clients. They should be straightforward for clients to apply and learn (self-hypnosis). The clients should be able to use the procedures with their eyes open and to generalize them to their everyday life. The procedures should not create iatrogenic reactions. They should emphasize self-control and be versatile enough to be used as methods of either relaxation or activation depending on the client’s needs.

To this end, the procedures of VMWH derive from the methods for increasing hypnotic suggestibility by Sachs and Anderson (1967), and recover Well’s basic ideas of waking hypnosis and Gibbons’ concept of hyperempiria. Moreover, the essential theoretical rationale of VMWH lies on the Response Expectancy Theory by Kirsch (1990, 1991, 1993), and disregards the concept of trance as Barber (1969), and Coe and Sarbin (1991) proposed. In this way, the model advocates the continuity between hypnotic and non-hypnotic behavior, resorting to variables such as expectations, motivation, attitudes, beliefs, etc. to produce the hypnotic responses (Capafons, 1999; Lynn & Kirsch, 2005; Spanos & Coe, 1992).

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ADVANTAGES OF WAKING HYPNOSIS OVER TRADITIONAL HYPNOSIS Waking hypnosis has several advantages; some of them had already been pointed out by Wells in 1924, namely: a) it has a less mysterious appearance and its impression is more desirable; b) it takes less time in obtaining results, usually two or three minutes if not earlier, than traditional hypnosis; c) requires less effort on the part of the therapist and it is easier for the beginner to learn; d) it can be used with more people successfully since the start; e) when it is needed or preferred to employ hypnosis by relaxation, the methods can be adapted with a greater chance of success if the suggestions given in waking hypnosis were successful (Wells, 1924). Our experience with the VMWH allows us to add further advantages. First, that the fact that clients can remain self-hypnotized while keeping their eyes open, talking, walking, and engaged in any other activities of their everyday life allows them to experience therapeutic suggestions where the problem they need them for arises (Alarcón & Capafons, 2006; Capafons, 1998b, 2004a, b). Accordingly, when homework assignments are included in the therapy, they are easier to carry out since the clients count with a coping strategy to go through them successfully. Thus, many of the post-hypnotic therapeutic suggestions can be ed by the client in situ, who, in this way, obtains benefits faster. Secondly, waking hypnosis strengthens clients’ expectancies for success, reinforces their motivation for subsequent sessions and therapy more generally, and magnifies their sense of general efficacy and self-control (Capafons & Mendoza, in press). Additionally, the VMWH introduces waking hypnosis as a strategy for coping and selfcontrol (Capafons, 1998b, 2001) disregarding the concept of an altered state of consciousness. Finally, it is worth pointing out that the VMWH fosters an active participation on the part of the client. In contrast, the Wells’ model was authoritarian promoting ivity in clients (John F. Chaves, personal communication to the first author, 12-1-2005), and was framed in a trance setting (Wells, 1924).

PROCEDURES OF THE VALENCIA MODEL OF WAKING HYPNOSIS As mentioned before, the methods of the VMWH are intended to be efficient and at the same time pleasant, easy and quick to learn and apply for both therapists and patients. In this sense, the Model puts forth a sequence that serves as a guide in the intervention with waking hypnosis (Fig. 1) and that can be adapted to each specific case. In order to establish a good rapport with patients, three procedures have been implemented as part of the Model, namely, a cognitive-behavioral introduction to hypnosis, a clinical assessment of hypnotic suggestibility, and a metaphor for hypnosis. Additionally, two hypnotic induction methods (Rapid Self-Hypnosis (RSH) and Waking-Alert Hypnosis (WAH), the latter also known as Alert-Hand Hypnosis (Cardeña, Alarcón, Capafons, & Bayot, 1998)) complement the VMWH. The core of the Model is RSH, and it is very structured, but, at the same time, flexible enough to be adapted to the cases and patients’ preferences and necessities. In the next paragraphs these procedures are explained in detail.

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Figure 1. Clinical intervention sequence of the VMWH (Taken from Alarcón & Capafons, 2006).

COGNITIVE-BEHAVIORAL INTRODUCTION TO HYPNOSIS After the therapist has a diagnosis and a functional analysis of the problem, the intervention plan is established without mentioning hypnosis and a good rapport is established. Then, it is convenient to assess the misconceptions about hypnosis that the

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patient holds as well as his/her attitudes toward it (Capafons et al., 2005). The most popular myths are as follows (Capafons, 1998a): 1. Hypnosis is beyond the scope of scientific research. Those who use it are showmen, quack doctors, and charlatans. People who improve through hypnosis are gullible, ignorant and “dependent”. 2. Hypnosis can make people get “stuck” in a trance, in a way that, being unable to “come out” of such state, they would lose their will and become insane. 3. Hypnosis can worsen people’s “latent” psychopathologies. It even can make healthy people to develop psychological alterations. People with psychopathological problems may get even worse by using hypnosis. 4. Hypnosis produces a sleep-like “state”, in which people show special characteristics. If such characteristics are not achieved, the person is not hypnotized. That special situation can only be achieved by means of a hypnotic induction method. 5. Hypnosis makes people lose their voluntary control. Thus, the person becomes an automaton in the hypnotist’s hands, and can commit crimes, or immoral or socially ridiculous acts. 6. Hypnosis generates exceptional, unusual, and quasi-magic reactions in people. 7. Hypnosis is an efficacious and quick therapy (hypnotherapy) that does not require any effort on the part of the client to change his/her behavior. However, only very suggestible people can benefit from it. Accordingly, these myths about hypnosis are dispelled and explained in detail, answering all doubts the clients may have. Subsequently, the therapist initiates the introduction to hypnosis from a cognitivebehavioral standpoint (Capafons, 2001; Capafons & Amigó, 1993; Coe, 1980; Kirsch, 1994), in which the following ideas are important to be conveyed: a) responses to suggestions are acts committed by the clients, and therefore not dependent on any “power” of the therapist. The hypnotist simply facilitates the experience of suggested responses. b) Actions during waking hypnosis are automatic, but at the same time, they are voluntary in the sense that individuals have the ability to initiate, stop, or resist suggested responses. c) What happens during hypnosis depends mainly on person’s ability to utilize their resources, which are activated in a manner similar to how they are activated on an everyday basis. d) Accordingly, hypnosis involves reactions in everyday life that can be activated or deactivated at will at any given moment. e) From this perspective, hypnosis is a form of self-control, even if less conscious effort is required on behalf of people to regulate certain behaviors. f) To be hypnotized does not require entering into a trance or altered state of consciousness, but rather involves preparing the mind to access resources that facilitate perceiving responses in daily life as automatic (Alarcón & Capafons, 2006; Capafons, 2001; Capafons & Mendoza, in press). To this end, the therapist performs an exercise with the Chevreul pendulum illusion (see the script of this exercise in Appendix I) (Capafons, 2004a; Capafons & Mendoza, in press). Obviously, the examples provided in this exercise can be adapted to the patient’s preferences, including cultural ones, as in some countries such type of exercise is used “to get in touch with spirits”, and the patient can be scared if the pendulum is used.

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The information conveyed through the presentation increases the probability that clients will feel comfortable with the hypnotic procedures, and reinforces the explanations given before when dispelling the above-mentioned myths. Additionally, according to a recent study (Capafons et al., 2006), this presentation reduces dropouts more than other presentation that emphasizes achieving a trance state when people who expressed reluctance to experience hypnosis are selected and given the opportunity of being (hetero) hypnotized. These results are in accordance with the findings of a study by Lynn, Vanderhoff, Shindler, and Stafford (2002), although they used a different trance explanation suggesting that an altered state of consciousness was instrumental to responding during hypnosis. However, it has been found that when reluctant people are offered to received a self-hypnosis method, no such differences in dropout rates are observed (Capafons et al., 2005).

CLINICAL ASSESSMENT OF HYPNOTIC SUGGESTIBILITY According to the VMWH, the initial assessment of hypnotic suggestibility is performed outside the hypnotic context and as a form of assessing patients’ collaboration with, and confidence in the therapist and the hypnosis itself. Patient’s expectancies and attitudes towards hypnosis are assessed as well, since it has been found that they are related to positive outcomes of psychological treatments that include hypnosis as an adjunctive (Barber, Spanos, & Chaves, 1974; Chaves, 1999; Schoenberger, Kirsch, Gearan, Montgomery, & Pastyrnak, 1997). Even though there are many forms of assessing hypnotic suggestibility, the VMWH puts forth these exercises that help reduce the fear many people have of being hypnotized and familiarize patients with “waking” suggestions. For the first exercise, postural sway, patients are asked to stand with their feet together and their eyes closed. Afterwards, the therapist suggests with a monotonous, firm, but nice voice to sway back and forth. If clients begin to gently sway, we can assume that they are not interfering or blocking reactions, since they are in an unbalanced position that, in itself, with no intervention of suggestions produces swaying. If clients markedly sway, that means they are collaborating and experiencing the effect of suggestions. Nevertheless, if clients do not sway at all, there is a high likelihood that they are resisting the natural effects of suggestions. In this case, it is convenient to determine the reasons why they are resisting. It may be due to their fears, reluctances, skepticism, or other interfering beliefs that should be further explained and dispelled. Additionally, clients are informed that, because of the posture, everyone sways slightly, unless they block the effects of the suggestions. The next exercise, falling back (Hilgard, 1965; Capafons, 2001; 2004a) is aimed to assess the clients’ confidence in the therapist with greater certainty than the previous one, since the therapist will catch the clients when they fall backwards. The exercise starts asking clients to close their eyes and try to guess the location and distance of the therapist from them. In this way, they can be sure that the therapist is in the right place to hold them when they fall backwards. Actually, the angle of fall should be small, just enough to allow therapists to test whether clients try to avoid falling in any way. Clients are then asked to let themselves fall before the exercise starts so that they can confirm that the therapist has the strength to hold

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them. After this, clients adopt the same position than in the postural sway exercise and the therapist gives them suggestions for feeling unbalanced and falling backwards. If clients avoid falling, the therapist asks for determining the reasons of their lack of confidence. Given that they let themselves fall before the exercise, it is assumed that their lack of confidence is not toward the therapist but toward hypnosis. Conversely, if the clients let themselves fall backwards, it can be assumed that they trust hipnosis and are collaborative. If they also report that they felt unbalanced, it can be assumed that clients experienced the subjective reaction suggested. In view of the fact that certain clients prefer to use their imagination to completely experience suggested reactions (T.X. Barber, 1999), the therapist can complement this exercise by using a metaphor to facilitate a “postural sway and fall backwards” response. This is a variant of the standard exercise in which the therapist asks clients to imagine that s/he is holding a powerful magnet his/her right arm, and that the magnet is being ed around clients’ head, which feels the attraction toward the magnet. Then the therapist indicates that the magnet is moving to the left and drawing the client’s body with it, after that to the right, then forwards, then backwards (which are the postural sway movements). Finally, the magnet attracts the client so strongly backwards that s/he becomes unbalanced and falls into the ing hands of the therapist. In case there are better responses after the application of the magnet metaphor, it can be concluded that this client benefits more from imaginative suggestions. In the next exercise, clients are asked to roll up their eyes and then close their eyelids without lowering their eyes. After this, they are instructed to attempt to raise their eyelids, without moving their eyes from this position, and the therapist inform that they will not be able to do so (challenge exercise). Often times, clients find it difficult to roll up their eyes and hold them in that position with their eyelids closed. If this is the case, the therapist can ask clients to look at a given spot on the ceiling. Obliging them to lift their gaze and then to lower their eyelids without moving their eyes from the target spot. If the clients do not open their eyes, the therapist ask them how they feel and explain the trick behind this exercise (i.e., it is virtually impossible to raise one’s eyelids while maintaining your eyes in this position). If, on the contrary, they open their eyes, the therapist asks them about any reluctance they experienced, and assesses whether they understood the instructions. In case the clients open their eyes because they were afraid, the therapist leaves aside the hypnotic suggestibility assessment, and addresses the possible causes of lack of confidence. When these difficulties are overcome, the exercise is repeated, and the “trick” is explained. At this point, the therapist clarifies to the clients that the tricks will be always explained to them, and that certain tricks are employed as a part of the treatment in order to improve their responsivity to suggestions, thus converting them into prompts for suggested responses. The last exercise is a motor challenge suggestion, hand clasping. It is introduced as an exercise involving mental self-control, and the therapist explains that it consists in getting the sense that the hands get stuck following suggestions that the hands are so tightly stuck together that they cannot be separated. When clients do not interfere with the reaction, they will feel they cannot separate their hands until they “break” the response and stop experiencing that their hands are stuck. If clients fail the challenge by separating their hands, they are asked if at least they felt tension in their fingers, or felt as if their hands were stuck together. If this is the case, the

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therapist asks them why they separated their hands. If clients report that they did so because they feared losing voluntary control, it is convenient to remind them of the trick, namely, the importance of experiencing the tension without interference. Also, they are reminded about the difference between automatic response and involuntary response explained in the cognitive-behavioral introduction to hypnosis. If the clients fail to experience any reaction, the exercise is repeated using counting and imagination techniques (i.e., a strong glue that sticks the hands together). If none of these endeavors succeeds clients are told that they are not in hypnosis, and that with some practice they will probably be able to perform the exercise while in hypnosis. In case the clients respond appropriately and do not become frightened by their failure to separate their hands, then the mechanism behind the exercise is explained, and they are told that there is a very high probability that they will respond well to the therapeutic suggestions that follow, since they have activated the tension response in their hands and have not interfered with it. If the clients have performed correctly most of these exercises and have a positive attitude toward hypnosis, the therapist may proceed to teach them a self-hypnosis method. Finally, it is worth pointing out that the way of using and interpreting these classic exercises is different to the usual one. By including the assessment of attitudes and expectancies in a qualitative way, the therapists can obtain useful information about the willingness of patients to collaborate and get involved in the therapy. Additionally, all these exercises are carried out in a relaxed atmosphere, using jokes to help establish rapport, and to decrease tension and concerns about testing.

RAPID SELF-HYPNOSIS AND ARM DISSOCIATION At this point, clients are invited to initiate their experience with self-hypnosis. Rapid Self-Hypnosis (RSH) is an induction method of waking hypnosis that also can be employed as a traditional method suggesting relaxation and restriction of peripheral attention. Before inducing hypnosis it is convenient to warn clients about the expected effects they can experience during the hypnotic induction. In case of suggesting relaxation, these reactions are similar to the ones experienced when relaxing by any other method, namely, dizziness, tingling, drowsiness, feeling of heaviness, lightheadedness, etc. Additionally, it is appropriate the establishment of a sign indicating the therapist that the client wants to come out of hypnosis. On the other hand, when RSH is used as an activation method, it should be explained what is expected from the clients so that they do not confuse the activation instructions with anxiogenic instructions. Finally, the therapist gives the clients strategies for them to cope with interfering thoughts and images that prevent them from concentrating. Rapid Self-Hypnosis consists of the three following steps: (1) hand clasping, (2) falling backwards, and (3) a challenge suggestion (“confirmation” exercise). The clients are informed that these exercises are designed to produce sensations of relaxation, heaviness and immobility, as well as to activate the brain so that it works in a rapid and effective way. The steps are very structured and the way the training is done is based on Applied Functional Behavior Analysis. That is, it consists of the shaping of the behavior through successive approximations to the goal, verbal explanations, modeling and the chaining of the

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behaviors. Therefore, the patients learn the steps separately and then they are put together. The ability to respond is then generalized to new therapeutic suggestions with no need of further shaping exercises. In this way, the whole procedure is similar to a process of stimulus fading and generalization. The therapist’s instructions, the instigating exercises, and the sensations of heaviness are faded, although the last two can be used to maintain the habit and optimize overlearning, or when relaxation is needed. A detailed description of the steps of these procedures is in Appendix II. Once this procedure is over, clients are interviewed to know their reactions and preferences, which will help the therapist to adapt exercises in future sessions to the clients’ characteristics. Additionally, clients are told that it is important to practice the method three times in a row in the morning, afternoon, and night, and they are also advised to perform it in various places according to the principle of stimulus generalization. With practice, these self-hypnosis procedures becomes more abbreviated and better disguised. Moreover, clients capable of reproducing extreme heaviness in their arm, with very little practice, can concentrate on the arm (with the eyes open, without interrupting their activities) and give themselves suggestions for feeling their arm heavy and immobile, as if “it were not theirs,” and experiencing a dissociation of the arm from the body. At that moment they are “in self-hypnosis” and, therefore, are ready to implement the therapeutic suggestions they need in a given situation. Simply put, RSH can be reduced in this way to a single instruction of reproducing a sensation, which, since it requires neither overt exercises, nor the closing of the eyes, nor the adoption of a relaxed posture, goes unnoticed by others. Clients thus gain access to self-hypnosis by fading the relaxation exercises and relinquishing the traditional hypnotic appearance (eyes closed, relaxed, sleepy). Accordingly, all individuals need to do in everyday life is to activate the dissociation of the arm in order to set the stage for self-istering therapeutic suggestions. This brief variation of RSH is called Arm Dissociation (AD) (Capafons, 1999), and it has been found that the AD method makes RSH a more efficient and effective hypnotic method. AD sures the initial method in a number of relevant characteristics: (1) it is more pleasant; (2) it can be applied easier to the client’s everyday life; (3) it is shorter; (4) it is less noticeable in public; and (5) it results in an increase of the client’s suggestibility (Reig, Capafons, Bayot, & Bustillo, 2001).

A METAPHOR FOR ATTITUDINAL CONSOLIDATION Once clients have experienced self-hypnosis, the therapist provides them with a metaphor aimed to convey the following ideas: (a) hypnosis is not dangerous, (b) successful responding does not imply a lack of effort or perseverance to achieve a change in behavior, and (c) hypnosis is an important tool that can act as a catalyst of other treatments, such as cognitivebehavioral interventions. Likewise, the metaphor is intended to be a didactic aid that allows clients to consolidate and the information about hypnosis explained to them before (Porush, 1987), as well as to activate self-efficacy expectations to facilitate therapeutic outcomes (Callow & Benson, 1990). The exercise consists in asking the clients to self-hypnotize and then imagine themselves being the main characters in an adventure story in a jungle facing a number of fictitious problems. They overcome them successfully with their own effort, creativity, and use of a

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multipurpose tool, a machete that represents hypnosis (see the full text of this metaphor in Appendix III). According to research, after listening to this metaphor, most participants change their opinion about hypnosis and consider it as an adjunct technique to the intervention that helps gain self-control (Capafons, Alarcón, & Hemmins, 1999).

HETERO-HYPNOSIS: WAKING-ALERT HYPNOSIS (WAH) This procedure (also known as Alert Hand Method, Cardeña, Alarcón, Capafons, & Bayot, 1998) was designed by the first author (Capafons, 1998a, b; 2001) as a part of the VMWH and to complement the RSH. It is especially helpful for those clients who prefer to be hypnotized by the therapist (Capafons, 1998a; 2001). In these cases, the therapist can hypnotize clients with the aim of reinforcing the efficacy of the self-istered suggestions, but with the understanding that clients will eventually use hypnosis on themselves. Waking-Alert Hypnosis, like RSH, encourages clients to keep their eyes open, adopt a normal everyday appearance, and even maintain a pleasant conversation with the therapist. Among the methods of alert hypnosis developed, the one created by Bányai (Bányai & Hilgard, 1976; Bányai, Zseni, & Turi, 1993) is probably the most researched of them, and the most similar to WAH in the sense that both promotes to keep the eyes open and general activation while remaining hypnotized. Nevertheless, current findings from research have shown that WAH counts with a number of advantages over Bányai’s method as follows: (a) WAH is more pleasant (Cardeña, Alarcón, Capafons, & Bayot, 1998), and promotes a greater level of suggestion (Alarcón, Capafons; Bayot, & Cardeña, 1999); (b) it includes some exercises to be performed previously to avoid that clients confuse the concepts of being activated with being anxious, something that could happen (Ludwig & Lyle, 1964); (c) it is easier to conduct that Banyái’s approach, since the latter requires an ergonomic bicycle, or a spacious room in which the clients can walk around and activate themselves; (d) WAH is easier to generalize to everyday life, since clients always keep their eyes open, whereas in Banyái’s method it is not this way all the time; (e) WAH produces fewer dropouts than Banyái’s method; and (f) it can be performed by clients who are in poor physical condition but still can benefit from suggestions of alertness (Cardeña, Alarcón, Capafons, & Bayot, 1998). A description of the introduction, pre-induction exercises, and WAH method can be found in Appendix IV.

PRACTICE AND TRAINING SUGGESTIONS One of the purposes of hypnosis, especially waking hypnosis, is to increase clients’ selfefficacy and outcome expectancies (Kirsch, 1985; 1986) fostering their motivation to get involved in the intervention. Insofar as in the VMWH the suggestions are given while clients keep their eyes open, it is possible to conduct several practice exercises in which clients start realizing that a series of stimuli (pencils, watches, or any object even imaginary ones) can provoke reactions that in a natural way, they would never provoke.

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These exercises start asking the clients to self-hypnotize. Then, reactions of heaviness and lightness are suggested to be evoked and associated to seeing or touching different objects. Next, these suggestions are reversed, that is, if it has been suggested that seeing a ball pen will generate heaviness, to reverse the suggestion means that the ball pen will evoke lightness later. By using Hull’s (1933), terminology the therapist explains the client that these exercises are useful to facilitate homoaction (i.e. the improvement of the responses through practice) and heteroaction (i.e. the improvement of the performance in difficult suggestions by practicing others less complicated). In this way, clients understand that responding to suggestions is also a matter of practice and learning that facilitates the use of self-hypnosis as a technique to promote coping skills. Clients also learn that they are developing their own ability to respond to hypnotic suggestions that is based on a sort of mental discipline. On the other hand, these exercises allow asking the following motivational questions to the clients: ¾ Do you think that there is any objective reason by which seeing or touching those objects would generate heaviness or lightness? Answer: No ¾ Do you think that the way you think, or imagine, as well as your attitude has favored those reactions? Answer: Yes. ¾ Do you think that the objects evoke the reactions that you have experienced due to the meaning that you have associated to those objects? Answer: Yes. ¾ Do you think that the magnitude and implications of your problem partially depend on your way of thinking, of imagining, and on your attitude towards it? In other words, do you think that your problem depends on the meaning that you have associated to it? Answer: Yes. ¾ Do you think that changing your way of thinking, of imagining, and your attitude towards the problem can help you solve it? Answer: Yes. ¾ Do you think that hypnosis can help you manage better your thoughts and your imagination, and keep a better attitude towards your problem? Answer: Yes. Usually, clients tend to respond adequately to the questions, what lead them to change the meaning of their symptoms. Now those symptoms are no longer out of their control, on the contrary, they are modulated, determined, and/or maintained by their attitude and understanding of the problem. In this way, self-hypnosis reveals to be an adjunctive method that helps increase self-control and self-regulation.

THERAPEUTIC SUGGESTIONS Once a patient has learned the procedures described so far, the therapist proceed to chose the kind of therapeutic suggestions more suitable for the case and the patient’s characteristics. An array of types of suggestions that the therapist can use is as follows: ¾ Suggestions for the efficacy of suggestions and techniques. ¾ Ego-strengthening suggestions: confidence, ability, strength, energy. ¾ Well-being: joy, satisfaction, relaxation.

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Distancing: indifference, objectivity, calmness, serenity. Desire / Control. Anxiety, confusion, sadness, excessive worry, panic. Repugnance, repulsion, rejection. Satiety – appetite. Analgesia / Anesthesia. Motor suggestions: immobility, slowing down or acceleration of movements. Automatic writing. Dissociation of parts of oneself, from surroundings. Amnesia, hallucinations of solutions, etc. Time distortion: acceleration (while in pain) and slowing down (while enjoying a meal). Age regression to the time the person did not have the problem (without looking for precision of the recall). Time progression to a date in which the problem has already solved. Alteration of the physiologic experience of anxiety or similar. Reinterpretation of psychophysiologic reactions and thoughts. Paradoxical intention (as a variant of challenge suggestions).

RECOMMENDATIONS TO INCREASE THE EFFICACY OF SUGGESTIONS It is important to take into the following aspects when using direct suggestions: ¾ To use the appropriate tone of voice for each message: emphasizing key words and talk with the rhythm, pauses, and pace adequate to the client. To modulate the tone of voice all the time, showing confidence and fluency. ¾ To use short suggestions or break them in short sentences. ¾ To use a positive wording. It is better to say “tobacco is indifferent to you”, than “you do not feel like smoking”. ¾ To involve as many sensory stimuli in the visualization as possible. ¾ Post-hypnotic suggestions will have a short and specific limit of time: “In a moment, when you come out of hypnosis, and during the next half an hour, you will feel refreshed and active… during the next half an hour, you will feel refreshed and active…” ¾ The suggestions have to be credible for the client. It is better to say: “As I face the situations I am afraid of, they will quit bothering me”, than saying: “From now on, I will always enjoy riding my bicycle” (in case of an agoraphobic patient). ¾ To have available a variety of suggestions to prevent boredom or habituation. ¾ To express suggestions forcefully and with confidence, even showing an intense emotional involvement. To avoid repeating the suggestions dully and mechanically. Finally, in case of failure in responding to the suggestions the following strategies may be helpful:

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¾ To turn to the learning of sensory/emotional recall control or the reproduction of responses in general. It has to be stressed that the idea is to evoke responses already in the repertoire of the patient, or to promt those not still in it. ¾ To emphasize the concept of interference, removing distrust and/or impatience. ¾ To distinguish between involuntary and automatic behaviors (the later can be controlled). ¾ To perform exercises to correct the response as outlined below: o Instigation and observation of the response aimed to suggest. o Association of that response to a verbal, visual, or both cue (optional). o Encouraging the response reproduction by activating the cue. ¾ To emphasize individual differences in speed and style of learning.

CLINICAL APPLICATION OF THE VMWH CASE J. (SURGERY ANXIETY AND PAIN MANAGEMENT) The patient is a 47 years old male who was in psychological therapy for Generalized Anxiety Disorder (GAD). In the course of this treatment he suffered an accident that resulted in an injury in his right wrist. At first, it was supposed to be a severe sprain and the patient was given a Velcro wrist splint that he took on and off, and was prescribed pain medication. After seven days, since J. had not improved at all, the physician decided to check for a hidden scaphoid fracture through an MRI. This diagnosis was confirmed and due to failure to diagnose and treat the fracture earlier and acutely, the only option left was surgery. The patient asked for help through hypnosis to manage pain and cope with peri-surgery anxiety, distress, and pain. Given that he was receiving cognitive-behavioral treatment for his GAD, J. was familiar with cognitive restructuring of irrational thoughts, diaphragmatic breathing, and progressive muscle relaxation. The goal of this part of the treatment was for J. to learn self-hypnosis and its applications to the problems he was facing at that time related to the injury of his wrist.

Session 1 First, the cognitive-behavioral explanation of hypnosis was introduced to the patient. By the means of several practical examples, including exercises using a pendulum, the presentation consisted of the following concepts: • • •

Correction of the misconceptions about hypnosis offering precise information ed by scientific research. Explanation of how hypnosis works. Explanation of the ways one can interfere with hypnotic procedures, such as different ways of not following the suggestions, distractions, unrealistic expectancies, and so on.

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J. was able to understand all these concepts and showed a good attitude to continue with the next exercises. Second, the initial assessment of hypnotic suggestibility was performed in order to assess J.’s collaboration with, and confidence in the therapist and the hypnosis procedure itself. All the exercises were done outside the hypnotic context. The first one was the “postural sway” as explained before in this chapter. The patient’s sway was pronounced in response to the suggestions to do so, therefore, it was assumed that J. was collaborating and experiencing the effect of the given suggestions. In the next exercise, “falling back”, the patient allowed himself to fall backwards and reported to have felt unbalanced as soon as the exercise started. The third exercise, “roll up the eyes”, was explained to the patient, who responded appropriately and found this exercise very amazing. Finally, the “hand clasping” exercise was not carried out, due to the patient’s injury in his wrist. It is worth pointing out that the rapport with this patient was already established since he was in an ongoing treatment with the same therapist for GAD. Therefore, J. had confidence in her and it was easy for him to do the exercises without fears. Also, he reported that he liked the exercises and found the session very fun, pleasant, and interesting.

Session 2 The patient came back a week later for this session. After asking him general questions about how he was doing and if there was something new about his wrist treatment, the therapist proceeded to teach J. Rapid Self-Hypnosis (RSH). Since the patient had pain in his wrist, a variant of the first step of the method (hand clasping) had to be made up. In this case, the therapist used a small rubber ball that the patient squeezed with his healthy hand to exert the pressure, and at the moment of dropping the hand on his leg, he let the ball go and relaxed his hand, while focusing on the feelings of heaviness in this hand. The other steps were taught to the patient separately without any other variants, and then they were chained together to complete the method. J. found the exercises easy to perform since they are closely related to the hypnotic suggestibility exercises practiced in the previous session. Subsequently, the patient was asked to hypnotize himself using the method he just learned and the therapist proceeded with the following exercise. It consisted in reading a fictitious story in which the patient had to imagine himself coping with a series of difficulties to survive in a jungle that he solved successfully thanks to his effort and the correct use of a machete that represents hypnosis (see Appendix III for a detailed script of the metaphor (Capafons, Alarcón, & Hemmings, 1999)). The goal of this exercise was to convey the ideas that hypnosis is safe, that it is required an effort on his part to change behaviors, and that hypnosis is a helpful agent in the treatment but not the entire intervention in itself. Therefore, the metaphor helped consolidate the information about hypnosis already given in the presentation. Finally, in this session another exercise was proposed to the patient. While he was selfhypnotized and kept his eyes open, the therapist suggested the patient to evoke reactions of

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heaviness and lightness. Then, each reaction was associated to the sight or touch of different objects; in this case, heaviness was associated to the touch of a red pen and lightness to the sight of a small notebook. The patient needed some time to do the associations and, when he had achieved them, the therapist asked him the questions mentioned in the “practice and training suggestions” section, that he answered as expected. J. understood well the rationale of this exercise and became aware that he had control over his problems and symptoms by changing his way of thinking about them, and his attitudes toward them, and that selfhypnosis would be a good tool to accomplish these changes. The assignments for the next session were to practice RSH three times in a row in the morning, afternoon, and night, and to make a list of the main worries he had about his surgery, his staying in the hospital, and the pain and difficulties this injury was causing him.

Session 3 This session took place one week after the last one. A review of the assignments indicated that the patient had understood well the RSH procedure and had been practicing it easily. In addition, J. had made the list of worries about his problem. He included catastrophic thoughts about not being able to bear the pain of his wrist after surgery and during the physical therapy; also, he was afraid that his sick absence was too long leading him to be dismissed from his work (he worked in an office using computers, so he needed a full recovery before being able to come back). Other thoughts were the following: “what if the surgeon makes a mistake”, “what if the delayed surgery results in non-union of the scaphoid bone and the subsequent osteoarthritis and deformity”, “I will be unable to sleep at all in the hospital”, “I will suffer intense pain after surgery”, “I will be very anxious all the time”, “I will be unable to learn to write with the left hand if the right one never heals”, and so on. Given that the patient had practiced RSH and was comfortable with it, the brief variation of this technique, called Arm Dissociation (AD) (Reig, Capafons, Bayot, & Bustillo, 2001), was taught to him. He was able to respond to the suggestion for arm dissociation quickly and found this method more straightforward and pleasant than the long version. J. was told that from now on, he would be able to use that method everywhere he needed to use self-hypnosis and to give himself therapeutic suggestions. Then, the patient was told to use AD and self-hypnotize for an exercise similar to the one carried out in the last session. The following sensations were suggested: cold/hot, heaviness/lightness, numbness, muscle tension/muscle relaxation, and dissociation of his right hand. All of them were suggested in his right hand except for the muscle tension/relaxation, since it might cause him pain. Once again these sensations were associated to several stimuli chosen by the patient, for instance, he associated the mental image of an ice cube to the sensation of cold in his hand. It is worth mentioning that it is not necessary that the suggested reaction is similar to the object, word, or image that will be associated to it, however, many patients prefer to choose cues reminding them the pursued sensation. It was easy for the patient to feel the suggested reactions and to associate them to cues. During this exercise he started to realize that he had much more control over his feelings and sensations than he thought which motivated him and made him feel more relaxed and positive about his situation. After finishing the exercise the patient was told that with practice, this ability of changing his sensations would improve and become more automatic.

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Subsequently, the “sensory substitution” exercise for pain management (Patterson & Jensen, 2003) was conducted. However, contrasting with the original script, in this case the patient kept his eyes open all the time like in any other waking hypnosis exercise, and AD was used as the self-hypnosis method. The idea of this exercise is to train the patient to substitute uncomfortable sensations (such as pain, anxiety, etc.) with other sensations (either pleasant or neutral). The associations practiced in the previous exercise were very helpful. The patient received the suggestions of substituting any uncomfortable sensation in his wrist (i.e. pain) with other sensations, such as cold, numbness, and dissociation of his hand. The advantages of adapting this exercise to waking hypnosis are that the patient is active in the process all the time and explains to the therapist how he feels and the difficulties he goes through during the exercise, and that it is easier to generalize to everyday life situations. J. had a good response to the “sensory substitution” practice, he reported that he had reproduced the alternative sensations easily and that, by concentrating on them, he had been able to increase their intensity in a way that the pain intensity decreased considerably. As assignments for the next session, J. was asked to practice the exercises of this session every day and anytime he would feel pain in his wrist or any other distress. Also, he was asked to restructure the irrational thoughts he had recorded in the way he had learned in his therapy for GAD (Beck, Rush, Shaw, & Emery, 1979).

Session 4 The patient came back for this session one week later. He reported to feel much better and having used successfully the exercises he had learned every time he felt pain or anxiety. The therapist reviewed the patient’s list of rational thoughts resulting from the cognitive restructuring and the more suitable were adapted in suggestions that J. could use in selfhypnosis, for instance: “I can manage successfully any uncomfortable sensation in my wrist”, “I have the ability of controlling my sensations and emotions”, “As I breathe deeply, I feel calmer and more relaxed”, etc. In order to help J. cope with his catastrophic thoughts, a time projection exercise was performed in this session. In this case, the patient preferred to close his eyes to concentrate better in visualizing himself healthy in a near future, relaxed during his stay in the hospital, going back to his job, etc. Likewise, some emotions he had found particularly helpful were used in this exercise. One of them was the idea of feeling proud of himself for having been able to control his anxiety and overcome all the problems related to the injury in his wrist. He had done a strong association with a cue and was well able to reproduce it quickly, which made him feel in control and with self-efficacy expectancies. Then, after a pause in which the patient talked to the therapist about his medical treatment for his wrist, another exercise with waking hypnosis was performed. This time J. kept his eyes open and the therapist suggested the same sensations than in the previous session to reinforce and consolidate the associations. Some of the emotions mentioned were also used in this exercise. Finally, it was used the “direct diminution” exercise (Patterson & Jensen, 2003), in which suggestions for the uncomfortable feelings become less clear, less strong, further away or smaller were provided. Also some imaginative metaphors were used for the uncomfortable sensations decrease (the therapist gave the patient the option of closing his

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eyes for this last part or the exercise, but he was used to waking hypnosis and felt so comfortable with it that he preferred to keep them open). Finally, some general suggestions for well-being, relaxation, self-confidence, etc. were also given to J. so that he could use them whenever he needed them. Particular suggestions, such as the suggestion for time distortion to accelerate difficult moments like the peri-surgical period, as well as suggestions for analgesia and anesthesia were explained in detail separately. Furthermore, due to the fact that J. reported problems to sleep, the therapist taught him how to use paradoxical intention as a variant of challenge suggestions, for instance: “the more I try to be awake, the sleepier I will feel”. Also, different suggestions for restorative restful sleep, for relaxation, and for a refreshed awakening in the morning were taught so that he could use them before going to sleep. Additionally, he was told to restructure any negative thoughts he could have relative to his problems to sleep.

Follow-Up 1 The patient came back after surgery, three weeks later than the last session. He reported that at that point he felt much better. He still needed to wear a cast for several weeks. The swelling had significantly diminished and the pain was bearable and less intense than he had thought. His level of anxiety had decreased dramatically since the last session, even before surgery. J. reported that self-hypnosis allowed him to remain calm and relaxed during all the hospitalization process, holding positive expectations about his fast recovery and his ability to manage pain, anxiety or any other discomfort he could suffer during this period. Moreover, he reported that he was sleeping well at nights.

Follow-Up 2 After two months of the surgery, the cast of the patient’s wrist had been recently removed and the X-rays performed indicated that the bones had healed properly. The patient was referred to begin a rehabilitation program. He reported that by using self-hypnosis he was able to stay relaxed and to manage pain during the ongoing sessions, in a way that the Physical Therapist worked easier with him. He found especially helpful the dissociation of the hand in cases in which the exercises were too painful, whereas in other cases reproducing sensations of cold or numbness was enough to make the movements bearable and almost without being aware of any discomfort. Moreover, it is worth mentioning that, according to his physician, he needed less medication, such as pain killers or anxiolitics, compared with other people suffering from the same problem. To sum up, in four sessions the patient was able to learn a self-hypnosis method and a variety of self-control strategies as well as suggestions management for reducing pain and anxiety related to a peri-surgical situation. The therapy outcomes reported by the patient were positive in all the areas for which the treatment was implemented. Moreover, he expressed a great satisfaction with the treatment and its results. The reasons he mentioned were: it was a short treatment, sessions were pleasant, fun, and interesting, little efforts yielded good results, and procedures were practical in the sense that he was able to use them anytime he needed them. Finally, in a telephone follow-up one year after the treatment, the patient reported to

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have reached full recovery of his wrist injury and to keep on using self-hypnosis and the other therapeutic procedures to any difficulty he has to deal with in his everyday life.

CONCLUSIONS The procedures of the Valencia Model of Waking Hypnosis described in this chapter count with empirical validation and come into view as potentially useful in clinical practice. All these methods of suggestion management have been described by both patients and therapists as pleasant, enjoyable, and useful, whereas they keep the efficacy attributed to other forms of hypnotic suggestion management. Moreover, the procedures have a great versatility, they are flexible and easy to adapt to the preferences, needs, and characteristics of the different cases. Likewise they are easily convertible into a general coping and self-control set of skills. The fact that the model is based on waking hypnosis entails some characteristics that distinguish them from other methods using traditional hypnosis, namely, the clients are able to respond to the suggestions while they remain active, keep their eyes open, maintain a fluent conversation with the therapist, and experience a strong sense of control. Additionally, they are as efficacious as other forms of hypnotic suggestion management and even sur a number of other methods in research . Findings in research on the VMWH validate and confirm some well-worn concepts: a) waking hypnosis is as effective and efficient as hypnosis by relaxation; b) almost everyone can experience hypnosis to some extent or be trained to be hypnotized; and c) hypnotic responses imply that clients can access certain resources that are also available in nonhypnotic circumstances. Finally, the procedures comprising the VMWH do not mention trance or altered states of consciousness that may frighten or discourage clients. On the contrary, concepts like selfcontrol and perseverance are emphasized. Therefore, this model puts forth waking hypnosis as a compelling alternative and complement to the traditional use of hypnosis by using pleasant, helpful, easy to learn and to apply, and, ultimately, efficient techniques. In fact, some interviewed therapist reported about VMWH (Capafons & Mendoza, in press) the following: •

• • •

• •

They have successfully used the Valencia Model of Waking Hypnosis, as an adjunctive, to treat different problems, and for increasing motivation and performance in sports. It can be used easily for urgent and/or very difficult cases (Pires, 2007). The Valencia Model of Waking Hypnosis reduces the duration of the interventions and makes them more pleasant. Patients perceive the Waking Hypnosis ways of hypnotic induction, and its ways of managing suggestions as very pleasant. Waking Hypnosis increases their interest and motivation for the treatment. Clients soon incorporate Waking Hypnosis ways of using suggestions as coping and self-control skills and abilities. The Valencia Waking Hypnosis methods are easy to learn for patients.

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Additionally, therapists of different countries (Brazil, Cuba, Portugal, Spain, USA, etc.) and diverse health professionals share similar opinions to those mentioned previously.

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Iglesias, A., & Iglesias, A. (2005). Awake-alert hypnosis in the treatment of panic disorder: A case report. American Journal of Clinical Hypnosis, 47, 249-258. Kirsch, I. (1985). Self-efficacy and expectancy: Old wine with new labels. Journal of Personality and Social Psychology, 49, 824-830. Kirsch, I. (1986). Early research on self-efficacy: What we already know without knowing we knew. Journal of Social and Clinical Psychology, 4, 339-358. Kirsch, I. (1990). Changing expectations. A key to effective psychotherapy. Pacific Grove, California: Brooks Cole Publishing Co. Kirsch, I. (1991). The social learning theory of hypnosis. In S.J. Jynn & J.W. Rhue (Eds.), Theories of hypnosis. Current models and perspectives (pp. 467-483). New York: The Gildford Press. Kirsch, I. (1993). Hipnoterapia cognitivo-comportamental: Expectativas y cambio de comportamiento (Cognitive-Behavioral Hypnotherapy: Expectancies and change of behavior). In A. Capafons & S. Amigó (Eds.), Hipnosis, terapia de auto-regulación e intervención comportamental. (Hypnosis, self-regulation therapy and behavioral intervention) (pp. 45-61). Valencia (Spain): Promolibro. Kirsch, I. (1994). Clinical Hypnosis as a nondeceptive placebo: Empirically derived techniques. American Journal of Clinical Hypnosis, 37, 95-106. Kratochvil, S. (1970). Sleep hypnosis and waking hypnosis. International Journal of Clinical and Experimental Hypnosis, 18, 25-40. Kuhner, A. (1962). Hypnosis without hypnosis. International Journal of Clinical and Experimental Hypnosis, 10, 93-99. Ludwig, A.M., & Lyle, W.H. (1964) Tension induction and the hyper-alert trance. Journal of Abnormal and Social Psychology, 69, 70–76. Lynn, S.J., & Kirsch, I. (2005). Teorías de hipnosis (Theories of hypnosis). Papeles del Psicólogo, 25, 9-15. Lynn, S.J., Vanderhoff, H., Shindler K., & Stafford J. (2002). Defining hypnosis as a trance: vs. cooperation: Hypnotic inductions, suggestibility, and performance standards. American Journal of Clinical Hypnosis, 44, 231-240. Martínez-Tendero, J. (1995). Investigación sobre la preferencia entre dos métodos de autohipnosis (A research about the preferente between two self-hypnosis methods). Unpublished pre doctoral degree thesis. University of Valencia (Spain). Matthews, W.J., Conti, J., & Starr, L. (1998). Ericksonian hypnosis: A review of the empirical data. In W.J. Matthews & J. Edgette (Eds.), Current thinking and research in brief therapy, solutions, strategies, narratives. Vol. II (pp. 239-263). Philadelphia: Taylor & Francis Pub. Pascal, G.R., & Salzberg, H.C. (1959). A systematic approach to inducing hypnotic behavior. International Journal of Clinical and Experimental Hypnosis, 7, 161-167. Patterson, D.R., & Jensen, M.P. (2003, November). Pain management. Workshop at 54th Annual Scientific Program of Society for Clinical & Experimental Hypnosis, Chicago, Illinois. Pires, C.L. (2007, July). Using clinical hypnosis to improve the effects of psychological therapies in some complicated clinical cases. Oral presentation at European Congress of Psychology. Prague, Czech Republic. Porush, D. (1987). What Homer can teach technical writers: The mnemonic value of poetic devices. Journal of Technical Writing and Communication, 17, 129-143.

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Reig, I., Capafons, A., Bayot, A., & Bustillo, A. (2001). Suggestion and degree of pleasantness of rapid self-hypnosis and its abbreviated variant. Australian Journal of Clinical and Experimental Hypnosis, 29, 152-164. Sachs, L.B. & Anderson, W.L. (1967). Modification of Hypnotic Susceptibility. International Journal of Clinical and Experimental Hypnosis. 4, 172-180. Schoenberger, N.E., Kirsch, I., Gearan, P., Montgomery, G., & Pastyrnak, S.L. (1997). Hypnotic enhancement of a cognitive behavioral treatment for public speaking anxiety. Behavior Therapy, 28, 127-140. Spanos, N.P., & Barber, T.X. (1976). Behavior modification and hypnosis. In M. Hersen, R.M. Eisler, & P.M. Miller (Eds.), Progress in behavior modification (pp. 1-43). New York: Academic Press Inc. Spanos, N.P., & Coe, W.C. (1992). A social-psychological approach to hypnosis. In E. Fromm & M.R. Nash (Eds.), Contemporary hypnosis research (pp. 102-130). New York: Guilford Press. Wark, D.M. (1998). Alert hypnosis: History and applications. In W.J. Matthews & J. Edgette (Eds.), Current Thinking and Research in Brief Therapy: Solutions, Strategies, Narratives. (pp. 287-304). Philadelphia: Taylor & Francis Pub. Wells, W. (1924). Experiments in waking hypnosis for instructional purposes. Journal of Abnormal and Social Psychology, 18, 389-404. Wilson, S.C., & Barber, T.X. (1978). The creative imagination scale as a measure of hypnotic responsiveness: Applications to experimental and clinical hypnosis. American Journal of Clinical and Experimental hypnosis, 20, 235-249. Wundt, W. (1892). Hypnotismus und suggestion (Hypnotism and suggestion). Leipzig: Engelmann.

APPENDICES Appendix I Cognitive-Behavioral Introduction to Hypnosis (Capafons, 2001, 2004a; Capafons & Mendoza, in press) This introductory presentation begins with the therapist providing the client with a pocket watch with a chain, or anything that can be used as a pendulum. The therapist explains and serves as a model for the following exercise: With the dominant arm stretched out in front of his/her, the therapist holds the pendulum between his/her thumb and forefinger. At this moment, the therapist asks the watch to perform circular movements or oscillations. When the therapist has finished the exercise, he or she asks the clients to do it in more or less the following way: Therapist: “Now stretch out your arm and allow the pendulum to come to rest completely still. Very good! Now ask the watch to move in some direction or other, to trace circles or move from left to right or backwards and forwards. Ask it whatever you wish but do not ask it to defy gravity and move up towards the ceiling. That particular one never works when I try it, and if it did work I would probably die of shock. So what have you asked the watch? [The

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client answers and the watch moves] Ah! Fantastic! I can see you are quite good at this. Why do you think the watch moved? Client: I don’t know. It just moved by itself. It’s incredible. Maybe I moved it without realizing it. T: Yes, its fun isn’t it? OK, lets try it again but this time I want you to watch your hand very closely (the watch moves). Can you notice anything? C: I think I notice very minute movements in my hand. But I’m not doing it on purpose! T: Exactly! Do you know what this pendulum is...? C: Well, of course I do, it’s a pendulum. T: OK, I guess that’s obvious. But in this case it works as an amplifier, which amplifies the almost unnoticeable movements of your hand at the end of the pendulum and for that reason you can see the movements. If we were to shorten the chain which suspends the watch [the therapist holds the pendulum near the watch end of the chain], it would hardly move at all regardless of what we ask it to do [the therapist demonstrates the idea]. Well, hypnosis, in a way, is like that. Whenever you hear my voice (or indeed your own voice) suggesting things to you your brain will send “orders” to the organs involved in the response which you experience, and you will do things in order to experience these responses. Generally, they will be so subtle that you will not even notice them and you will experience them as if they happened by themselves, as if they just happen. OK? But , it is always you who triggers the things, which happen. It is also you who puts an end to them. Let’s do another exercise. Stretch out your arm and ask the watch to move in a specific direction [the watch moves]. Now, I want you to think that what you are doing is really nonsense, just a stupid game, and that you are in fact being ridiculous... or just think of something urgent that you have to do at home or at work (the watch usually comes to a stand still). Can you see what happens? If you don’t move your hand the watch will stop moving. This is what we call interference. The word interference usually has negative connotations: interference impedes us from watching the television, or from using our mobile phone. If someone interferes, then they obstruct us in our attempts to achieve some goal or other. However, in my case, interference is something positive: You have shown me that you are an active person and that you control what occurs in hypnosis at any given moment. If there is anything that you do not like or if you think that anything is inappropriate, you can interfere with it and stop it. When a person is hypnotized s/he does not lose control. The reactions which that person experiences are automatic (you asked the watch to move, you did not ask your hand to move the watch, however, your brain understood the instruction and activated the hand movements by itself), but voluntary, given that you yourself initiated and detained the response once you thought that it was ridiculous, or once it stopped interesting you. Talking itself is a voluntary act, I can stop when I wish [the therapist stops talking for a few moments], but I do not have to search for the words in order to talk, they just jump out without having to think of them. In this way talking is automatic. If I had to speak to you in a different language which was not so familiar to me, I would have to think about many of my words, i.e. it would be something voluntary but not automatic. Hypnosis is like that, you will experience voluntary but automatic responses. Do you understand? C: Yes I think so: It’s just like walking, voluntary but automatic at the same time, right? T: Precisely! But let us try another exercise. Stretch out your arm and ask the watch to move but this time ask it as if your life depended on it, ask it forcefully and demandingly. Ask it now! [The client does so but the watch does not move]. You see, this is another form

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of interference. If you wish to experience something and you are waiting on it, forcefully demanding that it occur, then it most probably will not happen. It is just like when you try to something that is on the tip of your tongue, the more you try to it the more blank your mind goes. Have you ever had anything like that happen to you? C: Yes, many times. I think I am getting the hang of what it means to be hypnotized. T: Excellent! Just a moment ago I mentioned that, for me, interference is something positive. Nevertheless, there are interferences that would be inappropriate. Do you know what they are? C: No. I don’t know what you mean. T: I mean that if at any moment you feel unhappy or do not agree with any of the suggestions or with any of the things we do to help overcome the problem which has brought you here, and you do not communicate this to me but instead keep silent, this would be an inappropriate interference. This would not be positive, as it would imply a break in our communication. If this were to happen, then both you and I would be wasting our time here. Do you understand? C: Yes, yes I believe so. T: There is still one more thing, which I would like to ask you: If you wished to interfere with the suggestions or the therapy how do you think you might do it? C: Well, I don’t know, I don’t think I will interfere. T: Probably not, but try now to imagine what you would do in such a case. C: I suppose I would think of something else, perhaps not follow the instructions or not offer any ideas about looking for solutions. T: I see. I am going to ask a favor of you: If you discover that you are doing one of the things which you have just described, please tell me right away. Otherwise our communication will be broken, you will lose confidence in me and I will not be able to help you. As I said before in this case we would both be wasting our time. OK? C: All right, I’ll give it a try. T: Good, now I would like to explain something else. I know that you have understood what to expect from hypnosis but I would still like to us to agree on one more thing. I assure you that all the time that we spend here talking about this will be time saved in the future, if we can overcome all possible misunderstandings. Tell me, have you ever seen a horror movie? C: Yes. T: Do they frighten you? Do you notice anything about yourself? C: Yes I get scared. I notice tension, fear... T: Your heart beats faster perhaps, your hands sweat and you feel a sense of danger? C: Yes, sometimes, even though I like the movie, I look away from the most terrifying scenes. T: Perfect. Now try to imagine that I am an extra-terrestrial, and that I am observing you while you watch the movie. Do you think that I could believe it possible that you should be frightened by something that you know is not real but is actually a fantasy, a lie? Don’t you think that I should believe that you were not very intelligent? C: Well if you look at it like that (laughter), then I guess so. T: But really it’s not like that. The cinema is an art form. You know that there is a director, actors, cameras, a scriptwriter, etc., and you know that everything is just a story. Right?

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C: Yes of course (laughter). T: In other words, you voluntarily choose not to think of the fact that it is all a fantasy, and you become involved in the story that is being told. You unconsciously “forget” that behind the scenes there is a whole team of people who have recorded the movie and that all you see are the effects of a few lights reflecting consecutive stills on the screen. All things considered, it is actually a great effort, given that you must “forget” something that is obvious. C: Exactly, but it doesn’t take much effort unless of course the movie is really badly made. T: Precisely. So what happens when you watch an interesting movie is that you experience enriching intense automatic reactions? In spite of the fact that you know everything is false, you let yourself go along with the director’s proposals and thus you experience intense emotions. You may even experience certain behaviors a sudden start for example, covering your eyes, crying etc..., is that right? C: Yes, generally. T: Well, hypnosis works in a similar way: Sometimes I will be the director of the movie (directing the hypnotic suggestions) and at other times you will be the director (selfhypnosis). I will propose that you experience certain things, which deep down you will know are not true (for example that you cannot lift your arm or that you forget something.) because if you allow things to happen (just as in the cinema) then they will happen. Sometimes these reactions can be very intense but they will always be under your control. In fact, what do you or indeed other people do when they don’t want to see certain sequences of a horror movie? C: I look away, or I leave my seat, sometimes I cover my face with my hands and I look out from between my fingers. Some people actually leave the cinema. Sometimes I think that it is all a lie and I distance myself from the plot. T: That’s right. Don’t you think that these behaviors are like interferences? C: Well, now that you mention it, I guess they are. T: Going to the cinema is a voluntary act, just like “forgetting” that all is fantasy and paying attention to what happens on screen. The reactions that you experience are automatic, just like the fear, happiness or pity generated by the images. All of these reactions however are under your control. All you have to do is avoid going to the movies or stop paying attention to the director’s proposals. You can even get up and leave the theatre. OK, well hypnosis is just like a story or a film. What happens in hypnosis is voluntary and automatic at the same time. You may wish not to initiate the processes to experience certain reactions, or you may wish to interfere in it. It depends on you. If you like the proposed script, you can experience enriching intense sensations and reactions which will help you to overcome the problem which you have told me about. If you decide that the story does not interest you, just don’t listen to it, but do not forget to tell me. OK? C: Yes, OK. I never thought that hypnosis worked that way. I think that now I know why I sometimes get a sense that I do things almost without wanting to but without losing control. T: Perfect. If you wish we can begin with a few exercises that will give us information about your current level of responding to hypnotic suggestions. C: OK. I am looking forward to experiencing what it is like to be hypnotized.

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Appendix II Steps of Rapid Self-Hypnosis (RSH) (Capafons, 1998b) Before learning the steps, the therapist explains the rationale of the method more or less as follows: «There are many ways to induce hypnosis very rapidly, in a matter of seconds. We are going to use two of them. I have chosen them because they are very powerful and can be used in such a way that they will go unnoticed in everyday life. We will use hand-clasping and falling backwards (assuming that the client’s susceptibility to hypnosis has been assessed through the exercises of falling backwards and hand-clasping). When I assessed your hypnotic susceptibility, we did an exercise in which I suggested that you would fall backwards, and another one in which I suggested that your hands were so tightly stuck together that they could not be separated because of the sense that your hands got stuck together. Do you them? Well, these two exercises can be modified into fast methods to induce hypnosis. And that is what we will do next, but as a form of self-hypnosis. Don’t worry, the exercises we will practice are designed so that you won’t fall to the floor and get hurt.» Hand-Clasping After explaining the steps, the therapist clasps his or her hands without interlacing the fingers and without pressing them against each other. The client is told that «This way is useful so that I won’t get hurt if I wear rings or jewelry. It is also helpful with individuals who suffer from rheumatism, arthritis, etc.» Next, the therapist takes a deep breath and during the exhalation lightly presses each hand against the other. At that moment, the patient is told «Pay attention. It is very important to just exert a light pressure as you very slowly exhale. It is not appropriate to exhale abruptly or to use much pressure. It is not a matter of using a lot of pressure, but only enough to notice later on the sensation of heaviness in the arms. Making them feel tired in this exercise, it will be easier later on to notice their heaviness as we do an exercise of arm immobility. Slow breathing will help us notice general sensations of heaviness and relaxation. that we will use anything that will help us experience those sensations. Now, I am going to repeat the exercise twice, without relaxing the hands as I inhale (the therapist demonstrates). You must now do the exercise. (The client does the exercise, as the therapist helps and corrects as necessary.)» It may be useful to be very clear with the patients that with each exhalation they must very lightly press each hand against the other, so that by the third exhalation there is a level of pressure that is mild but strong enough to notice heaviness in the arms and hands when they are suddenly dropped on the legs. On the other hand, some people exhale too rapidly or abruptly. If the client finds it difficult to exhale slowly, the therapist can ask him/her to imagine a candle 25 cm. away from his/her mouth. As the client exhales, the flame must move but not go out. That is how softly the exhalation must be. If the patient cannot imagine that, or cannot exhale slowly, the therapist can use a real candle so that the patient will learn to move the flame without turning the candle out. Once this has been achieved, it is time to continue to go to the next exercise, after verbally reinforcing the patient: «Very good, you are learning very fast. This is a good

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sign that you can use this method successfully. Now we are proceeding to the next step, falling backwards.»

Falling Back Here the therapist models the exercise and says the following: « I am now reclining into the sofa so that I will be comfortable. This is the position that I will be in when I let myself fall backwards. Next I will lean forward, separating my back from the back of the sofa some 10 cm., and then I will let myself fall backwards, in a similar way as what I would do if I were sitting upright and I wanted to be more comfortable. (The therapist lets him/herself fall backwards twice of thrice). When I do this, I notice a sense of muscle relaxation (by being more comfortable) and of momentary paralysis. This light paralysis is a natural reaction. This is not a «hypnotic» reaction but a biological response that will help us evoke a later response, which is very important to activate our mind and enter self-hypnosis. Now you should repeat this exercise. You will see that it is not difficult or uncomfortable, but you must practice so that you can end up in a comfortable position and in such a subtle way that no one will notice anything. (The client repeats the exercise a number of times). All right, now we are going to link both steps. Afterwards, I will give you some suggestions so that you can focus on sensations of heaviness and paralysis. You know that if you do not interfere you will notice the reactions that I will propose to you. You will also know that if you do not like them, you can interrupt them any time and without difficulty, so I will ask you to collaborate as much as possible.» Chaining of the Two Steps As with the other two, the therapist models this exercise, separating from the back of chair, shaking the hands and inhaling. At the moment of exhalation, the therapist lightly will press the hands against each other and will exhale slowly. Next he or she does it again twice, without relieving the pressure on the hands with each inhalation, as we mentioned above. When the therapist has finished shaking the hands with the last exhalation, he or she abruptly lets the hands fall on the legs and the back on the back of the chair, while explaining to the client what is happening. Next, the therapist asks the client to do the same, assisting and correcting the client in a kind and encouraging way, while explaining what reactions should be occurring. «As you may have seen, the hands are very heavy, actually all of your body is heavier and you notice that you are lightly relaxed. (Some people get very relaxed at this stage; if this occurs, the therapist should show surprise and indicate that this is a good signal of what is to come). This allow us to stimulate the reactions of the following step (i.e., the sensation of relaxation instigates a sensation of immobility).» If clients indicate that they do not experience anything of what we have described, we should suspect that they are interfering, since the exercises are designed to let anybody experience heaviness and relaxation. Martínez-Tendero (1995) has shown experimentally that 90% of the people that used rapid self-hypnosis felt great heaviness, of which only 43% also had to use imagery to achieve heaviness. Hence, if the patients state that they do not feel heaviness (or lightness, as it is experienced by some patients), the therapist must interrupt the session and find out what the problem is. It could be fear of hypnosis, disbelief about what the

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person is experiencing, fear of being hurt, or disappointment that the method is not powerful or «esoteric» enough. Until those fears and doubts are eliminated, the therapist should not proceed to the following step. Once the client dominates the previous sequence, the therapist goes to the following stage: body immobility.

Body Immobility «Now - says the therapist- you will repeat the sequence you just learnt, and when you have “fallen backwards”, I will give you suggestions to feel your hands more and more glued to your legs. When it becomes very difficult to separate the hands from the legs, or you feel so heavy and relaxed that you feel too lazy to try to separate them, you will have activated your mind and your brain, and you will be able to produce some enriching and useful responses to your problem. that at any point you can interrupt those reactions. What matters here is that you may be able to use them so that you can self-ister the therapeutic suggestions in a very efficient way, and wherever and whenever you want. Is that all right?» Once the client has practiced once again shaking the hands and falling backwards, the therapist begins the suggestions: «Now, close the eyes, if you wish, and focus on your hands. One or both of them will feel heavier and heavier, glued to the legs ... (in a slow and rhythmic voice), heavier and heavier, glued, heavier and glued, as if they were fused to the legs. To help you achieve that, and if you so wish, you can use images of a soft rope that binds your hands to your legs, or of a very powerful glue that glues your hands to your legs, or of a very heavy object that does not allow you to lift the hands. If you notice these reactions, you will notice that in a moment it will be very difficult to lift the hands, and they feel even more glued to the legs. You know that, if you wish, you can lift your hands at any point, but if you put your mind in action, if you let your brain be sufficiently activated, you will notice that you cannot separate your hands from the legs. Furthermore, the more you try to separate them, the more difficult it will be to lift them and the more they will feel glued to the legs. Try it and you will notice how difficult it is to detach the hands from the legs (the client tries to do it and »cannot«). Very well, excellent, I notice that you are able to control your mind so that it can follow your instructions. Now, focus on your hands. They will feel lighter and lighter, and will recover their usual sensation... that’s right, you could separate them now. They are lighter and lighter... That’s it. I will now count to three and you will «come out» of self-hypnosis, you will open the eyes (if the patient closed them) and your mind will be active, clear, with a desire to work on the problem, calm and relaxed. All right, 1..., 2..., and 3 How are you feeling?»

Appendix III Metaphor for Attitudinal Consolidation (Capafons, 2001; Capafons, Alarcón, & Hemmings, 1999) Now imagine that you are driving a jeep through the South American jungle. You are travelling through a forest road, among giant trees, close to an equatorial river. You are going to a town where your expedition companions are waiting for you. Going by car it does not take more than an hour, but walking would take you about five. All of a sudden your car

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stops. You are surprised to find that you are out of gas. The sun is setting and it will be dark soon. You are afraid because you do not have supplies or water. You cannot even start a fire. The jungle is full of dangerous insects and deadly creatures, and you have nothing to defend yourself against them. You look at the additional gas tank, but it is also empty. You try to start the jeep, but there is no sound. You notice your anxiety [the therapist describes the patient's anxiety reactions]. You become more and more worried. You know that it can be very dangerous to try to walk to the village, and a death sentence to stay by the jeep. You are tense and confused, and desperately took for something that will get you out of this mess. Suddenly you find a very big machete. This scares you. It seems that the machete is a sharp and dangerous weapon, but you have no option. Reluctantly, you grab the machete. It frightens you but it is the only thing you have to save your life. You try to think what to do. Fear and uncertainty cloud your thoughts. But you suddenly realise that the river is close to the road you are on. You that the town is on the other side of the river. If you could cross it, you should shortly be in a safe place. Then, you decide to go for it. You start walking towards the river, strongly cutting the vines, bushes and shrubs that hinder your way with the machete. You are becoming more and more tired. The hand and arm with which you are holding the machete are increasingly fatigued and they are starting to hurt. Your feet seem exhausted and your legs seem to bend. You are increasingly tired, you are hungry and thirsty, but you continue clearing the path without pause. Suddenly, from within the trees a giant serpent with dangerous fangs attacks you. You are very scared and can barely avoid it. You know that the serpent wants to devour you. It is coming to you so fast that you can even smell its fetid breath. Just then, with a precise stroke of the machete, you behead it. You feel nauseous when you see the head separated from the body, which is still moving and from which blood is spurting. Nonetheless, you do not give up because you know that you have the machete to help you to continue struggling to reach your objective. You continue marching towards the river with self-assuredness, clearing a path through the jungle. Finally you reach the river's edge but notice with surprise and despair that the river is enormous and turbulent. You also that it is full of piranhas that would devour you in a few minutes. You are again overwhelmed by anxiety, fear, confusion, and despair. You are very tired and it is getting darker. But you that you still have the machete. You rapidly start to cut some small trees and lianas. With them, despite the pain in your hands and the overwhelming fatigue, you build a raft. In it you will be able to cross the river safely and reach the town's port where they are waiting for you and you will be safe. Once the raft is finished you enter the river, armed with an oar which you have built. There are very strong currents and raft is unstable. Once again you are scared, but you know that you are close to your goal. You can see the lights of the town and even hear some distant voices. You imagine how you will be received when you reach the port. You will feel satisfied, sure of your strength and ability. Your associates, bewildered, will greet you with iration. And, above all, you will have solved your problem with your own effort and courage. You use the oar strongly, despite the river's rapids and the protruding rocks that could destroy the raft. Finally you reach the port. A number of people are waiting for you, amazed and iring. You feel satisfied, happy, self-confident. You are no longer afraid. You have reached your objective, through your effort, perseverance, and reasoning, which have allowed you to overcome hopelessness, fear, and confusion. You know that with the machete you have been able to untangle and eliminate the obstacles in your path. You have been able to ward off the attacks of your enemies. You have got rid of

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what prevented you from reaching your goal, your objective. But you also know that this is not enough. It is not enough to firmly and decisively get rid of the obstacles. You have had to run risks, design and build something new to reach your goal. You have built the raft, a new way of transportation. And you have achieved all this with the help of the machete. It is a frightening instrument, but when you understand it and use it with decision, it can become a peerless instrument to go forward in the path we have traced. This is like life. We have to fight, struggle and persevere to attain what we aim for (decrease our fears, improve our habits, etc.), to eliminate hindrances and obstacles, but also to create new ways of life and relationships; to open new options by taking the risk of changing our life or the way we see it. The machete is like hypnosis. It seems dangerous and it scares us. But if we use it with cunning, intelligence, courage, and dexterity it becomes an instrument that can be of great benefit to reach our goals and objectives. The machete is the self-hypnosis. You can use it whenever you wish. But , it is a help to overcome your problems. Without your industry, perseverance, effort, courage and creativity, it is of no use whatsoever. Do that every time that you are afraid, confused or in despair, you can say the word "machete" to yourself and focus on the arm dissociation. At that moment, you will be able to control your anxiety and give yourself therapeutic suggestions so that, in such a way, you can look for the best solutions to the problems you may be facing.

Appendix IV Introduction, Pre-Induction Exercises, and Waking-Alert Hypnosis Method (Capafons, 1998a ; Cardeña, Alarcón, Capafons, & Bayot, 1998) Introduction (After establishing rapport, the following instructions are given.) To enter hypnosis, your mind must be receptive so that if you so wish, you can follow my suggestions and enjoy them. You know that it is not necessary to be relaxed or to close your eyes. In fact, many people prefer to keep their eyes open and not to relax, so that they can retain a greater sense of control and feel more comfortable. You can enjoy hypnosis without having to be relaxed. I can help you feel alert and active. It is not a matter of feeling unusual or anxious but active and alert, as when you expect something pleasant to occur. You will see that it is an enriching experience that will help your mind be active and work efficiently. But before doing hypnosis, we will do some exercises so that you can understand better what I am saying. Pre-Induction Exercises (Note: Exercises 1 and 3 will be done with every participant. The hypnotic induction follows if the participant understands the exercises. Otherwise, Exercises 2 and 4 can also be carried out.) Exercise 1 At some point, you must have felt impatient when waiting for something you wished for very much, for instance when you were going to meet someone you had not seen in a while and wanted very much to see. Try to that time. Imagine that it is 30 minutes before that

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encounter and that you are starting to feel anxious, pleasantly anxious, that is. As time goes by, you start to notice that your heart is beating faster, each minute beating faster, and that emotion over-whelms your body. It is only a few minutes before you will see that person, and you want it to happen. You feel restless, not an unpleasant restlessness but a very pleasant one. Do you understand what I mean? (If not) Don't worry. Let's do another example. (Go to Exercise 2)

Comments: (If yes) Very well! Now we'll go to another example. (Go to Exercise 3) Did you imagine the situationidescribed? Comments: Did you experience the sensations (heartbeats, anxiety) I described? Comments: Exercise 2 a time when you were taking a long walk. It is possible that at the beginning, when you decide to start strolling, it is a bit difficult and you feel a bit lazy. But after a while, surely you start feeling better. that as time goes by and you continue walking, you start to feel clear minded and refreshed, and you enjoy walking more and more. To continue walking becomes easier. As you continue walking, you feel more refreshed and active, and there is a pleasant sensation throughout your body. It is possible that your breathing will be faster, considering that many muscles in your body are working, but it is not a worrisome breathing. It is, instead, a very pleasant breathing because you feel increasingly more energy as you continue strolling. Do you understand what I mean? (If not) Don't worry. Let us do another example. (Go to Exercise 3.) (If yes) Very well! Now we will go to another example. (Go to Exercise 3.) Did you imagine the situation I described? Did you experience the sensations (breathing, energy) I described? Comments: Exercise 3 Let us do a little exercise. (The experimenter will need a drawing, and the phrasing of the exercise will change accordingly.) Focus on me word ("congratulations") above the drawing. Ready? Good, now try to see the bird underneath it.... The goal is to gradually increase your field of vision, so that your mind will also expand— If you do this, you will see that there are some houses and, in the periphery of your vision, a few trees. That's it, fine. Let us continue. Now, concentrate on the scene under the houses, look at the little animals and continue expanding your field of vision so that you will now see that some animals are eating ice cream and some others are playing with a ball. The time will come when you have the whole scene in your mind, because your mind is expanded and active. Have you followed the exercise? (If not) Don't worry, we'll do another exercise, and you will understand it then. (Go to Exercise 4.) (If yes) Perfect! Because I can see that you understand what I am talking about, how about if we start with the hypnosis session? Did you experience how your mind expanded? Comments:

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Exercise 4 "I am going to ask you to close your eyes and imagine what I am saying: Imagine that you are watching a TV show. You like this program very much and are absorbed in it, your mind is totally focused on the TV set. That's it, very good… Now, imagine the room with the TV set and try to see everything that is around the set, the closest things and those that are farthest away; for instance, imagine any piece of furniture the TV set is on, any chairs, furniture, lamps. You can see the whole room, you have a complete view. That's it. You continue to be in the room with the TV set, but now imagine that the roof and everything else over that room has disappeared, so that from above, you can continue seeing the TV set, that room and the rest of your house or apartment— Imagine the whole building, if you have an apartment, the street where your house or apartment is, the whole area, you can see it from the air.... Your mind is expanding more and more, and what I am describing to you is easier and easier because your mind is becoming more active. Now place your street in your city, look at all of the streets, any buildings or parks, any cars, lamps, stores, pedestrians… Try to imagine it all from above, as if you were flying over the city.... From that perspective, you can see your house or apartment over there, at the distance, the rest of the buildings… And, you start to go higher and higher, and you can see the people and the cars becoming smaller.... It is becoming easier to control your mind. We will continue imagining… Continue flying over the city as you get higher and higher, so that you will be able to see not only the city but the whole country. Try to imagine it. You can see your city and the whole country at a distance. You can see the country as if it were drawn on a map, very far away, so far that you can see its rivers, mountains, and oceans… Your mind expands more and more, to such an extent that you can see the Earth itself. You can see the whole globe and can differentiate high mountains, oceans, and so on. You are controlling your mind, which feels so expansive and activated that you can see the Earth within the Milky Way, you can see the whole space, the stars, the planets, the rest of the Universe— you can see the Earth from the vast space. Did you imagine the situationidescribed? Comments: Did you experience how your mind expanded? Comments: (Note: Once this exercise is done – for those who need it induction follows.) Waking-Alert Hypnosis Method (WAH) (Once we are ready to proceed with the induction and the client is comfortably seated in an armchair, we proceed.) Now, concentrate on your right hand. Start moving it up and down from the wrist, while you rest your arm on the arm of the chair. Keep moving the hand up and down without stopping… You will notice soon that the movement becomes more and more automatic and that the hand will start moving on its own, automatically… Your muscles will not get tired but the opposite, they will become more and more activated … Notice how the movement becomes more and more automatic, as if the hand had a mind of its own… The hand is becoming more and more active, more and more, as you notice that the arm feels also pleasantly tense and activated... Your heart is pumping more and more blood to move the muscles… and you can notice how your heart rate is increasing slightly, in a similar way as when you are impatient or somewhat excited... Your heartbeat is speeding up, and your breathing starts to speed up more and more... You are breathing more and more rapidly but with a nice rhythm…It is a

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fast but pleasant rhythm. And you start noticing that you are more and more hypnotized, activated and hypnotized… Your mind is working more and more rapidly, expanding… You can now stop the movements in your hand, but your breathing remains rapid and agitated and you are becoming more and more hypnotized... very hypnotized. All your body is becoming more and more active— The blood coming from your hand is irradiating throughout all the veins and arteries of your body, taking along a sensation of energy, expansion, and activation, similar to when you are alert, waiting for an event, a pleasant event, to happen... and you are feeling even more hypnotized. Your legs are more active and they have a tendency to move, your chest and head are also more active and feel like moving… You now feel the need to get up from the armchair and walk, calmly and at your pace, to the door of the room. (The person gets up and walks.) As you walk, you feel yourself more hypnotized, alert, with an activated and receptive consciousness… Your mind is prepared, activated and very, very expanded, increasingly clear and expanded... Your mind is hypnotized and ready to work quickly and effectively. (Note: After this induction, exercises such as arm levitation, or any other that may be of particular interest, may be carried out to "show" participants that their mind can do these exercises when it is activated.) (After the exercises, the person is dehypnotized in the following way.) Now concentrate on my voice, and as you do so, your heartbeat starts to gradually slow down, your breathing also becomes slower, both to a comfortable level.... As your heartbeat and breathing slow down, you start coming out of hypnosis, less activated physically and less expanded mentally. In a moment, I will count to 3. When I reach 3, you will have come out of hypnosis, you will feel calm, your muscles will be relaxed, and you will have an active mind.... You will sense the urge to be active, but in a serene and peaceful way. 1. Your muscles are less activated, and your breathing is slowing down 2. You are coming out of hypnosis, your mind is active but less expanded. 3. You are out of hypnosis but remain active and relaxed, with an urge to do things. That's it, very well. How are you feeling? (In a clinical setting, it may be profitable to do a quick reinduction and leave a cue for future sessions. The participant can be told, before the last count, the following.) To save time before the next sessions, I am going to give you a cue so that you will be able to re-hypnotize in a few seconds. This will be very helpful to you and me because we will be able to spend more time solving a problem. Now listen carefully, each time I touch your shoulder (or another appropriate cue) and tell you that you will "go into this active and alert mental state," and as long as you wish it, you will regain this level of mental activation (touch the shoulder or do another cue). that every time I touch your shoulder this way (touch the shoulder or do the other cue again), and as long as you wish it, you will achieve this same efficient and active mental state.

In: Hypnosis: Theories, Research and Applications Editors: G. D. Koester and P. R. Delisle

ISBN 978-1-60456© 2009 Nova Science Publishers, Inc.

Chapter 11

HYPNOSIS IN THE MANAGEMENT OF CHRONIC PAIN CONDITIONS, AND THE ACUTE PAIN ACCOMPANYING THEIR TREATMENT *

John F. Chaves The effective management of chronic pain continues to present a serious challenge to the health professions. Even though we now have a wide array of medical therapies that are relatively safe and largely effective in managing many forms of chronic and acute pain, these therapies have significant limitations, especially in the management of chronic pain. The pain relief achieved with traditional biomedical and surgical therapies is often incomplete and sometimes ineffective (Stevens, Dalla Pozza, Cavalletto, Cooper, and Kilham, 1994). Moreover, relief too often comes at a high cost in of the patient’s quality of life (Douglas, 1999). Adding to these considerations has been our growing awareness of the limitations of a narrow biomedical perspective on health and well-being and a recognition of the need to embrace a broader biopsychosocial perspective that encourages our examination of alternative approaches to pain management (Engel, 1977; 1987; 1997). This chapter describes and evaluates the ways in which one such alternative, clinical hypnosis, has been used in the management of chronic pain, including the management of acute pain associated with the treatment of underlying medical conditions producing chronic pain. It describes the nature of hypnotic interventions and the manner in which they have been used in chronic pain management. It also considers the spectrum of application of hypnosis in chronic pain management and reviews systematically collected data as well as case studies pertaining to several chronic pain problems. The emphasis is placed on finding reported since recent critical reviews by Spanos (1989; Spanos, Carmanico, and Ellis, 1994) and Chaves (1989; 1993; 1994). My goal is to provide a framework for clinicians who may be unfamiliar with this modality to understand better the nature of hypnotic treatment, help them appreciate *

A version of this book was also published as a chapter in The Handbook of Chronic Pain, edited by S. Kreitler, Diego Beltrutti, Aldo Lamberto and David Niv, published by Nova Science Publishers, Inc. It was submitted for appropriate modifications in an effort to encourage wider dissemination of research.

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the empirical evidence ing its use, and introduce some of the practical issues involved in its effective use in chronic pain management. To put this topic in context, it is important to note that contemporary approaches to chronic pain management have increasingly coming to reflect an awareness of the significant contribution of psychosocial factors in the etiology, diagnosis, and treatment of many painful medical conditions. That fact is due, in part, to the reconceptualization of pain perception provided by the gate control theory of pain (Melzack and Wall, 1965) that offered new ways of understanding the neurophysiological mechanisms by which psychosocial factors could amplify or attenuate the pain experience. Although the basic observation that pain could be profoundly modulated by various psychological interventions was already well known, the articulation of a formal theory that provided explicit mechanisms by which this modulation of pain could be produced had an enormous impact on research and clinical practice and helped to encourage the development of multidisciplinary approaches to pain management (Kotarba, 1983). Soon, systematic efforts were underway to refine older therapeutic strategies and to develop new strategies for exploiting psychological resources that were already available to patients as well as assisting them in developing new skills that could be beneficially applied to reducing their symptoms (Fordyce, 1976; Turk, Meichenbaum, and Genest, 1983). Although substantial gains in the clinical practice of pain management have been made since the Gate Control Theory was promulgated, the biomedical perspective has continued to dominate contemporary medical practice, even as more sophisticated psychological interventions for pain management were developed (Turk et al., 1983). In recent years, however, there has been substantial growth in the amount of research, including randomized clinical trials, being conducted on psychological interventions for chronic pain management. Favorable results have contributed to a growing acceptance of the notion that interventions like hypnosis, that can augment more traditional medical or pharmacological approaches, or reduce reliance on them, have the potential to play an important role in contemporary pain management (Chaves and Dworkin, 1997; Holroyd, 1996; National Institutes of Health, 1995).

A BRIEF HISTORICAL OVERVIEW OF CLINICAL HYPNOSIS Hypnosis is arguably one of the oldest forms of psychological therapy (Crabtree, 1993; Ellenberger, 1970). Although hypnotic-like phenomena have been observed throughout recorded history (Edmonston, 1986; Hilgard and Hilgard, 1983), the topic came to the serious attention of the health professions in the late 1700’s and early 1800’s. It was then that anecdotal reports began to appear in the medical literature suggesting that hypnosis, or Mesmerism, as it was then called, could be used to control the pain associated with various medical procedures. These reports described limb amputations, mastectomies, and dental extractions apparently completed with substantially less than the expected levels of pain (Deane, 1844; Delatour, 1826; Ward and Topham, 1842; West, 1836). By the time inhalation anesthetics had been discovered in the middle of the 19th Century, hypnosis had already attracted a substantial following in the medical community, led by John Elliotson, a wellknown physician at the University of London (Chaves and Dworkin, 1997). Of course, these s predate the discovery of inhalation anesthetics, so it is not surprising that evidence

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that surgical pain could be controlled received considerable attention. It is also noteworthy that the initial clinical reports focused almost entirely on the mitigation of pain associated with medical and dental procedures, rather than with chronic pain. Although we now accept the mitigation of chronic and acute pain as important and legitimate therapeutic goals, this was not always the case. For a variety of reasons, the health professions have, at times, expressed deep ambivalence about pain and its mitigation. During the Middle Ages, pain was seen both as a means of punishment and a means of redemption (Caton, 1985). Later, during the 17th and 18th Centuries, pain was thought to play an important facilitative role in the healing process (Rey, 1993). Some saw the induction of an unconscious state, by any means, as creating an ethical dilemma, because the unconscious patient would be unable to assess the speed, talent, and skill of the surgeon (Rey, 1993)! Even in colonial America, physicians, who were often of the clergy, displayed complex attitudes toward pain that were influenced by both the Augustinian tradition that interpreted pain as the just punishment of the wicked, and the redemptive view that pain was a means of moral growth and salvation (Rey, 1993). Accordingly attitudes towards pain and its relief by techniques like hypnosis, and later by inhalation anesthesia, must be understood within the cultural context of the era (Caton, 1985). That context probably served initially as a barrier to the adoption of inhalation anesthetics as well as the adoption of hypnosis (Chaves and Dworkin, 1997). Interestingly, as is probably true even today, the barriers to adopting new measures for pain relief seemed greater for professionals than for laymen. Indeed, Winter (1991; 1998) has provided us with a fascinating analysis of the brief but intense struggle between professionals who advocated the use of inhalation anesthetics and those who advocated the use of hypnosis in managing surgical pain. The superiority of inhalation anesthetics was not obvious at first, especially since its use was initially associated with high mortality rates. However, within a few years, inhalation anesthesia became a part of medical orthodoxy, while hypnosis was initially relegated to the margins of medical practice (Parssinen, 1979; Quen, 1973). Interest in hypnosis waxed and waned over the next several decades. Periods of heightened interest were most commonly associated with the appearance of clinical reports describing the successful use of hypnosis to control pain, such as that associated with battlefield injuries incurred during WW I and WW II, when pharmacological agents were unavailable, or in limited supply. Occasionally, other reports of the successful use of hypnosis in alleviating surgical pain appeared describing the fragile medical condition of patients that placed them at significant risk if pharmacological agents were employed (Chaves, 1989; Chaves and Barber, 1976). In the 1950s and 60s interest in hypnosis grew rapidly and important research programs developed that investigated, among other topics, the use of hypnosis to control pain (Barber, 1959; Barber, 1963; Hilgard, 1969; Hilgard and Hilgard, 1975; Hilgard, 1967; Weitzenhoffer and Hilgard, 1962). By bringing this phenomenon into the laboratory, it was hoped that a better understand might be achieved concerning which aspects of the hypnotic intervention were effective in reducing pain, and to better understand how hypnotic interventions might be devised that optimized the clinical application of these techniques. That line of research has continued to the present and in recent years has been augmented by psychophysiological and electrophysiological studies intended to assess the physiological dimensions of the response to hypnotic procedure. The development of newer neuroimaging strategies have also added tools that have been applied in an effort to understand how hypnotic interventions reduce clinical and experimental pain (Chen, 2001; Crawford, Gur, Skolnick, Gur, and Benson,

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1993; Hofbauer, Rainville, Duncan, and Bushnell, 2001; Rainville, Carrier, Hofbauer, Bushnell, and Duncan, 1999; Rainville et al., 1999). Before considering some of the chronic pain syndromes to which clinical hypnosis has been applied, it may be helpful to look at how hypnotic interventions are designed and implemented, with emphasis on some of the special issues that arise in its application in pain management.

THE CLINICAL APPLICATION OF HYPNOSIS IN PAIN MANAGEMENT The typical treatment protocol for chronic pain management with hypnosis can be divided into six phases, each with its own specific issues: (a) Patient Selection and Preparation, (b) Induction, (c) Deepening, (d) Therapeutic Suggestions, (e) Post-hypnotic suggestion and (f) Termination. All patients come to hypnosis with expectations about the nature of hypnosis (Chaves, 1993; Johnson and Hauck, 1999; Kirsch, 1999). Sometimes these include elaborate notions about who can or cannot be hypnotized and how the process of becoming hypnotized occurs. Some of these beliefs can facilitate responding (e.g. the belief that good hypnotic subjects are intelligent and imaginative individuals) (Cronin, Spanos, and Barber, 1971). Other beliefs and expectations can inhibit responding (e.g. good hypnotic subjects are gullible, easily led individuals who lose control during the process (Barber and de Moor, 1972). Special ethical and psychological complexities arise when hypnosis is employed for patients with cancer and patients or their family express the belief that the disease might be cured by the use of hypnotic suggestion (Syrjala and Roth-Roemer, 1996). Under these conditions it is important to be clear about the lack of evidence that hypnosis can directly alter the course of the disease and, at the same time, encourage positive expectations about its impact on patient comfort and motivation. Although three randomized prospective studies have shown a survival differences favoring cancer patients who have been exposed to psychosocial interventions, two others have not (Spiegel, Sephton, Terr, and Stites, 1998). Although the possible influence of such psychosocial interventions on neuroimmune pathways is under active investigation, the present state of the evidence makes it inappropriate to offer hope of cure or even hope of prolonged survival to patients at this time. On the other hand, the case for success in enhanced comfort, decreased reliance on pharmacological agents, and improved quality of life is much more compelling, as we shall see. The hallmark of the hypnotic intervention is often thought to be the induction process, although evidence indicates that suggestion, per se, can exert powerful effects in a wide variety of contexts (Spanos and Chaves, 1989). Although the nature, duration, and character of hypnotic inductions is highly variable, they typically include instructions to focus attention, suggestions for relaxation, and for entering a hypnotic state. They may also involve suggestions for overt responses that are often described by good hypnotic subjects as occurring effortlessly (e.g. automatic eye-closure in response to suggested drowsiness or movement of the arms in response to suggestions of lightness or heaviness). Such suggestions serve both as observable markers of the patient’s subjective response to the procedure for the therapist, and to illustrate the involuntary character of hypnotic responding for the patient.

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Deepening suggestions follow the induction and are intended to help the patient have a more profound experience through various images, suggested alteration of breathing patterns, suggestions of bodily heaviness, and so forth (Chaves, 1979). Eventually a point is reached where therapeutically relevant suggestions are istered. The nature of these suggestions is highly variable, even for chronic pain patients. Some of the considerations involved in developing these suggestions are discussed below. With chronic pain patients, post-hypnotic suggestions are generally istered to facilitate the continuation of treatment gains outside of the hypnotic context. This strategy is often augmented with further training in the use of self-hypnosis or by audiotaping the hypnotic intervention and asking the patient to listen to the tape on a regular basis at home. In working with chronic pain patients, significant issues arise with respect to the preparation, therapeutic suggestion, and post-hypnotic suggestion phases. Let is briefly consider some of these issues

SPECIAL ISSUES IN USING HYPNOSIS IN CHRONIC PAIN MANAGEMENT One of the most important challenges clinicians face in using hypnosis in chronic pain management concerns the management of patient’s expectations. Patients sometimes approach hypnosis with almost magical expectations regarding its efficacy. The dilemma facing the clinician is the decision about the extent to which to capitalize on initially positive expectations that may be unrealistic. While we often strive to assist patients in developing positive expectations about treatment outcomes, the failure to achieve unrealistically high initial expectations can make it difficult to pursue more modest, but attainable treatment goals. Patient expectations are known to play an important role in shaping treatment outcomes (e.g. Kirsch, 1999; Shutty, DeGood, and Tuttle, 1990; Shutty and DeGood, 1990). Indeed, neurophysiological evidence suggests that expectation of pain activates sites within the medial frontal lobes, insular cortex and cerebellum distinct from but close to sites activated during the pain experience (Ploghaus et al., 1999). In addition, evidence suggests that expectations can play an important role in shaping the hypnotic experience itself (Kirsch, 1990; 1999; Council, Kirsch, and Hafner, 1986). The process of engaging a chronic pain patient in treatment typically entails a complex and often difficult negotiation in which the patient comes to relinquish the goal of seeking a “cure” and accept the legitimacy of the of the goal of pain management. This is particularly true for patients with chronic benign pain syndromes, or disorders whose pathophysiological basis has not been clearly established. Accordingly, such treatment sub-goals as increased uptime, decreased reliance on medication, and increased participation in family activities become legitimate treatment objectives. Indeed, the gains achieved with respect to these specific, measurable outcomes can serve as important markers of patient progress and help document success for these patients. As Dworkin and I have noted (Chaves and Dworkin, 1997), this “rehabilitation model” is not consonant with the way hypnosis has traditionally been used. This application requires an approach that encourages positive expectations, while minimizing magical expectations of immediate cure.

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A second barrier encountered in preparing patient for the use of hypnosis for chronic pain, especially the chronic benign pain syndromes, is that these patients have often been told, “the pain is in your head.” This diagnosis is frequently offered in a context in which psychological causes for pain are implied if not explicitly stated (Chaves, 1993). Although often offered to assuage patient concerns about more serious medical conditions, these statements have the unintended consequence of creating ambivalence, if not aversion, to psychological interventions like hypnosis. The obvious dilemma for the patient is that successful treatment will confirm the dismissive diagnosis that the pain only existed “in their head.” The successful use of hypnosis in chronic pain management requires that both of these issues be successfully managed before beginning treatment. That requires that patient attitudes and expectations regarding treatment be carefully elicited prior to treatment. Patients’ views regarding the etiology and pathophysiology of their conditions, as well as their understanding of the views of the clinicians who have previously treated them, can be very helpful in developing a “heuristic model” for the patient that can help them understand the complex interplay between their cognitive and emotional life and their experience of pain. In turn, this model can provide a rationale for the hypnotic interventions to follow. This approach can be particularly important when patients are experiencing such subjectively puzzling phenomena as phantom limb pain, complex regional pain syndromes (e.g. reflex sympathetic dystrophies, causalgia, trigeminal neuralgia) or peripheral manifestations of central pain syndromes related to stroke or space-occupying lesions in the central nervous system). The period of patient preparation for hypnosis also provides an important opportunity to explore the patient’s phenomenology of the pain experience. This exploration provides a rich resource for the development of personally-relevant suggestions that may be therapeutically useful. My own clinical experiences, described elsewhere (e.g. Brown and Chaves, 1980; Chaves, 1981; 1985a; 1985b; 1989; 1993; 1996; 1997; 1999), indicate the importance of rejecting generic pain-relieving suggestions in favor of those that are shaped by the patient’s own phenomenology of the pain experience. The careful and empathic listening that is required to elicit this information also helps establish rapport and confers an important therapeutic benefit for those patients who too often are surrounded by those who have become tired of listening. Of course, commonly used suggestions for hypnotic analgesia, including suggestions that a painful part of the body is numb and insensitive, or that it is disconnected from the rest of the body, may be therapeutically valuable in chronic pain management. But their use can be enhanced when integrated with suggestive elements derived specifically from the patient’s own experience of pain. For example, a patient of mine with phantom-limb pain was asked to describe her experience of pain. She said that when she thought of her pain, two images came to mind. One included little red ants that were nibbling at her stump. The other involved rubber bands that she could imagine being tied tightly around the end of her stump. An added feature of this patient’s discomfort involved the vivid visual images she reported of her phantom limb when her pain was intense. The therapeutic suggestions derived to assist this patient included spraying her phantom limb with a powerful ant killer, cutting the rubber bands, and visualize her phantom being immersed in a dense fog that prevented her from seeing it, no matter how hard she tried. These brief examples illustrate how the clinician can assist the patient in developing cognitive strategies that may be idiosyncratically beneficial in

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reducing pain. Certainly, there is substantial evidence from the experimental pain literature ing the value of this kind of approach (Chaves and Brown, 1987; Chaves and Barber, 1974; Spanos, Horton, and Chaves, 1975) Patients do not readily it us to their phenomenal world. Indeed, at times, they may have difficulty grasping what you are driving at when you ask about their pain phenomenology. Nevertheless, these explorations can be quite fruitful and, in my experience, can greatly enhance the efficacy of interventions for pain management. Preexisting cognitive coping strategies and metaphors that have guided efforts at pain-self management pain can also be very helpful. By the same token, knowledge of the patient’s catastrophizing ideation, or other aspects of their phenomenology that limits their ability to cope can also be very helpful (Chaves, 2000). I view this phase of the hypnotic intervention as the most important in devising effective interventions. Properly conducted, it sets the stage for all other aspects of the hypnotic intervention and can play a vital role in its ultimate success.

THE SPECTRUM OF CLINICAL APPLICATION Hypnotic techniques have been applied to a wide variety of medical conditions. Here I review some of the more important areas of application that have been explored. The intent is not to provide a comprehensive critical review of that literature. Instead, the goal is to provide some samples of the ways in which hypnotic interventions for chronic pain are being implemented and evaluated. Although the focus is on the use of hypnosis in chronic pain management, many chronic pain conditions are accompanied by significant acute pain associated with medical treatments. Where relevant, I have included a description of ways in which hypnosis has been used in reducing pain associated with these treatments.

CANCER Cancer is often accompanied by pain associated with disease progression as well as with the implementation of uncomfortable diagnostic and treatment protocols. Hypnosis has been used in a multifaceted fashion for patients suffering from cancer. It has used as a tool for chronic pain management as well as to reduce the pain, discomfort, and anxiety associated with many aspects of cancer treatment (Chaves, 2000). Stam (1989) has provided a detailed critical review of much of the early literature. In recent years, other descriptive reviews have appeared (Genuis, 1995; Liossi and Mystakidou, 1996; Lynch, 1999). Steggles and his colleagues have provided useful annotated bibliographies of the relatively recent literature on the use of hypnosis in cancer in adults and in children and adolescents (Spanos, Steggles, Radtke-Bodorik, and Rivers, 1979; Steggles, Damore-Petingola, Maxwell, and Lightfoot, 1997; Steggles, Fehr, and Aucoin, 1986; Steggles, Maxwell, Lightfoot, Damore-Petingola, and Mayer, 1997; Steggles, Stam, Fehr, and Aucoin, 1987). A number of early reports described the application of hypnosis with cancer pain (Cangello, 1961; 1962; Lea, Ware, and Monroe, 1960). Methodological limitations, poorly specified treatment interventions and outcome measures limit the usefulness of these early reports, although their positive findings were encouraging. In addition they seemed to indicate

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that the benefits of hypnotic intervention could be seen across the entire spectrum of hypnotizability, indicating that its use need not be restricted to very good hypnotic subjects. In more recent years, more detailed and complete reports have become available describing the use of hypnosis with cancer pain and the pain associated with medical procedures frequently used with children suffering from cancer, including lumbar punctures and bone marrow aspiration (LP/BMA) (Katz, Kellerman, and Ellenberg, 1987; Kuttner, Bowman, and Teasdale, 1988; Zeltzer and LaBaron, 1982; Wall and Womack, 1989), and hyperthermia (Reeves and Shapiro, 1983). Zeltzer and LaBaron (1982) compared a hypnotic treatment that entailed therapistassisted deep breathing and pleasant imagery with alternative behavioral intervention, including deep breathing exercises and non-imaginal distractions (e.g. counting, talking). Although both procedures were effective in reducing the pain of BMA and anxiety associated with LP, the hypnotic procedure was more effective in reducing pain and anxiety. The hypnotic technique employed in this study might be more accurately described as a guided imagery intervention, since the procedure was not defined as a hypnotic intervention to either the patients or their families. Wall and Womack (1989) compared a hypnotic intervention to a distraction procedure in reducing pain associated with BMA and LP for children and adolescents. Both procedures were found to be effective in reducing pain, but not anxiety. Kuttner at al. (1988) randomized two groups of children receiving BMA, ages 3-6 and 7-10, to three treatment groups: hypnotic “imaginative involvement,” distraction, and standard medical practice. Two intervention sessions were investigated. During the first session distress was reduced for the younger group using the hypnotic treatment, while both treatments reduced distress for the older patients. During the second intervention, all groups showed reduced distress. The authors concluded that hypnosis had an “all-or-none effect” while the response to distraction only developed with experience. Katz et al. (1987) studied 12 female and 24 males aged 6-11 years with acute lymphoblastic leukemia who were undergoing repeated BMA. The patients were randomized to either a hypnosis or an unstructured play comparison group. The hypnotic intervention included eye fixation, relaxation, imagery, and coping suggestions. Both groups showed reduced self-reported fear and pain. Girls showed more distress than boys on 3 of 4 measures, and there was some suggestion of an interaction between gender and treatment. Hilgard and LeBaron (1982) examined the role of hypnotizability and relief of BMA pain in children. They found that children identified as highly hypnotizable showed greater reductions in self-reported and observer-rated pain than low hypnotizables. This finding has not been confirmed in other studies by Wall and Womack (1989) and Katz et al (1987), although rapport seemed to predict pain reduction in the Katz et al study. The use of hypnosis for pain management usually involves the istration of suggestions for relaxation as well as suggestions that are specifically intended to attenuate pain and discomfort. However, Spiegel and his colleagues have explored the benefits of a complex psychosocial intervention for patients with metastatic breast cancer that includes teaching them to use self-hypnosis. The intent of the intervention was to encourage patients to express and deal with strong emotions and also focuses on clarifying doctor-patient communication. Spiegel and his associates (Classen et al., 2001) studied the impact of this intervention on sixty four-women were randomized to the intervention group, while another 61 were assigned to a control condition. The intervention included weekly group therapy and

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educational materials in addition to a self-hypnosis exercise. Participants were assessed at baseline and every four months during a 12-month period. Results showed that the intervention reduced traumatic stress symptoms and mood disturbance. Spiegel and Moore (Spiegel and Moore, 1997) reported a 10-year follow-up of a randomized trial involving 86 women with cancer showing that this kind of intervention also conferred a survival benefit, significantly increasing survival duration and time from recurrence to death. Syrjala and associates (Syrjala, Cummings, Donaldson, and Chapman, 1987) reported that hypnotherapy reduced oral pain secondary to chemotherapy and radiation treatment for cancer (caused by oral mucositis). In a later study (Syrjala, Cummings, and Donaldson, 1992) they compared the benefits of hypnosis, cognitive behavioral coping skills training, therapist , and usual treatment in 67 patients with hematological malignancies who were undergoing BMT. Hypnosis was effective in reducing treatment-related oral pain for these patients. The treatment groups did not differ with respect to nausea, emesis and opioid use. Interestingly, the cognitive-behavioral intervention was not effective in reducing symptoms in this study. In related study (Syrjala, Donaldson, Davis, Kippes, and Carr, 1995) oral mucositis pain levels were compared in 94 patients receiving BMT. A cognitive-behavioral skills training and a hypnotic-like relaxation-imagery intervention were equally effective in reducing pain. However, adding behavioral skills training did not improve pain levels beyond the level achieved with the relaxation-imagery intervention alone.

HEADACHE Hypnosis has often been applied to the management of headache. Complete or moderate success has been reported in relieving pain associated with migraine headache. Some reports used hypnotic imagery techniques (Davidson, 1987; Friedman and Taub, 1984; Harding, 1967; Milne, 1983); others used rational stage-directed hypnotherapy (Howard, Reardon, and Tosi, 1982) and still others employed suggested hand warming (Ansel, 1977; Graham, 1975; Milne, 1983). Comparative studies of hypnotic and non-hypnotic treatment of migraine, tension or mixed migraine/tension headaches have appeared (Andreychuk and Skriver, 1975; Friedman and Taub, 1985; Friedman and Taub, 1984; Olness, MacDonald, and Uden, 1987; Schlutter, Golden, and Blume, 1980; Spinhoven, Van Dyck, Zitman, and Linssen, 1985; Mellis, Rooimans, Spierings, and Hoogdiun, 1991; Nolan, et. al., 1994 Spanos et al., 1993; Spinhoven, 1988; Zitman, Van-Dyck, Spinhoven, and Linssen, 1992). Taken together, these studies suggest that hypnotic interventions seem to be consistently effective in treating these headaches, although they do not consistently demonstrate a superiority of hypnotic interventions over other cognitive-behavioral interventions. Holden, Deichmann, and Levy (1999) reviewed 31 investigations of recurrent pediatric headache that have appeared since 1981 using predetermined criteria to evaluate the adequacy of research methodology. They concluded that sufficient evidence exists to the conclusion that hypnosis/self-hypnosis is a well-established and efficacious treatment for recurrent headache.

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Gysin (1999) compared the efficacy of five weekly hypnosis/self-hypnosis sessions with behavior therapy and physician counseling for children and adolescents suffering from chronic episodic headaches. Although both treatment interventions reduced headache frequency and intensity, hypnosis was thought to enhance patient control of headaches. Spinhoven and ter Kuile (2000) explored the role of hypnotizability in the treatment of patients with chronic tension-type headaches. They allocated 169 patients to either a selfhypnosis or an autogenic training treatment. Pain reduction immediately following treatment and at later follow-up was significantly associated with hypnotizability. Moreover, early treatment responders had higher hypnotic susceptibility scores than non-responders. These findings confirmed those of an earlier study that also found a correlation between hypnotizability and response to hypnotic treatment or to autogenic training for recurrent headache (ter Kuile et al., 1994). Although hypnotizability appears to predict treatment response for headache pain, many other personal and demographic variables do not seem to predict treatment outcomes. ter Kuile, Spinhoven and Linssen (1995) employed cognitive self-hypnosis training or autogenic training for 156 patients with chronic recurrent headache. At 6 month follow-up, 43 were classified as responders (greater than 50% pain reduction) while 113 were classified as nonresponders. Although patients who expected more pain reduction at pretreatment achieved greater pain reduction, none of the other pretreatment differences predicted either immediate or long term pain reduction. This included demographic and medical status variables, measures of psychological distress, personality, coping strategy use and pain appraisals.

NEUROPATHIC PAIN A variety of neurological conditions are associated with chronic pain. These include post herpetic neuralgia, diabetic neuropathy, complex regional pain syndrome, spinal cord injury, post amputation and AIDS-related neuropathy (Haythornthwaite and Benrud-Larson, 2001). While clinical reports of the use of hypnosis to manage the pain associated with these conditions have appeared, no clinical trials have been reported. Nevertheless, a few examples suggest some of the ways that hypnosis has been employed in these conditions. Gainer (1993) employed hypnosis and self-hypnosis to treat a patient with reflex sympathetic dystrophy (RSD). Over a two year period, the patient reportedly achieved complete relief from her RSD symptoms. In this case, hypnosis was combined with other psychotherapeutic interventions. Phantom limb pain is a common sequelae of surgical or traumatic amputation and is frequently unresponsive to conventional medical/surgical interventions (Chaves 1985b). A number of case reports describe the use of hypnosis with phantom limb pain. Muraoka and associates (Muraoka, Komiyama, Hosoi, Mine, and Kubo, 1996) describe the use of hypnosis in the treatment of severe lower limb phantom limb pain and an associated post-traumatic stress disorder. In this case, hypnosis was employed as one part of a more complex intervention that included antidepressants. Rosen and colleagues (Rosen, Willoch, Bartenstein, Berner, and Rosjo, 2001) used hypnosis to modify the experience of phantom limb pain in two patients. Positron emission tomography (PET) was employed to study the central pathways by which the phantom limb

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was experienced and hypnotically modified in these patients. The authors concluded that hypnosis can be incorporated into treatment protocols for phantom limb pain. This finding was subsequently extended in a study with 8 patients where hypnosis was used to alternate between sensations of pain and movement (Willoch et al., 2000). They found that phantom limb pain sensations were associated with activation of the anterior and posterior cingulate cortex. Chaves (1985b; 1993) described the hypnotic treatment of phantom limb pain in two different cases using a combination of suggestions designed to reduce pain sensations, reduce awareness of the phantom, and alleviate depressive symptoms. In both cases, deriving therapeutically relevant pain-relieving suggestions from the patient’s pain phenomenology seemed important to achieving a successful outcome. Another important element was the use of audiotapes of clinical sessions to reinforce daily practice with the hypnotic intervention. One patient was successfully treated in three sessions (Chaves, 1985b), while for the other, hypnosis was only one part of a more complex intervention.

BURN PAIN Patients who suffer burns experience pain associated with their injury as well as procedural pain associated with surgery and wound debridement. Patterson and his colleagues have made important contributions to this literature (e.g. Everett, Patterson, Burns, Montgomery, and Heimbach, 1993; Martin-Herz, Thurber, and Patterson, 2000; Patterson, 1992; Patterson, 1995; Patterson, Everett, Burns, and Marvin, 1992; Patterson, Goldberg, and Ehde, 1996; Patterson and Ptacek, 1997; Patterson, Questad, and Boltwood, 1987; Patterson, 1989; Patterson, Adcock, and Bombardier, 1997). The use of hypnosis in the management of burn pain is ed by numerous clinical reports as well as by controlled studies, although ittedly the former seem stronger than the latter (Patterson et al., 1997). Indeed, in one case, hypnosis proved effective in managing the pain of a 55-year old man with an extensive burn who had experienced significant respiratory depression due to low dosage of opiods that had been istered during wound care (Ohrbach, Patterson, Carrougher, and Gibran, 1998). An excellent outcome was achieved with little or no opioids, no anxiolytic medication and a shortened length of wound care. Wright and Drummond (2000) asked 30 hospitalized burn patients to rate their levels of pain and relaxation for four burn care sessions. Hypnosis was employed twice on 15 patients while the remaining 15 patients served as controls. Self-reported ratings of the sensory and affective dimensions of pain decreased significantly during and after hypnosis. In addition, anticipatory anxiety prior to subsequent dressing changes decreased in the hypnosis group.

IRRITABLE BOWEL SYNDROME Irritable bowel syndrome (IBS) is not always responsive to conventional medical therapies. A number of studies, mostly conducted in the UK, have suggested that hypnosis can be an effective intervention for patients who are unresponsive to conventional medical treatments for this condition, which generally includes dietary and pharmacological

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interventions (Camilleri, 1999; Wald, 1999). The evaluation of these findings is somewhat complicated by the fact that a comorbid psychiatric diagnosis is common in IBS. Moreover, many symptomatic individuals never seek treatment (Goldberg and Davidson, 1997). Nevertheless, it is instructive to review how hypnosis has been employed with this population. Forbes et al. (Forbes, MacAuley, and Chiotakakou-Faliakou, 2000) compared gutdirected hypnotherapy with a specially-devised non-hypnotic audiotape in a randomized controlled trial involving 52 patients with established IBS who had not responded to dietary and pharmacological therapy. The patient-selection criteria included abdominal pain or discomfort. Their hypnosis treatment protocol followed that advocated by Whorwell in several important earlier investigations (Whorwell, 1990; Whorwell, Prior, and Colgan, 1987; Whorwell, Prior, and Faragher, 1984). Hypnotic induction employed eye-fixation with suggestions for closure. When patients displayed eye-closure and altered breathing pattern, additional deepening suggestions were istered, including suggestions for progressive muscle relaxation and hand levitation. Therapeutic suggestions were then istered that focused on the predominant IBS symptoms. Post-hypnotic suggestions form only a “modest” part of the therapy and regressive strategies (e.g. to uncover psychodynamic factors) were not used. The non-hypnotic tape lasted approximately 30 minutes and consisted of background information about IBS, stress management strategies, and structured relaxation. Patients were encouraged to use the tape on a daily basis. Those assigned to hypnotherapy received 6 treatment sessions scheduled at two-week intervals. Sessions lasted about 30 minutes, with the hypnotic intervention consuming only about 15 minutes of that period. An audiotape was made of one of the sessions, generally the third, and this was provided to the patient for practice at home. For the 45 patients who provided complete data, more than half of the patients in each group clinically improved, but those in the hypnotherapy group showed significantly greater symptom reduction. The authors concluded that, for economic reasons, the tape might be recommended as a second line of intervention for patients who had not responded to traditional IBS treatment, saving the more effective, but more expensive intervention with hypnosis for treatment failures. Galovski and Blanchard (1998) confirmed the findings reported in the UK studies in a study with 6 pairs of matched IBS patients assigned to either a gut-directed hypnotherapy group or to a symptom-monitoring wait list control. Subjects in the control condition were later crossed into the treatment condition. On a composite measure of IBS symptoms, hypnotherapy was significantly better than the control condition. Treated patients also showed reduced state and trait anxiety scores. Interestingly, there was no correlation between hypnotic susceptibility and treatment gain. The clinical gains achieved in using hypnosis with IBS patients do not seem restricted to disease-specific symptoms (e.g. abdominal pain, bloating, bowel habits, flatulence, backache, dyspareunia). Houghton, Heyman, and Whorwell (1996) found that IBS patients treated with hypnotherapy also demonstrated improvements on a number of measures of quality of life and had reduced absenteeism from work as compared to control patients with disease of comparable severity. They concluded that hypnotherapy was a good long-term investment, in spite of its higher initial cost. It is difficulty to say at this point whether it will be possible to achieve significant economies of scale in using hypnotherapy in treating IBS. Some of those

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who have reported successful use of the procedure are convinced that an individually-tailored approach is necessary to achieve the best treatment outcomes (Vidakovic-Vukic, 1999).

APPLICATION OF HYPNOSIS WITH OTHER PAINFUL SYNDROMES Hypnosis has occasionally been applied with a variety of other painful disorders including arthritis (Nolan, 1983, Domangue, Margolis, Lieberman, and Kaji, 1985), recurrent aphthous stomatitis (Andrews and Hall, 1990), head, facial, and back pain, (Toomey and Sanders, 1983), sickle cell disease (Thomas, Koshy, Patterson, Dorn, and Thomas, 1984; Dinges et al., 1997), multiple sclerosis ((Dane, 1996), (Sutcher, 1997); temporomandibular disorder (Stam, McGrath, and Brooke, 1984); Oakley et al., 1994; Simon and Lewis, 2000); repetitive strain injuries (Moore and Wiesner, 1996; Karjalainen et al., 2000); ischemic pain associated with Burger’s disease (Klapow, Patterson, and Edwards, 1996) and interstitial cystitis (Webster and Brennan, 1995). for these applications is generally based on case reports or small clinical studies. There is a need for more systematic data to be collected with respect to all of these applications to document more fully the efficacy of hypnotic interventions and specify the indications and contraindications for its use.

CONCLUSIONS Those working with more conventional biomedical therapies for chronic pain need to be aware of the potential contribution of hypnotic interventions. Hopefully this may not only permit hypnosis to be considered when conventional interventions have failed, but also enable more prospective exploration of where hypnosis might be introduced earlier in the painmanagement process to maximize its benefits. We also need additional information about how hypnotic interventions might be beneficially added to the array of service offered to patients during end-of-life care (Pan, Morrison, Ness, Fugh-Berman, and Leipzig, 2000). In spite of the methodological limitations that apply to many of the studies cited here, taken together, they point strongly to the potential value of hypnosis as an effective intervention for the relief of clinical pain that is not or cannot be managed effectively with conventional medical therapies. This conclusion is ed not only by clinical case studies, but also meta-analyses of systematic studies that have evaluated the use of hypnosis for both clinical and experimental pain (Montgomery, DuHamel, and Redd, 2000). Of course, a number of important questions remain. How can we select patients most likely to benefit from hypnosis as an intervention? What is the role of hypnotizability in determining treatment outcome? How can we best prepare patients for clinical hypnosis? What are the best treatment protocols for using hypnosis in pain management? What is the role of practice and training in optimizing clinical outcomes? What comorbid conditions are indications or contraindications for hypnotic intervention? At present, the answers to these questions remain incomplete and ultimately will require more systematic data. In the meantime, however, hypnosis has demonstrated substantial promise and is sufficiently benign in the hands of properly trained professional health care

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providers, that it probably should be considered in any case where pain control is incomplete or unsatisfactory with conventional therapies. Evidence seems to suggest that the relationship between hypnotizability and clinical outcome is complex, and probably influenced by a complex array of factors. Accordingly, hypnosis should not be ruled out on the basis of apparent low hypnotizability alone. The presence of chronic pain or a life-threatening condition can change patient motivation, and make acceptable interventions that might not have been welcomed under other circumstance. For most clinical purposes, the assessment of hypnotizability is not necessary before conducting a clinical trial with hypnosis. Another advantage of the use of hypnosis is that its flexibility permits the simultaneous pursuit of a wide range of therapeutic targets. This makes it possible to address concurrent anxiety and depressive symptoms as well as other disease-related symptoms beside pain. Indeed, it is sometimes the improvements achieved in mitigating non-pain related symptoms that convinces patients that hypnosis can make it possible to reduce pain (Chaves, 1993).

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INDEX

A absorption, ix, 69, 118, 149, 161, 162, 169, 170, 178, 179, 186, 231, 285 abstinence, 147 academic, 121 ACC, 166, 167, 168, 169, 180, 183 acceptance, xii, 272 accessibility, 11, 16 accidental, 62 accidents, 106 ing, 46, 54, 70 accuracy, 179, 215 acid, 193, 204 acne, 190, 191, 192, 197, 202, 203 activation, viii, 99, 101, 103, 122, 123, 126, 132, 133, 134, 163, 164, 165, 166, 167, 168, 169, 213, 227, 239, 245, 247, 270, 281 activity level, 166 actuarial, 210 acupuncture, 220, 285, 289 acute, xi, 106, 123, 176, 184, 190, 218, 220, 233, 271, 273, 277, 278, 288, 292 acute lymphoblastic leukemia, 278 acute stress, 184 adaptation, 36, 37, 86, 111, 216 adaptive control, 167 addiction, 25, 34 adipocytes, 214 adjunctive therapy, 198, 291 adjustment, 165, 215, 216, 230 istration, 38, 68, 278 adolescents, 203, 218, 236, 277, 278, 280, 287, 291, 292 adult, 7, 16, 28, 86, 132, 181, 231, 234 adults, x, 129, 146, 181, 195, 197, 204, 207, 209, 218, 219, 277, 288

affective dimension, 281, 289 affective experience, 169 African Americans, 41 afternoon, 123, 246, 252 age, 9, 10, 25, 32, 44, 56, 58, 64, 75, 136, 150, 180, 181, 197, 203, 229, 288 agent, 5, 106, 132, 221, 251 agents, 132, 231, 273, 274 aggression, 177 agoraphobia, 121, 123 aid, 21, 33, 47, 188, 246 AIDS, 280 air, 7, 126, 179, 269 alcohol, 4, 41, 47 alcoholics, 46 alcoholism, 3, 46 alertness, 247 alleles, 193 allergic rhinitis, 3 allergy, 203 alopecia, 190, 192, 197, 202, 204 alopecia areata, 190, 192, 197, 202, 204 alpha, 70, 76 altered state, 60, 69, 78, 93, 105, 127, 138, 194, 238, 240, 242, 243, 255 alternative, xi, 100, 111, 116, 124, 129, 168, 198, 199, 217, 220, 228, 232, 235, 239, 253, 255, 257, 271, 278, 289 alternative medicine, 232, 235, 289 alternatives, 115, 118, 220, 225 alters, 194 amalgam, 137, 141 ambivalence, 273, 276 ambivalent, 101

294

Index

American Psychological Association, 27, 100, 219, 256, 257, 285, 288 amino acid, 193 amplitude, 214 amputation, 280, 286, 292 Amsterdam, 91, 292 amygdala, 180 analgesia, ix, 50, 56, 75, 107, 129, 130, 161, 163, 166, 194, 199, 200, 201, 202, 203, 233, 254, 276, 285, 286, 287, 288, 289, 290, 292 analgesic, 169, 219 analgesics, 220 analysts, 150 anatomy, 172 anesthetics, 272, 273 anger, 33, 69, 139, 188, 213 animals, 153, 181, 186, 268 anomalous, 128 antagonistic, 148 antagonists, 221 anterior cingulate cortex, 170, 172, 173, 194, 200 antibiotic, 198 antidepressant, 111 antidepressants, 123, 126, 217, 280 antipsychotic, 103, 126 antipsychotic drugs, 103 antithesis, 168 anti-tumor, 221 ants, 276 anxiety, x, 2, 3, 25, 38, 40, 46, 70, 102, 103, 104, 106, 107, 121, 122, 123, 126, 128, 129, 150, 152, 155, 175, 176, 177, 178, 179, 180, 182, 187, 188, 192, 196, 197, 199, 200, 210, 211, 214, 215, 216, 217, 218, 219, 221, 222, 223, 224, 226, 229, 231, 232, 235, 236, 249, 250, 253, 254, 259, 266, 267, 268, 277, 278, 281, 282, 284, 285, 287, 288, 291, 292 anxiety disorder, 152, 216 anxiety reaction, 2, 266 anxiolytic, 281 anxious mood, 233 APA, 2 appetite, 125, 249 application, viii, xi, 1, 38, 46, 48, 50, 69, 74, 106, 107, 108, 127, 143, 230, 231, 238, 244, 271, 273, 275, 277, 285 appraisals, 280 argument, 135, 137, 139 arousal, 40, 69, 153, 179 arrhythmia, 170 arteries, 270 arthritis, 46, 263, 283, 288 articulation, xii, 272

ASCs, 81 asphyxia, 124 aspiration, 219, 278 assault, 103, 173 assessment, ix, 56, 105, 108, 109, 128, 131, 176, 204, 235, 243, 244, 245, 251, 284, 287 assessment procedures, 109 assets, 11 assumptions, vii, ix, 23, 104, 109, 121, 145 asthma, 3, 46, 220 Atlantic, 95 atmosphere, 59, 65, 71, 75, 146, 153, 156, 245 atopic dermatitis, 190, 191, 192, 197, 204 attachment, 54, 86 attacks, 103, 239, 266 attention, 192, 195, 200, 272, 274 attitudes, xi, 4, 5, 7, 8, 11, 27, 37, 38, 41, 65, 105, 108, 154, 195, 215, 237, 238, 239, 242, 243, 245, 252, 257, 273, 276 attribution, 132 Australia, 161, 188 Austria, 158 authority, 10, 28, 75 autism, 138, 143 autogenic training, 198, 280, 291, 292 automaticity, 16 autonomic nervous system, 229 autonomy, 14, 27, 29 aversion, 4, 276 avoidant, 86 awareness, xi, xii, 16, 36, 44, 57, 60, 61, 65, 69, 137, 150, 151, 153, 155, 162, 167, 169, 172, 178, 191, 192, 194, 271, 272, 281

B back pain, 283 background information, 282 bacterial, 189 bacterial infection, 189 barrier, 273, 276 barriers, 273 beating, 36, 268 behavior, vii, 1, 2, 3, 4, 7, 8, 9, 11, 12, 15, 16, 17, 18, 26, 27, 30, 31, 35, 38, 39, 47, 49, 50, 75, 148, 149, 150, 169, 176, 177, 178, 179, 181, 185, 190, 193, 197, 224, 226, 239, 242, 245, 246, 256, 258, 259, 280 behavior modification, 226, 259 behavior therapy, vii, 1, 2, 280 behavioral change, 12, 37, 48, 226 behavioral manifestations, 84 behaviours, ix, 135, 161

Index belief systems, 12 beliefs, ix, xi, 7, 8, 9, 19, 25, 27, 29, 59, 101, 109, 128, 143, 149, 150, 175, 176, 225, 226, 230, 237, 238, 239, 243, 274, 290 benefits, vii, viii, 1, 24, 34, 41, 46, 48, 63, 99, 100, 101, 105, 108, 109, 111, 119, 155, 192, 240, 244, 278, 279, 283 benign, 275, 276, 283 benzodiazepines, 103, 123, 126 bias, 163, 164, 213 Bible, 32, 33, 147 binding, 166 bio, vii, ix, 1, 9, 20, 21, 26, 35, 36, 38, 39, 48, 161, 169, 173, 191, 201, 223, 284, 290, 291 bio training, 169, 290 biological processes, 213 biological rhythms, x, 207, 233 biopsy, 129, 219, 234 bipolar disorder, 1, 26, 48 birds, 115, 181 black-box, 208 bleeding, 107, 220 blocks, 34 blood, 45, 46, 48, 54, 121, 189, 201, 213, 214, 266, 269, 285 blood flow, 189, 201, 285 blood pressure, 45, 48 blood pressure reduction, 45 blood vessels, 189 bloodstream, 25, 28 BMA, 278 body image, 69, 78 boils, 202 bonding, 146 bonds, 65, 135 bone marrow, 218, 220, 233, 278 bone marrow aspiration, 218, 233, 278 bone marrow transplant, 220 borderline, 155 boredom, 249 Boston, 285, 286, 292 bowel, 220, 281, 282, 284, 286, 287, 292 boys, 278 brain, ix, 32, 101, 118, 119, 122, 123, 125, 132, 133, 134, 137, 138, 145, 146, 148, 149, 156, 161, 165, 168, 169, 172, 177, 178, 182, 183, 194, 208, 245, 260, 265, 285, 289, 292 brain activity, 178, 194 brain stem, 169 brain structure, 133, 137, 172 Brazil, 256 breakdown, 26, 166, 168 breast, 232

295

breast cancer, 33, 210, 211, 212, 213, 216, 217, 220, 222, 226, 227, 231, 232, 233, 234, 235, 236, 278, 285 breast carcinoma, 235 breathing, 36, 57, 67, 68, 75, 85, 121, 122, 123, 153, 179, 191, 192, 193, 250, 263, 268, 269, 270, 275, 278, 282 Britain, 289, 292 Buddhism, 192 buildings, 269 burn, 106, 129, 130, 200, 281, 286, 288, 289, 292 burning, 59, 196 burnout, 85 burns, 129, 281, 289 bushes, 266

C Canada, 188 cancer, vii, x, 26, 31, 32, 34, 46, 188, 200, 201, 203, 207, 208, 209, 210, 211, 212, 213, 214, 215, 216, 217, 218, 219, 220, 221, 222, 223, 224, 225, 226, 227, 229, 230, 231, 232, 233, 234, 235, 236, 274, 277, 279, 284, 285, 287, 288, 290, 291, 292 cancer care, 233 cancer cells, 212, 227 cancer progression, 217 cancer treatment, 221, 233, 235, 277, 291 candidates, 214 capacity, ix, 34, 161, 177, 181 carbon, 121 carbon dioxide, 121 carcinoma, 189, 235 caregivers, 220 CAS, 204 cassettes, 284 cast, 254 catalyst, 246 catechol, 193, 203 categorization, 133, 143 category a, 102, 103 causalgia, 276 causality, 135, 136 C-C, 27 cell, 133, 189, 200, 213, 227, 233, 283, 286, 291 cell culture, 227 cellular immunity, 213 Cellular response, 214 central nervous system, 190, 276 CEO, 33 cerebellum, 275 cerebral blood flow, 285 cerebral cortex, 194

296

Index

cerebral function, 171 cerebral hemisphere, 142 CFA, 68 channels, 62 charities, 136 chemicals, 25, 190 chemotherapeutic drugs, 225 chemotherapy, 32, 33, 212, 214, 221, 222, 225, 231, 232, 233, 234, 236, 279, 291 chewing, 124 CHILD, 89 childbirth, 191 childhood, 5, 45, 136 children, x, 3, 9, 122, 124, 126, 143, 146, 181, 185, 195, 197, 201, 203, 204, 207, 209, 218, 219, 220, 225, 231, 232, 234, 235, 236, 277, 278, 280, 287, 288, 291, 292 chocolate, 199 cholinergic, 189 Christmas, 135 chronic disorders, 106 chronic myelogenous, 198, 200 chronic pain, vii, xi, xii, 107, 218, 220, 223, 232, 271, 272, 273, 274, 275, 276, 277, 280, 283, 284, 285, 286, 288, 292 chronic recurrent, 280 chronic stress, 188, 190 chronobiology, 229 cigarettes, 41 cingulated, 185 circadian rhythms, 214, 226, 233 circulation, 214 classes, 40, 47, 131, 192, 230 classical, 18, 28, 29, 50, 55, 70, 133, 138, 147, 223 classical conditioning, 18, 28, 29, 50 classification, 101, 106, 107 classroom, 181 classrooms, 180 clients, xi, 47, 60, 237, 239, 240, 242, 243, 244, 245, 246, 247, 248, 255, 259, 264 clinical approach, 109 clinical assessment, xi, 105, 109, 119, 237, 240 clinical trial, xii, 197, 215, 219, 221, 230, 235, 272, 280, 284, 291 clinical trials, xii, 215, 219, 221, 272, 280 clinician, 58, 222, 275, 276 closure, 238, 274, 282 clouds, 115, 140, 192 clusters, 133 CNS, 190 Co, 186, 258 cobalt, 34 coding, 193

coffee, 50 cognition, 67, 143 cognitive, viii, ix, x, xi, 9, 10, 12, 14, 16, 26, 27, 28, 37, 61, 67, 74, 75, 103, 105, 107, 108, 123, 125, 126, 127, 128, 130, 131, 133, 135, 137, 139, 140, 151, 152, 156, 158, 161, 165, 166, 167, 168, 169, 170, 171, 172, 173, 178, 179, 180, 185, 195, 207, 215, 217, 218, 219, 220, 222, 223, 228, 231, 233, 234, 235, 237, 238, 240, 242, 245, 246, 250, 253, 256, 257, 259, 276, 277, 279, 280, 285, 287, 289, 290, 291, 292 cognitive activity, 168 cognitive domains, viii, 131 cognitive function, 61 cognitive impairment, 231 cognitive involvement, 123 cognitive level, 67 cognitive process, 168, 169 cognitive processing, 168 cognitive psychology, 168 cognitive style, 67, 74, 152 cognitive-behavioral therapies, 228 coherence, 166 cohort, 236 collaboration, 105, 124, 170, 243, 251 colorectal cancer, 214, 234 colors, 136 communication, 61, 94, 142, 152, 162, 181, 184, 239, 240, 261, 278 community, 272 competence, 40, 209 competition, 162, 164, 165, 184 complement, 240, 244, 247, 255 complex regional pain syndrome, 276, 280 complexity, 100, 137, 177 compliance, 194, 216, 220, 225 complications, 218 components, 16, 38, 78, 126, 168, 169, 191, 224, 238, 284 comprehension, 132, 133, 134, 135, 137, 138, 181 concentrates, 8 concentration, 25, 31, 36, 61, 102, 163, 178 conceptualization, 151 conceptualizations, 147 concordance, 57, 66, 67, 83, 85 concrete, 134, 135, 136, 137, 138, 140 condensation, 151 conditioned response, 9, 20, 27, 28, 29, 51, 190 conditioned stimulus, 23 conditioning, vii, 1, 5, 6, 7, 8, 9, 12, 16, 20, 24, 27, 28, 29, 30, 48, 49, 186, 204 conductive, 61

Index confidence, 7, 43, 45, 105, 114, 119, 121, 211, 220, 243, 244, 248, 249, 251, 261 confidence intervals, 211 confirmatory factor analysis, 68, 69 conflict, ix, 103, 161, 164, 165, 166, 167, 171, 185, 186 confusion, 102, 195, 213, 249, 266 Congress, 35, 49, 91, 93, 94, 97, 98, 130, 136, 158, 258, 291 connectionist, 137 connectionist models, 137 connectivity, 143, 163, 166, 167, 168, 170, 171 conscious awareness, 16, 137, 162, 167, 178 consciousness, 13, 60, 61, 65, 68, 73, 78, 81, 93, 105, 127, 135, 138, 141, 144, 149, 150, 172, 178, 194, 223, 232, 238, 240, 242, 243, 255, 270 consensus, 219, 221 consolidation, 147 constipation, 220 construction, ix, 131, 142, 289 consumerism, 188 consumption, 226 context-dependent, 150, 156 continuity, xi, 237, 239 control condition, 107, 168, 278, 282 control group, 20, 22, 40, 107, 199, 200, 211, 217, 221, 222, 225, 228 controlled studies, 34, 281 controlled trials, 196, 218 conversion, 176, 178, 180, 183, 185, 186 conversion disorder, 185 conviction, 60, 102 coping, 277, 278, 279, 280 coping strategies, 100, 277 coping strategy, 240, 280 cornea, 228 correlation, 6, 14, 71, 73, 77, 78, 83, 84, 90, 166, 213, 228, 280, 282 correlation coefficient, 71, 228 correlations, 68, 73, 76, 77, 78, 79, 80, 81, 82, 83, 84, 90, 133 cortex, 7, 8, 28, 132, 134, 143, 148, 158, 165, 166, 168, 169, 171, 180, 182, 183, 184, 185, 194, 200, 275, 281 cortical processing, 163 cortisol, 213, 214 cost-effective, 195, 200 costs, 213, 219 cough, 220 coughing, 62 counseling, 33, 101, 104, 111, 280 covering, 65, 262 cranial nerve, 182

297

creativity, 246, 267 credibility, 40 credit, 147, 188 creep, 36 crimes, 46, 242 critical analysis, 285 criticism, 15, 23, 85 cross-sectional, 232 crying, 262 Cuba, 256 cues, 75, 139, 178, 179, 182, 252 culture, 188, 224 cybernetics, 38, 40, 43, 45, 47, 50 cycles, 214, 225 cystitis, 283, 292 cytokine, 233, 236 cytokines, 213 cytotoxic, 213, 221 cytotoxicity, 213, 214 Czech Republic, 258

D danger, 5, 176, 177, 179, 261 death, 48, 123, 124, 210, 212, 215, 226, 234, 266, 279 death sentence, 266 debridement, 107, 130, 281, 289 debt, 147 decision making, 169 decisions, 3 deep-sea, 25 defense, 146, 147, 150 defense mechanisms, 146, 147, 150 defenses, 32, 212, 216, 225, 227 deficit, 41, 138 deficits, 11, 165 definition, 24, 28, 31, 176, 179, 194, 216 degradation, 194 delirium, 103 delivery, 107, 221 delusion, 25 delusions, 24, 26 demand characteristic, 22 dentistry, 285 dependent variable, 23, 40 depressed, 11, 34, 125, 139, 140, 216, 217, 224, 231, 234 depression, x, 3, 11, 26, 37, 46, 47, 103, 125, 126, 136, 139, 190, 197, 207, 210, 213, 214, 215, 216, 217, 220, 221, 222, 223, 224, 227, 229, 231, 233, 235, 281 depressive disorder, 26

298

Index

depressive symptoms, 217, 281, 284 deprivation, 9, 20, 22, 50 derivatives, 218 dermatitis, 3, 189, 190, 191, 192, 193, 197, 198, 204 dermatologic, x, 187, 192, 194, 196, 203 dermatology, 200, 202, 203 dermatosis, 189 desensitization, 4 desire, 195 desires, 191 detachment, 190 detection, 50, 63, 166, 167, 203 deviation, 57 diabetes, 46 diabetic neuropathy, 280 dichotomy, 286 diet, x, 207, 226 dietary, 226, 281, 282 differentiation, 137 disability, 107 disabled, 115 disappointment, 265 disaster, 184 discipline, 146, 147, 168, 180, 181, 183, 248 disclosure, 65, 150, 151, 154, 155 discomfort, x, 103, 187, 196, 199, 218, 219, 254, 276, 277, 278, 282 discontinuity, 127 disease progression, 214, 216, 235, 277 disease-free survival, 210 diseases, 31, 188, 190, 194, 195 disorder, vii, 1, 26, 102, 103, 107, 121, 122, 143, 184, 186, 216, 231, 280, 283, 288 dissociation, 14, 61, 62, 63, 147, 163, 166, 167, 178, 184, 185, 246, 252, 253, 254, 267 distortions, ix, 161 distraction, 166, 194, 201, 219, 235, 278 distress, x, 101, 123, 188, 191, 207, 216, 217, 218, 219, 222, 224, 225, 231, 232, 234, 236, 250, 253, 278, 280, 285, 288, 292 distribution, 72, 81 diversity, 108 division, 167, 219 dizygotic, 90 dizygotic twins, 90 dizziness, 176, 179, 245 doctor-patient, 278 doctors, 9, 28, 32, 33, 34, 242 dogs, 177, 203 domain, 286 dominance, 9, 10, 14, 19 dopamine, 194 dorsolateral prefrontal cortex, 165

dosage, 32, 126, 281 dream, 61, 151 drinking, 47 drive theory, 147 dropouts, 243, 247 drowsiness, 24, 238, 239, 245, 274 drug addiction, 46 drug treatment, 25 drug-related, 46 drugs, 9, 24, 25, 101, 102, 104, 126, 129, 208, 218, 221, 225 DSM-IV, 103 dualism, 183 duplication, 135 duration, 6, 57, 108, 198, 199, 212, 231, 255, 274, 279 duties, 41 dysmenorrhea, 3 dyspareunia, 282 dysphagia, 222 dysphoria, 123 dyspnea, 289

E ears, 117 eating, 10, 43, 47, 124, 125, 226, 268 eating disorders, 226 economies of scale, 282 ectoderm, 188 eczema, 200 education, 38, 40, 42, 49, 50, 130 EEG, ix, 143, 161, 163, 166, 167, 168, 172, 194, 285 ego, 45, 65, 69, 93, 157, 195, 197 ego strength, 197 elbows, 119 elderly, 215, 216 electrodes, 166 electroencephalogram, 163 electromyograph, 169, 173 elementary school, 180 EMG, 21, 191 emission, 194, 200, 280, 292 emotion, 178, 182, 196, 268 emotional, vii, x, 1, 31, 32, 34, 38, 40, 48, 57, 65, 67, 68, 85, 86, 100, 102, 104, 105, 107, 109, 115, 117, 118, 119, 120, 121, 122, 123, 125, 130, 132, 139, 151, 153, 154, 167, 170, 177, 179, 184, 187, 189, 191, 198, 203, 215, 216, 224, 249, 250, 276 emotional distress, 191 emotional experience, 65, 153, 154, 167 emotional information, 179 emotional intelligence, vii, 1, 48, 50

Index emotional memory, 130 emotional responses, 184 emotional stability, 102 emotions, 37, 54, 75, 78, 81, 118, 119, 139, 153, 179, 253, 262, 278 empathy, x, 62, 132, 138, 150, 151, 156, 175, 178, 179, 181, 182, 183 employees, 41 encoding, 132 encopresis, 141 encouragement, 188 endocrine, 190, 217 endocrine glands, 190 end-of-life care, 283 endothelial dysfunction, 170 energy, 103, 125, 141, 248, 268, 270 engagement, 170, 183 England, 212 entanglement, 154 environment, 27, 162, 178, 180, 183, 218, 227 environmental context, vii, x, 175 environmental effects, 84 environmental stimuli, 182 enzyme, 193, 203 epidemic, 177, 179, 181, 183, 184, 185, 186, 188, 292 epidemics, 176, 177, 179, 182 epilepsy, 3 episodic headache, 280, 287 equality, 153 equilibrium, 47 equipment, 190 erythema nodosum, 196 escitalopram, 111 ethical questions, 57 ethics, 224 etiology, xii, 210, 272, 276 Europe, 101 evening, 47, 122, 126 evidence, xi, 193, 194, 196, 272, 274, 275, 277, 279, 284 evil, 30 evoked potential, 134 evolution, 135, 210, 212 excitability, 182, 183 excitation, 8 exclusion, 31, 162 execution, 132, 134 executive functioning, 69 executive functions, 15, 165 exercise, 43, 105, 106, 111, 112, 113, 114, 115, 116, 118, 124, 125, 242, 243, 244, 245, 246, 251, 252, 253, 259, 260, 263, 264, 268, 269, 279, 284

299

expectations, 274, 275, 276, 288 experimental condition, 65, 181 experimental design, 132, 229 expert, 76, 209 expertise, 40, 224, 230 exposure, viii, 41, 99, 101, 103, 104, 121, 123, 124, 176, 189, 190 external environment, 136 extinction, 20, 27, 29 eye , 86 eyes, xi, 9, 10, 11, 36, 44, 59, 62, 105, 111, 114, 115, 118, 125, 154, 192, 228, 237, 238, 239, 240, 243, 244, 246, 247, 251, 253, 255, 262, 265, 267, 269

F facial expression, 184 factor analysis, 68, 69, 70 failure, 35, 37, 39, 42, 43, 44, 169, 211, 245, 249, 250, 275 fainting, 176 fairness, 15 faith, 9, 12, 28, 30, 31, 32, 34, 48, 59, 185 false belief, 143 family, 26, 121, 122, 188, 274, 275 family life, 188 family , 274 fatigue, 214, 221, 222, 266 fear, xi, 3, 4, 33, 35, 69, 70, 74, 105, 121, 124, 156, 177, 189, 218, 219, 237, 243, 261, 262, 264, 266, 278 fears, 3, 4, 13, 41, 45, 47, 155, 183, 225, 243, 251, 265, 267 , 19, 20, 38, 39, 40, 51, 60, 165, 167, 173, 180, 188, 228 feeding, 199 feelings, 3, 25, 36, 44, 57, 58, 59, 62, 63, 64, 66, 67, 68, 83, 85, 86, 123, 135, 140, 141, 149, 150, 153, 154, 155, 156, 178, 179, 188, 196, 198, 215, 228, 251, 252, 253 feet, 4, 46, 111, 115, 116, 138, 192, 243, 266 females, 55, 56 fetus, 188 fibers, 189 film, 262 filters, 135 fire, 132, 143, 266 fixation, 278, 282 flame, 191, 263 flashbacks, 122 flatulence, 282 flavors, 125 flexibility, 230, 284

Index

300

flight, 181 float, 36 floating, 36 flow, 136, 139, 141, 164, 171, 189, 201, 285 fluoxetine, 126 fluvoxamine, 126 fMRI, 132, 134, 135, 143, 165, 166, 167, 171, 285 focusing, 30, 150, 152, 155, 162, 168, 169, 212, 216, 251 food, 41, 102, 124, 125 forgetting, 4, 262 fracture, 250 , 188, 207, 232, 234, 235 free association, 146 free will, 15, 17, 30, 31, 48 freedom, 135 Freud, 5, 145, 146, 147, 151, 156, 157, 158, 223, 285 Freudian theory, 149 friction, 42 frontal lobe, 142, 171, 275 frontal lobes, 171, 275 frustration, 43 fulfillment, 30 functional analysis, 241 funding, 170 furniture, 269

G Galvanic Skin Response (GSR), 21, 189 gambling, 41 gas, 176, 179, 266 gases, 186 gastrointestinal, 292 gauge, 195 gender, 64, 76, 278 gene, 149, 193 gene expression, 149 generalization, 246 generalized anxiety disorder, 250 generation, 137, 163 genes, 134 genetic factors, 227 , 91, 188, 285 gestalt, 134, 136 gestures, 181, 185 gift, 153 girls, 62 glass, 215 global management, 230 goals, 11, 12, 21, 34, 37, 39, 42, 43, 44, 47, 115, 117, 123, 125, 132, 143, 163, 219, 223, 267, 273, 275 God, 30, 32, 147

gold, 228 gold standard, 228 government, 180 grades, 46, 154 grass, 138, 140, 141, 143 gravity, 259 Greece, 215 grief, 103, 234 grounding, 136, 140 group therapy, 46, 211, 212, 217, 220, 229, 230, 231, 233, 235, 278, 285 grouping, 38, 46, 47 groups, 22, 23, 40, 65, 71, 83, 84, 90, 107, 176, 177, 192, 200, 217, 224, 230, 232, 278, 279, 291 growth, xii, 197, 227, 272, 273 guidance, 12, 17, 31, 37, 38, 153 guidelines, 30, 36, 37, 40, 209, 221, 233 guilt, 3, 33, 85, 123 guilty, 4 gut, 282 gyrus, 134

H H1, 59, 60, 61 H2, 60, 62 habituation, 249 HADS, 216 hallucinations, 24, 26, 176, 238, 249 handling, 45 hands, 21, 26, 111, 113, 114, 115, 118, 119, 123, 124, 141, 191, 242, 244, 245, 261, 262, 263, 264, 265, 266, 283 happiness, 30, 33, 49, 262 harm, 65, 66, 67, 70, 86 harmony, 65, 66, 67, 70, 86 hazards, 190 headache, 200, 279, 280, 284, 286, 287, 288, 289, 290, 291 healing, 12, 28, 29, 31, 32, 33, 34, 48, 85, 148, 150, 154, 185, 191, 193, 194, 195, 196, 232, 273, 285 health, xi, 29, 31, 33, 34, 37, 45, 49, 124, 126, 188, 192, 220, 227, 232, 236, 256, 271, 272, 273, 283 health care, 283 health problems, 46 hearing, 39, 42, 121, 122, 133 heart, 21, 31, 36, 46, 49, 57, 62, 122, 170, 171, 200, 228, 232, 261, 268, 269, 290 heart disease, 31, 46, 200 heart rate, 21, 57, 122, 170, 269 heart rate variability, 171 heartbeat, 269, 270 Hebrew, 157

Index height, 40 hematological, 221, 279 hemodynamic, 200 herbal, 220 herbal therapy, 220 heritability, viii, 54, 74, 81 heroin, 25, 41 herpes simplex, 190, 192, 198 herpes zoster, 198 heuristic, 276 high blood pressure, 46 high risk, 109, 218 high school, 41, 46, 121 higher order conditioning, 9 Hispanics, 41 HIV, 140 hives, 199 holistic, 33, 138 holistic approach, 33 homework, 119, 152, 192, 240 homosexuality, 3 hopelessness, 28, 31, 32, 101, 216, 217, 266 horizon, 126, 136, 139 hormone, 190, 227 hormones, 190, 213, 214 hospital, 4, 107, 108, 145, 224, 225, 252, 253 hospitalization, 122, 254 hospitalized, 154, 281 hospitals, 230 host, 212 HRV, 229 human, 2, 16, 30, 85, 86, 104, 131, 132, 133, 135, 136, 142, 143, 144, 146, 148, 149, 178, 182, 185, 226, 230, 236, 256, 285, 286, 289, 292 human behavior, 16, 30, 104 human brain, 131, 133, 135, 148, 185, 289, 292 human cognition, 136 human experience, 132, 148 human interactions, 86 human nature, 2 humanism, 286 humans, 17, 31, 137, 153, 181, 182, 183, 185 Hungarian, 68, 69, 70 Hungary, 53, 97 hunting, 122 husband, 25, 26, 32, 47 hyperhidrosis, 191, 192, 196, 198, 201, 202 hypersensitive, 167 hypertension, 3 hyperthermia, 278 hyperventilation, 36, 176, 220 hypothalamus, 190

301

hypothesis, 10, 17, 20, 21, 23, 27, 41, 51, 84, 132, 134, 137, 153, 156, 172, 180, 181, 182, 186, 217, 220 hypoxia, 214, 231 hysteria, 146, 157, 176, 177, 178, 184, 185, 186

I iatrogenic, 101, 239 ice, 21, 252, 268, 287 ICU, 289 id, 21, 22, 26, 84, 139, 140, 197, 217, 279 identification, 132, 150, 151, 154, 196 identity, 148, 232 IL-1, 213 IL-15, 213 IL-2, 213 IL-6, 213 Illinois, 201, 202, 203, 258 illusion, 36, 121, 132, 156, 242 imagery, ix, x, 37, 66, 69, 83, 84, 90, 131, 132, 142, 156, 187, 193, 198, 199, 200, 201, 202, 203, 211, 212, 213, 220, 221, 223, 226, 231, 233, 235, 236, 264, 278, 279, 284, 289, 291 images, 4, 130, 138, 140, 153, 154, 156, 245, 262, 265, 275, 276 imagination, 9, 15, 16, 59, 103, 143, 148, 155, 195, 218, 223, 238, 244, 245, 248, 259 imaging, viii, 32, 131, 132, 167, 168 imaging techniques, viii, 32, 131, 132 imitation, 132, 148 immune cells, 214, 226 immune function, x, 187, 212, 214, 217 immune response, x, 28, 31, 187, 188, 190, 216 immune system, 28, 31, 190, 220, 225, 227 immunity, x, 207, 212, 213, 226, 227, 229, 233, 235 immunodeficient, 204 immunological, 213, 214, 232 immunology, 229 immunoreactivity, 191 immuno-suppressive, 31 immunotherapy, 221, 233 impairments, 216 implementation, 101, 102, 104, 105, 111, 124, 165, 168, 277 impotence, 3, 139 impregnation, 141 impulsive, 138 in situ, 240 in transition, 151 in vivo, 124 inattention, 15, 16, 226 incentive, 41

302

Index

incidence, 217 inclusion, 77, 217, 228 incomes, 188 independence, 64 indication, vii, 2, 102, 225 indicators, x, 81, 208, 228, 229 indices, 62, 78, 85, 86, 164 individual character, 100 individual characteristics, 100 individual differences, 9, 15, 19, 35, 162, 250 inducer, 181 induction, vii, x, xi, 1, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 28, 35, 37, 40, 48, 49, 51, 56, 57, 58, 62, 75, 81, 103, 105, 109, 115, 116, 117, 119, 121, 127, 138, 157, 164, 180, 187, 191, 192, 193, 194, 195, 223, 228, 237, 238, 239, 240, 242, 245, 247, 255, 256, 258, 267, 269, 270, 273, 274, 282, 284, 290, 292 induction methods, xi, 237, 240 industrial, 179, 188 industry, viii, 1, 38, 42, 48, 229, 230, 267 inert, 28 infants, 132, 143, 144, 152, 181 infection, 140, 182, 189, 198, 220 infections, 189 infectious disease, 177 inferences, 137 inferior frontal gyrus (IFG), 134, 138, 166 inferiority, 25 infertility, 3 inflammation, x, 187 inflammatory, x, 187, 188, 190, 191, 220 information processing, 137, 140 infrared, 214 ingestion, 24, 125 inhalation, 264, 272, 273, 292 inhibition, vii, 1, 8, 9, 16, 24, 28, 49, 164, 177, 182, 183 inhibitory, ix, 8, 9, 10, 12, 15, 16, 18, 24, 27, 28, 161, 168, 169, 182 injection, 28, 29 injuries, 273, 283, 288 injury, 106, 129, 190, 200, 250, 251, 252, 253, 255, 280, 281, 289 inner tension, 62 insane, 242 insects, 266 insecurity, 180 insight, 148, 150 insomnia, 3, 46, 102, 196, 220, 222, 288 instruction, 58, 64, 65, 125, 165, 197, 246, 260 instructors, 40, 41 instruments, 108, 216

integration, 127, 155, 168, 169 intellectualization, 155 intelligence, 267 intensity, 108, 126, 198, 222, 253, 280 intentionality, 141 intentions, 75, 132, 149 interaction, viii, 53, 54, 57, 63, 64, 66, 67, 69, 70, 71, 72, 73, 74, 78, 84, 85, 86, 87, 88, 92, 133, 135, 136, 149, 153, 157, 164, 166, 177, 180, 185, 188, 278 interaction effect, 166 interactions, viii, 54, 70, 73, 76, 77, 83, 85, 86, 133, 134, 135, 138, 149, 153, 169, 190, 193 interest, 273 interface, 149 interference, 15, 27, 43, 164, 172, 173, 231, 245, 250, 260, 261 interference theory, 27 internal consistency, 70 internal processes, 68, 69, 83, 84, 89, 90 interpersonal interactions, 149 interpretation, 68, 78, 167, 176 interrelationships, 54 interstitial, 283, 292 interstitial cystitis, 283, 292 interval, 69, 165, 210 intervention, viii, ix, x, xi, 99, 100, 102, 104, 106, 107, 108, 115, 118, 121, 122, 123, 124, 125, 126, 127, 131, 139, 140, 202, 204, 207, 208, 211, 212, 213, 214, 215, 217, 219, 223, 224, 225, 226, 230, 232, 233, 235, 236, 237, 240, 241, 243, 247, 251, 258, 273, 274, 275, 277, 278, 279, 280, 281, 282, 283, 285 interview, 64, 162, 184, 232 interviews, 41 intimacy, 61, 72, 73, 74, 77, 81, 86 intraoperative, 200 intravenous, 103 intrinsic, 105 intuition, 140, 150 invasive, x, 129, 200, 202, 207, 218, 219, 221, 223, 231 investigative, 51 investment, 155, 282 iris, 228 irritability, 102, 216 irritable bowel syndrome, 107, 129, 284, 286, 287, 292 irritation, 222 ischemic, 283, 285

Index

J JAMA, 231, 232 jewelry, 263 job training, 42 jobs, 41, 126, 188 judge, 15, 65, 66, 77, 178 judges, 76 judgment, 76, 81

K killing, 28, 29 kindergarten, 155 kinetic studies, 214 knowledge, 277, 289, 290, 292

L lack of confidence, 244 language, ix, 61, 62, 131, 133, 135, 136, 137, 138, 139, 140, 142, 143, 144, 148, 196, 260 language acquisition, 148 large-scale, 129 laughing, 176, 181, 182 laughter, 261, 262 law, 8 laws, 7 lawyers, 9 learning, 16, 27, 28, 38, 39, 41, 44, 49, 117, 128, 132, 146, 230, 248, 250, 263 learning skills, 38 left hemisphere, 138 legislation, 224 lenses, 63, 140 leptin, 213, 214 lesions, 164, 165, 194, 196, 198, 200, 220, 276 leukemia, 198, 200, 278 leukocyte, 227 LH, 50, 138 lichen, 190, 191, 192, 198 lichen planus, 190, 191, 192, 198 life changes, 35 lifestyle, 31, 32, 35 lifestyle changes, 31, 32, 35 life-threatening, 284 likelihood, 165, 167, 243 Likert scale, 216 limitations, xi, 12, 104, 108, 271, 277, 283 linguistic, 69, 133, 135, 137, 138, 139, 140, 142 linguistic metaphors, 140 linguistic processing, 135, 137

303

linguistics, ix, 131, 133 linkage, 179 liquids, 124 liquor, 47 listening, 111, 117, 134, 192, 247, 276 location, 243 London, 91, 92, 93, 94, 95, 96, 98, 129, 142, 156, 157, 159, 184, 185, 186, 256, 272, 292 loneliness, 59, 218 long period, 126 longitudinal studies, 214 long-term potentiation, 180 Los Angeles, 40, 41, 46, 49 loss of control, 222 love, 25, 26, 34, 69, 70, 74, 136 lover, 153 LSD, 41 LTP, 180 lumbar, 218, 278 lumbar puncture, 218, 278 lungs, 34 lying, 126, 140, 146 lymph, 32, 34 lymph gland, 32 lymph node, 34 lymphocyte, 213 lymphoid, 213 lymphoma, 211

M machines, 141 macrophages, 28 magnet, 244 magnetism, 234, 256 magnets, 114 main line, 147 mainstream, 146 maintenance, xi, 193, 237 maladaptive, 4 males, 55, 56, 278 malignant, 213, 214, 231, 236, 284 malignant cells, 214 malignant melanoma, 213, 231, 236 management, xi, xii, 14, 42, 103, 106, 152, 197, 204, 209, 210, 212, 215, 216, 220, 221, 222, 223, 224, 225, 229, 230, 232, 233, 253, 254, 255, 257, 258, 271, 272, 274, 275, 276, 277, 278, 279, 281, 282, 283, 284, 285, 286, 288, 289, 290 mania, 26, 183 manic, 26 manipulation, 137, 172 mapping, 135, 138, 163, 285

304

Index

margin of error, 188 marijuana, 41 marriage, 3 marrow, 219, 278 mask, 25, 224 mastery, 39 maternal, 74, 76, 77, 78, 81, 86, 152, 153 mathematics, 179 matrix, 68, 149 meals, 43 meanings, 138, 143 measurement, 162, 234 measures, x, 42, 54, 68, 70, 71, 74, 76, 81, 83, 85, 107, 178, 207, 213, 219, 221, 222, 229, 232, 273, 277, 278, 280, 282, 287 median, 132 mediation, 151, 192 medical care, 288 medical student, 146 medication, 29, 47, 101, 102, 104, 107, 123, 124, 126, 140, 199, 218, 220, 221, 250, 254, 275, 281 medications, 101, 102, 126, 218, 221 medicine, viii, 1, 28, 38, 45, 48, 101, 107, 130, 149, 202, 204, 208, 209, 220, 230, 231, 232, 235, 287, 288, 289, 290, 291 meditation, x, 122, 187, 188, 191, 192, 193, 196, 202, 217, 223, 231 Medline, 209 MEG, 91, 93, 285 melanin, 190 melanocytes, 190 melanoma, 227, 231, 236 melatonin, 213, 214 memory, 11, 15, 38, 39, 43, 69, 102, 126, 130, 147, 161, 178 men, 42, 55, 62, 135, 141, 147 mental activity, ix, 161, 164 mental illness, 26 mental image, 132, 134, 136, 252 mental imagery, 132, 136 mental life, 152 mental state, 28, 31, 132, 149, 156, 169, 270 mental states, 149, 156, 169 mentor, 146 messages, 140 meta-analysis, 107, 129, 200, 203, 212, 221, 224, 228, 232, 233, 288 metabolic, 226 metabolism, 213, 214 metaphor, ix, xi, 105, 106, 109, 117, 129, 131, 135, 136, 137, 138, 139, 140, 141, 143, 144, 237, 240, 244, 246, 247, 251, 257

metaphors, ix, 66, 131, 133, 135, 136, 137, 138, 139, 140, 141, 144, 239, 253, 277 metastasis, 32 metastatic, 33, 210, 211, 214, 220, 233, 234, 235, 278, 285 methionine, 194 methodology, 279 Mexican, 38 Mexico, 180, 188, 201 midbrain, 169 Middle Ages, 176, 273 migraine, 279, 284, 286, 287, 288, 289 migraine headache, 279, 284, 286, 287 migraine therapy, 286 mind-body, 33, 34, 193, 194 minority, 25, 41 minority students, 41 mirror, x, 131, 132, 138, 143, 144, 148, 149, 153, 156, 158, 175, 181, 182, 183, 185 misconceptions, vii, 2, 35, 38, 105, 109, 118, 128, 241, 250 misleading, 23, 24 mobile phone, 260 modalities, 133, 195, 197 modality, xi, 135, 151, 195, 271 modeling, 167, 168, 245, 285 models, viii, 29, 50, 86, 99, 100, 108, 109, 111, 127, 128, 137, 147, 156, 158, 159, 164, 177, 182, 227, 258, 264 s, 290 modulation, xii, 168, 171, 172, 182, 233, 272, 289 modules, 133, 149 molecules, 229 momentum, 137 money, 43, 188 monitoring, 282 monoclonal, 221, 229 monoclonal antibodies, 221, 229 monozygotic, 90 mood, 21, 47, 59, 102, 124, 213, 214, 215, 216, 217, 222, 231, 233, 234, 279 mood change, 47 mood disorder, 102, 234 morale, 42 morality, 135 morbidity, 195 morning, 46, 123, 179, 181, 246, 252, 254 morphine, 29, 218 mortality, 33, 226, 232, 273 mortality rate, 273 MOS, 236 motion, 57, 136, 143, 144, 153

Index motivation, xi, 5, 9, 13, 125, 127, 149, 151, 155, 237, 239, 240, 247, 255, 274, 284 motives, 154, 155 motor actions, 133, 141, 158 motor area, 137, 183, 185 motor behavior, 180, 183 motor control, 168 motor function, 176, 180 motor skills, 134, 137 motor system, 132, 133, 134, 142, 144, 182 mountains, 269 mouth, 62, 117, 125, 134, 181, 263 movement, 16, 21, 47, 48, 75, 115, 117, 119, 136, 137, 139, 147, 157, 181, 269, 274, 281 MPI, vii, ix, 175, 179 MRI, 166, 250, 285 mRNA, 236 multidimensional, 54, 228 multidisciplinary, xii, 158, 272 multiple sclerosis, 283, 286, 291 muscle, 169, 190, 191, 250, 252, 264, 282, 290 muscle contraction, 290 muscle relaxation, 190, 250, 252, 264, 282 muscles, 155, 182, 189, 191, 192, 268, 269, 270 music, 85, 153 mutuality, 86

N nail biting, 196 naming, 164, 165, 166 narcissistic, 155 narcotic, 130, 289 narratives, 140, 258 National Academy of Sciences, 172 National Institutes of Health, 272, 288 natural, x, 9, 28, 29, 30, 32, 36, 61, 62, 63, 125, 135, 136, 137, 191, 207, 213, 243, 247, 264 natural killer, x, 207, 213 natural killer cell, x, 207 nausea, 176, 179, 221, 222, 225, 232, 234, 235, 236, 279, 289, 291 neck, 32, 34 negative attitudes, 3, 4, 8, 118 negative consequences, 85, 102, 220 negative emotions, 123 negative experiences, 219 negative outcomes, 11 negativity, 167 negotiation, 124, 275 neoangiogenesis, 214 neonates, 185 nerve, 188

305

nerve fibers, 188 nerves, 182, 188, 220 nervous system, 177, 184, 188, 190, 276 nervousness, 216 network, ix, 134, 135, 148, 161, 163, 167, 168 neural function, 170 neural mechanisms, vii neural network, ix, 161, 162 neural networks, ix, 161, 162 neuralgia, 192, 193, 198, 276, 280 neurohormonal, 194 neuroimaging, ix, 133, 161, 166, 169, 171, 273, 285 neuro-immunology, 226 neuroleptic, 103 neurological condition, 280 neurons, 131, 132, 144, 148, 149, 156, 175, 181, 185 neuropathic pain, 220, 287 neuropathology, 146 neuropathy, 221, 280 neuropeptide, 188 neuropeptides, 188 neurophysiology, x, 143, 171, 175, 182 neuropsychology, 137 neuroscience, ix, 137, 143, 144, 145, 156, 158, 161, 165, 168, 170, 171, 173, 208, 230 neuroscientists, 181 neurotransmitters, 101 neutral stimulus, 23 New York, 48, 49, 50, 51, 91, 92, 93, 94, 95, 96, 97, 98, 128, 129, 130, 142, 143, 144, 156, 157, 158, 159, 170, 171, 172, 173, 184, 185, 200, 201, 202, 204, 205, 256, 257, 258, 259, 285, 286, 287, 290, 291, 292 Newton, 210, 234 nicotine, 34 nitrogen, 34 NK cells, 214 nocebo, 29 nociceptive, 220 nodes, 34, 168, 169 non invasive, 214 non toxic, 229 non-pharmacological, 129, 202 non-steroidal anti-inflammatory drugs, 220 nontoxicity, 195 non-union, 252 normal, 14, 44, 48, 57, 61, 63, 78, 81, 127, 179, 190, 221, 247 normal distribution, 81 norms, 81 novelty, 104 nurse, 223 nurses, x, 184, 207, 224

Index

306 nursing, 129

O obesity, 46, 234 objective reality, ix, 161 objectivity, 249 observations, 162, 287 observed behavior, 183 obsessive-compulsive, 2, 104 obsessive-compulsive disorder, 104 oceans, 269 offenders, 46 office-based, 234 oncology, 207, 226, 230, 231, 232, 233, 234, 236, 290, 291, 292 one dimension, 215 openness, 170 operator, 21 opiates, 220, 284 opioid, 279, 289 opioids, 281, 289 oral, 130, 135, 201, 279, 290, 291 orbitofrontal cortex, 180 organ, 188 organic, 67, 74, 75, 152, 198 organic disease, 198 organism, 7, 29, 227 organization, 44, 155, 168, 170, 185 organizations, 184, 195 orientation, 58, 59, 69, 78, 96, 172 originality, 212 oscillations, 171, 259 osteoarthritis, 252 outpatient, 129, 202, 232 outside-of-school, 38 ovarian cancer, 233 overeating, 11 overload, 188 oxygen, 121, 214 oxygen saturation, 214 oxygenation, 123

P Pacific, 258, 288 pain, vii, x, xi, xii, 28, 29, 46, 106, 107, 126, 129, 130, 153, 154, 167, 176, 186, 192, 194, 196, 198, 199, 200, 201, 207, 210, 211, 215, 216, 218, 219, 220, 221, 222, 223, 224, 225, 229, 230, 231, 232, 233, 234, 235, 236, 249, 250, 251, 252, 253, 254, 257, 266, 271, 272, 273, 274, 275, 276, 277, 278,

279, 280, 281, 282, 283, 284, 285, 286, 287, 288, 289, 290, 291, 292 pain management, xi, xii, 210, 216, 220, 223, 233, 253, 257, 271, 272, 274, 275, 276, 277, 278, 283, 285 pain reduction, 107, 194, 278, 280, 290 palliative, 215, 218, 230, 233, 288, 291 palliative care, 230, 233, 288, 291 pallor, 189 palpitations, 222 panic attack, 103, 121, 239 panic disorder, 101, 121, 123, 124, 258 paradoxical, 6, 254 parallel processing, 69 paralysis, 176, 180, 183, 186, 264 parameter, 81, 210, 213, 229 paranoia, 25 paranoid schizophrenia, 25, 26, 27 parasympathetic, 169, 229 parasympathetic nervous system, 169 parent-child, 83, 84 parents, 124, 125, 149, 219 paresis, 176 parietal cortex, 148 ive, 147, 192 paternal, viii, 53, 74, 76, 77, 78, 86, 152, 153 path analysis, 17 pathogenic, ix, 175 pathology, 224, 290 pathophysiological, 275 Pathophysiological, 205 pathophysiology, 276 pathways, 148, 164, 274, 280 patient management, 224 Pavlov, Ivan, 177 pedal, 60 pedestrians, 269 pediatric, 218, 219, 221, 230, 233, 235, 236, 279, 287, 292 peer, 47 pendulum, 21, 36, 116, 242, 250, 259, 260 pepsin, 10 perceived outcome, 225 perceived self-efficacy, 40 percentile, 42 perception, ix, xii, 18, 59, 69, 78, 104, 131, 133, 134, 136, 137, 138, 153, 171, 178, 179, 215, 272 perceptions, 7, 8, 18, 27, 54 performance, 22, 39, 40, 44, 59, 125, 163, 164, 167, 171, 172, 220, 222, 234, 248, 255, 258 periodic, 2 permit, 138, 170, 196, 283 perseverance, 106, 246, 255, 266, 267

Index personal, ix, 7, 33, 34, 38, 40, 75, 86, 140, 146, 152, 153, 161, 185, 216, 217, 218, 220, 224, 225, 230, 240, 280 personal communication, 240 personal efficacy, 38 personal history, 86 personal life, 33 personal relations, 7 personal relationship, 7 personality, 3, 7, 32, 44, 49, 63, 64, 65, 138, 149, 152, 155, 162, 180, 185, 223, 226, 280 personality characteristics, 49 personality disorder, 155 personality traits, 180 Person-Centered Approach, 96 perspective, xi, xii, 271, 272, 285, 287, 290, 291 persuasion, 9, 39, 40 PET, 163, 168, 194, 200, 280, 285 PFC, 165, 169 phantom limb pain, 276, 280, 281, 285, 288, 290 pharmaceutical, 229 pharmaceutical industry, 229 pharmacological, xii, 100, 101, 102, 103, 107, 123, 125, 129, 272, 273, 274, 281, 282 pharmacological treatment, 100, 101, 103, 123, 125 pharmacotherapy, 230 phenomenology, viii, 53, 54, 58, 84, 276, 277, 281 Philadelphia, 50, 158, 258, 259 philosophical, 109, 134 philosophy, 47, 127 phobia, 199 phone, 122, 125, 260 PHS, 23 phylogenesis, 134 physical activity, x, 196, 207, 226 physical force, 136 physical therapy, 252 physical world, 135, 136, 139 physicians, x, 33, 102, 126, 207, 208, 224, 230, 273, 286 physiological, 18, 21, 39, 67, 85, 122, 132, 153, 172, 178, 179, 229, 273 physiology, ix, 18, 161, 178, 185 pilot study, 201, 204, 213, 222, 231 pituitary, 190 placebo, 9, 12, 28, 29, 31, 50, 51, 204, 226, 233, 258, 290 plague, 41, 176 planets, 269 planning, 61, 169 plantar, 204 plasticity, 138, 149

307

play, x, xii, 9, 16, 17, 25, 30, 31, 59, 138, 167, 169, 181, 195, 201, 207, 228, 272, 273, 275, 277, 278 pleasure, 125 pluralism, 159 poisoning, 185 political aspects, 183 politicians, 9 polymorphism, 203 polymorphisms, 172 POMS, 213, 216 poor, viii, 9, 22, 37, 99, 101, 155, 210, 214, 216, 218, 219, 247 population, 25, 209, 213, 216, 230, 236, 282 population size, 213 portfolio, 212 positive attitudes, 11, 38 positive behaviors, 226 positive correlation, 71, 78 positive emotions, 75 positive , 38, 40, 188 positive relation, 67, 68, 163 positive relationship, 67, 68, 163 positron, 194, 200, 292 positron emission tomography, 194, 200, 292 posterior cortex, 166 postoperative, 199 post-traumatic stress, 123, 185, 186, 216, 280, 288 posture, 57, 60, 67, 75, 85, 153, 243, 246 power, 9, 15, 16, 26, 28, 29, 30, 31, 33, 34, 35, 36, 38, 39, 85, 163, 212, 213, 214, 225, 228, 230, 242 powers, 9, 30, 85 PPI, 169 pragmatic, 285 prayer, 223 prediction, 285, 291 pre-existing, 133 prefrontal cortex (PFC), 165, 171, 172 premotor cortex, 134, 143, 148 pressure, x, 43, 44, 45, 46, 48, 111, 175, 220, 251, 263, 264 prestige, 9, 10, 25, 28, 40, 177 prevention, 51, 104, 210, 232 preventive, 123 primary care, 149, 151 primary caregivers, 149, 151 primate, 148 primitives, 137 principal component analysis, 143 private, 100, 101, 108, 118, 179 private practice, 100, 101, 108, 118 probability, 6, 10, 19, 21, 37, 221, 243, 245 probation, 38 problem solving, 38, 40, 122

308

Index

production, 15, 163 productivity, 42, 49, 133 professions, xi, 271, 272, 273 prognosis, 33, 210, 216, 226, 229 prognostic factors, 235 program, vii, 1, 4, 11, 25, 33, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 145, 192, 269 programming, 4, 17, 30, 37, 45 progress reports, 39 proliferation, 200 promote, x, 193, 194, 207, 230, 248 property, iv prophylaxis, 191 propranolol, 289 prostitution, 25 protection, 188 protein, 149 protein synthesis, 149 protocol, 57, 62, 70, 83, 107, 111, 112, 127, 129, 200, 211, 212, 219, 224, 229, 274, 282 protocols, 107, 169, 208, 218, 219, 277, 281, 283 prototype, 135 pruritus, 192, 194, 196, 198, 200 pseudo, 176 psoriasis, x, 187, 189, 190, 191, 192, 193, 198, 200, 201, 202, 204 psyche, x, 149, 151, 204, 207, 224, 227 psychiatric diagnosis, 282 psychiatric disorder, 231 psychiatrist, 147 psychiatrists, 224, 234 psychoanalysis, vii, ix, 1, 6, 34, 103, 145, 146, 147, 148, 149, 150, 151, 152, 156, 157, 158, 159, 196, 223, 228, 229 psychoanalytic theories, 147 psychogenic, 201, 203 psychological distress, 216, 218, 280 psychological perspective, 96 psychological problems, 221 psychological processes, 63, 150 psychological resources, xii, 272 psychological stress, 182 psychological variables, 127 psychological well-being, 235, 290 psychologist, 104, 224 psychology, x, 2, 51, 147, 157, 163, 177, 185, 207, 208, 223, 224, 287 psychopathology, 139, 146, 150, 184, 238 psychophysiology, 184, 287 psychoses, 3, 25 psychosis, 25 psychosocial factors, xii, 203, 209, 272

psychosomatic, x, 3, 94, 149, 173, 185, 187, 188, 191, 194, 196, 198, 202, 203, 229, 231, 284, 287, 288, 291, 292 psychotherapeutic, 133, 280 psychotherapy, ix, 7, 76, 131, 132, 138, 139, 141, 142, 145, 150, 151, 156, 158, 159, 217, 225, 228, 230, 231, 234, 256, 258, 288 psychotic, 5, 24, 25, 26, 122, 154, 200 psychotic states, 154 psychotic symptoms, 25 psychotropic drugs, 230 PTSD, 186, 216 public, xi, 33, 105, 208, 238, 246, 259, 287 publishers, 232 pumping, 269 punishment, 37, 196, 273

Q QLQ-C30, 215, 230 QOL, 214, 215, 216 qualifications, 146 quality of life, xi, 107, 210, 214, 215, 216, 224, 229, 230, 231, 233, 234, 235, 271, 274, 282, 287 questioning, 23, 24 questionnaire, viii, 40, 53, 69, 70, 73, 85, 86, 95, 213, 215, 216, 222, 228 questionnaires, 70, 75, 78, 83, 180, 214, 215 quizzes, 39

R race, 48 radiation, 32, 33, 34, 221, 279, 291 radical, 32, 132 radiological, 220 radiotherapy, 221, 234 rain, 115, 140 range, 2, 6, 37, 43, 71, 72, 109, 138, 162, 169, 182, 214, 222, 239, 284 rape, 103 rat, 50 ratings, 169, 281 rationality, 69 reaction time, 50, 134, 163, 164 reactivity, 290 reading, 43, 47, 59, 164, 192, 251 reading comprehension, 43 reality, ix, 15, 61, 69, 78, 96, 130, 135, 140, 150, 161, 162, 172, 177, 179, 182, 218 reasoning, 102, 109, 111, 126, 133, 140, 143, 266 reasoning skills, 133

Index recall, 249, 250 receptors, 188 reciprocity, 86, 157 recognition, xi, 46, 138, 152, 156, 158, 271 reconditioning, 5 recovery, 6, 34, 35, 107, 194, 199, 252, 254, 255 recreation, 151 recruiting, 22 rectal sensitivity, 107 recurrence, 198, 210, 279 reduction, 45, 46, 104, 121, 126, 163, 167, 192, 194, 197, 198, 200, 202, 218, 221, 222, 233, 235, 236, 278, 280, 282, 288, 290, 291, 292 reflex sympathetic dystrophy, 280, 286 reflexes, 177, 185 refractory, 204, 292 regional, 285 regression, 56, 61, 75, 147, 201, 203, 204, 211, 212, 236, 238, 249 regrowth, 197 regular, 40, 47, 182, 225, 275 regulation, ix, 161, 166, 168, 169, 170, 172, 224, 248, 256, 257, 258 rehabilitation, viii, 1, 38, 48, 232, 254, 275, 286, 288 rehabilitation program, 254 reimbursement, 195 reinforcement, 8, 20, 21, 35, 239 rejection, 2, 249, 289 relapse, x, 3, 4, 102, 207, 226 relationship, vii, viii, ix, 5, 7, 53, 54, 57, 59, 62, 65, 67, 68, 73, 74, 76, 78, 81, 83, 86, 95, 101, 103, 105, 108, 117, 121, 126, 136, 138, 139, 145, 147, 150, 153, 157, 163, 166, 168, 178, 179, 216, 217, 218, 222, 225, 284 relationships, 73, 76, 77, 86, 149, 151, 214, 267 relatives, 62, 83, 84 relaxation, x, 13, 15, 16, 17, 21, 24, 36, 38, 39, 44, 47, 60, 68, 75, 103, 115, 119, 121, 128, 129, 155, 173, 187, 188, 190, 191, 192, 193, 194, 195, 197, 199, 200, 201, 203, 212, 213, 220, 221, 223, 226, 232, 233, 236, 238, 239, 240, 245, 246, 248, 250, 252, 254, 255, 256, 263, 264, 274, 278, 279, 281, 282, 284, 288 relevance, xi, 173, 237 reliability, 76 religion, vii, 1, 30 religions, 30 religious belief, 30 remission, 203, 210, 217, 226 repair, 191 replication, 178 repression, 185 reproduction, 250

309

research, vii, x, xii, 13, 50, 54, 56, 57, 60, 63, 64, 69, 81, 84, 86, 100, 104, 107, 108, 128, 132, 134, 139, 146, 148, 152, 154, 165, 167, 168, 169, 170, 171, 182, 183, 187, 207, 208, 209, 210, 211, 214, 217, 219, 224, 229, 230, 233, 235, 239, 242, 247, 250, 255, 258, 259, 271, 272, 273, 279, 289, 290 researchers, 13, 14, 29, 34, 64, 132, 148, 162, 163, 170, 228 residential, 47 resistance, 103, 124, 189, 202, 214, 217, 223 resolution, 194, 196, 197, 198, 203, 227 resources, xii, 33, 138, 141, 162, 164, 209, 242, 255, 272 respiratory, 121, 218, 281 respiratory rate, 121 responsibilities, 136 responsiveness, 5, 6, 8, 9, 13, 17, 19, 20, 23, 24, 25, 26, 81, 83, 129, 152, 167, 178, 179, 182, 259 restructuring, 17, 103, 126, 250, 253 retention, 130 rhetoric, 135, 138, 140 rhythm, 57, 67, 85, 171, 234, 249, 269 rhythms, x, 155, 207, 214, 226, 233, 234 right hemisphere, 138, 140, 143, 166 rigidity, 60, 61 rings, 263 risk, x, 38, 109, 140, 156, 207, 211, 212, 213, 216, 218, 220, 226, 227, 232, 267, 273 risk factors, 227 risks, 226, 267 risperidone, 126 rivers, 269 role-playing, 156 romantic relationship, 121 rosacea, 190, 192, 198 Royal Society, 142

S sacrifice, 215 sadness, 69, 122, 153, 154, 249 safety, 104, 108, 121, 122, 148, 177 saline, 28 saliva, 33, 214 sample, 70, 72, 73, 74, 76, 84, 164, 167, 188, 208, 214, 219, 221, 222, 229, 290 sand, 126 SAS, 162, 163, 164, 165 satisfaction, 226, 248, 254 saturation, 214 scalp, 197 Scandinavia, 186 scaphoid fracture, 250

310

Index

scheduling, 163 schema, 136, 137, 163, 164 schemas, 136 schizophrenia, vii, 1, 25, 26, 27, 48 school, 3, 38, 40, 41, 46, 121, 146, 152, 179, 180, 183, 220 scientists, 131, 148, 286 sclerosis, 283, 286, 291 scores, viii, 20, 53, 68, 69, 71, 72, 73, 74, 76, 77, 78, 79, 81, 83, 84, 88, 89, 194, 215, 216, 217, 219, 222, 228, 230, 231, 280, 282 scripts, 10 search, 31, 162, 260 searching, 41, 59, 101 seborrheic dermatitis, 190 secretion, 10, 28, 29 secularization, 284 sedation, 200, 202 sedatives, 219 seeds, 44 seizures, 176 selective attention, 15, 16, 163 selectivity, 86 self, vii, xi, 1, 37, 39, 42, 47, 48, 49, 51, 68, 92, 93, 94, 105, 121, 130, 144, 151, 155, 161, 168, 196, 220, 225, 237, 240, 245, 251, 258, 263, 275, 277, 278, 279, 280, 281, 286, 287, 289, 290, 291, 292 self esteem, 214 self image, 190, 197 self worth, 34 self-actualization, vii, 1, 37, 48 self-awareness, 155 self-confidence, 42, 43, 45, 254 self-control, xi, 105, 128, 238, 239, 240, 242, 244, 247, 248, 254, 255, 256 self-doubt, 85 self-efficacy, vii, 1, 39, 40, 41, 48, 246, 247, 253, 258 self-help, 127 self-image, 4, 8, 25, 37, 41, 43 self-regulation, ix, 161, 169, 170, 172, 248, 256, 257, 258 self-report, 78, 107, 216, 278 self-worth, 195 semantic, 133, 136, 144 semantics, 135, 159 sensation, 116, 119, 125, 218, 238, 246, 252, 253, 263, 264, 265, 268, 270 sensations, 118, 125, 135, 140, 191, 192, 196, 197, 245, 246, 252, 253, 254, 262, 263, 264, 268, 281, 292 sensing, 22 sensitivity, 61, 86, 107, 228

sensory modality, 151 sensory nerves, 188 sentences, 50, 134, 135, 142, 249 separation, 119, 147 sepsis, 221 sequelae, 280 series, viii, 10, 11, 15, 35, 36, 37, 53, 55, 58, 67, 68, 106, 130, 162, 164, 169, 211, 225, 247, 251, 284, 286, 290 set theory, 50 severity, 197, 225, 282 sex, 43, 58, 84, 85, 90, 190 sex hormones, 190 sexuality, 146, 157 shape, 43, 149, 151, 215, 225, 288 shaping, x, 237, 245, 275 sharing, ix, 108, 139, 145, 149, 151, 153, 154, 155, 224, 230 shock, viii, 99, 100, 101, 103, 259 short period, 15 shoulder, 117, 270 shrubs, 266 sibling, 153, 154 siblings, 56, 83, 84 sickle cell, 283, 286, 291 side effects, 124, 126, 195, 210, 221, 229 sign, 67, 85, 211, 245, 264 signaling, 7, 28 signs, 25, 57, 61, 63, 65, 125, 153 similarity, 10, 11, 17, 19, 73, 84, 111 simulation, ix, 131, 132, 134, 135, 136, 137, 142, 143, 156 Singapore, 98 sites, 166, 194, 275 skills, xi, xii, 28, 38, 40, 57, 122, 133, 134, 137, 138, 149, 219, 220, 222, 224, 225, 238, 248, 255, 257, 272, 279 skills training, 219, 220, 279 skin, x, 60, 172, 187, 188, 190, 191, 192, 194, 195, 196, 197, 198, 200, 201, 202, 203, 214 skin cancer, 188, 203 skin conductance, 172 skin diseases, 188, 190, 194, 195 skin disorders, x, 187, 188, 190, 191, 192, 194, 195, 196, 197, 203 sleep, 16, 24, 35, 45, 47, 122, 179, 191, 197, 214, 222, 223, 242, 252, 254, 256, 285 sleep disturbance, 197 smoke, 105 smoking, 11, 34, 46, 47, 105, 157, 226, 249 smoking cessation, 157 social anxiety, 121, 155 social attitudes, 195

Index social cognition, 142 social construct, 289 social fabric, 178 social group, 180 social influence, 239 social learning, 158, 258 social learning theory, 158, 258 social network, 135, 177 social relations, 214 social relationships, 214 social skills, 122 social-psychological perspective, 285 sociocultural, 184 soil, 141 somatosensory, 171 sores, 84 sounds, 191 species, 181 spectrum, xi, 143, 271, 278 speculation, 51 speech, 3, 7, 30, 118 speed, 136, 250, 269, 273 spin, 36 spinal cord, 280 spinal cord injury, 280 spine, 32 spiritual, 34, 135, 215 splint, 250 spontaneity, 155, 230 spontaneous abortion, 3 spontaneous recovery, 20 sports, 134, 255 sprain, 250 stability, 81, 102, 140, 200 stabilization, 104, 105, 109, 115, 120, 121 stabilize, 122 stages, 118, 121, 125, 127, 213 standardization, 70 standards, 258 Staphylococcus aureus, 197 stars, 269 statistical analysis, 72, 208, 210, 229 statistics, 207, 208, 216, 229, 230 stereotypes, 218 stimulus, 8, 9, 10, 14, 16, 19, 23, 28, 63, 68, 164, 165, 190, 246 stimulus generalization, 246 stomach, 60 stomatitis, 190, 283, 284 strain, 11, 177, 283, 288 strategies, xii, 100, 107, 169, 211, 217, 225, 227, 233, 245, 249, 254, 258, 272, 273, 276, 277, 282, 284, 285, 290, 292

311

strategy use, 280 strength, 35, 140, 213, 243, 248, 266 stress, 15, 25, 31, 34, 38, 39, 42, 57, 60, 61, 103, 123, 129, 155, 170, 171, 176, 179, 180, 181, 182, 184, 185, 188, 190, 191, 192, 194, 195, 196, 197, 198, 199, 202, 203, 205, 216, 279, 280, 282, 285, 288, 290 stress level, 155, 197 stressful life events, 232 stressors, 176 stress-related, 170 stretching, 190, 192 strikes, 184 stroke, 31, 266, 276 students, 38, 39, 40, 41, 42, 46, 48, 55, 58, 179, 180, 181 stupor, 47, 177 subjective, viii, ix, 53, 55, 56, 57, 58, 60, 64, 65, 66, 67, 68, 73, 74, 75, 76, 81, 83, 84, 85, 86, 132, 142, 145, 146, 148, 149, 151, 153, 154, 167, 208, 239, 244, 274 subjective experience, viii, 53, 55, 57, 60, 64, 65, 68, 74, 75, 76, 81, 86, 154, 239 subjective judgments, 73 subjectivity, 146, 148, 150, 155, 229 substance abuse, 40 substitution, 3, 5, 195, 196, 253 subtraction, 194 success rate, vii, 1 successive approximations, 239, 245 suffering, 3, 25, 32, 37, 101, 102, 103, 104, 106, 107, 111, 121, 123, 137, 141, 193, 195, 254, 277, 278, 280 suicidal, 3, 102 suicidal ideation, 102 suicide, 216 summaries, 42 summer, 33, 140, 198 superiority, 273, 279 supernatural, 30 supervision, 155 supply, 273 suppression, 188 surgery, 32, 34, 106, 107, 128, 187, 194, 195, 196, 199, 200, 213, 218, 219, 221, 250, 252, 254, 281, 285, 290 surgical, xi, 106, 107, 129, 220, 254, 271, 273, 280, 288 surgical intervention, 107, 280 surprise, 4, 104, 108, 109, 111, 114, 118, 119, 127, 226, 264, 266

Index

312

survival, x, 34, 207, 210, 211, 212, 213, 214, 215, 216, 224, 225, 226, 229, 230, 233, 234, 235, 236, 274, 279 surviving, 106 survivors, 217, 222, 232 susceptibility, x, 5, 22, 49, 50, 51, 57, 58, 64, 65, 70, 71, 72, 76, 81, 83, 84, 143, 152, 156, 162, 164, 166, 170, 172, 173, 178, 185, 186, 188, 198, 203, 208, 219, 228, 230, 231, 233, 257, 263, 280, 282, 290 sweat, 189, 261 sweets, 43 swelling, 254 symbiotic, 57 symbols, 133 sympathetic, 169, 172, 189, 276, 280, 286 sympathetic fibers, 189 sympathetic nervous system, 169 symptom, 2, 3, 4, 5, 25, 103, 195, 216, 218, 222, 229, 230, 233, 282, 291 symptoms, ix, x, xii, 2, 3, 4, 5, 25, 26, 101, 103, 104, 106, 107, 123, 125, 126, 172, 175, 176, 177, 179, 180, 191, 194, 207, 208, 217, 220, 221, 222, 225, 226, 229, 234, 248, 252, 272, 279, 280, 281, 282, 284 synchronous, 57, 67, 85, 222 syndrome, 126, 183, 280, 281, 284, 286, 287, 291, 292 synthesis, 149, 164, 203 systems, 153, 162, 164, 170, 192, 194

T talent, 273 targets, 229, 284 task performance, 167 taste, 33 T-cell, 233 teachers, 180 teaching, 44, 48, 191, 223, 224, 230, 232, 278 technology, 48, 188 Technology Assessment, 288 telephone, 254 television, 192, 195, 260 temperature, 21, 189, 190, 214 temporal, 65, 66, 123, 132, 134, 138, 147, 184 temporomandibular disorders, 107, 290 tension, 43, 47, 73, 169, 176, 180, 191, 197, 213, 216, 244, 245, 252, 261, 279, 280, 288, 290, 291, 292 tension headache, 279, 291, 292 terminal illness, 232

terminally ill, x, 35, 207, 215, 216, 217, 224, 226, 233, 234 terrorism, 183 testicular cancer, 34 tetrad, 194 theory, vii, ix, xii, 1, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 24, 27, 28, 29, 30, 31, 35, 36, 37, 38, 41, 48, 49, 50, 60, 93, 132, 133, 134, 135, 136, 138, 142, 144, 147, 148, 149, 150, 156, 157, 161, 162, 166, 169, 170, 171, 172, 194, 226, 256, 257, 272, 284, 285, 288 therapeutic benefits, 105, 108 therapeutic change, 13, 24, 140 therapeutic goal, 123, 273 therapeutic process, 122, 126 therapeutic relationship, 105, 222 therapeutic targets, 284 therapists, 2, 4, 5, 7, 18, 63, 85, 140, 141, 231, 240, 243, 245, 255, 256 therapy, vii, 1, 2, 6, 7, 8, 10, 11, 17, 19, 34, 46, 51, 63, 100, 107, 126, 133, 138, 139, 140, 142, 143, 151, 152, 154, 155, 194, 197, 198, 199, 201, 202, 203, 204, 210, 217, 219, 220, 222, 223, 225, 234, 235, 240, 242, 245, 250, 253, 254, 257, 258, 261, 272, 278, 280, 282, 285, 286, 291 theta, 163, 171, 194 thinking, ix, 25, 43, 44, 45, 102, 126, 131, 135, 144, 162, 223, 248, 252, 258 third party, 182 threat, 43, 176, 179 threatening, 39, 215 threats, 25, 39, 177 threshold, 134, 210, 216, 290 thyroid, 190 timing, 66, 167, 173 tin, 36, 131, 197, 245 title, 155 tobacco, 249 tolerance, 220 ToM, 149 tongue, 93 tonic, 169 top-down, 163, 164, 165, 167, 168 toxic, 179, 185, 221 toxicity, 215, 221 tradition, 134, 136, 152, 273 trainees, 41, 42 training, 42, 85, 109, 121, 125, 147, 169, 191, 192, 195, 198, 202, 212, 213, 217, 219, 220, 223, 224, 225, 229, 233, 235, 236, 245, 252, 275, 279, 280, 283, 284, 286, 290, 291, 292 trait anxiety, 282 transcranial magnetic stimulation, 134

Index transcripts, 76, 78 transfer, 7, 63 transference, 54, 57, 58, 62, 63, 146, 147, 154, 158 transformations, 135 transition, 120, 186, 226 translation, 167 transmission, x, 175, 177 transplantation, 220 transportation, 267 trauma, x, 103, 122, 123, 147, 180, 185, 190, 207, 216, 225, 227 traumatic events, 178, 227 treatable, 6 trees, 116, 265, 266, 268 trend, 4, 196, 209, 216 trial, 27, 28, 30, 129, 197, 198, 200, 202, 209, 210, 211, 212, 213, 214, 217, 219, 224, 225, 230, 231, 232, 233, 235, 279, 282, 284, 285, 291, 292 trichotillomania, 152, 192, 199, 201, 203 trigeminal, 276 trigeminal neuralgia, 276 triggers, 165, 179, 180, 183, 260 trisomy, 124 trisomy 21, 124 trust, 65, 105, 156, 244 trustworthiness, 40 tumor, 31, 34, 212, 217, 220, 221, 227 tumor invasion, 220 tumor progression, 217 tumors, 214, 227 turbulent, 266 twins, 56, 82, 83, 84, 85, 86, 87, 89, 90

U ubiquitous, 136, 168 UCR, 29 ultraviolet, x, 187, 190, 192 ultraviolet B, 192 ultraviolet light, x, 187, 190 uncertainty, 154, 266 underlying mechanisms, 208 United Kingdom (UK), 98, 107, 129, 143, 173, 188, 281, 282 United States, 97, 188 universality, ix, 131, 177 university students, 58 urticaria, 191, 192, 196, 199, 203

313

V Valencia, vii, viii, x, xi, 99, 100, 104, 108, 110, 127, 128, 130, 237, 238, 239, 240, 255, 256, 257, 258 validation, 81, 95, 215, 255 validity, 196 valine, 193 values, 70, 71, 88, 135, 214, 228 variability, 170, 171, 208, 214, 215, 229, 232 variable, x, 7, 23, 60, 77, 83, 84, 126, 175, 274, 275 variables, xi, 6, 35, 73, 83, 100, 229, 237, 238, 239, 280 variance, 70, 83, 88 variation, 9, 11, 54, 146, 182, 219, 228, 246, 252 varimax rotation, 70 vascularization, 227 vasoconstriction, 189 vasodilation, 288 vehicles, 134 ventricular arrhythmia, 170 verbal persuasion, 39, 40 versatility, xi, 238, 255 vertigo, 111 vessels, 189 veterans, 185 vignette, 152, 153, 154, 155 village, 266 virtual reality, 130 visible, 18, 21, 228 vision, 147, 268 visual field, 142 visual images, 276 visualization, 11, 33, 34, 37, 203, 249 vitiligo, 190, 192, 199 voice, 16, 23, 33, 60, 146, 155, 156, 243, 249, 260, 265, 270 voiding, 219 vomiting, 221, 222, 225, 232, 236, 289 voodoo, 29

W waking, vii, x, xi, 6, 14, 20, 55, 57, 65, 78, 105, 108, 118, 123, 124, 127, 128, 194, 237, 238, 239, 240, 242, 243, 245, 247, 253, 255, 257, 258, 259 walking, 126, 140, 240, 260, 265, 266, 268 warts, 194, 199, 201, 202, 203, 204 watches, 247 water, 125, 141, 177, 266, 287 weakness, 43, 220 wear, 254, 263 web, 133

314

Index

weight reduction, 45 welfare, viii, 1, 38, 41, 48 well-being, x, xi, 102, 207, 210, 214, 222, 226, 229, 230, 235, 254, 271, 290 western countries, 218, 230 wheelchair, 115 wind, 140 windows, 137 wine, 258 winning, 44, 146 winter, 198 withdrawal, 101, 102, 104, 126 women, 42, 55, 129, 135, 147, 211, 217, 219, 233, 234, 278 word naming, 165, 166 word recognition, 138 workers, 44, 134, 137 worry, 249, 263, 268

writing, 20, 47, 249

X x-rays, 34, 254

Y yawning, 181, 182 yield, 74, 83, 226

Z Zen, 192